1
|
Abstract
Growth is the task of children. We review the normal process of linear growth from the fetus through adolescence and note that growth is the result of age- and gender-dependent interactions among key genetic, environmental, dietary, socioeconomic, developmental, behavioral, nutritional, metabolic, biochemical, and hormonal factors. We then define the wide range of normative data at each stage of growth and note that a pattern within this range is generally indicative of good general health and that growth significantly slower than this range may lead to growth faltering and subsequent short stature. Although not often emphasized, we detail how to properly measure infants and children because height velocity is usually determined from two height measurements (both relatively large values) to calculate the actual height velocity (a relatively much smaller number in comparison). Traditionally the physiology of growth has been taught from an endocrine-centric point-of-view. Here we review the hypothalamic-pituitary-end organ axes for the GH/IGF-1 and gonadal steroid hormones (hypothalamic-pituitary-gonadal axis), both during "mini"-puberty as well as at puberty. However, over the past few decades much more emphasis has been placed on the growth plate and its many interactions with the endocrine system but also with its own intrinsic physiology and gene mutations. These latter, whether individually (large effect size) or in combination with many others including endocrine system-based, may account in toto for meaningful differences in adult height. The clinical assessment of children with short stature includes medical, social and family history, physical exam and importantly proper interpretation of the growth curve. This analysis should lead to judicious use of screening laboratory and imaging tests depending on the pre-test probability (Bayesian inference) of a particular diagnosis in that child. In particular for those with no pathological features in the history and physical exam and a low, but normal height velocity, may lead only to a bone age exam and reevaluation (re-measurement), perhaps 6 months later. he next step depends on the comfort level of the primary care physician, the patient, and the parent; that is, whether to continue with the evaluation with more directed, more sophisticated testing, again based on Bayesian inference or to seek consultation with a subspecialist pediatrician based on the data obtained. This is not necessarily an endocrinologist. The newest area and the one most in flux is the role for genetic testing, given that growth is a complex process with large effect size for single genes but smaller effect sizes for multiple other genes which in the aggregate may be relevant to attained adult height. Genetics is a discipline that is rapidly changing, especially as the cost of exome or whole gene sequencing diminishes sharply. Within a decade it is quite likely that a genetic approach to the evaluation of children with short stature will become the standard, truncating the diagnostic odyssey and be cost effective as fewer biochemical and imaging studies are required to make a proper diagnosis.
Collapse
Affiliation(s)
- Roberto Bogarín
- Department of Pediatric Endocrinology, National Children's Hospital, San José, Costa Rica
| | - Erick Richmond
- Department of Pediatric Endocrinology, National Children's Hospital, San José, Costa Rica
| | - Alan D Rogol
- Department of Pediatric Endocrinology, University of Virginia, Charlottesville, VA, USA -
| |
Collapse
|
2
|
Collett-Solberg PF, Ambler G, Backeljauw PF, Bidlingmaier M, Biller BM, Boguszewski MC, Cheung PT, Choong CSY, Cohen LE, Cohen P, Dauber A, Deal CL, Gong C, Hasegawa Y, Hoffman AR, Hofman PL, Horikawa R, Jorge AA, Juul A, Kamenický P, Khadilkar V, Kopchick JJ, Kriström B, Lopes MDLA, Luo X, Miller BS, Misra M, Netchine I, Radovick S, Ranke MB, Rogol AD, Rosenfeld RG, Saenger P, Wit JM, Woelfle J. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Horm Res Paediatr 2019; 92:1-14. [PMID: 31514194 PMCID: PMC6979443 DOI: 10.1159/000502231] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022] Open
Abstract
The Growth Hormone Research Society (GRS) convened a Workshop in March 2019 to evaluate the diagnosis and therapy of short stature in children. Forty-six international experts participated at the invitation of GRS including clinicians, basic scientists, and representatives from regulatory agencies and the pharmaceutical industry. Following plenary presentations addressing the current diagnosis and therapy of short stature in children, breakout groups discussed questions produced in advance by the planning committee and reconvened to share the group reports. A writing team assembled one document that was subsequently discussed and revised by participants. Participants from regulatory agencies and pharmaceutical companies were not part of the writing process. Short stature is the most common reason for referral to the pediatric endocrinologist. History, physical examination, and auxology remain the most important methods for understanding the reasons for the short stature. While some long-standing topics of controversy continue to generate debate, including in whom, and how, to perform and interpret growth hormone stimulation tests, new research areas are changing the clinical landscape, such as the genetics of short stature, selection of patients for genetic testing, and interpretation of genetic tests in the clinical setting. What dose of growth hormone to start, how to adjust the dose, and how to identify and manage a suboptimal response are still topics to debate. Additional areas that are expected to transform the growth field include the development of long-acting growth hormone preparations and other new therapeutics and diagnostics that may increase adult height or aid in the diagnosis of growth hormone deficiency.
Collapse
Affiliation(s)
- Paulo F. Collett-Solberg
- aDisciplina de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil,*Paulo Ferrez Collett-Solberg, MD, PhD, Pavilhão Reitor Haroldo Lisboa da Cunha, térreo, Rua São Francisco Xavier 524, Maracanã, Rio de Janeiro 20550-013 (Brazil), E-Mail
| | - Geoffrey Ambler
- bInstitute of Endocrinology and Diabetes, The University of Sydney, Sydney, New South Wales, Australia
| | - Philippe F. Backeljauw
- cDivision of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Martin Bidlingmaier
- dEndocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Beverly M.K. Biller
- eNeuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pik To Cheung
- gPaediatric Endocrinology, Genetics, and Metabolism, Virtus Medical Group and The University of Hong Kong, Hong Kong SAR, China
| | - Catherine Seut Yhoke Choong
- hDepartment of Endocrinology, Perth Children's Hospital, Child and Adolescent Health Service, Perth, Washington, Australia,iDivision of Paediatrics, School of Medicine, University of Western Australia, Perth, Washington, Australia,jThe Centre for Child Health Research, Telethon Kids Institute, University of Western Australia, Perth, Washington, Australia
| | - Laurie E. Cohen
- kDivision of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pinchas Cohen
- lLeonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Andrew Dauber
- mDivision of Endocrinology, Children's National Health System, Washington, District of Columbia, USA
| | - Cheri L. Deal
- nEndocrine and Diabetes Service, CHU Sainte-Justine and University of Montreal, Montreal, Québec, Canada
| | - Chunxiu Gong
- oEndocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Yukihiro Hasegawa
- pDivision of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Andrew R. Hoffman
- qDepartment of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Paul L. Hofman
- rLiggins Institute, University of Auckland, Auckland, New Zealand
| | - Reiko Horikawa
- sDivision of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Alexander A.L. Jorge
- tUnidade de Endocrinologia Genética (LIM25), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anders Juul
- uDepartment of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Kamenický
- vService d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Vaman Khadilkar
- wHirabai Cowasji Jehangir Medical Research Institute (HCJMRI), Jehangir Hospital, Pune, India
| | - John J. Kopchick
- xEdison Biotechnology Institute and Department of Biomedical Sciences, HCOM Ohio University Athens, Athens, Ohio, USA
| | - Berit Kriström
- yInstitute of Clinical Science, Pediatrics, Umeå University, Umeå, Sweden
| | - Maria de Lurdes A. Lopes
- zUnidade de Endocrinologia Pediátrica, Area da Mulher, Criança e Adolescente, Centro Hospitalar Universitário de Lisboa Central-Hospital de Dona Estefânia, Lisbon, Portugal
| | - Xiaoping Luo
- ADepartment of Pediatrics, Tongji Hospital, Tongji Medical Colleage, Huazhong University of Science and Technology, Wuhan, China
| | - Bradley S. Miller
- BDivision of Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Madhusmita Misra
- CDivision of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Irene Netchine
- DExplorations Fonctionnelles Endocriniennes, AP-HP Hôpital Trousseau, Centre de Recherche Saint Antoine, INSERM, Sorbonne Université, Paris, France
| | - Sally Radovick
- EDepartment of Pediatrics, Robert Wood Johnson Medical School, Child Health Institute of New Jersey-Rutgers University, New Brunswick, New Jersey, USA
| | | | - Alan D. Rogol
- GDepartment of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Jan M. Wit
- JDepartment of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joachim Woelfle
- KPediatric Endocrinology Division, Children's Hospital, University of Bonn, Bonn, Germany
| |
Collapse
|
3
|
Storr HL, Chatterjee S, Metherell LA, Foley C, Rosenfeld RG, Backeljauw PF, Dauber A, Savage MO, Hwa V. Nonclassical GH Insensitivity: Characterization of Mild Abnormalities of GH Action. Endocr Rev 2019; 40:476-505. [PMID: 30265312 PMCID: PMC6607971 DOI: 10.1210/er.2018-00146] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/31/2018] [Indexed: 12/12/2022]
Abstract
GH insensitivity (GHI) presents in childhood with growth failure and in its severe form is associated with extreme short stature and dysmorphic and metabolic abnormalities. In recent years, the clinical, biochemical, and genetic characteristics of GHI and other overlapping short stature syndromes have rapidly expanded. This can be attributed to advancing genetic techniques and a greater awareness of this group of disorders. We review this important spectrum of defects, which present with phenotypes at the milder end of the GHI continuum. We discuss their clinical, biochemical, and genetic characteristics. The objective of this review is to clarify the definition, identification, and investigation of this clinically relevant group of growth defects. We also review the therapeutic challenges of mild GHI.
Collapse
Affiliation(s)
- Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Sumana Chatterjee
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Louise A Metherell
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Corinne Foley
- Division of Endocrinology, Cincinnati Center for Growth Disorders, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ron G Rosenfeld
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Philippe F Backeljauw
- Division of Endocrinology, Cincinnati Center for Growth Disorders, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew Dauber
- Division of Endocrinology, Cincinnati Center for Growth Disorders, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Vivian Hwa
- Division of Endocrinology, Cincinnati Center for Growth Disorders, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|