Placebo-controlled, double-blind, cross-over trial of growth hormone treatment in prepubertal children with chronic renal failure

Stunted growth is a serious problem for children with chronic renal failure (CRF) despite normal endogenous growth hormone secretion and normal or elevated plasma concentrations of insulin-like growth factors (IGF) I and II. Biosynthetic growth hormone (GH) was given to 20 prepubertal children (eleven boys, nine girls; mean age 9.5 years, range 4-16) with CRF and severe growth retardation in a placebo-controlled, double-blind, cross-over trial. 6 months of subcutaneous injection of GH (4 IU/m2 per day) was either preceded or followed by 6 months of placebo injection. The patients had a full examination every 3 months. Sixteen children completed the study. Height velocity improved significantly with GH therapy (p less than 0.0001) and placebo (p less than 0.04), but the GH-induced height-velocity increase exceeded that of placebo by 2.9 cm per 6 months. There was a positive relationship between prestudy height velocity and height-velocity increase. Bone maturation was not affected. GH caused a significant increase in IGF-I and a moderate increase in IGF-II plasma concentrations. The pretreatment elevation of IGF-binding protein-1 decreased by almost 50% during GH therapy, while IGF-binding protein-3 increased significantly in concentration, although this increase was significantly smaller than the GH-induced increase in IGF-I. Fructosamine, lipid, and parathyroid concentrations remained constant. Renal function deterioration did not accelerate. Impressive height-velocity increase can be achieved with GH therapy in children with CRF and growth retardation without changes in renal function. Bone maturation appears unaffected suggesting improved final height. Treatment is best started before growth retardation becomes considerable.

Immunologic studies in Turner syndrome before and during treatment with growth hormone. The Dutch Growth Hormone Working Group

Immunologic studies of 14 girls with Turner syndrome were done before and during treatment with biosynthetic growth hormone (GH). Compared with control subjects, the patients before treatment had a decreased CD4/CD8 ratio and an increased number of cells bearing the natural killer cell marker CD16; serum immunoglobulin levels were within the normal range. During GH treatment some of the girls had a slight reduction in the percentage of CD20+ B cells, but we observed no impairment of B lymphocyte function as demonstrated by the normal in vivo antibody response to the primary antigen Helix Pomatia hemocyanin, administered 6 months after the start of GH treatment. The number of CD16+ natural killer cells returned to normal. Although the number of children with thyroid antibodies increased from two before treatment to five after 1 year, no conclusion about an adverse effect of GH is warranted, because the phenomenon might be part of the natural course of the disease. We conclude that girls with Turner syndrome have minor changes in some immunologic measurements and that GH treatment resulted in some alterations that have no effect on immune function.

Testosterone esters advance skeletal maturation more than growth in short boys with chronic renal failure and delayed puberty

Four young males with chronic renal failure and absent or stagnant puberty were treated with testosterone esters. Endocrine evaluation before therapy showed low plasma follicle stimulating hormone (FSH) levels and relatively high luteinizing hormone (LH). Following therapy skeletal maturation accelerated more than growth velocity, resulting in a lower predicted adult height. In three patients osteoporosis increased or rickets developed. Testosterone therapy was effective in developing sex characteristics, but endogenous pubertal development was not stimulated. Growth velocity was increased, but the effect on growth was more than outweighed by bone age acceleration.

Plasma lipids and apoproteins, body fat distribution and body fatness in early pubertal children

Besides body fatness, the body fat distribution is associated with coronary risk in adults, but little has been reported on this aspect in children. This study describes body fatness, body fat distribution (waist-to-hip ratio, WHR) and the plasma lipid and apoprotein profile (TC, HDL-C, LDL-C, TG, apo A-I and apo B) in 60 boys (age 10.8 +/- 0.1 year; mean +/- s.e.m.) and 64 girls (age 10.2 +/- 0.1 year), all caucasian. To avoid interference by the large changes in plasma sex hormone levels during puberty, only pre- and early pubertal children (Tanner stages of genital c.q. breast development 1 or 2) participated. Physical and sports activity was scored in hours per week using a questionnaire. The boys were taller than the girls (146.2 +/- 0.7 vs 143.2 +/- 0.9 cm; ANOVA, P less than or equal to 0.05) and their WHR was larger (0.88 +/- 0.01 vs 0.83 +/- 0.01; ANOVA, P less than or equal to 0.05). The boys spent 8.0 +/- 0.4 hours weekly on physical and sports activities, the girls 5.5 +/- 0.3 (ANOVA, P less than or equal to 0.05). The plasma lipid and apoprotein profiles were similar in both groups. Body fatness was significantly associated with the lipid and apoprotein profile, although in different ways in boys and girls. In boys there was a relationship with TG (r = 0.49), with apo B (r = 0.33) and with the apo A-I to apo B ratio (r = -0.24); in girls with TG (r = 0.25), HDL-C (r = -0.39), apo A-I (r = -0.28) and with the HDL-C to TC ratio (r = -0.31); P less than 0.05 for all correlations. A regional component of the subcutaneous fatmass, assessed by the partial correlations of the individual skinfold thicknesses with the plasma lipid and apoprotein profile after controlling for body fatness, was lacking in these early and prepubertal children. The WHR was associated with TC (r = 0.35), LDL-C (r = 0.32), apo B (r = 0.36) and with apo A-I/apo B (r = -0.34) in the girls after controlling for body fatness. Although closer investigation into the validity of the WHR as a measure of fat distribution in children is needed, the tentative conclusion is that in pre- and early pubertal girls the WHR has an impact on the plasma lipid and apoprotein profile similar to that seen in adults. It is suggested that in boys these relationships develop later in puberty.

Respiratory deterioration during growth hormone therapy in a case of congenital nemaline myopathy

Congenital nemaline myopathy (CNM) is generally classified as a non-progressive or slowly progressive neuromuscular disease. We describe a boy with CNM and an isolated partial growth hormone (GH) deficiency. From the onset of GH therapy his respiratory capacity deteriorated rapidly. The possible association between this deterioration and GH therapy is discussed.

Insulinomas in MEN-I patients: early detection and treatment of insulinomas in patients with the multiple endocrine neoplasia syndrome type-I

In the multiple endocrine neoplasia syndrome type I (MEN-I syndrome), periodic screening of patients and their close relatives may improve prognosis and life expectancy. Although there is diffuse involvement of the pancreas with microadenomatosis, insulinomas in the MEN-I syndrome usually occur as single tumours. This is illustrated here by two patients with insulinomas and the MEN-I syndrome. Preoperative localization of the tumours was achieved accurately by digital subtraction angiography combined with dynamic computerized tomography after a bolus injection of contrast medium. At present, two and three years after elective surgery both patients are asymptomatic. The early detection and treatment of insulinomas is extremely important because of the high risk of cerebral damage associated with late diagnosis. Periodic investigation of MEN-I family members can promote the early diagnosis and treatment of insulinomas, especially in young patients, whose life expectancy and quality of life may be improved.

Twenty-four-hour plasma growth hormone (GH) profiles, urinary GH excretion, and plasma insulin-like growth factor-I and -II levels in prepubertal children with chronic renal insufficiency and severe growth retardation

We studied 24-h plasma GH profiles, maximal GH responses to arginine provocation and insulin-like growth factor-I (IGF-I) and IGF-II levels in plasma in 22 euthyroid prepubertal children (mean age, 9.5 yr) with chronic renal insufficiency (glomerular filtration rate, less than 20 mL/min.1.73 m2) and severe growth retardation [mean (+/- SD) height SD score (SDS), -2.8 (1.1)]. The 24-h GH profiles were analyzed using the Pulsar program. Girls had significantly higher 24-h GH secretion than boys (P less than 0.004). Children with end-stage nephrotic syndrome had higher baseline GH levels and total area under the curve (AUCo) than patients with dysplastic kidneys (P less than 0.05), while the area under the curve above baseline (AUCb) was similar in all types of renal diseases. The type of treatment (conservative, peritoneal, hemodialysis) did not significantly influence the 24-h GH secretion. No correlation was found between 24-h GH profiles and age, height SDS for chronological age, height velocity SDS for bone age, and weight for height. Fourteen children showed a normal 24-h GH profile, defined as a GH profile with well defined, regular GH peaks returning to baseline GH levels and a distinct day and night pattern (AUCb, 90-300 micrograms/L.24 h). Four children had low profiles, with GH peaks below 10 micrograms/L, returning to baseline GH levels and occurring almost exclusively during the night (AUCb, less than 90 micrograms/L.24 h). The remaining four children had elevated 24-h GH profiles, with GH peaks on top of elevated baseline GH levels of more than 3 micrograms/L (AUCb, 35-205 micrograms/L.24 h; AUCo greater than 300 micrograms/L.24 h). In all patients 24-h urinary GH and beta 2-globulin excretion was 100-1000 times higher than that in controls. The urinary GH excretion correlated significantly with all characteristics of the 24-h GH profiles (r = 0.57-0.59; P less than 0.05). The maximal GH response during the arginine tolerance test was normal in 66% of the children. The mean (+/- SD) SDS for bone age for the IGF-I plasma levels was +1.1 (1.9), and that for IGF-II was +3.6 (3.4). IGF-I levels correlated significantly with the AUCb, maximum GH, and GH peak characteristics of the 24-h GH profiles (r = 0.05-0.73; P less than 0.02-0.001). IGF-II levels did not show any correlation with the characteristics of the endogenous GH secretion.(ABSTRACT TRUNCATED AT 400 WORDS)

Two-year results of treatment with methionyl human growth hormone in children with Turner syndrome. Dutch Growth Hormone Working Group

Methionyl growth hormone (somatrem) in a daily dosage of 4 IU/m2 body surface area was administered to 16 girls with Turner syndrome. Low dose ethinyl estradiol (0.1 microgram/kg body weight) was added in girls aged 13 years or more. Mean (SD) height velocity increased from 3.4 (0.9) to 7.2 (1.7) and 5.3 (1.3) cm/year in the first and second year, respectively. Bone age advanced 1.8 years over 2 years and predicted adult height was increased. Apart from the occurrence of anti-GH antibodies there were no side effects. In conclusion, somatrem is an efficacious and safe therapy for short stature in Turner syndrome over a period of 2 years. Longer follow-up is needed before conclusions about its effect on final height can be drawn.

Sexual precocity induced by ovarian follicular cysts. Is autoimmunity involved?

A 2-year-old girl presented with gonadotrophin-independent precocious puberty due to ovarian follicles. Central precocious puberty was excluded by several GnRH-tests and overnight LH sampling. There were no signs of McCune-Albright syndrome. An ovarian tumour was excluded by laparotomy and biopsies. Abdominal sonography demonstrated follicles occurring mostly in the left, sometimes in the right, ovary. Immunoglobulin G (IgG) purified from the patient's serum was capable of stimulating DNA synthesis in granulosa cells of rat ovarian segments kept in organ culture. Since FSH had a similar in-vitro action it is hypothesized that this patient's IgG mimics the action of FSH.

Premature thelarche: a possible adverse effect of cimetidine treatment

An 18-month-old girl is reported in whom marked unilateral breast enlargement occurred after 4 weeks of cimetidine therapy. After withdrawal of the drug the enlargement rapidly disappeared. This observation points to cimetidine as a possible cause of premature thelarche. Cimetidine, a selective H2 receptor blocking agent, is known to cause gynaecomastia in males. This effect seems related to elevated plasma oestrogens, gonadotropins, or to binding of the drug to androgen receptors. Ranitidine, a much more potent selective H2 receptor blocker, does not cause gynaecomastia and seems therefore preferable to cimetidine.

The offspring of mothers with anorexia nervosa: a high-risk group for undernutrition and stunting?

Seven children from three families presented with stunting and low weight-for-height. Their mothers had a history of anorexia nervosa (AN). Evidence was gathered that the children were nourished insufficiently, possibly in combination with psychosocial deprivation. Low growth hormone secretion was documented in three cases. With the increasing ability to induce fertility in anorectic women one should be aware of the effects of maternal AN on the offspring.

Effects of two years of methionyl growth hormone therapy in two dosage regimens in prepubertal children with short stature, subnormal growth rate, and normal growth hormone response to secretagogues. (Dutch Growth Hormone Working Group)

Thirty short, slowly growing children with normal plasma growth hormone response to standard provocation tests were randomly assigned to a group (n = 20) undergoing therapy with methionyl growth hormone, 2 IU/m2 subcutaneously once daily, (group 1) or a control group (n = 10, group 2). The mean (+/- SD) height velocity increment in group 1 was 3.0 +/- 1.9 cm/yr in the first year, compared with -0.2 +/- 0.7 cm/yr in group 2. Of the 18 children who completed the first year of treatment, 12 had a height velocity increment of more than 2 cm/yr and 11 of them continued treatment for a second year (group 1A). The remaining six children also reached height velocities greater than the mean for bone age, but because of a low height velocity increment they were termed nonresponders and their growth hormone dosage was increased to 4 IU/m2/day (group 1B). Of the 10 children in the control group, seven received authentic biosynthetic growth hormone in the second year of the study (group 2); the remaining three received no therapy (group 3). The mean height velocities (measured in centimeters per year) before and during the first and second years of therapy were 3.6, 7.6, and 6.1 in group 1A; 5.7, 6.9, and 7.3 in group 1B; 4.2, 4.0, and 6.7 in group 2; and 5.0, 4.9, and 5.2 in group 3. The effect of doubling the dosage was a further increase of 1.9 cm/yr. Bone age advance paralleled growth acceleration, resulting in an unchanged height standard deviation score for bone age and ambiguous results on final height prediction. Growth hormone therapy in such short children appears to be safe and efficacious in increasing growth velocity for 2 years, but its efficacy in terms of increasing final height is uncertain.

A controlled trial of methionyl growth hormone therapy in prepubertal children with short stature, subnormal growth rate and normal growth hormone response to secretagogues. Dutch Growth Hormone Working Group

Thirty short and slowly growing children with normal plasma growth hormone (GH) responses to standard provocation tests were randomly assigned to either a group (n = 20) undergoing treatment with methionyl GH (somatrem), 2 IU per m2 body surface s.c. daily, or a control group (n = 10). Twelve out of 18 children who completed the first year of treatment showed a height velocity increment of more than 2 cm/year. The mean (SD) growth velocity of the treatment group increased by 3.0 (1.9) cm/year over the first year, compared with -0.2 (0.7) cm/year in the control group. Neither parameters of endogenous GH secretion nor plasma IGF-I levels showed a significant correlation with the growth response. Of the auxological variables studied, pre-treatment growth velocity (r = -0.8) and the short-term height velocity increment (r = 0.7-0.9) showed significant correlations with the growth response in the first year of treatment. Somatrem therapy was without side effects, except in one child who developed anti-GH antibodies in combination with a poor growth response.

Gastric drip feeding in patients with glycogen storage disease type I: its effects on growth and plasma lipids and apolipoproteins

In 19 patients with a deficiency of glucose-6-phosphatase and 1 patient with a deficiency of glucose-6-phosphate translocase, the effect of nocturnal gastric drip feeding (GDF) on growth and plasma lipids and apolipoproteins was studied. The effect on growth was estimated by determining the height standard deviation score (SDS) of the patients and comparing its changes (delta SDS) over 4-, 2-, and 1-y periods before and 1-, 2-, 5-, and 8-y periods after the institution of GDF. The effect of GDF on plasma lipids and apolipoproteins was investigated by following the concentrations of triglycerides, cholesterol, and apolipoproteins A-I, A-II, B, C-I, C-II, C-III, and E. Growth caught up significantly or remained in the normal range in 14 patients. They were defined as responders to GDF. In the other six patients, growth caught up insufficiently or showed a further deceleration. They were defined as nonresponders to GDF. GDF had only a temporary and marginal effect on plasma lipids and apolipoproteins, but after 5-8 y, the levels of plasma triglycerides, cholesterol, apolipoprotein, B, C-I, C-II, C-III, and E increased further in both responders and nonresponders, whereas apolipoproteins A-I and A-II decreased in nonresponders. There were minor differences in the levels of lipids and apolipoproteins between responders and nonresponders without any discernible trends during the first years of GDF.(ABSTRACT TRUNCATED AT 250 WORDS)

Total deficiency of growth hormone and prolactin, and partial deficiency of thyroid stimulating hormone in two Dutch families: a new variant of hereditary pituitary deficiency

Four out of 10 children in two unrelated families presented with a total pituitary growth hormone (GH) and prolactin deficiency and a partial thyrotropin (TSH) deficiency. The GH gene was intact in family I. The pituitaries, visualized by magnetic resonance imaging, were normal. All children responded well to GH and L-thyroxine therapy. Baseline plasma somatostatin and its peak response to arginine infusion were elevated in family I and they had a milder TSH deficiency than family II. Plasma insulin showed a poor response to arginine infusion. This hereditary combination of pituitary deficiencies suggests a deficiency of a common positive transcription factor.

Methionyl human growth hormone in Turner's syndrome

Sixteen girls with Turner's syndrome aged 7.9-15.2 years (bone ages 7.0-11.8 years) were given methionyl growth hormone (somatrem) 4 IU/m2 body surface daily, corresponding to 0.9 IU/kg/week. During one year of treatment their mean (SD) height velocity increased from 3.4 (0.9) to 7.2 (1.7) cm/year and height prediction from 148.2 (4.4) to 150.0 (4.4) cm. All the girls except one had a height velocity increment of more than 2 cm/year and these velocities are above the age references for girls with Turner's syndrome. The girl with a low growth response had antibodies against growth hormone with high binding capacity (3.7 U/l). The height velocity increment was inversely correlated with age and bone age, but this might be partly due to the somewhat higher dosage/m2 body surface and kg body weight that the younger patients were given because of the rounding off of the dose. The better results of our study compared with those of other workers who used similar dosages but did not give the drug as often suggest that giving it daily might have increased the growth response as it does in children deficient in growth hormone.

Excessive growth in a child with craniopharyngioma and growth hormone deficiency

In a 5-year-old boy presenting with clumsiness and excessive growth, a large craniopharyngioma was diagnosed. Biochemically, there was a deficiency of growth hormone, a hypothalamic hypothyroidism and hypocorticalism, a thyroxine binding globulin elevation, an abnormal gonadotropin secretion and a mild hyperprolactinaemia. After removal of the tumour growth stopped almost completely. Plasma insulin-like growth factor (IGF)-I was in the lower normal range. Plasma IGF-II decreased after tumour removal. It is speculated that the tumour produced a growth factor causing excessive growth.

The effect of human growth hormone therapy on skinfold thickness in growth hormone-deficient children

Skinfold thickness (ST) was measured in 43 children with various forms of growth hormone (GH) deficiency during the first year of GH therapy. The average (and SEM) initial ST, expressed as standard deviation score (SDS) was 1.17 (0.25) for subscapular, 0.63 (0.18) for triceps, and 0.40 (0.21) for biceps ST. During therapy the average decrease is 1 SD. Children in the pubertal age group and those with partial GH deficiency showed smaller decreases. A larger decrease of triceps ST was associated with lower GH and insulin peaks, and lower age, bone age and initial weight-for-height. Some correlations between ST decrease and growth response in the first year were significant, but still too low to allow of reliable predictions. The same was true for other clinical parameters. These data indicate that a chronic lack of GH leads to unequal fat distribution, possibly due to different sensitivities to GH in the trunk and extremities. The variability of ST responses to GH therapy limits clinical applications.

Heterozygotes for 17 alpha-hydroxylase deficiency can be detected with a short ACTH test

A short ACTH test was performed in the six parents, and four siblings, of three cases with 17 alpha-hydroxylase deficiency. Baseline steroid levels were all normal in female heterozygotes but in males 17 alpha-hydroxyprogesterone levels were elevated. After ACTH-stimulation, plasma levels of corticosterone were elevated in five obligate heterozygotes and 18-hydroxydeoxycorticosterone levels were increased in four of them. Two of the four siblings had biochemical signs of heterozygosity. The short ACTH test appears to be an efficient method for detecting heterozygosity, but the abnormalities found are more heterogeneous than previously suggested.

In vivo and in vitro studies in a 46, XY phenotypically female infant with 17-ketosteroid reductase deficiency

A 46, XY phenotypically female infant with 17-ketosteroid reductase (17-KSR) showed normal plasma androgens for chromosomal sex shortly after birth, but did not show the physiologic testosterone rise. One intramuscular injection with human chorionic gonadotropin resulted in high ratios between androstenedione/testosterone and dehydroepiandrosterone/delta 5-androstenediol, confirming the diagnosis. In spermatic vein plasma similarly elevated ratios were found. A urinary steroid profile revealed elevated levels of metabolites of 17-OH-progesterone and androstenedione. In vitro studies in testicular tissue showed a decreased capacity of 17-ketosteroid reductase, the reduction capacity being more affected than the oxidation capacity. The activity of 3 beta-hydroxysteroid-dehydrogenase was slightly increased. The serial analysis of plasma androgens provides more insight in the natural history of 17-ketosteroid reductase.

Fetal treatment for thyrotoxicosis in non-thyrotoxic pregnant women

Euthyroid or even hypothyroid pregnant women without antithyroid medication but with a history of treatment for thyrotoxicosis, almost always a subtotal strumectomy, may still produce thyroid-stimulating immunoglobulins. This can induce fetal and neonatal thyrotoxicosis. Without treatment this results in a high fetal and neonatal mortality and morbidity. Fetal treatment by administering antithyroid drugs during pregnancy improves this prognosis remarkably. A case is described, the literature is reviewed and guidelines for diagnosis and treatment are presented.

Assessment of the usefulness of weekly knemometric measurements in growth studies

In 31 healthy children the variability of lower leg length growth over 12 weekly measuring sessions, each consisting of 6 measurements, was assessed with a knemometer. The average SD of 6 measurements was 0.12 mm. In many cases not only a rising trend, but also a zig-zag pattern was observed. The linear regression was not significant (p greater than 0.05) in 1 child. The average (+/- SD) lower leg length velocity (LV) was 0.36 +/- 0.14 mm/week, and the average statural growth velocity 1.27 +/- 0.54 mm/week. The median ratio was 3.3. The range of both velocities was greater than the range of annual height velocities. When LV over the first 6 weeks was compared with LV over the next 6 weeks, a significant difference was found in 5 children. If the effect of growth-promoting or -inhibiting drugs were to be analyzed over such periods, a difference of 0.37 mm/week over two 6-week-periods would be necessary for significance at a 5% level. This would be equivalent with a statural growth response of at least 6.3 cm/year. In conclusion, short-term knemometric growth response cannot be used as a reliable predictor of long-term statural growth response.

[Obese children and their treatment]

Retrospectively the data were analyzed of 188 children treated for obesity. The mean age at which obesity begins is 5,5 years, but the mean age at which medical help is sought is 9,5 years. In 78% of these children one or both parents were obese. The mean caloric value of the pretreatment feeding pattern was 924 kJ (220 kCal) less than the reference quantities for age. Thirty-nine percent of cases stopped visiting the clinic themselves. Mean weight loss is 10% of the median weight-for-height. No differences were found between the results of various therapeutical regimens.

Intra- and inter-observer variability in the assessment of testicular descent

Measurements of the distance between the testis and the pubic tubercle have been used to differentiate retractile testes from "real" cryptorchidism and to measure the effect of therapy. The intra- and inter-observer variation of these measurements was determined in 21 boys with incompletely descended testes treated with placebo. Patients were investigated in supine and squatting position, before and during moderate caudal traction. In squatting position the average distance is 20 mm greater than in supine position. The intra-observer SD is approximately 10 mm. It is doubtful if quantitative measurements can be used to define retractile testes. The wide prediction intervals should be taken into account in interpreting results of therapy.

Comparison of short-term lower leg growth with statural growth in children treated with growth promoting substances

Lower leg growth was determined by knemometry in 11 children with short stature, before and during therapy with growth promoting drugs. The growth response of lower leg length was determined by comparing growth velocities over periods of 6 weeks. The growth response of total body height was determined by comparing the growth velocity during 3 months of therapy with the growth velocity over 1 year before therapy. Significant knemometric growth responses were always associated with positive height responses, but smaller knemometric responses were associated with positive as well as negative height responses.

A phenotypic male with true hermaphroditism and a 46,XX/46,XY/47,XXY karyotype

A phenotypic boy presenting with gynaecomastia showed a mixed karyotype of 46,XX/46,XY/47,XXY. The left gonad was normally descended into the scrotum, but proved to be an ovary without any testicular structures. After left gonadectomy, plasma androgen and estrogen levels showed that the right gonad only contained testicular tissue. Seven patients with this form of triple mosaicism have been described but the clinical features are strikingly different among the described cases.

Short-term effect on growth of two doses of GRF 1-44 in children with growth hormone deficiency: comparison with growth induced by methionyl-GH administration

In a double-blind study 12 prepubertal children with idiopathic growth hormone (GH) deficiency were treated with growth hormone releasing factor (GRF) 1-44 in a dosage of 7.5 or 15 micrograms/kg body weight, administered once a day subcutaneously. With 7.5 micrograms/kg the average growth velocity increased from 2.5 to 4.6 cm/year, an insufficient response. With the higher dosage the average growth velocity increased from 2.7 to 7.0 cm/year, a similar increase as observed with GH therapy in subsequent periods. In 3 of the 6 children treated with the higher dose appropriate catch-up growth was observed. The growth response of the lower leg length was not always consistent with the statural growth response.

[Current developments in the treatment of growth delay using growth hormone]

In this paper five new developments in the field of growth hormone (GH) deficiency and its treatment are discussed. Firstly, the changing concepts on the definition of GH deficiency are described. The main criteria for GH deficiency are a low growth velocity and a decreased GH secretion, but for none of these parameters clear limits can be drawn. Secondly, the results of GH therapy in children with normal GH responses to provocative stimuli are reviewed. Growth velocity does increase in many of these children, but it is not yet known if the final height will increase. Thirdly, new modes of administration are discussed, as well as the GH dosage and the frequency of injections. Daily subcutaneous administration seems to be superior in terms of growth promoting effect. The fourth new development, the production of biosynthetic GH, is certainly the most important. This will soon lead to an unlimited supply of GH with great consequences for the type of patients that will be treated and for the dosage that will be given. Finally, the pharmacological agents which can stimulate the GH secretion are described, particularly growth hormone releasing factor (GRF). The therapeutical use of GRF is still in an experimental phase. In the present circumstances it is very important that GH therapy be given in a well standardized way. For the time being concentration of patients into the centres of pediatric endocrinology will remain advantageous.

Growth response to human growth hormone treatment in children with partial and total growth hormone deficiency

The growth response during the first and second years of human growth hormone (hGH) treatment was studied in 14 prepubertal children with so-called "partial" GH deficiency (peak GH between 8 and 15 mU/l) and compared to 28 prepubertal children with "total" GH deficiency (peak GH less than 8 mU/l). There was no difference in growth acceleration between children with partial and total GH deficiency, when initial covariables were taken into account. In a stepwise multiple regression analysis initial stature, pre-treatment growth velocity and skinfold thickness were shown to be most related to growth response, but after exclusion of 3 children with a genetic form of total GH deficiency and partial TSH deficiency this relationship was lost. GH levels during provocation tests and auxological criteria have a poor predictive value for growth response to hGH therapy.

Effect of LHRH treatment on testicular descent and hormonal response in cryptorchidism

In a double-blind placebo-controlled study in 49 boys with cryptorchidism the effect of intranasal synthetic LHRH was studied. After 8 weeks improvement in testicular location was found in 13 testes (37%), but this improvement was considered sufficient of only six testes. Placebo resulted in an improved location in 18% of the testes. The mean change in testicular position (expressed in cm) after LHRH therapy was slightly greater than after placebo but only in the squatting position did this difference reach significance. Aggressive behaviour was reported in 23% of the children treated with LHRH. A second LHRH course did not result in significant improvement in any of the patients. At follow-up reascent was frequently seen. The final results in unilateral cryptorchidism are poorer than those in bilateral cryptorchidism. LHRH therapy leads to higher plasma LH levels and a lower FSH in response to an intravenous LHRH test. In 15 boys plasma testosterone levels rose above 0.4 nmol/l. We conclude that intranasal LHRH application has a limited value for the treatment of cryptorchidism but may be suitable as a diagnostic test.

Thyroid-stimulating immunoglobulins and thyroid function tests in two siblings with neonatal thyrotoxicosis

Thyroid function and serum TSI levels in two siblings with neonatal thyrotoxicosis are described. The first infant was treated with exchange transfusion and potassium iodide. The second infant was treated with intrauterine propylthiouracil followed by potassium iodide. In contrast to the first infant, the second infant had no clinical sign of neonatal thyrotoxicosis. He also had lower TSI levels with a biological half-life of 5 days. Only one of three assays showed some TSI activity in breast milk.

Cerebral gigantism (Sotos syndrome). Compiled data of 22 cases. Analysis of clinical features, growth and plasma somatomedin

An in depth study on growth, bone age, cranial CT scans and plasma somatomedin activity (SM-act) was made of 22 children with Sotos syndrome. In addition to the known characteristics of the syndrome, thin and brittle nails were found in three adolescent patients. The mean body stature, expressed as standard deviation score, increased from 2.2-2.8 in the 1st year of life, followed by a fall to 2.0 in the 2nd year. Thereafter the SDS increased slowly to values of 3.0 at 10 years of age. At least two subjects have reached an exceptionally tall final stature. After the age of 2 years, delta SDS/year remained very stable (-0.1-0.2), concurring with growth velocities in the upper normal range. Bone age was advanced in all patients. Cranial CT scans showed ventricular widening, mid-line cava and Sylvian anomalies in nine, six, and three patients respectively. SM-act dropped from high or normal values in the 1st year, to below normal from 1-5 years, and returned thereafter to the lower half of normal or below the normal range.

Neonatal thyrotoxicosis treated with exchange transfusion and Lugol's iodine

An infant with neonatal thyrotoxicosis was born to a mother who had become euthyroid after subtotal thyroidectomy for Graves' disease. Exchange transfusion resulted in a 50% decrease of serum thyroxine levels and thyroid stimulating immunoglobulins. After 10 days mild thyrotoxic signs reappeared with high serum thyroxine levels, which were treated successfully with Lugol's iodine for 4 weeks. TSI was undetectable at 7 weeks of age. TSI was present in breast milk.

Plasma somatomedin activity and urinary hydroxyproline excretion during administration of human growth hormone in children with short stature. Short-term effects

15 prepubertal children with short stature and varying peak growth hormone (GH) levels were given daily injections of increasing doses of human growth hormone (hGH) for consecutive periods of 7 days. Somatomedin activity (SM-act) and total urinary hydroxyproline excretion (THP) were determined in each period. In patients with a varying degree of GH deficiency, but without non-pituitary dependent abnormalities, there was a high correlation between basal SM-act and height velocity. Patients with catch-up growth had an unproportionally low SM-act and the Prader-Willi and transient Cushing patients had an unproportionally high one. All patients showed increases of SM-act and THP on hGH administration, but there was considerable variation of the shape of the curve and of the amplitude of the response. 3 1/2 days after the last injection, SM-act was back to basal level. There was a good correlation between weight-for-height and SM-act during the first two hGH doses, which fits the hypothesis of GH and insulin synergism on SM generation.

Plasma somatomedin activity and urinary hydroxyproline excretion during administration of human growth hormone in children with short stature. Long-term effects and relation with short-term changes

Growth velocity, somatomedin activity (SM-act) and total urinary hydroxyproline excretion (THP) were studied in 9 prepubertal short children on long-term human growth hormone (hGH) therapy, and compared to the short-term responses to hGH, described in the accompanying paper. Positive correlations were found between the short-term increases of either SM-act or THP and growth acceleration, but these were too weak to be used as a predictor. On a schedule of biweekly injections, pre-injection SM-act values were only slightly higher than pre-treatment values, but post-injection values were considerably higher and similar to the values obtained with comparable hGH doses in the short-term study. There was an excellent relationship of the increment of SM-act during chronic therapy over untreated values and the increases of growth velocity. During the first year on hGH therapy the mean SM-act, mean THP and growth acceleration showed strong correlations.