Child Health Needs and the Pediatric Endocrinology Workforce: 2020-2040.

The pediatric endocrinology (PE) workforce in the United States is struggling to sustain an adequate, let alone optimal, workforce capacity. This article, one of a series of articles in a supplement to Pediatrics, focuses on the pediatric subspecialty workforce and furthers previous evaluations of the US PE workforce to model the current and future clinical PE workforce and its geographic distribution. The article first discusses the children presenting to PE care teams, reviews the current state of the PE subspecialty workforce, and presents projected headcount and clinical workforce equivalents at the national, census region, and census division level on the basis of a subspecialty workforce supply model through 2040. It concludes by discussing the educational and training, clinical practice, policy, and future workforce research implications of the data presented. Data presented in this article are available from the American Board of Pediatrics, the National Resident Matching Program, and the subspecialty workforce supply model. Aging, part-time appointments, and unbalanced geographic distribution of providers diminish the PE workforce capacity. In addition, limited exposure, financial concerns, and lifestyle perceptions may impact trainees. Additional workforce challenges are the subspecialty's increasingly complex cases and breadth of conditions treated, reliance on international medical graduates to fill fellowship slots, and high relative proportion of research careers. The recent limitations on pediatric endocrinologists providing gender-affirming care may also impact the geographic distribution of the subspecialty's workforce. Deliberate actions need to be taken now to continue serving the needs of children.

Effect of conjugated linoleic acid on body fat accretion in overweight or obese children.

BACKGROUND: Conjugated linoleic acid (CLA) is a supplemental dietary fatty acid that decreases fat mass accretion in young animals. OBJECTIVE: The aim of this study was to determine CLA's efficacy with regard to change in fat and body mass index (BMI; in kg/m(2)) in children. DESIGN: We conducted a 7 +/- 0.5-mo randomized, double-blind, placebo-controlled trial of CLA in 62 prepubertal children aged 6-10 y who were overweight or obese but otherwise healthy. The subjects were randomly assigned to receive 3 g/d of 80% CLA (50:50 cis-9,trans-11 and trans-10,cis-12 isomers) or placebo in chocolate milk. RESULTS: Fifty-three subjects completed the trial (n = 28 in the CLA group, n = 25 in the placebo group). CLA attenuated the increase in BMI (0.5 +/- 0.8) compared with placebo (1.1 +/- 1.1) (P = 0.05). The percentage change in body fat measured by dual-energy X-ray absorptiometry was smaller (P = 0.001) in the CLA group (-0.5 +/- 2.1%) than in the placebo group (1.3 +/- 1.8%). The change in abdominal body fat as a percentage of total body weight was smaller (P = 0.02) in the CLA group (-0.09 +/- 0.9%) than in the placebo group (0.43 +/- 0.6%). There were no significant changes in plasma glucose, insulin, or LDL cholesterol between groups. Plasma HDL cholesterol decreased significantly more (P = 0.05) in the CLA group (-5.1 +/- 7.3 mg/dL) than in the placebo group (-0.7 +/- 8 mg/dL). Bone mineral accretion was lower (P = 0.04) in the CLA group (0.05 +/- 0.03 kg) than in the placebo group (0.07 +/- 0.03 kg). Reported gastrointestinal symptoms did not differ significantly between groups. CONCLUSIONS: CLA supplementation for 7 +/- 0.5 mo decreased body fatness in 6-10-y-old children who were overweight or obese but did not improve plasma lipids or glucose and decreased HDL more than in the placebo group. Long-term investigation of the safety and efficacy of CLA supplementation in children is recommended.

Effects of inhaled steroids on growth, bone metabolism, and adrenal function.

For children who have persistent asthma of any degree, ICS treatment is recommended. Although topical airway corticosteroid therapy has improved the control of asthma markedly while lessening the risk of corticosteroid side effects, the use of ICS continues to be accompanied by a fear of potential adverse systemic effects. Unfortunately, these fears result in some children being deprived of appropriate and effective treatment or even exposed to a greater risk of periodic oral corticosteroid treatment. Nevertheless, because these agents may be used for long periods of time in a large number of children, safety issues are paramount. Important overall conclusions seem well supported by the literature. First, ICS used in small doses present no significant risk for systemic side effects. When ICS are used at higher dosages and continuously for long periods of time, important differences in drug characteristics, in particular the efficiency of inactivation of swallowed drug (which does not exert a therapeutic effect prior to gaining access to the systemic circulation), affect the ratio of therapeutic to systemic effect of individual ICS. From a practical viewpoint, the long-term clinical history of ICS therapy is informative. Clinically significant suppression of the HPA axis resulting from ICS therapy alone is rare. Detectable suppression of childhood growth can occur when ICS with relatively poor first-pass inactivation are administered at doses greater than or equal to 400 microg per day; this effect on 1-year growth is reduced when clinically equivalent doses of ICS with improved first-pass inactivation of swallowed drug are used. Administration of ICS alone, however, is not associated with any detectable effects on final adult height. Harmful effects of ICS on bone metabolism, although not yet studied adequately, are not expected with the use of an ICS dosage that does not suppress basal HPA axis function or childhood growth. An important caveat to these conclusions is that they refer to the use of ICS used alone and in recommended doses, not in combination with intranasal or other topical corticosteroids. Differences in safety profiles among the available ICS exist, but there are few direct comparative studies attempting to establish rank in benefit-to-risk ratios. The safety profile of all ICS preparations, which focus anti-inflammatory effects on the lung, is markedly better than that of oral glucocorticoids. Risk of adverse effects is minimized by using the lowest effective dosage, by limiting systemic availability of the drug through careful selection of the inhalation device and proper technique, by the adjunct use of alternative anti-inflammatory agents, and, when higher doses are required, by choice of ICS medication. Monitoring growth in children is a sensitive method of detecting significant ICS systemic effects and can enhance a family's confidence in the safety of the medication. When long-term, high-dose therapy is required, periodic evaluations of adrenal function and bone density may be advisable. ICS are highly effective and, because their benefits clearly exceed potential risks, can be used safely in children who have persistent asthma.

Inhaled corticosteroids: past lessons and future issues.

Inhaled corticosteroids play a pivotal role in the treatment of asthma. Inhalation permits effective delivery of the corticosteroid in high concentration to target sites within the lung while minimizing systemic exposure. Consequently, the safety profile of inhaled corticosteroids is markedly better than that of oral corticosteroid therapy. However, although it was first thought that direct delivery might eliminate systemic adverse effects, this has not been confirmed by clinical trials and experience. Inhaled corticosteroids are absorbed from the lungs into the systemic circulation, in which they can acutely decrease growth velocity in children, an effect that fortunately appears to be temporary and might have no effect on final adult height. In sufficient dosages, they also produce bone mineral loss leading to osteoporosis and might increase the risk of cataracts, glaucoma, skin atrophy, and vascular changes that increase the risk of ecchymoses. Effective evaluation of the severity and significance of these complications is challenging because highly sensitive tests do not reliably predict clinically significant events, and short-term observations do not predict long-term consequences. Also, compliance wanes with long-term treatment, and susceptibility to a particular adverse event can vary over time, even in the same individual, because of developmental or hormonal changes. This journal supplement will review what has been learned about the safety of inhaled cortico-steroids during the past decade, discussing some of the questions that remain and considering the characteristics of an "ideal" inhaled corticosteroid: one with high local activity in the lung and minimal or no adverse systemic effects.