Choosing Wisely: Limit Endocrine Tests in Kids, AAP Says

Ricki Lewis, PhD

October 05, 2017

The American Academy of Pediatrics (AAP) Section on Endocrinology has added five tests commonly ordered for children and teens showing signs of early puberty, short height, or other hormone-related concerns to the 15 tests already making up their Choosing Wisely campaign.

The lists aim to alert parents and physicians to discuss tests that might be overused, especially among otherwise healthy individuals.

Past Choosing Wisely recommendations have included perinatal issues, the inappropriateness of prescribing antibiotics for viral respiratory illnesses in children, and not to order computed tomography or magnetic resonance imaging scans for simple febrile seizures.

Choosing Wisely is an initiative of the ABIM Foundation, in conjunction with Consumer Reports. The complete list and the five new entries are both available on the Choosing Wisely website.

The five endocrine-inspired tests may expose otherwise healthy children to unnecessary risks for few benefits, said Paul Kaplowitz, MD, PhD, a pediatric endocrinologist at Children's National Health System, Washington, DC, and past chairperson of the AAP Section on Endocrinology. Dr Kaplowitz headed the effort to compile the new entries.

Many pediatric specialties are currently working on Choosing Wisely lists, Dr Kaplowitz told Medscape Medical News, but endocrinologists have been particularly concerned about overtesting. "Parents and pediatricians need to be more aware that short children who are healthy and growing at a normal rate at the low end of the curve rarely benefit from the extensive testing that is often done," he explained.

Endocrine disorders are not on the rise, Dr Kaplowitz said. "There is no increase in the frequency of children who have some signs of early puberty. However, we encourage pediatricians in most cases not to order a large number of tests before the child is seen by a specialist, so we can focus on the testing that is truly helpful," he added.

The "Five Things Physicians and Patients Should Question" are:

  1. Tests for luteinizing hormone and follicle-stimulating hormone and estradiol or testosterone for children with pubic or axillary hair and/or underarm odor, but no other signs of puberty, such as rapid growth or breast development.

  2. Screening tests to detect chronic disease or endocrine disorders in healthy children growing at or above the third percentile with a normal growth rate and weight gain. Tests to specifically question are complete blood count, comprehensive metabolic panel, insulin-like growth factor-1, thyroid, and celiac antibody tests. Such tests reveal underlying conditions in only about 1% of cases. Tiered or sequential further testing may, however, be indicated for children with significantly short stature.

  3. Routine vitamin D screening in otherwise healthy children, including those who are overweight or obese. Only test "patients with disorders associated with low bone mass such as rickets and/or a history of recurrent, low-trauma fractures," the authors write. Children who are obese and do not receive sufficient vitamin D from the diet should take supplements. Variability in vitamin D assays and inconsistent cutoffs for deficiency may lead to overdiagnosis.

  4. Thyroid function and/or insulin level tests in children with obesity. Thyroid hormone testing should be confined to children whose stature and/or height velocity is decreased relative to the stage of puberty, because slight thyroid-stimulating hormone elevation rarely reflects true hypothyroidism. Insulin levels in healthy, but obese, children should not be measured because the results do not alter treatment.

  5. Routine thyroid ultrasounds in children who have simple goiters or autoimmune thyroiditis. Reserve these scans for children who have very large thyroids, unilateral swelling, or palpable nodules. Ultrasound scans may reveal small but harmless nodules, are stressful for parents, and are costly. Instead, physicians should assess the thyroid at the annual exam for children at increased risk for thyroid cancer and follow up with ultrasound if indicated.

Dr Kaplowitz describes situations that do warrant testing as "when the child is significantly below the 3rd percentile in height and/or is falling further below the curve over time. For puberty, the red flags that justify early testing are progressive breast enlargement with rapid growth in a girl under 8 years old or genital enlargement with rapid growth in a boy who is less than 9 years old."

He added that ordering thyroid tests and insulin levels is appropriate for a child being referred to a specialist.

"This new Choosing Wisely list will enhance discussions physicians and families have about issues in growth and development that often come up, and help craft the best treatment plans," Dr Kaplowitz concluded.

Dr Kaplowitz has disclosed no relevant financial relationships.

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