[Differential diagnosis in children with small stature]

BACKGROUND

Physiological growth is a sensitive long-term indicator of child health. Impaired growth of children may be the first manifestation of a serious chronic disease. In order to find a rational examination procedure, the authors analyzed retrospectively the diagnosis in children with impaired growth who were referred for examination to the university hospital.

METHODS AND RESULTS

In the course of 5.5 years 190 children (boys/girls, 124/66) with short stature, age 2.5 to 16.5 years were examined. In 93 (68/25, 48.9%) the condition was classified as short-normal, i.e. short but healthy, incl. 25 (11/14, 13.2%) with familial short stature, in 26 (21/5, 13.7%) constitutional growth retardation (and retarded puberty) and in 42 (36/6, 22.1%) a combination of the two conditions. In 97 children (56/41, 51.1%) a pathological condition was found: in 14 girls (7.4%) Turner's syndrome, in 55 children (37/18, 29.0%) deficiency of growth hormone, incl. 11 as a results of a tumour or anomaly of the CNS, and in 28 children (19/9, 14.7%) another serious cause of a growth disorder. In three families the authors detected an autosomal dominant disorder in a parent-child pair, the parent not being aware of the disorder (renal tubular acidosis, vitamin D resistant rickets, hypochondroplasia). Based on analysis of these data the authors suggest a rational differential diagnostic procedure in children with short stature.

CONCLUSIONS

The stepwise examination of children with short stature is based on the unequivocal differentiation of short-normal children and assessment of the cause of the growth disorder in the other affected children. The procedure is focused on a sparing, rapid and accurate diagnosis with subsequent early treatment of children with a serious pathological condition.

[The effect of treatment on growth in children with central precocious puberty]

BACKGROUND

Modern treatment of central precocious puberty (CPP) by agonist analogues of gonadoliberin (aGnRH) block the development of secondary sex characteristics, it delays bone maturation and improves the prospects of reaching optimal height. The objective of the present study was to compare the effect of formerly used treatment with synthetic progestin, Cyproterone acetate (Androcur, Schering), with contemporary treatment using aGnRH Triptoreline (D-Trp-6-LHRH, Decapeptyl depot, Ferring) on growth parameters of female patients.

METHODS AND RESULTS

The authors treated 12 girls with CPP. The first group comprised 7 girls treated solely with Cyproterone acetate (first signs of CPP at the age of 4.9 +/- 1.8 years, onset of study at calendar age (CA) 7.1 +/- 1.3 years, bone age (BA) 10.2 +/- 1.3 years, follow-up period 1.8 +/- 0.8 years). The second group was formed by five girls originally treated for a period of 1.8 +/- 1.7 years (4-56 months) with Cyproterone acetate and subsequently with Triptoreline for a period of 1.5 +/- 0.3 years. The latter group developed signs of CPP at the age of 4.9 +/- 2.6 years. At the onset of Triptoreline treatment and thus at the onset of the study the girls' age was 7.4 +/- 0.7 years and BA 9.6 +/- 1.9 years. Secondary sex characteristics did not progress in either of the investigated groups during the study period. The authors observed in both groups before the investigation an acceleration of BA per calendar year (dBA/CA) of 1.5 +/- 0.6 SD (p < 0.01), as compared with standards of the healthy population. In the course of the investigation in the first group dBA/CA of 1.4 +/- 0.6 years (p < 0.01) persisted, in the second group a decline of dBA/CA to a normal level occurred (0.9 +/- 0.4 years). The growth rate in the two groups did not differ during the investigation from standards for the healthy population. Height in relation to bone age (BH/BA SDS) declined in the first group during the investigation from -1.8 +/- 0.9 SDS to -2.2 +/- 1.0 SDS (p = 0.06). In the second group this indicator did not change.

CONCLUSIONS

During Triptoreline treatment, as compared with Cyproterone acetate treatment, in patients with CPP the rate of bone maturation declined to normal and their height in relation to bone age did not decline. This led to the assumption of a smaller future adult height loss in patients treated with aGnRH Triptoreline.

[Growth hormone therapy in children with growth hormone deficiency: study of dose-response relationship]

BACKGROUND

Despite different age, stature, severity of hormone deficiency and target height children with growth hormone deficiency are usually given a uniform therapeutic dose of the preparation. Knowledge of the basic variables which influence individual therapeutic effects of growth hormone would make it possible to elaborate for individual patients a specific therapeutic strategy with the aim to cath up with the deficiency in height at an appropriate calendar age.

METHODS AND RESULTS

The authors treated for a period of one year, using three different dosages of growth hormone, 25 prepubertal children with growth hormone deficiency (post-stimulation level < 8 mIU/l). Group A (9 children aged 11.2 +/- 2.0 years) were treated with 0.42 IU/kg/week, group B (7 children, aged 11.4 +/- 4.6 years) 0.7 IU/kg/week and group C (9 children, aged 10.2 +/- 2.4 years) 1.0 IU/kg/week. The preparation was administered daily before bedtime by the s.c. route. The growth rate during treatment increased from (mean +/- SD) 2.6 +/- 0.9 to 9.3 +/- 1.5 cm/year (group A), from 2.3 +/- 1.0 to 10.4 +/- 2.5 cm/year (group B) and from 3.1 +/- 0.7 to 12.6 +/- 1.9 cm/year (group C, p < 0.05 as compared with group A). The height age increased per year of treatment significantly more in children of group C (by 2.1 +/- 0.3 year) than in group A (by 1.6 +/- 0.3 year) or in group B (by 1.7 +/- 0.3 year). No difference was found between the groups in the ratio of changes in height and bone age. From 10 analyzed variables the growth rate during treatment is predicted above all by the therapeutic dose (r = 0.60), and to a lesser extent by the target height (r = 0.53).

CONCLUSIONS

The therapeutic dose is the decisive parameter for prediction of the therapeutic effect of growth hormone in children with growth hormone deficiency. It is justified to modify the therapeutic dose individually with regard to the initial characteristic and therapeutic target of every given patient.

Urinary growth hormone excretion in diabetic children: relation to nocturnal course of blood glucose levels

A potential relation was evaluated between nocturnal urinary growth hormone (GH) excretion as a parameter for integrated GH secretion and the course of blood glucose (BG) levels during night and morning hours. Twelve diabetic children aged 11.6 +/- 2.0 years (mean +/- SD), with diabetes duration 4.4 +/- 1.6 years, took part in the study. Urine for GH estimation by a highly sensitive EIA was collected from 24.00 to 07.00 h during a diabetic summer camp. BG was monitored at 24.00, 04.00 and 07.00 h. Mean nocturnal GH excretion measured from 158 collections was 5.6 +/- 5.1 ng/g creatinine, with a wide range of 0.36-36.6. Remarkable intra-individual variations were found between distinct nights. GH excretion correlated positively with BG levels at 07.00 h (p = 0.003) and with the increment of BG between 24.00 and 07.00 h (p = 0.002). Thus, endogenous variations in nocturnal GH levels may be involved in the day-to-day fluctuations in fasting BG in diabetic subjects.

[The effect of food supplementation with organically bound chromium on indicators of compensation in diabetic children and adolescents]

To the food of 33 diabetic patients typ I (in the age of about 15 years) organically bound chromium was added for 6 weeks. The influence on the metabolic compensation could not be proven, although in some individuals of this group the favorable effect of chromium can not be excluded.

[Diagnosis of Turner's syndrome 1965-1989: karyotype, age at diagnosis and determining signs]

Early diagnosis of Turner's syndrome makes possible optimal application of all procedures of substitution and symptomatic therapy and offers also psychological support to the parents and the patients. In 1965-1989 in two centres 135 girls with Turner's syndrome were detected, 72 with karyotype 45, X, 63 with a chromosomal mosaic and/or structural anomaly. Girls and women with karyotype 45, X are detected sooner (9.4 +/- 6.9 years, as compared with 14.2 +/- 8.1 years, p = 0.0003). Before the age of three 28% of the girls with karyotype 45, X were detected (by congenital lymphoedemas, coarctation of the aorta, poor progress), only 9% of the others. Growth impairment revealed the diagnosis in 27% of the affected girls. Girls with karyotype 45, X were diagnosed on account of impaired growth sooner (7.9 +/- 2.2 years as compared with 11.8 +/- 2.7 years, p = 0.00005). At a time when the diagnosis of girls with karyotype was practically completed, 16% of the spontaneously maturing and menstruating women with chromosomal mosaic where the syndrome was detected during examination of sterility or habitual abortion were still not diagnosed.

[Cyproterone acetate in the treatment of girls with central precocious puberty]

Cyproterone acetate (Androcur, Schering Co) was administered within the range of recommended doses to seven girls with central premature puberty. During the investigation period, on average within 1.8 years, in all girls regression of the premature development of sex signs and gonads occurred, as well as normalization of the vaginal cytology. The growth rate corresponded to that of girls of similar calendar age, while there was progress of bone maturation. The growth prognosis deteriorated on average by 3.7 cm per year, during the whole investigation period by as much as 5.1 cm. Cyproterone acetate did not meet the demands of adequate comprehensive treatment of children with central premature puberty.

[The effect of enalapril on the development of diabetic nephropathy in children and adolescents]

Diabetic nephropathy is the most frequent cause of chronic renal insufficiency in adults. Its early stage, characterized by increased albuminuria, develops in susceptible subjects already manifestation of diabetes. This stage can be treated by inhibitors of the angiotensin-converting enzyme which reduce the pathologically elevated intraglomerular pressure even in normotonic subjects. Enalapril was administered for a period of 12 weeks to eight children and adolescents with a normal blood pressure and albuminuria of 30-300 mg/24 hours during repeated assessments. During treatment there was not only a significant decline of albuminuria (from 104.6 +/- 42.7 mg/24 hours to 47.2 +/- 15.4, p = 0.003) but also a drop of the pathological glomerular hyperfiltration (from 3.38 +/- 1.87 ml/s to 1.48 +/- 0.54 ml/s within six weeks - p = 0.02 and to 2.05 +/- 0.80 ml/s resp. within 12 weeks, n.s.). The favourable effect persisted also for some time after discontinuation of treatment. Treatment was relatively well tolerated by the patients. The problem remains whether it is possible to retard or prevent in this way the development of further stages of diabetic nephropathy, include chronic renal failure.

[Efficient diagnosis of hypothalamo-hypophyseal nanism: 5 years' experience with the clonidine stimulation test in the diagnosis of growth hormone secretion]

The clonidine stimulation test, using doses of 37.5--75 micrograms clonidine and assessment of growth hormone levels at times 0, 60 minutes, is a suitable, safe and relatively reliable screening test for ambulatory work. As ensues from examinations of 156 children, it is possible to select by this test, as compared with the test of insulin induced hypoglycaemia, more than 70% children with a normal post-stimulation response of growth hormone.

[The effect of increased production of androgens on the development of body build morphology. Case report of an androgen-active tumor in a monozygotic twin]

The authors present an account on monozygotic twins where in one girl an androgen-active adenoma of the adrenal cortex during early puberty led to the development of the Morphogram of Body Build (Case-report of throughout the period of investigation intact from the hormonal aspect. Four years after resection of the tumour endocrine and anthropometric characteristics of the two sisters were evaluated: the hormonal status of both is normal, the somatic differences are manifested by a different final height, biacromial width and chest circumference. The results are conceived as a precedent for evaluation of risks associated with administration of anabolic steroids in children.

[What do we owe the families of diabetic children?]

An enquiry by means of questionnaire in 211 families of diabetic children in Prague and the Central Bohemian region with the aim to express objectively the influence of diabetes of the child in the socio-economic position of the family.