SOP for Lab Follow-up in HH Clinic

Screening recommendations from Barlow, “Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity: Summary Report” Pediatrics: 2007; 120; S164.

25-Hydroxy Vitamin D: For children age 9-18 years (Adapted from 2011 Endocrine Society CPG)

  1. <20 = Deficient 
  2. Replete with 2000 IU daily for 6 weeks or 50,000 IU weekly for 6 weeks + Simultaneous daily supplement: Oscal – 1 tab BID = total of 800 IU daily + 1.2g calcium
  3. Continue maintenance therapy with Oscal – 1 tab BID (400 IU Vit D + 600mg Ca)
  4. Repeat 25 OH vitamin D level 3 months from original labs
  5. If still <30, repeat repletion cycle above until follow up 25 OH D is >30ng/Dl
  6. 20-30mg/dL = insufficient
  7. Initiate daily supplement with Oscal – 1 tab BID = total of 800 IU daily + 1.2g calcium
  8. Repeat 25 OH vitamin D level 3 months from original labs
  9. If still <30, consider adding more vit D only (without increasing Calcium)
  10. >30 = sufficient
  11. No intervention

Liver Associated Enzymes

  1. AST or ALT elevated, but <200 (and Bilirubin normal)
  2. Counsel that patient likely has NAFLD
  3. First intervention is 6 months of HH and goal of 10% weight loss
  4. Repeat in 6 months, if not normal refer to GI
  5. AST or ALT >200
  6. referral to GI

Free and Total testosterone(WRNMMC pediatric endocrine department consensus)

  1. Free testosterone > upper limit of normal in CHCS / AHLTA and NO clinical concern for PCOS
  2. Medical follow up in 6 months with clinical assessment for PCOS symptoms and repeat Free / Total Testosterone and LH/FSH.
  3. Free testosterone > upper limit of normal in CHCS / AHLTA and any clinical concern for PCOS
  4. Refer to endocrinology
  5. If total Testosterone >200, call and refer to endocrine

FSH

  1. If >20 and menstrual irregularity, refer to endocrine.
  2. If 10-20 and you have clinical concern for ovarian failure, refer to endocrine

LH

  1. Can be variable throughout menstrual cycle, if FSH and testosterone panel are normal, no specific action required for high levels.

HbA1c (WRNMMC pediatric endocrine department consensus)

  1. If >5.7, continue HH clinic with goal wt loss of 10%
  2. Repeat HbA1c in 6 mo (add to written summary plan)
  3. If still >5.7, refer to endocrine
  4. If >6.0 order 75g 2 hour OGTT and refer to endocrine

Fasting Glucose(adapted from Standards of Medical Care in Diabetes - 2011; ADA Position Statement)

  1. FBG >100
  2. Counsel patient that they meet criteria for impaired fasting glucose and are high risk for type 2 diabetes.
  3. First intervention is weight loss which should be tried for 6 months with goal of 10% weight reduction.
  4. Repeat fasting glucose in 6 months  if still >100, refer to endocrinology for OGTT
  5. FBG >126
  6. Counsel patient that they may have diabetes, but will need further testing to confirm
  7. Refer to endocrinology for OGTT

Lipids: Adapted from Daniels and Greer, “ Lipid Screening and Cardiovascular Health in Childhood.” Pediatrics: 2008; 122: 192-208.

  1. If LDL <110, no targeted intervention  continue HH
  2. If LDL >110, start CHILD Diet (discuss nutrition referral and provide handout)
  3. Repeat Lipid panel in 6 months (add to written summary)
  4. If LDL >200, start diet and refer to endocrine for consideration of additional testing and medication
  5. If patient carries diagnosis of Diabetes Mellitus (type 1 or 2), refer to more conservative lipid goals listed in table below.

Reference tables:

Urine Microalbumin : Creatinine ratio

  1. If <30
  2. No intervention.
  3. If >30
  4. Counsel that there is evidence that weight may already be affecting kidneys.
  5. If already have diagnosis of diabetes, refer to Nephrology for initiation of ACEi.
  6. If already on ACEi, refer back to prescribing provider for further management.
  7. Continue HH clinic with goal of 10% weight loss.
  8. Repeat Urine microalbumin : Cr ratio in 6 mo.
  9. If still >30, refer to Nephrology.

TSH and FT4(WRNMMC pediatric endocrinology department consensus)

  1. If TSH >10
  2. Refer to endocrine
  3. If TSH above upper limit of normal for assay in CHCS / AHLTA (but <10)
  4. Repeat labs in 1 month (in conjunction with 1st follow up is fine, non-fasting) with anti TPO and anti TG antibodies.
  5. If TSH persistently elevated or anti-TPO/TG antibodies positive, refer to endocrine for counseling and consideration of treatment.
  6. General counseling – hypothyroidism does not cause obesity, but obesity can cause mild abnormalities in thyroid function tests that usually normalize with weight loss.