A new monitoring system for nutritional status assessment in children at home

Regular monitoring of children's nutritional status is essential to prevent micronutrient deficiencies, nutritional status abnormalities as stunting, wasting, overweight and obesity. Nutritional status assessment is usually performed by paediatricians by using anthropometry (body mass index, weight to height indices) and/or by body fat-mass measurement (bioimpedance analysis, dual-energy x-ray absorptiometry, computer tomography, etc.). Parents are also interested in but usually fail to evaluate their child's nutritional status. To help the sufficient collaboration between the physician and parents a new nutritional status monitoring method is developed for families. The new monitoring system was developed under a paediatrician's supervision by considering national and international recommendations, references as well as the anthropometric measurement possibilities at home. The model requires age, sex, body mass, height, waist circumference and hand circumference as predictor (input) variables of nutritional status, while (1) the centile values of the measured body dimensions, (2) body fat percentage and the centile of body fat percentage, (3) the nutritional status category (undernutrition, normal nutritional status, overfat/obese) can be predicted (outcome variables) by the new method. The predictive accuracy of the model for nutritional status category was 94.88% in boys and 98.66% in girls. The new model was developed for nutritional status assessment in school-aged children and will be incorporated in the healthy lifestyle module of 'Teenage Survival Guide' educational package to be developed by the Health Promotion and Education Research Team, Hungarian Academy of Sciences, Hungary. The new monitoring system could help the families to identify the early signs of malnutrition in children. Nutritional status assessment in children at home is suggested twice a year, and in case of suspicious nutritional status abnormality it is recommended to visit the general practitioner.

A proposal for the adjustment of bone mineral density for body dimensions in children

Objectives: The precise age estimation is of high importance in bone mineral density (BMD) assessment in children, since the bone structure of a studied child is evaluated by using the age and gender dependent references. In addition, the biological age - the bone age in this case - estimation could help this bone structural evaluation process, since the developmental status of the skeletal system can significantly alter from the theoretical developmental status determined by chronological age in healthy, but early or late maturing children. The aims of the study were (1) to check whether volumetric BMD (vBMD) Z-scores estimated by considering chronological age and biological age differ significantly in children aged between 7-18 years, and (2) in the case of significant inaccuracy of Z-score estimation based on chronological age to construct new vBMD standards adjusted for body developmental status. Subjects and methods: Body structural and densitometry data of 476 healthy children aged between 7 and 18 years were used in the analysis. pQCT measurements were performed at the distal radius using Stratec XCT-2000 equipment (Stratec Inc, Germany). The centile curves of vBMD parameters were estimated by using lmsChartMaker Pro 2.3 software. Ulnar length age was used as biological age in the analysis. Results: The total and 'cortical + subcortical' vBMD changed by age in the studied age interval in both genders, while the trabecular vBMD showed significant change by age only in females. Our results confirmed that when the biological age of a child significantly differs from her/his chronological age, vBMD evaluation should be done by considering her/his biological age. Due to the increase in individual variability of rate and timing of pubertal developmental processes, the sensitivity of vBMD evaluation by considering body developmental status was the lowest in the age between 12 and 16 years in the boys and between 10 and 12 years in the girls. Therefore the suggested vBMD adjustments for biological ages are highly recommended to use at least in children with ages outside these age intervals. Conclusion: If the estimation of any biological age cannot be carried out, vBMD references adjusted for height or other body dimensions should be used in the bone health status estimation in children.

Body structural and cellular aging of women with low socioeconomic status in Hungary: A pilot study

OBJECTIVES

The health status of an individual is determined not only by their genetic background but also by their physical environment, social environment and access and use of the health care system. The Roma are one of the largest ethnic minority groups in Hungary. The majority of the Roma population live in poor conditions in segregated settlements in Hungary, with most experiencing higher exposure to environmental health hazards. The main aim of this study was to examine the biological health and aging status of Roma women living in low socioeconomic conditions in Hungary.

METHODS

Low SES Roma (n: 20) and high SES non-Roma women (n: 30) aged between 35 and 65 years were enrolled to the present analysis. Body mass components were estimated by body impedance analysis, bone structure was estimated by quantitative ultrasound technique. Cellular aging was assessed by X chromosome loss estimation. Data on health status, lifestyle and socioeconomic factors were collected by questionnaires.

RESULTS

The results revealed that low SES women are prone to be more obese, have a higher amount of abdominal body fat, and have worse bone structure than the national reference values. A positive relationship was found between aging and the rate of X chromosome loss was detected only in women with low SES. Waist to hip ratio, existence of cardiovascular diseases and the number of gravidities were predictors of the rate of X chromosome loss in women.

CONCLUSIONS

The results suggested that age-adjusted rate of X chromosome loss could be related to the socioeconomic status.

Pharmacokinetics and Pharmacodynamics of Macimorelin Acetate (AEZS-130) in Paediatric Patients With Suspected Growth Hormone Deficiency (GHD)

Growth hormone deficiency (GHD) in children is a rare, aetiologically diverse condition that results in growth failure and short stature. Inadequate response to two different growth hormone stimulation tests (GHST) is required for the diagnosis of GHD. Macimorelin acetate, a potent, orally administered growth hormone (GH) secretagogue, is approved by the FDA and EMA for the diagnosis of adult GHD. Study AEZS-130-P01 is the first of two studies to investigate macimorelin acetate as a diagnostic test in children with suspected GHD.

This was an open-label, group comparison, dose escalation trial to investigate the safety, tolerability, pharmacokinetics and pharmacodynamics of single-dose 0.25, 0.5 and 1 mg/kg oral macimorelin acetate in paediatric subjects with suspected GHD. The macimorelin GHST was administered between two standard GHST, conducted as per local clinical practice, with a recovery period of 7-28 days between tests. Blood samples were collected pre-dose (±15 min) and 15, 30, 45, 60, 90, 120 and 360 minutes after macimorelin acetate intake.

Overall, 24 paediatric subjects (8 per cohort [C1, C2, C3]) were included in the pharmacokinetic/pharmacodynamic (PK/PD) analysis. Five males and 3 females were observed in C1 and C2, 7 males and 1 female in C3. In all three cohorts, at least 3 subjects represented Tanner stages I or II. All 24 subjects (100%) were white, with a median age of 9.8, 9.0 and 10.5 years (range 4-15 years) and a median body-mass index of 16.1 kg/m2 (12.4-21.4 kg/m2) at screening. Overall, 88 adverse events were reported, many related to the standard GHST; none were considered related to the macimorelin test. Maximum plasma concentrations for macimorelin were mainly observed between 30-45 min. The mean Cmax values were 3.46, 8.13 and 12.87 ng/ml for C1, C2, and C3, respectively. The AUCs increased with dose; the mean AUC0-6 values were 6.69, 18.02 and 30.92 h*ng/mL. The mean elimination half-lives were 1.22, 1.61 and 1.71 h, respectively. PK and PD profiles for all three cohorts were comparable, with peak GH levels mainly observed within 30-60 min following macimorelin intake.

Macimorelin acetate was safe and well tolerated in all dosing cohorts. A dose-dependent increase in macimorelin Cmax and AUC in children and adolescents correlated well with data from adult subjects. A robust dose-proportional GH response was also achieved. PD results showed that GH response was comparable in all dose groups, with a slight shift to earlier tmax at higher macimorelin doses.

SAT-LB15 24-Month Efficacy and Safety of Once Weekly and Every Other Week Administration of GX-H9, Hybrid FC-Fused Long-Acting Human Growth Hormone: A Phase 2 Study in Children With Growth Hormone Deficiency

Objectives GX-H9 is a long-acting form of recombinant human GH under clinical development for both adults and children with GHD. In this report, 24-month efficacy and safety of once weekly and every other week (EOW) administration of GX-H9 were evaluated, in addition to Genotropin^® switch-ability to GX-H9 after 12-month of treatment. Methods Subjects were randomly assigned to receive either one of three doses of GX-H9 (0.8 mg/kg/week, 1.2 mg/kg/week or 2.4 mg/kg every other week) or 0.03 mg/kg/day of Genotropin^®. Treatment duration is 24-month for all patients in GX-H9 arms while patients in Genotropin^® arm were re-randomized to one of three doses of GX-H9 at the completion of the first 12-month of treatment. Doses of GX-H9 were adjusted throughout the treatment period whenever necessary, based on IGF-1 levels. Results Out of 56 randomized, 54 received either GX-H9 or Genotropin^®. Fifty subjects completed the 12-month treatment period. Of 50, 45 subjects completed the next 12-month, comprising 33 patients from GX-H9 and 12 patients who switched from Genotropin^®. First year/second year mean±SD annualized height velocity (aHV) for 0.8 mg/kg/week, 1.2 mg/kg/week or 2.4 mg/kg every other week of GX-H9 were 10.50±2.54/9.14±1.96, 11.76±1.96/9.88±1.92 and 11.03±2.92/9.72±1.90 cm/year, respectively. First year mean±SD aHV for Genotropin^® was 9.14±3.09 cm/year. Patients switched to one of the three doses of GX-H9 in the second year showed comparable aHV in the second year (8.73±2.69/7.60±0.90/9.13±1.07 cm/year for 0.8 mg/kg/week, 1.2 mg/kg/week and 2.4 mg/kg/EOW GX-H9, respectively). No significant slow-down of the growth was observed in the second year from patients who received GX-H9 throughout and patients who switched from Genotropin^®. Mean change in height SDS after 12 months/24 months of GX-H9 treatment throughout from baseline treatment improved continuously (+1.10/+1.61 and +1.31/+1.89 and +1.15/+1.69 for 0.8 mg/kg/week, 1.2 mg/kg/week and 2.4 mg/kg EOW GX-H9, respectively). First year mean change in height SDS for Genotropin^® was +0.92 SDS, and showed comparable improvement in height SDS after switching to GX-H9 weekly arms (+0.76 and +0.79 SDS for 0.8 mg/kg/week and 1.2 mg/kg/week, respectively). Most treatment-emergent adverse events were evaluated as unrelated to the study drug and were mild or moderate in severity. No new safety concerns were observed throughout 24 months of long-term GX-H9 treatment or after switching to GX-H9 from Genotropin^®.Conclusions Growth response and safety profile of GX-H9 in children with GHD is comparable to those of daily GH, achieving robust growth rates after 24-month treatment. Subjects switched from Genotropin^® in the second year, also showed substantial catch-up growth indicated by improvement in height SDS. GX-H9 has a unique potential to be a convenient long-term GH providing not only weekly but also twice-monthly treatment.

A comparison of skeletal maturity assessed by radiological and ultrasonic methods

OBJECTIVES

The estimation of skeletal maturity is a useful tool in pediatric practice to determine the degree of delay or advancement in growth disorders and the effectiveness of treatment in conditions that influence linear growth. Skeletal maturity of children is commonly assessed using either Greulich-Pyle (GP) or Tanner-Whitehouse methods (TW2 and TW3). However, a less invasive ultrasonic method, that does not use ionizing radiation, has been suggested for use in epidemiological studies of skeletal maturity. The main purpose of the present study was to determine the accuracy of an ultrasonic method based on the GP maturity indicators compared to the standard GP radiographic method.

METHODS

Skeletal maturity of 1502 healthy children, aged from 6 to 18 years, was estimated by quantitative ultrasound and compared to GP bone ages estimated from left hand and wrist radiographs of a subsample of 47 randomly selected participants.

RESULTS

The ultrasonic bone age estimation demonstrated very strong correlations with all the radiological age estimations. The correlation coefficients ranged between 0.895 and 0.958, and the strongest correlation of ultrasonic skeletal maturity estimation was found with the Tanner-Whitehouse RUS method. The ultrasonic bone age estimation is suggested for use between the chronological ages of 8.5-16.0 years in boys and 7.5-15.0 years in girls.

CONCLUSIONS

The ultrasonic bone age estimation is suggested for use in epidemiological surveys since the sensitivity for screening for not normal bone development is appropriate, at least within the 8-15 years age interval.

Growth hormone and treatment outcomes: expert review of current clinical practice

Although there are guidelines for treatment of short stature, open questions regarding optimal management of growth hormone therapy still exist. Experts attending six international meetings agree that successful therapy results in the patient attaining mid-parental height, and relies on correct diagnosis and early intervention. Experts advocate patient followup every 3-6 months, and that growth and adherence should be monitored at each visit. Growth response is variable, and an accepted definition of good/poor response is lacking. Combined with patient education and regular patient follow-up, a definition of treatment response could lead to improved treatment outcomes. Few experts use prediction models in clinical practice, but all agree that pharmacogenetics might improve prediction, enable early therapy modulation, and promote growth. Poor growth is often due to low adherence. Guidance on optimal management of growth hormone therapy is required, with focus on early diagnosis, dosing, treatment monitoring, adherence, and motivation.

Congenital disorders of the thyroid: hypo/hyper

This article summarizes the ontogenesis and genetics of the thyroid with regards to its possible congenital dysfunction and briefly refers to the roles of the mother-placenta-fetal unit, iodine effect, and organic and functional changes of the negative feedback mechanism, as well as maturity and illness, in some forms of congenital hypo- and hyperthyroidism. This article also describes the published literature and the authors' data on the clinical aspects of congenital hypothyroidism, on the alternating hypo- and hyperthyroidism in the neonatal period, and on neonatal hyperthyroidism.

Congenital disorders of the thyroid: hypo/hyper

This article summarizes the ontogenesis and genetics of the thyroid with regards to its possible congenital dysfunction and briefly refers to the roles of the mother-placenta-fetal unit, iodine effect, and organic and functional changes of the negative feedback mechanism, as well as maturity and illness, in some forms of congenital hypo- and hyperthyroidism. This article also describes the published literature and the authors' data on the clinical aspects of congenital hypothyroidism, on the alternating hypo- and hyperthyroidism in the neonatal period, and on neonatal hyperthyroidism.

Appropriate sampling times for growth hormone (GH) measurement during insulin tolerance testing (ITT) in children

BACKGROUND

The Pfizer International Metabolic Database (KIMS), a large pharmacoepidemiologic database for adults with growth hormone deficiency (GHD), was recently analyzed to determine which tests are in use to assess GHD and how well they correlate. At the time of this analysis, a total of 15,724 tests had been reported to KIMS. The most frequently used is the insulin tolerance test (ITT), followed in order by the arginine stimulation test (AST), the glucagon stimulation test (GST) and the GH-releasing hormone+arginine (GHRH+arg) test. The ITT correlated with both the AST and the GST, but not with the GHRH+arg.

CONCLUSIONS

For the AST and GST, use of a diagnostic threshold of 3 mug/l does not attenuate the effects of severe GHD.

High prevalence of PROP1 gene mutations in Hungarian patients with childhood-onset combined anterior pituitary hormone deficiency

Combined pituitary hormone deficiency is characterized by the impaired production of pituitary hormones, commonly including growth hormone. The pathomechanism of the childhood-onset form of this disorder may involve germline mutations of genes encoding pituitary transcription factors, of which PROP1 gene mutations have been studied most extensively. However, controversy exists about the significance of PROP1 gene mutations, as both low and high frequencies have been reported in these patients. Because the different results may be related to differences in patient populations and/or the variability of clinical phenotypes, we performed the present study to examine the prevalence and spectrum of PROP1 gene mutations in 35 patients with non-acquired childhood-onset growth hormone deficiency combined with at least one other anterior pituitary hormone deficiency. Genetic testing indicated the presence of disease-causing mutations in exons 2 and 3 of the PROP1 gene in 15 patients (43% of all patients; homozygous mutations in 10 patients and compound heterozygous mutations in 5 patients). Comparison of clinical data of patients with and without PROP1 gene mutations failed to show significant differences, except an earlier growth retardation detected in patients with PROP1 gene mutations. In one patient with PROP1 gene mutation, radiologic imaging showed an enlargement of the anterior lobe of the pituitary, whereas the other patients had hypoplastic or normal pituitary gland. All patients with PROP1 gene mutations had normal posterior pituitary lobe by radiologic imaging. These results indicate that using our inclusion criteria for genetic testing, PROP1 gene mutations can be detected in a high proportion of Hungarian patients with non-acquired childhood-onset growth hormone deficiency combined with at least one other anterior pituitary hormone defect.

Changes of urinary iodine excretion of newborns over a period of twenty years

OBJECTIVE

The use of iodized salt is not mandatory in Hungary and supply is irregular since decades. The effect of this anomaly was studied on the neonatal urinary iodine excretion over a period of twenty years.

DESIGN

Urinary iodine content of 286 newborns' samples was tested in different areas of Hungary in 1980, 1991, and 1999.

METHODS

Colorimetric ceric ion-arsenious acid method based on Sandell-Kolthoff reaction was used for determination of urinary iodine content. Fitfy-one samples were excluded from evaluation because of suspicion of iodine contamination.

RESULTS

Decreased iodine excretion was demonstrated in different areas and at various times over this period of twenty years in accordance with the results of other (schoolchildren, pregnants) surveys in Hungary.

CONCLUSIONS

Iodine deficiency of newborns in these areas changed from year to year, documenting a fluctuating iodine intake. Universal salt iodization should be introduced throughout the country instead of the present "silent iodine prophylaxis" to prevent iodine deficiency, especially in the perinatal period.

[Changes in osteocalcin serum levels in children with growth hormone deficiency during substitution therapy]

Osteocalcin (OC), a specific marker of osteoblast activity, was measured in 21 short, growth hormone deficient (GHD) children before and during 2 years of growth hormone (GH) therapy. Anthropometric and serum measurements were performed in every three-month during the first year (15 patients) and after the second year (16 patients). Mean OC concentration was significantly lower in GHD children compared to normal value (11.9 +/- 2.1 ng/ml (n = 15) and 11.4 +/- 2.5 ng/ml (n = 16) vs. 17.5 +/- 4.9 ng/ml). During the GH treatment serum OC increased continuously: 15.5 +/- 2.4 - 20.5 +/- 8.2 - 26.1 +/- 8.6 - 25.1 +/- 9.8 ng/ml (n = 15) and 24.9 +/- 9.1 ng/ml (n = 16) then decreased (16.6 +/- 9.7 ng/ml). OC level measured in the 9th and 12th months was markedly higher than in normal children (p = 0.01 and p < 0.001).

IN CONCLUSION

1. Serum OC is low in short statured GHD children. 2. In the first 9-12 months of GH therapy OC raises continuously exceeding the normal mean value. 3. During the second year of GH treatment OC decreases to the normal level. 4. OC concentration measured does not correlate with change of other parameters observed (growth velocity, bone maturation, height for age). 5. Although OC is a sensitive marker of bone formation, it has no prognostic value concerning the growth.