Prepubertal Child Research Articles

Sex hormone binding globulin concentration as a prepubertal marker for hyperinsulinaemia in obesity

BACKGROUNDOverweight children become obese adults who are prone to develop the “metabolic syndrome” and premature coronary arterial disease (CAD).AIMSTo assess whether sex hormone binding globulin (SHBG) is a potential marker...

US of the pediatric female pelvis: a clinical perspective.

When investigating pelvic pathologic conditions in female pediatric patients, one needs to be aware of the developmental changes that take place around puberty. The prepubertal uterus is thin, with a fundus equal in size to the cervix. Owing to the hormonal stimulation of puberty, the uterus enlarges and the fundus becomes prominent. The ovaries are demonstrated with ultrasonography (US) at all ages. Ovarian volume increases after 6 years of age. Microcystic follicles are normally seen throughout childhood. US is the modality of choice for imaging the pediatric female pelvis. The main indications for pelvic US in the pediatric age group are pubertal precocity or pubertal delay, pelvic pain or pelvic masses, and ambiguous genitalia. Vaginal bleeding in the prepubertal child can be due to a vaginal foreign body, vaginal rhabdomyosarcoma, or precocious puberty. Common causes of primary amenorrhea in teenagers include gonadal dysgenesis (Turner syndrome) and müllerian (uterovaginal) anomalies. Pelvic pain or pelvic masses in pediatric patients can be due to ovarian torsion, hemorrhagic ovarian cyst, pelvic inflammatory disease, or ectopic pregnancy.

Aldara™ as treatment for condylomata acuminata in the prepubertal child

BACKGROUND: Treatment of condylomata acuminata in the prepubertal child has previously presented difficulties. Initial treatment has often involved the expense and morbidity of general anesthesia and CO2 laser. Adult modalities have been tried such as tricarboxylic acid (TCA) or intralesional interferon but often are discontinued because of significant pain and/or morbidity. AldaraTM is the brand name for an Imiquimod containing cream. Imiquimod is an immune response modifier. It has been approved by the FDA for the treatment of genital and perianal warts in the population 18 years of age and older.METHODS: JH is a 7-YO WF seen for evaluation for sexual abuse. The perpetrator is known. She had a normal hymeneal circumference and STD cultures and serologies. However, her exam was complicated by multiple condylomata of the clitoral, periclitoral, labia majora and minora, and perihymeneal area. She was significantly symptomatic with burning and itching that was mildly helped by the constant use of Desitin cream. One condyloma was selected for a test dose of the AldaraTM cream (enough to cover a Calgiswab). The mother was asked to give her daughter a sitz bath in six hours and to continue them BID until return.RESULTS: Upon return in one week, patient described no untoward complaints. All of the condylomata were gone except one perihymeneal area at 7 o'clock. The previous areas were still slightly red but this resolved over time. Sitz baths were continued. Two weeks later the remaining perihymeneal lesion was excised and sent for documentation at the request of the prosecuting attorney and the mother. To date, at three months, there has been no recurrence.CONCLUSION: The exact mechanism of AldaraTM upon the eradication of genital warts is unknown. Side effects are usually mild to moderate. Most common side effects are redness, peeling, and swelling in the area where the AldaraTM is applied. This patient had mild redness with only a very small test dose. Other reported side effects not experienced by this patient are burning, itching, swelling and difficulty with urination. There may be a significant role for AldaraTM in the treatment of symptomatic genital condyloma in the prepubertal child. More research and experience is needed especially in establishing correct dosing and safety for this population.

Associations between maternal peak bone mass and bone mass in prepubertal male and female children.

The aim of this study was to estimate heritability of bone density in premenopausal women, prepubertal male, and prepubertal female child pairs. We studied 291 pairs (mothers, mean age, 33 years, range 22-45 years; children, mean age, 7.92 years, range 7.32-8.92 years). Bone density and body composition were assessed by dual-energy X-ray absorptiometry. Height and weight were measured in both mother and child. Body size-adjusted heritability estimates for areal bone density (g/cm2) were all statistically significant (femoral neck, 59%; lumbar spine, 38%; total body, 41%) and were consistently and significantly higher in mother-daughter pairs (n = 105) as compared with mother-son pairs (n = 186). Heritability estimates for bone mineral apparent density (BMAD; g/cm3) were marginally lower but remained statistically significant at all sites (femoral neck, 51%; lumbar spine, 32%; total body, 38%). Maternal osteopenia was associated with significant reductions in bone mass at all sites in the children (femoral neck, 0.75 SD and p < 0.0001; lumbar spine, 0.61 SD and p < 0.0001; total body, 0.43 SD and p = 0.012). Mother-child bone areal bone density correlation coefficients and prediction of low bone mass in the child were greater (but this did not reach statistical significance) if the corresponding anatomical site in the mother was used for prediction with the exception of the total body. These data confirm that heritability of bone mass extends to prepubertal children and is gender- and possibly site-specific as well as under separate genetic control to growth. Furthermore, the strength of the mother-child association is such that bone density screening of mothers would make it possible to identify most prepubertal children at higher risk of osteoporosis in later life.

DIAGNOSIS AND MANAGEMENT OF TERATOMAS AND EPIDERMOID CYSTS

One can strongly suspect a benign lesion in a prepubertal child on the basis of preoperative sonographic, biochemical, and clinical evaluation; however, when considering a testis-sparing enucleation, the definitive diagnosis must be established by pathologic frozen section of the tumor. The high incidence of benign testicular lesions in the prepubertal patient, the absence of associated carcinoma in situ in prepubertal germ cell tumors, and the universally benign behavior of the specific tumors described in this article are supportive evidence for testis-sparing surgery versus orchiectomy, for these benign lesions.

Testicular simple cyst and teratoma: asynchronous bilateral occurrence within the first year of life

Benign and malignant testicular tumors are rare in infancy. Moreover, only a few cases of bilateral testicular tumors in children have been reported to date. To our knowledge, we report the first case of an asynchronous bilateral simple testicular cyst and testicular teratoma in an infant. This case demonstrates that although both lesions are benign in the prepubertal child, treatment decisions should be made carefully.

Growth monitoring: testing the new guidelines

OBJECTIVETo assess the impact of recent guidelines from the UK joint working party of child health surveillance recommending that all children be measured at age 5 and again between 7...

Evaluation of vaginal bleeding in the preadolescent child.

Vaginal bleeding in a prepubertal child is always a serious medical concern. Vaginal bleeding in this age group may result from estrogen stimulation, which is more likely to be pathological than physiological, infections, tumors of the lower genital tract, ovarian tumors, foreign bodies, or trauma. Evaluation and management of the prepubertal child requires an understanding of the techniques of the physical examination, comprehension of the normal prepubertal unestrogenized anatomy, and indications for a more comprehensive examination under anesthesia. Caution should be exercised by the clinician so that the physical examination and workup do not further traumatize the child.

Malnutrition in children with cystic fibrosis: the energy-balance equation.

Malnutrition in children with cystic fibrosis: the energy-balance equation.

Diagnosis of Chlamydial Infection in the Pediatric Population

The genus Chlamydia now contains 4 species, 2 of which, Chlamydia trachomatis and C. pneumoniae are important human pathogens. Both organisms cause infections in children and adults, but infection in children pose a unique set of problems. As C. trachomatis is primarily a sexually transmitted disease, the presence of rectal or genital infection in a prepubertal child has been used as evidence of sexual abuse. Although there are several categories of non-culture tests the have been approved for genital sites in adults, these tests are not approved for these sites in children. Of these tests in rectal and vaginal specimens in children have been associated with a high rate of false positives. C. pneumoniae is emerging as a frequent cause of community acquired pneumonia in adults and children. Because culture is not generally available, serologic diagnosis is used more frequently. However, currently available serologic methods appear to be insensitive in children. The availability of a commercial PCR test will greatly facilitate the diagnosis of C. pneumoniae infections in children.

Cutaneous Malignant Melanoma in Children and Adolescents in Scotland, 1979-1991

All cases of cutaneous malignant melanoma in Scotland have been registered by the Scottish Melanoma Group since 1979, and there are currently more than 4700 cases on the registry. Of these, only 50 cases are in patients 18 years of age and younger (1.04 percent of all melanomas); 15 of these were prepubertal, i.e., 14 years or younger (0.3 percent of all melanomas). The nine cases of documented metastases occurred in children with tumor thickness of 1.50 mm or more, with only one of these metastases occurring in a prepubertal child. Eight of these patients with metastatic disease died, with a maximum survival of 4 years. A reliable clinical history was obtained from the families of 23 patients. Eight of them had a history of preexisting congenital nevocellular nevus. In this series, no case arose in a large congenital nevocellular nevus. Histological review showed that the majority of cases (58 percent) exhibited typical cytological and architectural features of malignant melanoma. In the remaining cases, the lesions were difficult to fit into any of the classic patterns of malignant melanoma or of the known benign nevocellular lesions.

Moderating effects of physical abuse and perceived social support on the potential to abuse

This study investigated the moderating effects of perceived prepubertal social support on the relationship between prepubertal childhood physical abuse and child abuse potential as well as on the relationship between a childhood history of abuse and conflict and depth in adult relationships. Three hundred and sixty-nine undergraduate men and women were classified as abused or nonabused based on their responses to the Childhood History Questionnaire. Multiple regression analyses revealed interactions of social support and a childhood history of physical abuse on both the potential to abuse and the quality of participants' relationships with their parents. Differences between abused and nonabused individuals were obtained only under conditions of low perceived social support. When social support was perceived to be high, abused and nonabused individuals did not differ in the potential to abuse or in the ratings of the depth of their relationships with parents. Implications of these findings for the intergenerational transmission of abuse are discussed.

Paediatric vulvovaginitis

Vulvovaginitis in the prepubertal child may present with itch, irritation, pain, dysuria or discharge as a result of poor hygiene, contact irritants, sexual abuse or skin disease involving the genital area. Common infectious causes include threadworms, group A beta-haemolytic streptococci and Haemophilus influenzae. A full history and examination are essential. Investigations may include swabs, midstream urine, biopsy, ultrasound and examination under anaesthesia.

Growth at puberty: interaction of androgens and growth hormone

Puberty is characterized by the onset and continued development of secondary sexual characteristics and an abrupt onset of linear growth. Growth in boys occurs due to the rising levels of androgens and also indirectly mediated by growth hormone (GH) and the insulin-like growth factors. Data are presented to show marked androgen-dependence of GH increases at puberty. The mode of this increase is through an augmentation in the amplitude of the pulses rather than in their frequency. Shortly after the maximal rate of growth, the pattern of GH release reverts toward that of the prepubertal child. To investigate the neuroendocrine mechanism through which androgens increase the mean circulating GH level, deconvolutional analysis has been applied. At mid-puberty the maximal rate of GH release per secretory burst and the total amount released per burst were increased. There were no significant alterations in the duration or frequency of the GH secretory burst or in the serum half-life reflecting the metabolic clearance of the hormone. Thus, the pubertal growth spurt in boys is likely subserved by the altered neurosecretory dynamics for GH. These altered hormone levels likely produce the equally profound changes in body composition, regional fat distribution, and muscular strength that occur during puberty in boys.

MR imaging diagnosis of central precocious puberty: importance of changes in the shape and size of the pituitary gland.

Central precocious puberty occurs as a result of premature pituitary stimulation and increased secretion of gonadotropins. The aims of this study were to analyze MR imaging findings in the pituitary glands of children with central precocious puberty compared with matched control subjects, to define MR imaging-derived variables useful in the diagnosis of central precocious puberty, and to correlate MR imaging-derived variables with the hormonal profile and other imaging and clinical findings. Twenty-six children with central precocious puberty (two boys and 24 girls) were divided into two subgroups according to MR imaging findings: idiopathic (21 patients) and nonidiopathic (five patients: three hypothalamic hamartomas, one pineal tumor, one empty sella syndrome). The control group consisted of 17 normal age- and sex-matched children (two boys, 15 girls). Analyzed parameters included pituitary height, length, width, midsagittal cross-sectional area, calculated volume, and shape. The shape was assessed by a pituitary grading system and two other shape indexes (length-to-height and length-to-width ratios). Pituitary grade was defined by the concavity of the upper pituitary surface (grade 1 = marked concavity, grade 2 = mild concavity, grade 3 = flat, grade 4 = mild convexity, grade 5 = marked convexity). Pituitary grade showed a highly significant difference among groups (p < .001). Area, height, and length-to-height ratio were significantly different (p < .05), whereas length, width, length-to-width ratio, and volume were not. There was no significant difference in any of the variables compared between idiopathic and nonidiopathic groups. When selected variables (pituitary grade, area, height, length) in the central precocious puberty group were stratified by bone age and findings on pelvic sonograms, patients with advanced bone age had a significantly higher pituitary grade (p < .01) and had a tendency toward a greater pituitary length. Pituitary size and shape correlated with the hormonal profile. Change in pituitary grade is the most helpful variable for the diagnosis of central precocious puberty in a prepubertal child. A high pituitary grade (4 or above) is highly predictive of central precocious puberty, with the highest specificity and positive predictive value, but with low sensitivity. The use of combinations of high pituitary grade with two other positive findings (height and area greater than 1 SD from the respective means in the control group) improves the sensitivity, specificity, and predictive value of MR imaging in the diagnosis of central precocious puberty.

Book Reviews

Books reviewed in this article: Childhood Onset Anorexia Nervosa and Related Eating Disorders. Edited by B. Lask and R. Bryant‐Waugh. Drawings from a Dying Child, Insights into Death Groan a Jungian Perspective. By Judi Bertoia. Seminars in Child and Adolescent Psychiatry. Edited by D. Black &amp; D. Cottrell. The Student With a Genetic Disorder: Educational Implications for Special Education Teachers and for Physical Therapists, Occupational Therapists, and Speech Pathologists. Edited by D. Plumridge, R. Bennett, N. Dinno and C. Branson. Effects of Psychotherapy With Children and Adolescents. By J. R. Weisz and B. Weiss. Emotional and Psychological Abuse of Children. By Kieran O'Hagan. A Practical Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. By A. P. Giardino, M. A. Finkel, E. R. Giardino, T. Seidl and S. Ludwig. Young Children's Understanding of Pretense. By Paul L. Harris and Robert D. Kavanaugh. AIDS: The Hidden Agenda in Child Sexual Abuse. By C Bennetts, M. Brown and J. Sloan. Attentional Deficit Disorder in Children and Adolescents. By J. L. Faddy and V. N. Hosler. Group Counseling &amp; Psychotherapy with Adolescents. By B. W. MacLennan and K, R. Dies. Enhancing Children's Communication: Research Foundations for Intervention. Edited by A. P. Kaiser &amp; D. B. Gray. Extending Families: The Social Networks of Parents and Their Families. By M. Cochran, M. Larner, D. Riley, L. Gunnarson and C. R. Henderson, Jr. Children of Drug Abusers. By Stephen J. Levy and Eileen Rutter. Adolescent Sexuality. Edited by T. P. Gullotta, G, R. Adams and R. Montemayor.

The role of cutaneous afferent during tendon vibration stimulus between the biceps and triceps muscles

Autonomic dysreflexia (AD) is a well-established association of high spinal cord injury (SCI), particularly in those occurring above T6. When a noxious stimulus is encountered, the body responds by stimulating an increase in blood pressure, which is then countered by vasodilation. In patients with autonomic dysreflexia, the patient is unable to vasodilate below the level of spinal injury due to interruption of the autonomic innervation below the injury. This then leads to persistently elevated blood pressure causing uncoordinated autonomic responses such as headache, flushing, sweating, and even hypertensive crisis. The noxious stimulus most commonly reported is bladder or bowel distention [1]. This potential trigger is especially important since many patients with SCI require catheterization and repeated urodynamic testing, both of which predispose them to bladder distention.In response to an incident during which a patient developed severe hypertension during UDS, institutional concern was raised about the potential risk of AD in other patients with SCI ≥ T8 and other severe neurological disease undergoing urodynamic testing, and a protocol was initiated in 2007 for monitoring for AD during UDS. Although no long-term complication was encountered in this incident, the need for improvement in our understanding of the detection and treatment of AD during urodynamic testing was highlighted. However, due to the potential of UDS to trigger AD and possible subsequent severe cardiovascular crisis, a protocol was established at our institution. Because of reports documenting episodes of AD for patients with severe, non-SCI neurologic disease and the unknown risk, these patients also were historically monitored at our institution as well.Autonomic dysreflexia (AD) is an uncoordinated autonomic response seen in patients with spinal cord injury (SCI). AD is often triggered by bladder distention, which may occur during urodynamic studies (UDS), and has potentially life-threatening consequences. Our purpose is to determine the prevalence and associated factors of AD in children undergoing UDS with either SCI or other neurological disease.We identified 13 pediatric patients with SCI at the eighth thoracic vertebrae or above (SCI ≥ T8) or other severe neurological disorder with urodynamic evaluations between 2007 and 2011 at our institution. We retrospectively reviewed these patients for age, gender, bladder volume, bladder compliance, detrusor instability, symptoms of AD, blood pressure, and urinary infection.There were a total of 13 patients with SCI ≥ T8 (9), transverse myelitis (2), and encephalomyelitis (2). There were a total of 41 urodynamic studies with an average of 3.2 studies per patient. One adolescent with C1/2 injury and a prepubertal child with T2/3 injury developed AD. AD was not observed in non-SCI patients. The patients who developed AD had multiple subsequent episodes with follow up UDS. No statistical associations were found for the variables evaluated. No major complications occurred, and AD was successfully managed conservatively.With appropriate monitoring and education, AD is easily recognized and managed conservatively. We found an increased risk of patients developing subsequent AD episodes after an initial episode. Patients who did not have autonomic dysreflexia during initial UDS did not experience autonomic dysreflexia on subsequent UDS. We did not observe autonomic dysreflexia occurring in children with transverse myelitis or encephalomyelitis.

Monitoring the heights of prepubertal children.

If the height of a prepubertal child is measured at one time and again a year later, any decision about the child's growth should be based on the distributions of the later height and height velocity conditional on the value of the initial height. The standard charts for height and height velocity derived by Tanner, Whitehouse and Takaishi (TWT) (1966) can be used in this context provided a correction is subsequently made, either by calculation or by reference to a suitable table. Moreover, the data provided by TWT, on which the charts are based, can be used to show that, over a certain age-range, the correlation between successive 12-month heights of a child is greater than 0.9 and approaches 1 with increasing age. On the other hand, the correlation between the height at any age and the velocity over the ensuing 12 months is low, while the correlation between two successive 12-month velocities is so low as to make it reasonable to treat them as independent. One phenomenon that has been much observed is that a child who grows along the third centile for height seems to grow along the 25th-30th centile for velocity. This effect follows when a conditional velocity is plotted onto a chart giving the distribution of an unconditional velocity. There is, moreover, a slight regression back to the population mean from any age to the next; this has little effect on the mean height but a noticeable effect on the mean velocity.

Relationship between MMPI and penile plethysmograph in accused child molesters

We investigated the relationship between the MMPI and penile plethysmograph in a sample of 90 alleged child molesters. Men who had been accused of molesting a prepubertal child were divided into two groups on the basis of penile plethysmograph results (Deviant and Non‐Deviant Profiles). The MMPI scales were used to predict group membership using discriminant function analysis. The results revealed that the MMPI scores were statistically related to the penile plethysmographic profiles. However, MMPI code types were equally distributed across groups, and no single profile could be described as characteristic of men who exhibited pedophilic arousal using the penile plethysmograph results. Approximately one third of men were misclassified on the basis of MMPI scores alone. Our results extend previous findings showing that accused child molesters constitute a heterogeneous group.

EFFECT OF A CONTINUOUS INFUSION OF A SOMATOSTATIN ANALOGUE ON GROWTH RATE, GROWTH HORMONE SECRETION AND HEIGHT PREDICTION IN TALL CHILDREN

We studied the effects of reducing growth hormone (GH) secretion on the growth rate and change in height prediction of 9 tall children (5 F;4M). All children had height predictions of 180cms or more and received a continuous infusion of a somatostatin analogue (Octreotide) (SMS) in a dose of between 50 and 100 micrograms given over a 12 hour period for 1 year. SMS infusion significantly reducted mean 24 hr GH concentrations after 7 days of administration (mean GH pre SMS 5.3 mU/I; mean GH at 1 week 2.2 mU/I). This reduction was maintained over the year of treatment (p < 0.01). SMS treatment increased the percentage of time during the 24 hr period at which serum GH concentrations were lower than the sensitivity of the assay (mean increment over 1 year 27%). Serum insulin like growth factor 1 concentrations remained unchanged during the course of treatment. Growth rate over the year of treatment was reduced by between 30 and 40%. A significant reduction in height prediction of 4cms resulted from SMS treatment for one year (P=0.03). No adverse effect on thyroid status or parameters of glucose metabolism were observed. These data suggest that SMS treatment may play an important role in reducing growth rate, height prediction and ultimately final height in children with tall stature. The specific effect of SMS on the GH axis suggest that this treatment may be of value in the prepubertal tall child.