Abstract
IntroductionPediatric endocrinology rely greatly on hormone stimulation tests which demand time, money and effort. The knowledge of the pattern of pediatric endocrinology stimulation tests is therefore crucial to optimize resources and guide public health interventions. Aim of the study was to investigate the distribution of endocrine stimulation tests and the prevalence of pathological findings over a year and to explore whether single basal hormone concentrations could have saved unnecessary stimulation tests.MethodsRetrospective study with data collection for pediatric endocrine stimulation tests performed in 2019 in a tertiary center.ResultsOverall, 278 tests were performed on 206 patients. The most performed test was arginine tolerance test (34%), followed by LHRH test (24%) and standard dose Synachthen test (19%), while the higher rate of pathological response was found in insulin tolerance test to detect growth hormone deficiency (81%), LHRH test to detect central precocious puberty (50%) and arginine tolerance test (41%). No cases of non-classical-congenital adrenal hyperplasia were diagnosed. While 29% of growth hormone deficient children who performed an insulin tolerance test had a pathological peak cortisol, none of them had central adrenal insufficiency confirmed at low dose Synacthen test. The use of basal hormone determinations could save up to 88% of standard dose Synachthen tests, 82% of arginine tolerance + GHRH test, 61% of LHRH test, 12% of tests for adrenal secretion.ConclusionThe use of single basal hormone concentrations could spare up to half of the tests, saving from 32,000 to 79,000 euros in 1 year. Apart from basal cortisol level <108 nmol/L to detect adrenal insufficiency and IGF-1 <-1.5 SDS to detect growth hormone deficiency, all the other cut-off for basal hormone determinations were found valid in order to spare unnecessary stimulation tests.
Highlights
Pediatric endocrinology rely greatly on hormone stimulation tests which demand time, money and effort
Stimulation tests are used to assess the maximum secretion of a hormone and/or are as a proxy parameter of endogenous secretion, in order to evaluate if a child is producing enough or too much hormones compared to the normal functioning of endocrine system for age [2]
In case of suspected non-classical-congenital adrenal hyperplasia (NC-CAH), a Standard Dose Synacthen Test (SDST) was performed and 17-hydroxy-progesterone (17-OH-P) data were interpreted according to New’s nomogram [9], while in case of suspected central adrenal insufficiency (CAI), a Low Dose Synacthen Test (LDST) was performed and a normal response was considered a peak cortisol level of ≥430 nmol/L [10,11,12]; for peak values between 430 and 500 nmol/l, a rise in cortisol levels >200 nmol/l was used as confirmation of normal response [13]
Summary
Pediatric endocrinology rely greatly on hormone stimulation tests which demand time, money and effort. Diagnosis rely greatly on laboratory testing: while for some disorders a single blood sample is sufficient (e.g. primary hypothyroidism), in others (e.g. growth hormone deficiency [GHD] or central precocious puberty [CPP]) the determination of basal hormones is of limited diagnostic value, since many hormones are secreted in pulses or have specific oscillatory activity. Stimulation tests demand time, money and effort: they require the use of an intravenous line to inject the stimulating hormone and/or chemical substance and can take up to three or more hours; they need special staff skills, and are typically conducted in a hospital outpatient setting; for instance, in Italy the costs for stimulation test – which is free of charge for patients and families and covered by the Italian National Health System – vary from 305 to 591 euros, while a single hormone determination costs from 9.40 to 16.90 euros. Stimulation tests are still extensively used and considered the gold standard in the diagnosis of many endocrine diseases
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