Only in Scandinavia! A study by Jerker et al. (doi:10.1542/peds.2014-2561) brings us follow-ups to ten years of age from the prenatal period in a racially, socially, economically and ethnically homogenous population with near 100% subject retention. The authors appear to have nailed down a primary etiologic biomarker and in turn mechanism of the much discussed but less well understood “toxic stress” response (Garner AS, Shonkoff JP. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatr. 2012;129:e224-3)—using hair cortisol levels.
High-sensitivity C-reactive protein (hs-CRP) has become an oft used measure of cumulative inflammation and cardiovascular risk in the world of internal medicine (Koenig W. High-sensitivity C-reactive protein and atherosclerotic disease: from improved risk prediction to risk-guided therapy. Int J Cardiol. 2013;168:5126-34, and others).Will hair cortisol become our all-encompassing pediatric counterpart to hs-CRP? As a “novel biomarker,” hair cortisol appears to measure prolonged or frequent activation of the HPA (hypothalamic pituitary axis) and thus can serve as a proxy for accumulated stress over time. Its correlation with a scaled measure of psychosocial vulnerability is intriguing. You may agree or disagree with the authors’ composite of 11 Likert scaled items that are used to measure psychosocial risk, but the impact of this well done study is difficult to disregard.
Where to from here? For primary care physicians, serving children from diverse backgrounds, none of us can afford to be skeptical about the potential impact of psychosocial adversity on our patients, and on their long term mental and physical health. While we won’t likely be measuring hair cortisol at one year of age in the near future, we need to consider a more focused approach to antecedents of health. Some might counter that pediatric clinicians do not want to always have to take on the role of social worker as well, and spend precious well care visit minutes delving into the family’s personal life. I respectfully and vociferously disagree with you. The 11 elements of psychosocial vulnerability and risk measured in this study are hardly obscure or excessively personal questions- if we don’t know the answers, honestly, we don’t know our families; and if you don’t know the family in front of you, how in the world are you planning to help the child, your patient? This terrific article opens up a world of possibility for each of us in our everyday practice- please read it and consider if you now see your practice with new eyes.
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