Nocturnal pulsatile growth hormone releasing hormone treatment in growth hormone deficiency

[Treatment of growth hormone deficiencies with growth hormone releasing hormone. Current status and perspectives]

Results of clinical trials performed with human hypothalamic growth hormone releasing factor (GRF) are conflicting, but rather disappointing for most of them. Pulsatile administration of GRF has been found to increase growth hormone secretion as well as growth velocity, but is not convenient for practical use. All other routes and rhythms of administration lead only to sub-optimal results, and generally does not seem to procure an appropriate GRF bio-availability. Improvements are possible, particularly the development of agonists and new galenic forms with sustained release. Therapeutic approach with hexapeptides, or hexapeptides analogs, looks promising, but could be more complementary than competitive.

A comparative study of growth hormone (GH) and GH-releasing hormone(1-29)-NH2 for stimulation of growth in children with GH deficiency

In this study, 60 patients with proven growth hormone deficiency (GHD) of hypothalamic origin were randomized into three equal groups, and received growth hormone-releasing hormone(1-29)-NH2 (GHRH(1-29)-NH2), 30 or 60 micrograms/kg/day, or growth hormone (GH), 0.1 IU/kg/day, for 6 months. There were no significant differences in growth between the two groups given GHRH(1-29)-NH2, but growth in the GH group was significantly better than in the other two groups (p < 0.01). Mean height velocities at 6 months were 9.2, 9.3 and 14.6 cm/year for the three groups, respectively. Plasma GHRH concentrations increased steadily over the 6-month treatment period, with higher levels in the group on the higher dose. During GHRH(1-29)-NH2 treatment, serum concentrations of insulin-like growth factor I rose initially, but then fell to values similar to those before treatment. No GH antibodies were detected, but all 20 patients on high-dose GHRH(1-29)-NH2 and 19 of 20 patients on low-dose GHRH(1-29)-NH2 developed GHRH antibodies. These had almost disappeared by 9 months after stopping treatment. There was no correlation between antibody titres and increase in height. No serious side-effects were seen, but three patients receiving GHRH(1-29)-NH2 reported mild irritation at the injection site. These results from the continuous infusion of GHRH(1-29)-NH2 over 6 months suggest that this treatment, or the related use of a depot preparation, is unlikely to be as effective as GH for the promotion of growth in GHD.

Pharmacokinetics of growth hormone-releasing hormone(1-29)-NH2 and stimulation of growth hormone secretion in healthy subjects after intravenous or intranasal administration

The growth hormone-releasing hormone analogue GHRH(1-29)-NH2 was administered intravenously or intranasally to 30 healthy men aged 19-43 years. Intravenous injection of the lowest dose tested, 0.25 microgram/kg body weight, elicited significant release of growth hormone (GH). Maximal release (mean GH peaks of about 90 mU/l) was obtained with a dose of 1-2 micrograms/kg. Although GHRH(1-29)-NH2 was rapidly eliminated after intravenous injection, GH levels were elevated for about 3 hours. Absorption of GHRH(1-29)-NH2 through the nasal mucosa was found to be low, and the bioavailability was only 3-5%. There was a dose-dependent release of GH after intranasal administration of GHRH(1-29)-NH2, with the maximal response obtained with about 50 micrograms/kg; this dose was approximately as potent as 1 microgram/kg injected intravenously. The GH response after repeated intranasal administration of GHRH(1-29)-NH2 was sustained; there was no suppression of GH secretion during the night following a day when GHRH(1-29)-NH2 had been given three times intranasally. Based on these findings and the obvious convenience of intranasal administration compared with injections, it would be justified to test intranasal therapy for treatment of short stature in children with GH deficiency caused by hypothalamic damage.

Growth response to growth hormone-releasing hormone(1-29)-NH2 compared with growth hormone

To assess the growth-promoting effect of different doses of growth hormone-releasing hormone(1-29)-NH2 (GHRH(1-29)-NH2) in GH deficiency (GHD) of hypothalamic origin, 43 prepubertal children aged between 4.3 and 18.9 years (mean 10.4 +/- 2.9 years) were randomly assigned to three treatment regimens: low-dose GHRH(1-29)-NH2 (LD group; n = 15), high-dose GHRH(1-29)-NH2 (HD group; n = 12) and GH (GH group; n = 16). The LD group received GHRH(1-29)-NH2 at 30 micrograms/kg/day s.c. in three daily doses, the HD group received 60 micrograms/kg/day s.c. in three daily doses and the GH group received GH, 0.1 IU/kg/day s.c. once daily. All children were treated for a period of 6 months. Evaluation included anthropometry, bone age, intravenous and subcutaneous GHRH(1-29)-NH2 tests and determination of insulin-like growth factor I (IGF-I) levels. An increase in height velocity of 2 cm/year or more was observed in all except two children. Height velocity during treatment was lowest in the LD group, but comparable in the HD and GH groups. An increase in height SDS for bone age occurred only in the GH-treated group. GH responses to intravenous GHRH(1-29)-NH2 showed a priming effect of the LD GHRH(1-29)-NH2 treatment, while a decrease in response occurred in the GH-treated group. Following a subcutaneous test dose of one-third of the daily dose of GHRH(1-29)-NH2, GH levels remained unchanged in both the LD and HD groups. There was accumulation of GHRH immunoreactivity over time in the HD group, but there was no correlation between measured GHRH and GH levels.(ABSTRACT TRUNCATED AT 250 WORDS)

The therapeutic use of growth-hormone-releasing hormone

As a significant number of children with growth hormone deficiency have been shown to be able to respond to GHRH with a rise in serum growth hormone (GH) levels, GHRH has been used to treat such children with varying success. GHRH has been given subcutaneously (SC) in GH deficient children to improve growth in dose frequencies of daily, twice daily, three-hourly overnight or three-hourly throughout the day. The dosages of GHRH used have been wide ranging, varying from 4 micrograms/kg/day to 50 micrograms/kg/day. Continuous infusion of GHRH has been shown to augment GH secretion in normal adults and GH deficient children without evidence of desensitization of the somatotrophs. Continuous SC infusion of GHRH has been shown to promote growth in short slowly growing children. Poor growth response to GHRH has been reported by some authors using daily SC injection while others reported significant growth acceleration in 42-87% of GH deficient children treated using different GHRH regimens. Although GH treatment in GH-deficient children results in more consistent growth acceleration, comparable growth response can be seen in some children treated with GHRH. The optimal mode of GHRH therapy remains to be determined, but it would appear that the growth response is dependent on the dose used and possibly on the frequency of administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of growth hormone secretion and treatment

The secretion of growth hormone (GH) is regulated by a complex system that includes both neurotransmitters and feedback by hormonal and metabolic substrates. Over the last few years it has been recognized that GH release varies over a wide spectrum from deficient to excessive secretion. The diagnosis of GH deficiency is based on a combination of anthropometric and clinical signs on the one hand and an inadequate stimulated and/or spontaneous GH secretion on the other. There is no distinct boundary between deficient and sufficient GH secretion. The cut-off limit for normal GH release is accordingly relative and has increased over the past decade from 5 to 10 micrograms/l. The effect of GH therapy on growth can be evaluated only after treatment for at least 6 months. There is, therefore, an indisputable need for methods that would reflect growth response soon after the start of treatment. There are several promising biochemical candidates, e.g. the aminoterminal propeptide of type III procollagen, the carboxyterminal propeptide of procollagen I and the bone Gla-protein, which may turn out to be useful early indicators of the growth response to long-term GH therapy.

Pyridostigmine fails to increase either spontaneous or GHRH-stimulated GH secretion during day or night in growth hormone-insufficient children

OBJECTIVE The aim of the study was to investigate whether pyridostigmine, a cholinesterase inhibitor which is thought to act at the hypothalamus to inhibit somatostatin secretion, would augment spontaneous or GHRH-stimulated serum GH levels in patients with GH-insufficiency. DESIGN Oral pyridostigmine 60 mg or placebo was administered at the start of a 9-h subcutaneous infusion of either GHRH (1-29)NH2 10 micrograms/kg/h or saline control. Studies were performed during the daytime (0900-1800 h) in five patients, and the night-time (2100-0600 h) in a further five. PATIENTS Ten short, pre-pubertal children (aged 6-11 years; eight boys) with growth hormone insufficiency were studied. MEASURES Blood for serum GH was sampled every 20 min, and analysed using the PULSAR program. RESULTS The subcutaneous infusion of GHRH 10 micrograms/kg/h increased mean serum GH levels (+/- SEM): by day 17.7(+/- 6.8) vs placebo 2.2(+/- 0.4) mU/l (P less than 0.01), and by night 26.9(+/- 3.3) vs 5.5(+/- 1.3) mU/l (P less than 0.05). There was a significant rise in mean 'baseline' GH concentration: by day 5.5(+/- 1.7) vs 1.0(+/- 0.0) mU/l (P less than 0.05); and night 8.2(+/- 2.7) vs 1.3(+/- 0.3) mU/l (P less than 0.05). Pyridostigmine failed to produce a significant overall increase in either spontaneous or GHRH-stimulated GH secretion by day or night, although there was a significant rise in mean GH levels during the 3 h following pyridostigmine administration in the morning: 4.4(+/- 1.1) vs 2.4(+/- 0.5) mU/l (P less than 0.001). GHRH or pyridostigmine given singly or in combination had no significant effect on the number of pulses. Side-effects attributable to pyridostigmine occurred in seven children. CONCLUSIONS Pyridostigmine, either on its own or as an adjuvant therapy in combination with GHRH, acts for only a brief time and does not offer any potential benefit in the management of children with short stature.

The neurophysiological regulation of growth hormone secretion

With the advent of genetic engineering, the importance of GH in the regulation of growth and metabolism in domestic species has been clearly demonstrated. Ample evidence of an integral role for GH in the processes of growth and lactation exists in dairy cattle (1,2), sheep (3), beef cattle (4) and swine (5). For example, circulating GH levels are high during the period of rapid growth in several species including cattle (6), swine (7) and poultry (8). Endogenous GH secretion is primarily controlled by the central nervous system (CNS) via two specific hypothalamic neurohormones, growth hormone-releasing factor (GRF) and somatostatin (SRIF), an inhibitor of GH release. The secretion of GRF and SRIF is governed by a host of neuropeptides and neurotransmitters which provide a functional link between higher CNS centers and hypophysiotropic neurons. This review will focus on the CNS regulation of GH secretion and circulating factors which feedback to either stimulate or inhibit its release.

Subcutaneous growth hormone-releasing hormone augments pulsatile nocturnal GH release in GH-insufficient children, but may also raise basal GH secretion

Growth hormone-releasing hormone (GHRH) when given s.c. to GH-insufficient children either as pulses, or once or twice daily, promotes linear growth. These treatment regimens, however, are not ideal as they require frequent drug administration and a significant proportion of patients do not show improved growth. We have now investigated the GH response to a nocturnal s.c. infusion of GHRH (1-29)NH2, at two dosages, 5 and 10 micrograms/kg/h, in a group of five GH-insufficient children. The s.c. infusion of GHRH between 2100 h and 0600 h augmented nocturnal pulsatile GH release in all five children. There was a dose-dependent response for the GH area under the curve (AUC), and mean total GH concentration. The AUC for GH was significantly greater after the 10 than 5 micrograms/kg/h GHRH which in turn was greater than that after placebo; mean (SD) AUC: 14816 (3978), 8125 (1931), 3032 (1582) mU min/l respectively (P less than 0.01 and P less than 0.05). There was no significant change in the number of GH pulses during the 9-h infusions when the subjects were infused with GHRH 10 or 5 micrograms/kg/h compared to placebo, and they occurred at similar times although the number of pulses tended to be greater after GHRH; the mean (SD) numbers of GH pulses were 5.0 (0.7), 3.8 (0.8), 3.2 (0.8), respectively. There was however a significant rise in the mean baseline GH concentration in all patients during the infusion of GHRH 10 micrograms/kg/h compared to placebo, but not with 5 micrograms/kg/h. Thus, GHRH(1-29)NH2 given s.c. augmented nocturnal pulsatile GH release in GH-insufficient children but it also increased baseline GH secretion. These results suggest that a sustained release preparation of GHRH could be a potential treatment for GH-insufficient children, and that a dose of 5 micrograms/kg/h would promote pulsatile GH release, but that at higher dosage it may also raise basal GH secretion.

Continuous subcutaneous GHRH(1-29)NH2 promotes growth over 1 year in short, slowly growing children

We have treated eight pre-pubertal children with partial GH insufficiency with continuous subcutaneous infusions of GHRH(1-29)NH2 at a dose of 60 ng/kg/min for periods of up to 1 year. In five children treated for 1 year, mean growth velocity increased from 4.6 cm/year (range 4.4-5.2) to 7.0 cm/year (5.7-8.7) (P = 0.04). Three children treated for 3-6 months showed similar height velocity increases. A return to pretreatment growth rates was seen after cessation of treatment in all children. Twenty-four-hour GH profiles performed at intervals of 3 months showed sustained augmentation of pulsatile GH secretion without evidence of desensitization. The presence of pulsatile GH secretion during continuous GHRH administration provides strong evidence in man for the role of somatostatin in determining GH pulse frequency. The ability of the pituitary to respond to a supramaximal bolus of GHRH remained constant during the treatment. Continuous administration of GHRH(1-29)NH2 will become a practicable treatment when formulated into a sustained release or depot preparation. We have shown this to be an effective therapy for some short, slowly growing children. Further studies are required to establish the optimal dosage regimen.

GHRH treatment: studies in an animal model

This study examined the effects of chronic deletion of circulating growth hormone-releasing (GHRH) and/or somatostatin (SRIF) on normal growing male rats, as well as the effects of exogenous GHRH (1-29)NH2 and/or SMS 201-995 administration on the growth of rats with hypothalamic ablation. Passive immunization with anti-rat GHRH goat gamma-globulin (GHRH-Ab) for 3 weeks caused a marked decrease in the levels of pituitary GH mRNA and severe growth failure. Treatment with anti-SRIF goat gamma-globulin (SRIF-Ab) for 3 weeks produced a more modest decrease in GH mRNA levels in the pituitary and a slight but significant inhibition of normal somatic growth. Hypothalamic ablation produced a marked decrease in the level of mRNA in the pituitary. Chronic continuous administration of GHRH (1-29)NH2 stimulated pituitary GH synthesis, elevated serum levels of insulin-like growth factor I and increased body weight gain in rats with hypothalamic ablation treated with replacement doses of cortisone, testosterone and L-thyroxine. Combined treatment with GHRH (1-29)NH2 and SMS 201-995 appeared to promote the effect of GHRH on pituitary GH release and somatic growth in these animals. The results suggest that continuous administration of GHRH will be useful in the treatment of children with growth retardation resulting from hypothalamic disorders. In children with combined GHRH and somatostatin deficiencies, the addition of somatostatin to a GHRH treatment regimen may produce better results.

Use of continuous subcutaneous growth hormone-releasing hormone (GHRH (1-29)NH2) infusions to augment growth hormone secretion and to promote growth

It has previously been shown that an 8-day continuous subcutaneous infusion of GHRH (1-29)NH2 in adult males augments growth hormone (GH) secretion with no evidence of desensitization of the response. The present report details the results of treatment with continuous subcutaneous infusions of GHRH (1-29)NH2 in eight children aged 6-9 years with partial GH insufficiency. All the children showed augmentation of GH secretion and an increase in growth velocity after 3 and 6 months of therapy.

Growth hormone releasing hormone or growth hormone treatment in growth hormone insufficiency?

Sixteen prepubertal children who were insufficient for growth hormone were treated with growth hormone releasing hormone (GHRH) 1-40 and GHRH 1-29 for a mean time of nine months (range 6-12 months) with each peptide. Eleven children received GHRH 1-40 in four subcutaneous nocturnal pulses (dose 4-8 micrograms/kg/day) and eight (three of whom were also treated with GHRH 1-40) received GHRH 1-29 twice daily (dose 8-16 micrograms/kg/day). Altogether 73% of the children receiving GHRH 1-40 and 63% receiving GHRH 1-29 showed a growth response. Double the daily dose of GHRH 1-29 was required to obtain equivalent growth response to pulsatile GHRH 1-40. A significant linear correlation was shown between growth hormone secretion and height velocity on GHRH 1-40 but not on GHRH 1-29 and there was a significant correlation between plasma GHRH and serum growth hormone concentrations during GHRH 1-40 administration. Response to conventional growth hormone treatment in a matched group of children was significantly better than the response after GHRH. A significant improvement in height velocity was observed in the children transferred to growth hormone replacement. Growth hormone remains the treatment of choice in growth hormone insufficiency. GHRH treatment may be of benefit in children with less severe growth hormone insufficiency in the presence of pulsatile endogenous growth hormone secretion.

Continuous subcutaneous growth hormone releasing factor analogue augments growth hormone secretion in normal male subjects with no desensitization of the somatotroph

The effects of 8 day continuous subcutaneous (s.c.) infusions of growth hormone releasing hormone analogue (NLE27GRF(1-29)NH2 (GHRH.A)) on growth hormone (GH) secretion were studied in 14 normal adult male volunteers. GHRH.A was administered in doses which ranged from 7.5 to 120 ng/kg/min in doubling steps. Baseline GH profiles obtained during a 24 h infusion of normal saline in each subject were compared with profiles performed on days 1 and 8 of the infusion. Doses above 30 ng/kg/min augmented GH pulse amplitude and frequency. Doses of 60 ng/kg/min and 120 ng/kg/min appeared more satisfactory as these represented doses on the upwards slope of the dose response curve. However, at a dose of 120 ng/kg/min the GH secretion did not return to baseline for 12 of the 24 h. There was no evidence of desensitization or of depletion of the releasable GH pool with any dose. The possibility of treatment of short children with depot preparations of GHRH.A appears promising.

The molecular basis of growth hormone deficiency

A well-known law states that 'if a thing can go wrong it will go wrong'. This clearly applies to the hypothalamic-pituitary-somatic axis as to many other physiological and biochemical systems. Defects of this axis, giving rise to stunted growth, can occur at several different points, as has been discussed in detail in this review. Defects at the level of the brain can lead to inadequate production or secretion of the factors that control growth hormone secretion. Defects at the level of the pituitary can lead to failure to produce or secrete adequate quantities of growth hormone, or to production of inactive hormone. Defects at the level of target organs can lead to inability to respond to growth hormone or somatomedins. The axis involved in the production and effects of growth hormone is a complex one, and defects have been identified at most of the points that 'could go wrong', although in many cases the molecular details are far from fully understood. Increased understanding of the biochemistry and physiology of the hormonal control of growth, and of the impairments to which it is subject, should provide an improved basis for treatment of growth defects. Nevertheless, there remain many points at which our knowledge is very incomplete. The field is a rapidly moving one and further developments in both basic understanding and clinical treatment are to be expected during the next few years.

The effect of total body irradiation and bone marrow transplantation during childhood and adolescence on growth and endocrine function

Seventeen children (11 M, 6 F) with acute leukaemia and myeloproliferative disorders were investigated for growth and endocrine dysfunction. All had undergone bone marrow transplantation prepared with cyclophosphamide and single fraction total body irradiation (900-1000 cGy) between 1.5 and 3.8 (mean 2.2) years previously. The majority of children exhibited growth failure, which was of multiple aetiology. Ten patients, of whom eight had had previous prophylactic cranial irradiation, had evidence of growth hormone deficiency based on the reduced growth hormone response to insulin induced hypoglycaemia. Three patients had evidence of hypothalamic damage as shown by their growth hormone response to 200 micrograms GHRH (1-29) NH2 intravenously. Gonadal failure was common, assessed clinically, and biochemically by basal gonadotrophin and sex steroid concentrations. All four girls of adolescent age (10.6-14.1 years) had ovarian failure requiring sex steroid replacement. Of the eight boys of adolescent age (12.3-18.3 years), two had testicular failure requiring sex steroid supplements. Both of these had had previous testicular irradiation. Five others had compensated gonadal failure, and one had normal Leydig cell function. Abnormalities of the TSH response to TRH occurred in 10 patients but only three had overt hypothyroidism. Unlike growth hormone deficiency, gonadal and thyroid dysfunction showed no correlation with previous cranial radiotherapy.

Plasma immunoreactive GHRH and serum GH concentrations following pulsatile GHRH 1-40 administration in GH deficient children

We have studied the clearance from plasma of immunoreactive growth hormone releasing hormone 1-40 (IR-GHRH) following intravenous (i.v.) and subcutaneous (s.c.) administration and the relationship between exogenous plasma IR-GHRH concentrations and GH secretion in five GH insufficient children receiving long term nocturnal pulsatile GHRH 1-40. The i.v. studies with GHRH 1-40 1 micrograms/kg demonstrated a distribution half life (t1/2) of 3.9 (SD 0.9) min and an elimination t1/2 of 53.1 (SD 3.2) min. In the s.c. studies the elimination phase was similar to the i.v. results but the transit time to the GHRH peak was slower than the i.v. distribution t1/2 9.9 (SD 3.6) min. These characteristics were maintained during successive pulses of subcutaneous GHRH. The mean IR-GHRH peaks following s.c. GHRH 1-40 administration of 1 microgram/kg and 2 micrograms/kg were 37- and 18-fold lower respectively than the mean IR-GHRH peak observed after the i.v. 1 microgram/kg bolus study. A significant correlation was shown between peak plasma IR-GHRH and serum GH concentrations during the s.c. (r = 0.75) but not the i.v. studies. Pulsatile GHRH administration has been shown to stimulate GH secretion and growth acceleration in GH insufficient children. Knowledge of the relationship between GHRH 1-40 absorption from the subcutaneous site and GH secretion is important for the development of an optimal GHRH treatment regimen in GH insufficient children.

The place of intravenous GHRH 1-40 studies in the therapy of growth hormone-deficient children with GHRH

We studied GH responses to i.v. GH releasing hormone (GHRH) (1 microgram/kg) before and during the treatment of 11 GH deficient children with s.c. nocturnal pulsatile GHRH 1-40; seven for 9 months and four for 6 months. Each subject demonstrated GH stimulation at each i.v. study. There was a wide variation of response between subjects and in each subject on different occasions. Significant growth acceleration following s.c. GHRH was demonstrated in eight of 11 patients (73%). The sensitivity or true positive rate of the index GHRH study to predict a clinical response to s.c. treatment, regardless of the GH response achieved, was also 73%. When an index GH 'cut-off' response of less than 10 mU/l was employed, the probability of an increase in growth rate to s.c. GHRH fell to 0.50 (sensitivity 80%). The GHRH study was unhelpful, and in fact misleading, when assessed as a method of monitoring clinical progress and the outcome of pulsatile s.c. GHRH treatment. The growth response of a child to s.c. GHRH therapy is of far greater importance than the GH response following an i.v. bolus of GHRH. The index study gave no useful indication of either the potential GH pituitary reserve or which subjects would respond to treatment. Pretreatment and repeated GHRH studies are of limited value and should be interpreted with caution.

Treatment of growth-hormone deficiency with growth-hormone-releasing hormone

18 prepubertal growth-hormone (GH)-deficient children were treated with twice-daily subcutaneous injections of a growth-hormone-releasing hormone analogue, GHRH (1-29) NH2. In 12 of the children the height velocity rose on GHRH treatment, and 8 were judged to have shown a worthwhile response to therapy in that their height velocities during the first 6 months of treatment increased by greater than 2 cm/yr (range 2.7-11.2 cm/yr). These 8 children have now been treated for 6 to 18 months and their increase in height velocity has been maintained. In the 14 patients who had previously received human GH (hGH) height velocity on hGH correlated with that on GHRH. 4 of these patients showed growth deceleration with GHRH, for unknown reasons. A pretreatment peak serum GH response of above 30 mU/l during an intravenous GHRH test was predictive of a good growth response to GHRH but a lower peak did not preclude a growth response. There was no consistent evidence of a priming or desensitisation effect of therapy on the GH responses to GHRH. Although anti-GHRH antibodies developed in 14 patients, these did not seem to have adverse effects on either growth or the GH responses to GHRH. GHRH (1-29) NH2 therapy is an alternative to conventional hGH in the treatment of some GH-deficient children. Ideal dose regimens need to be established.

Growth hormone releasing hormone in the assessment and long-term treatment of growth hormone deficiency

The secretion of hGH after the administration of the analogue of growth hormone releasing hormone, GHRH (1-29)NH2, to 8 normal adults and 41 short children has been studied. The children were classified on the basis of their hGH response to insulin-induced hypoglycaemia; 28 had severe hGH deficiency (peak serum hGH less than 7 mIU/litre) and 13 had simple short stature (peak serum hGH greater than 15 mIU/litre). The hGH response to GHRH was similar in normal adults and short stature children, but significantly lower in the hGH deficient children. In 23 (82%) of the hGH deficient children the peak serum hGH in response to GHRH was greater than 7 mIU/litre (the maximum value seen during hypoglycaemia), and in 14 (50%) the peak serum hGH in response to GHRH was greater than 15 mIU/litre. This suggests that in the majority of hGH deficient children the defect in hGH secretion results from hypothalamic GHRH deficiency. The hGH responses of the short stature children to insulin-induced hypoglycaemia were mainly in the low range of normal, and the majority showed normal hGH responses to GHRH. Eighteen prepubertal children with definite hGH deficiency have been treated for 3-18 months with twice daily, subcutaneous injections of GHRH. This has promoted linear growth in 12 children, of whom 8 showed an increment in height velocity of 2-11 cm/year. GHRH provides a valuable method for the assessment of hGH secretion, but by itself it cannot be used to establish deficient hGH secretion; this requires a stimulation test that promotes hypothalamic GHRH secretion, such as insulin-induced hypoglycaemia. GHRH is a practical alternative therapy to hGH for some hGH-deficient children.