Are short normal children at a disadvantage? The Wessex growth study

Dilemmas of growth hormone treatment for GH deficiency and idiopathic short stature: defining, distinguishing, and deciding

Worrisome growth can be a sign of underlying pathology but usually reflects healthy variation. It is often recognized through short stature, which is defined by arbitrarily separating height, a physical trait on a continuum, into "normal" and "abnormal." In some cases of worrisome growth, recombinant human growth hormone (rhGH) treatment is indicated to hasten growth/increase height. This review addresses the two most frequently treated indications for rhGH, growth hormone deficiency (GHD) and idiopathic short stature (ISS). A review of worrisome growth itself, of the history of GH treatment, of the blurry line between partial GHD and ISS, of the GH stakeholders, and of the outside pressures involved in these cases demonstrates the ambiguous platform upon which treatment decisions are made. The rhGH treatment decision process can be examined further by considering the three most impactful factors on parental height-related medical decision-making: treatment characteristics, child health, and psychosocial function. While it is important to note that treatment for classical GHD is uncontroversial and supported, treatment decisions for partial GHD and ISS are more complicated and require careful evaluation of both patient needs and the supporting evidence. As the rhGH community grows, physicians, parents, and patients are encouraged to engage in a shared decision-making process to navigate the many challenges facing the GH field. Although this review addresses GHD and ISS specifically, the issues discussed are often applicable to pediatrics as a whole.

How sociophenomenology of the body problematises the 'problem-oriented approach' to growth hormone treatment

This article examines how people who are shorter than average make sense of their lived experience of embodiment. It offers a sociophenomenological analysis of 10 semistructured interviews conducted in the Netherlands, focusing on if, how, and why height matters to them. It draws theoretically on phenomenological discussions of lived and objective space, intercorporeality and norms about bodies. The analysis shows that height as a lived phenomenon (1) is active engagement in space, (2) coshapes habituated ways of behaving and (3) is shaped by gendered norms and beliefs about height. Based on this analysis, the article challenges what we label as the 'problem-oriented approach' to discussions about growth hormone treatment for children with idiopathic short stature. In this approach, possible psychosocial disadvantages or problems of short stature and quantifiable height become central to the ethical evaluation of growth hormone treatment at the expense of first-hand lived experiences of short stature and height as a lived phenomenon. Based on our sociophenomenological analysis, this paper argues that the rationale for giving growth hormone treatment should combine medical and psychological assessments with investigations of lived experiences of the child. Such an approach would allow considerations not only of possible risks or disadvantages of short stature but also of the actual ways in which the child makes sense of her or his height.

Effects of Siwu decoction on chondrocyte proliferation of growth plate in adolescent rats

ETHNOPHARMACOLOGICAL RELEVANCE

According to traditional Korean medicine theory in which children's growth retardation is attributed to blood deficiency, Siwu decoction (SWD), a representative treatment for blood deficiency, was chosen as a sample.

AIM OF THE STUDY

To evaluate the effects of SWD on chondrocyte proliferation of growth plate in adolescent female rats.

MATERIALS AND METHODS

Female adolescent rats were allocated to one of the following four groups; SWD 100 and 300 mg/kg, recombinant human growth hormone, and vehicle for 4 days. Tetracycline was intraperitoneally injected at 48 h before sacrifice to obtain a band exhibiting fluorescence by binding newly formed bone. Bromodeoxyuridine was injected at day 2-4 to mark proliferating chondrocytes. To evaluate possible mechanisms of SWD, expressions of insulin-like growth factor-1 (IGF-1) and bone morphogenetic protein-2 (BMP-2) in the growth plate were examined by immunohistochemistry.

RESULTS

Treatment with SWD significantly increased the number of BrdU-positive chondrocytes and the new bone formation in the proximal growth plate of tibia compared to the vehicle treated control group. SWD also increased the expression of IGF-1 and BMP-2 in the proliferative and hypertrophic zones of the growth plate.

CONCLUSIONS

SWD 300 mg/kg stimulates chondrocyte proliferation and new bone formation in the growth plate. Immunohistochemical studies indicate that the effects of SWD may be due to upregulation of local IGF-1 and BMP-2 expression in the growth plate, which may be considered as a GH-dependent paracrine-autocrine pathway.

Growth hormone therapy and short stature-related distress: A randomized placebo-controlled trial

CONTEXT

Growth hormone (GH) treatment of short healthy children is based on the belief that short stature is associated with psychosocial problems and a diminished quality of life.

OBJECTIVE

To determine the impact of GH therapy on psychosocial well-being and the ability of psychological metrics to define short stature-related distress.

METHODS

Sixty prepubertal boys with idiopathic short stature (age: 10.0 ± 1.4 years, height-SDS: -2.38 ± 0.3) were enrolled in this 4-year intervention study (1-year double-blinded, randomized, placebo-controlled [GH/placebo-2:1] and 3-year open-labelled GH therapy). Explicit (conscious/voluntary) psychological metrics (Pediatric Quality of Life Inventory [PedsQL], Silhouette Apperception Test [SAT], Rosenberg Self-Esteem Scale [RSES], Child Behavior Checklist [CBCL]) and implicit (unconscious/involuntary) psychological metrics (Single-Category Implicit Association Test for height [SC-IAT-H], Height Perception Picture Test [HPPT]). Psychosocial evaluations were performed at study entry, after 1 and 4 years.

RESULTS

At study entry, PedsQL of boys with idiopathic short stature was lower than Israeli norms (P = 0.001). After 1-year blinded intervention, only the GH-treated boys improved their actual and anticipated adult height perception (SAT, P < 0.001 and P = 0.022) with reduced short stature-related distress (SC-IAT-H, P < 0.001). At study end, RSES and SC-IAT-H improved significantly (P < 0.001), with no change in PedsQL and CBCL.

CONCLUSIONS

Our finding of improved psychosocial functioning only in the GH-treated boys after 1-year blinded intervention suggests that it was the GH therapy, rather than being enrolled in a clinical trial, which contributed to the outcome. Long-term open-labelled GH treatment significantly improved height perception and self-esteem. Future studies are needed to fully assess the relevance of complementing the routinely used explicit self-report measures with the implicit measures.

Effects of Eleutherococcus Extract Mixture on Endochondral Bone Formation in Rats

Eleutherococcus extract mixture (EEM) is an herbal mixture of dried stem of Eleutherococcus sessiliflorus and germinated barley, which has been highly effective, in previous screening and among the traditional medicines to tonify innate qi and acquired qi, respectively. In this study, we investigate the effects of EEM on endochondral bone formation. Female adolescent rats were given EEM, growth hormone or vehicle for 10 days. Tetracycline was intraperitoneally injected to light the fluorescent band 72 h before sacrifice to determine endochondral bone formation. In order to evaluate endocrine or paracrine/autocrine mechanisms, expressions of insulin-like growth factor 1 (IGF1), insulin-like growth factor binding protein 3 (IGFBP3), or bone morphogenetic protein 2 (BMP2) were evaluated after EEM administration in liver or growth plate (GP). EEM oral administration significantly increased endochondral bone formation and proliferative and hypertrophic zonal heights of tibial GP. EEM also upregulated hepatic IGF1 and IGFBP3 mRNA expressions, and IGF1 and BMP2 expressions in GP. Taken together, EEM increases endochondral bone formation through stimulating proliferation and hypertrophy with upregulation of hepatic IGF1 and IGFBP3 expressions. Considering immunohistochemical studies, the effect of EEM may be due to increased local IGF1 and BMP2 expression in GP, which may be considered growth hormone (GH)-dependent endocrine and autocrine/paracrine pathways.

Cognition, Health-Related Quality of Life, and Psychosocial Functioning After GH/GnRHa Treatment in Young Adults Born SGA

BACKGROUND

Children born small for gestational age (SGA) with a poor adult height (AH) expectation benefit from treatment with GH and additional gonadotropin-releasing hormone analog (GnRHa). Because both SGA birth and GnRHa treatment might negatively influence cognition, health-related quality of life (HRQoL), and psychosocial functioning, we assessed these outcomes at AH.

METHODS

A randomized, dose-response GH study until AH involving 99 adolescents born SGA, of whom 61 children received 2 additional years of GnRHa treatment. At AH, the Wechsler Adult Intelligence Scale and TNO-AZL Adults Quality of Life questionnaire were administered to the study group. Additionally, the study group and 67 adolescents born SGA (19 GnRHa) from a second study group completed the Self-Perception Profile of Adolescents and Child/Adolescent Behavior Checklist at AH. Scores in GH-treated young adults with GnRHa treatment (GH/GnRHa group) were compared with GH-treated adolescents without GnRHa treatment (GH group) and a reference population.

RESULTS

Mean age (SD) at AH was 17.5 (1.2) and 17.4 (1.4) years in the GH/GnRHa and GH group, respectively. Intelligence quotient scores were similar in GH/GnRHa and GH groups (96.33 vs 92.47). HRQoL was similar between both groups and also when compared with the reference population, but the GH/GnRHa group had a significantly lower perception of cognitive functioning. Self-perception and problem behavior were similar in the GH/GnRHa and GH groups. AH did not correlate with HRQoL, self-perception, or problem behavior.

CONCLUSION

Combined GH/GnRHa treatment has no long-term negative effects on cognition, HRQoL, self-perception, and behavior in early adulthood, compared with GH treatment only.

Associations between Psychological Problems and Quality of Life in Pediatric Short Stature from Patients' and Parents' Perspectives

Short stature has been associated with psychosocial impairments, but whether treatments and achieved height impact on health-related quality of life (HrQoL) and psychological functioning of children/adolescents is still controversial. This study aimed to examine the effects of height deviation and treatment status on psychosocial adaptation outcomes and to identify clinical and psychosocial determinants of internalizing/externalizing problems in a large cohort of short statured children/adolescents from seven European countries. Participants were 345 children aged 8–18 years with a clinical diagnosis of short stature and 421 parents of 4–18 year-old patients. Children and parents reported on psychological problems (Strengths and Difficulties Questionnaire), generic (KIDSCREEN) and condition-specific HrQoL (QoLISSY). According to analyses of covariance, children/adolescents with current short stature presented more parent-reported internalizing problems and lower self- and parent-reported condition-specific HrQoL, compared to patients with an achieved height above -2SD. Treated children self-reported better HrQoL than the untreated group. Hierarchical regression analysis showed that, rather than height–related clinical variables, children’s sex, younger age and poorer HrQoL were the best predictors of psychological problems, explaining 39% of the variance in patient- and 42% in parent-reported internalizing problems, and 22% of the variance in patient- and 24% in parent-reported externalizing problems. Treatment status also moderated the negative links between patient-reported HrQoL and internalizing problems, explaining 2% of additional variance. These results suggest that children with current short stature are at greater risk for internalizing problems. Routine assessment of HrQoL in pediatric healthcare may help identify children for referral to specialized psychological assessment and intervention.

Effects of Phlomis umbrosa Root on Longitudinal Bone Growth Rate in Adolescent Female Rats

This study aimed to investigate the effects of Phlomis umbrosa root on bone growth and growth mediators in rats. Female adolescent rats were administered P. umbrosa extract, recombinant human growth hormone or vehicle for 10 days. Tetracycline was injected intraperitoneally to produce a glowing fluorescence band on the newly formed bone on day 8, and 5-bromo-2'-deoxyuridine was injected to label proliferating chondrocytes on days 8-10. To assess possible endocrine or autocrine/paracrine mechanisms, we evaluated insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3) or bone morphogenetic protein-2 (BMP-2) in response to P. umbrosa administration in either growth plate or serum. Oral administration of P. umbrosa significantly increased longitudinal bone growth rate, height of hypertrophic zone and chondrocyte proliferation of the proximal tibial growth plate. P. umbrosa also increased serum IGFBP-3 levels and upregulated the expressions of IGF-1 and BMP-2 in growth plate. In conclusion, P. umbrosa increases longitudinal bone growth rate by stimulating proliferation and hypertrophy of chondrocyte with the increment of circulating IGFBP-3. Regarding the immunohistochemical study, the effect of P. umbrosa may also be attributable to upregulation of local IGF-1 and BMP-2 expressions in the growth plate, which can be considered as a GH dependent autocrine/paracrine pathway.

Short Stature: Is It a Psychosocial Problem and Does Changing Height Matter?

Some proponents of recombinant human growth hormone (rhGH) treatment in growth hormone-sufficient children cite height, as an isolated physical characteristic, as being associated with psychosocial morbidity. Others question the reliability of the evidence underpinning the quality-of-life rationale for treatment as well as the bioethics of rhGH treatment. The following questions are addressed: (1) Is short stature an obstacle to positive psychosocial adjustment? and (2) Does increasing height with rhGH treatment make a difference to the person's psychosocial adaptation and quality of life? Three clinical case examples are used to illustrate the complexities associated with decision-making surrounding rhGH use.

Understanding the impact of statural height on health-related quality of life in German adolescents: a population-based analysis

Improving health-related quality of life (HrQoL) is one aim of growth hormone treatment for short-statured patients. Yet, evidence of the relationship between height and HrQoL is inconclusive, especially for young people. This study investigates the association of height and HrQoL in the general German adolescent population. A total of 6646 adolescents and 6388 parents from the German Health Interview and Examination Survey for Children and Adolescents (KIGGS) were included in the analysis. An analysis of covariance was used to evaluate the effect of height deviation on HrQoL as assessed with the KINDL-R in adolescent self-report and parent-report, taking into account sociodemographic and health-related variables. Height was found to be a weak predictor of HrQoL in both adolescent-report and parent-report. Short and tall adolescents did not substantially differ from the normal statured. Sociodemographic and health-related variables failed to significantly interact with height. In contrast, psychosocial variables contributed to the explained HrQoL variance.

CONCLUSION

Height does not appear to be a strong determinant of HrQoL on the population level. These results suggest that the height gain in short stature treatment may not be the most important objective. Contrary to prevalent stereotypes, short adolescents can experience a high HrQoL.

Parents' perception about child's height and psychopathology in community children with relatively short stature

PURPOSE

This study investigated the relationship between height and psychopathology in community children with relatively short stature according to the parents' reports. Also, the matter of parental concern about child's height was explored.

METHODS

The child behavior checklist (CBCL), the Brief Encounter Psychosocial Instrument (BEPSI), and the child-health questionnaire-parent form 50 (CHQ-PF50) were administered to 423 parents (from elementary and middle school children's) in Gangnam, South Korea. Subjects were divided into three groups; (1) relatively short (n=30), (2) average stature (n=131), (3) relatively tall (n=153). CBCL, BEPSI, and CHQ-PF50 scores were compared among three groups.

RESULTS

There were no significant differences in psychosocial burden associated with relatively short stature measured by Korean version of the BEPSI and Korean version of the CBCL scores among three groups. But general health perception score of relatively short was significantly lower than that of nonshort on the CHQ-PF50. Also, they were more used complementary medicines, milk and growth hormone compared to the nonshort. The parents' expected height of their children was 180.6±3.5 cm for boys and 166.7±3.5 cm for girls. This is respectively 90 percentile and 75-90 percentile for the Korean standard adult height.

CONCLUSION

Our study shows that in Korea, Parents tended to regard relatively short children as having health problems. Also, the parental expectation for their child's attainable height is unrealistically tall, mostly due to lack of correct medical information.

Implications of parent and child quality of life assessments for decisions about growth hormone treatment in eligible children

OBJECTIVE

To determine differences between parents and children in ratings of child health-related quality of life (HRQL) prior to growth hormone treatment.

METHOD

HRQL measures were collected from 144 children and their caregivers. Inclusion criteria were aged between 10 and 16 years, diagnosed with Turner's syndrome, acquired or idiopathic growth hormone deficiency (AGHD or IGHD) and eligible to begin human GH treatment (GHT), or non-growth hormone deficient (GHD) short stature.

RESULTS

Parents rated children to have poorer physical and psychosocial HRQL than children rated themselves. Differences depended on the measure used. Parents rated children with IGHD and non-GHD short stature better than children rated themselves, but they rated children with AGHD or Turner's much worse than children rated themselves in terms of physical but not psychosocial functioning.

CONCLUSIONS

Decisions to prescribe GHT should include children's perspectives of HRQL whenever possible. Differences between parents and children are most likely in conditions that involve more complex medical needs (AGHD and Turner's). Generic and disease-specific HRQL measures may vary in sensitivity to HRQL differences between groups. More work is required to evaluate HRQL among younger children.

Debate: idiopathic short stature should be treated with growth hormone

In this paper we outline the case for and against the treatment of idiopathic short stature with growth hormone. Drs Ambler and Fairchild argue that many of those with 'idiopathic' short stature are not 'short, normal children' and will ultimately receive molecular diagnoses. They also argue that there is a subset of children who suffer negative psychosocial consequences of their stature for whom growth hormone therapy is effective. Growth hormone has a very good safety record and is likely to be as cost-effective in idiopathic short-stature as in some other conditions that are currently funded. Dr Wilkinson counters that short stature is not associated with physical or psychological illness, and that there is no evidence that growth hormone improves psychological or physical wellbeing. Moreover, growth hormone for idiopathic short stature represents a form of enhancement rather than treatment, and is not a fair use of resources. Socially mediated disadvantage should be treated by attention to prejudice and not by hormone treatment.

Physical growth and cognitive skills in early-life: evidence from a nationally representative US birth cohort

This paper establishes associations between length/height and cognitive skills in infancy, toddlerhood, and school-entry. The data come from the Early Childhood Longitudinal Study--Birth Cohort (ECLS-B), a representative longitudinal sample of US children born in 2001. A positive association between length/height and cognition is found as early as 9 months and continues through school-entry. These associations are robust to controls for birthweight and economic status. Early growth is also shown to be a stronger predictor of reading and math skills in kindergarten than attained height. Girls exhibit stronger evidence of this latter result than boys. These findings have implications for the interpretation of early life as a critical period for the growth-cognition relationship.

Height and health-related quality of life: a nationwide population study

CONTEXT

Treatment for short stature in childhood has been recommended with the purpose of improving adult health-related quality of life (HRQoL). However, there are only limited data available concerning the consequences of body height for HRQoL in adulthood.

OBJECTIVE

Our objective was to investigate the relationship between body height and HRQoL.

DESIGN, SETTING, AND PARTICIPANTS

This national representative, cross-sectional household survey of the French general noninstitutionalized population included 8857 men and 9248 women, aged 18-50 yr, in 2003.

MAIN OUTCOME MEASURES

Scores on the eight subscales of the Medical Outcomes Study 36-item Short Form (SF-36) were the primary outcomes. Univariate and multivariate linear regression analyses were used to evaluate the effect of height on HRQoL while controlling for age and various socioeconomic variables and pathological conditions.

RESULTS

Height was found to be a very weak predictor of HRQoL both for men and women. Only heights lower than 149.2 and 136.0 cm and higher than 203.6 and 188.7 cm, in men and women, respectively, were associated with a clinically significant reduction in physical functioning. The effects of body height on other (mental and social) dimensions of HRQoL were negligible or undetectable.

CONCLUSIONS

Height appears to have minimal consequences for physical functioning and negligible effects on other dimensions of HRQoL. These results contrast with widely popularized stereotypes and common beliefs and should be carefully considered to avoid further stigmatization and unnecessary medical care of individuals who are at the lower end of the growth distribution.

Emerging options in growth hormone therapy: an update

Growth hormone (GH) was first used to treat a patient in 1958. For the next 25 years it was available only from cadaver sources, which was of concern because of safety considerations and short supply. In 1985, GH produced by recombinant DNA techniques became available, expanding its possible uses. Since that time there have been three indications approved by the US Food and Drug Administration (FDA) for GH-deficiency states and nine indications approved for non-GH-deficiency states. In 2003 the FDA approved GH for use in idiopathic short stature (ISS), which may indirectly cover other diagnoses that have short stature as a feature. However, coverage for GH therapy is usually more reliably obtainable for a specific indication, rather than the ISS indication. Possible future uses for GH therapy could include the treatment of syndromes such as Russell-Silver syndrome or chondrodystrophy. Other non-short-stature indications could include wound healing and burns. Other uses that have been poorly studied include aging and physical performance, in spite of the interest already shown by elite athletes in using GH. The safety profile of GH developed over the past 25 years has shown it to be a very safe hormone with few adverse events associated with it. The challenge for the future is to follow these patients into adulthood to determine whether GH therapy poses any long-term risks.

Health-related quality of life and cognitive functioning in pediatric short stature: comparison of growth-hormone-naïve, growth-hormone-treated, and healthy samples

The objective of this study was to evaluate the impact of short stature on generic health-related quality of life (HRQOL) and cognitive functioning in pediatric patients. Eighty-nine youth, 48 who were initially seen with short stature (SS group) and 41 with a history of short stature being treated with growth hormone (GHT group) and one of their legal guardians participated in the study. HRQOL and cognitive functioning were assessed using the PedsQL™ 4.0 Generic Core Scales and PedsQL™ Cognitive Functioning Scale. Comparisons were made between the study groups and with a previously obtained matched healthy sample. For the GHT group, height Z score was found to be a positive predictor of overall HRQOL while duration of GHT was found to be a predictor of physical functioning. For the SS group, the difference between midparental height Z score and height Z score was found to be a negative predictor of overall HRQOL and cognitive functioning. Comparison with the healthy sample demonstrated significant negative impact on HRQOL for child self-report and on HRQOL and cognitive functioning for parent proxy-report in both study groups. The GHT group had a significantly higher child self-reported Physical Functioning score than the SS group (effect size (ES) = 0.52, p < 0.05). In conclusion, the GHT group had slightly better HRQOL scores than the SS group, but the difference was not statistically significant. Both groups had significantly lower HRQOL and cognitive functioning scores than healthy sample. Predictors of HRQOL and cognitive functioning found in this study lend support to the use of the PedsQL™ 4.0 Generic Score Scales and PedsQL™ Cognitive Functioning Scale in routine assessment of children with short stature in order to identify children at increased risk for impaired HRQOL and cognitive functioning.

Growth hormone use in children: necessary or designer therapy?

Society often rewards the beautiful, the smart, and the intelligent. The possibility that children with idiopathic short stature (ISS) will sustain psychological damage as a result of ridicule from their peers is a concern. The desire for children to become tall adults provides a difficult quandary for parents and caregivers. Growth hormone (GH) treatment in children requires subcutaneous injections six to seven times weekly. The cost of treating with GH can be more than $52,000, and many third-party payers do not cover the cost of GH treatment. Research to date would indicate that while the administration of GH may improve final adult height in children with ISS, children treated with GH will remain short when compared with peers. More research is needed to study whether the administration of GH is beneficial for children with ISS. This article will discuss ISS and the use of GH in children.

Relationship between childhood short stature and academic achievement in adolescents and young adults--a longitudinal study

AIM

To determine if short stature at 14 or 21 years and patterns of 'catch-up' growth from 5 to 14 or 21 years are related to academic achievement in adolescents.

METHODS

The Mater University of Queensland Study of Pregnancy is a longitudinal study of 7223 singleton infants born between 1981 and 1984. Data were available for cross-sectional analyses of 3785 adolescents of whom 2149 were seen as young adults. Longitudinal patterns of growth were examined for 2936 subjects from 5 to 14 years and 1753 subjects from 5 to 21 years.

RESULTS

Adolescents or young adults with height <10th centile had a lower mean Wide Range Achievement Test (WRAT) score in adolescence and at 21 years than those of normal height (2.7 and 3.0 points, respectively) and increased odds of a WRAT score <85 (1.57 and 1.87, respectively) and learning difficulties (1.61 and 1.78, respectively). For growth patterns from 5 to 14 years, adolescents short at 5 years, irrespective of height at 14 years, had a lower mean WRAT score and increased odds of WRAT score <85 and learning difficulties. However, for growth patterns from 5 to 21 years, only the group short at both ages had increased learning difficulties.

CONCLUSIONS

Youth short at 14 years or at 21 years and those persistently short have an increased prevalence of academic difficulties. Catch-up growth by 21, although not 14 years, was associated with improved outcomes.

Managing idiopathic short stature: role of somatropin (rDNA origin) for injection

Idiopathic short stature (ISS) is a term that describes short stature in children who do not have growth hormone (GH) deficiency and in whom the etiology of the short stature is not identified. Between 1985 and 2000, more than 40 studies were published regarding GH therapy for ISS. Only 12 of these had data to adult height, of which only 4 were controlled studies. A subsequent placebo-controlled study that followed subjects to adult height indicated that there was a gain of 3.7–7.5 cm in height with GH treatment. In 2003, the US Federal Drug Administration (FDA) approved GH for treatment of short stature. Even before FDA approval, patients with ISS made up about 20% of patients in GH databases, which is largely unchanged since FDA approval. There remains some controversy as to whether GH should be used to treat ISS. This controversy centers on the fact that there has been no definitive demonstration that short stature results in a disadvantage or problems with psychological adjustment, and thus, no demonstration that GH therapy results in improvement in quality of life.

Mental health and psychosocial functioning in adolescents with esophageal atresia

PURPOSE

We examined mental health and psychosocial functioning in adolescents with esophageal atresia (EA) and searched for predictors of impaired outcome.

METHODS

The study group comprised 21 adolescents with EA and 1 or both parents. A comparison group comprised 36 adolescents from the general population. Mental health, self-esteem, psychosocial functioning, and parental/family functioning were assessed by standardized questionnaires and semistructured interviews. Physical health was assessed by growth and clinical symptoms.

RESULTS

Mental health and psychosocial functioning did not differ from the comparison group. Seven of 21 EA adolescents had special education. Dilatations of esophagus, birth weight, well-being, and maternal psychological distress were prognostic factors predicting mental health. Height, birth weight, well-being, dissociative symptoms, and family strain were prognostic factors predicting psychosocial functioning.

CONCLUSION

Adolescents with EA adjusted well, and mental health and psychosocial functioning did not differ from controls. Dilatations of esophagus and birth weight were significant predictors of mental health and psychosocial functioning.

Idiopathic short stature: conundrums of definition and treatment

Children with idiopathic short stature (ISS) are statistically defined by height SDS < −2 for their bone age and should be distinguished from children with familial short stature for whom height SDS corresponds to mean parental SDS and from the most common explanation for short stature referred to pediatric endocrinologists, constitutional delay in growth and maturation (CDGM), in which there is normal height for bone age and predicted normal adult stature. Low IGF-I levels reported in ISS may be the result of subtle undernutrition or reference to standards appropriate for chronologic age but not osseous maturation in CDGM inappropriately labeled as ISS. While growth hormone (GH) treatment of ISS may add 4-5 cm to adult height, meta-analysis indicates that there is no documented evidence that such treatment improves health related quality of life or psychological adaptation. Thus, the estimated cost of US$52 000/inch gained is difficult to justify. Absence of data regarding efficacy of the use of IGF-I for treatment of ISS has been noted in a recent consensus statement from the North American and European pediatric endocrinology societies. This report further emphasizes the importance of discouraging the expectation that taller stature from GH treatment will improve quality of life.

Childhood growth and development associated with need for full-time special education at school age

OBJECTIVE

To explore how growth measurements and attainment of developmental milestones in early childhood reflect the need for full-time special education (SE).

METHODS

After stratification in this population-based study, 900 pupils in full-time SE groups (age-range 7-16 years, mean 12 years 8 months) at three levels and 301 pupils in mainstream education (age-range 7-16, mean 12 years 9 months) provided data on height and weight from birth to age 7 years and head circumference to age 1 year. Developmental screening was evaluated from age 1 month to 48 months. Statistical methods included a general linear model (growth measurements), binary logistic regression analysis (odds ratios for growth), and multinomial logistic regression analysis (odds ratios for developmental milestones).

RESULTS

At 1 year, a 1 standard deviation score (SDS) decrease in height raised the probability of SE placement by 40%, and a 1 SDS decrease in head size by 28%. In developmental screening, during the first months of life the gross motor milestones, especially head support, differentiated the children at levels 0-3. Thereafter, the fine motor milestones and those related to speech and social skills became more important.

CONCLUSION

Children whose growth is mildly impaired, though in the normal range, and who fail to attain certain developmental milestones have an increased probability for SE and thus a need for special attention when toddlers age. Similar to the growth curves, these children seem to have consistent developmental curves (patterns).

Body image in adolescents with disorders of steroidogenesis

AIM

Little is known about body image in children with endocrine conditions. We evaluated body image in children with congenital adrenal hyperplasia (CAH), familial male precocious puberty (FMPP), and Cushing's syndrome (CS).

STUDY DESIGN

We compared 67 patients (41 CAH, 12 FMPP, 14 CS) age 8-18 years with 55 age-matched controls.

RESULTS

Patients expressed more weight unhappiness than controls (females: p < 0.001; males: p = 0.01). This difference remained for females after adjusting for body mass index (BMI) (p = 0.03), but not for males (p = 0.12). Unhappiness with height and age of appearance was similar between groups. In female patients, higher BMI was a significant predictor of weight unhappiness (p = 0.01).

CONCLUSION

Adolescents with CAH, FMPP, and CS are at risk for negative body image regarding weight, but not height or age of appearance. Weight unhappiness is partially related to greater weight, but factors unrelated to physical findings seem to contribute to negative body image in female patients.

Issues in measuring child health

Assessing child health is critical to a variety of child health, educational, and social programs, as well as to clinical research and practice. However, despite the apparent wealth of measures available in health, education, and legal and social welfare systems, little agreement exists as to what are the most important measures and for what domains of health. Development of improved measures may capitalize on advances in conceptualization of child health, including the dynamic nature of the interplay of child health and development over time. The need for enhanced measures can be illustrated by consideration of various aspects of pediatric care: well-child care, acute illness care, and the management of children with special health care needs. In particular, the strong theoretical perspectives on aspects of development such as cognition and behavioral development need to be informed by the experience of various states of health and their developmental implications. If generalist academicians are to further their research and educational mission, they must engage, and urgently, in the development and measurement of child health.

Idiopathic short stature: management and growth hormone treatment

In the management of ISS auxological, biochemical, psychosocial and ethical elements have to be considered. In boys with constitutional delay of growth and puberty androgens are effective in increasing height and sexual characteristics, but adult height is unchanged. GH therapy is efficacious in increasing height velocity and adult height, but the inter-individual variation is considerable. The effect on psychosocial status is uncertain. Factors affecting final height gain include GH dose, height deficit in comparison to midparental height, age and first year height velocity. In case of a low predicted adult height at the onset of puberty, addition of a GnRH analogue can be considered. Although GH therapy appears safe, long-term monitoring is recommended.

Associations of birth size, gestational age, and adult size with intellectual performance: evidence from a cohort of Norwegian men

The influences of prenatal and postnatal growth on intellectual performance are unclear. We examined the associations of birth size and gestational age with intellectual performance and explored whether these associations were influenced by adult body size and social factors. In this nationwide cohort study, the records of 317,761 male infants registered in the Medical Birth Registry of Norway (1967-1979) were linked to the Norwegian Conscript Service (1984-1999). The variation in intelligence test score at age 18 due to birth weight and birth length was evaluated using absolute and standardized (z scores) values. Mean intelligence score increased by gestational age, birth weight, and birth length. However, a decline in intellectual performance was observed for gestational age >41 wk and birth weight >4500 g. There was a strong interaction on intellectual performance between birth size and gestational age (p < 0.0005). Adjusting for adult size strongly attenuated the association of birth size with intellectual performance. The overall R of intellectual performance explained by birth size was <1%; however, adding adult body size and social factors to the model increased R to 12%. In conclusion, the association of birth size with intellectual performance was weak, but still present after adjustment for adult body size and social factors.

Association between low height and eating disorders: cause or effect?

OBJECTIVE

Few studies have explored the relationship between stature and eating disorders (ED). We aimed to investigate the connection between height and risk for ED in a cohort of female subjects.

METHOD

The sample was composed of 1,031 subjects with ED and 832 controls. All participants belonged to the same birth cohort and were living in the same geographical area.

RESULTS

ED subjects were, on average, shorter than control subjects, independently from the age of onset. In early-onset anorexia nervosa only, age of onset and lowest body mass index were significant predictors of height. In the whole sample, a lower height was associated with an increased risk of having an ED, even after controlling for possible confounding variables.

CONCLUSION

The association between EDs and low stature is statistically significant. Further studies are necessary to understand which genetic and/or environmental factors might explain this association.

An evaluation of the relationship between adult height and health-related quality of life in the general UK population

OBJECTIVE

Short stature has previously been shown to influence several social factors during childhood and adult life. However, limited data exist to determine the influence of short stature on health-related quality of life (HRQoL) because of underpowered studies and the fact that children find questionnaires very difficult to complete. The objective of this study was to examine the influence of height on HRQoL for the general adult population in the UK.

DESIGN

The 2003 Health Survey for England (HSE03), commissioned by the Department of Health, provides a random general population sample for the population living in private households in England. Observations for 14 416 adults (aged > 18 years) were included in the analysis.

MEASUREMENTS

The survey involved a questionnaire-based interview and a nurse visit, where measurements and blood samples were taken. HRQoL was measured using the EQ-5D questionnaire. Social class (I-V) was derived according to definitions from UK National Statistics. Height was converted from centimetres to height standard deviation scores (HSDS).

RESULTS

Mean EQ-5D scores were lower in subjects with greater height deficit than in taller subjects. Three significantly different subgroups were identified using an analysis of variance (anova). The first subgroup 'HSDS </= -2.0' had significantly lower EQ-5D scores compared with the second group '-2.0 > HSDS </= 0' and the third group 'HSDS > 0'. Multivariate linear regression analysis showed significant correlations between height and HRQoL, such that an increase in height of 1 HSDS predicts an improvement in EQ-5D score of 6.1% for subjects shorter than -2.0 HSDS. Social class was a significant predictor of HRQoL in taller, but not in shorter, subjects.

CONCLUSION

The results of this study demonstrate that height in adult life is correlated with HRQoL and that short stature in adult life may be associated with a significant reduction in HRQoL.

Growth status related to brain responses, nutrition, home environment, and behavior in infants and toddlers

To investigate whether growth status in infants and toddlers affects processes involved in speech perception and discrimination, cortical event-related potentials (ERPs) to consonant-vowel syllables were recorded from 48 healthy babies: 26 low in growth status (LGS, < 25 th percentile in growth measures) and from 22 normal in growth status (NGS, 25t--75 th percentile in growth measures). Food records indicated no significant differences in the amounts of various nutrients consumed in the two groups, but LGS babies consumed slightly more of most nutrients than NGS babies. In response to speech stimuli (either /pa/ or /ba/ presented with 20 and 80% randomized occurrence), brain ERPs showed two prominent post-stimulus components: a large positive wave peaking at about 484 msec and a negative but positive going slow wave (SW) between 867 and 1199 msec. Principal components analysis followed by promax rotation revealed four additional important components. Maximum peak and latency values-for these components showed that NGS and LGS babies differed from one another on all measures in either amplitude, latency, or both. Comparing the two groups of babies, only the LGS group demonstrated a deficit in the phonetic discrimination of speech sounds. The growth deficiencies of the LGS group could not be attributed to the lack of an adequate diet. These negative findings are present in babies generally considered to be healthy (lowest 10-25% in growth measures). This underscores the need for research examining in more detail the relationship between growth status and cognitive growth.

Age at Growth Hormone Therapy Start and First-Year Responsiveness to Growth Hormone Are Major Determinants of Height Outcome in Idiopathic Short Stature

AIM

To develop methods to identify factors associated with a favorable outcome in GH-treated children with idiopathic short stature (ISS).

METHODS

From 4,685 children listed as having ISS within KIGS (Pfizer International Growth Database), we studied (a) the prediction model group (n = 657) to develop the first-year prediction model, and (b) the near adult height group (NAH; n = 256) which received GH for >4 years to develop descriptive models for adult height and overall height gain.

RESULTS

NAH group at GH start: age was 10.0 years, height -2.5 SD score (SDS), weight -2.3 SDS, height minus mid-parental height (MPH) -1.5 SDS; GH dose 0.19 mg/kg/week. Height gain was 1.1 SDS at a median age of 17.2 years. Growth response correlated positively with GH dose and weight at the start of GH treatment, and negatively with age and height SDS minus MPH SDS. The model explains 39% (error SD 1.2 cm) of the variability. Adult height correlated (R(2) = 0.64) positively with height at GH start, MPH and the first-year responsiveness to GH, and negatively with age.

CONCLUSIONS

Prepubertal children with ISS who show an appropriate first-year response to GH are likely to benefit from long-term treatment, even on low GH dosages.

Growth in early life and childhood IQ at age 11 years: the Newcastle Thousand Families Study

BACKGROUND

It has been suggested that in addition to genetic factors, fetal and post-natal growth influence childhood cognition, although it is unclear whether such an effect continues throughout childhood. This study aimed at investigating the potential relationships between childhood IQ at age 11 years and birth weight and height at the ages of 9 and 13 years, after adjusting for the confounding factors available to this investigation.

METHODS

The Newcastle Thousand Families study, a prospectively followed cohort, originally consisted of all 1142 births in the city of Newcastle in May and June 1947. Using data on 733 members of this cohort, we investigated the associations between IQ at age 11, and birth weight and height at ages 9 and 13 years.

RESULTS

Birth weight showed no association with childhood IQ. However, height at age 9 years was a significant predictor of childhood IQ after adjusting for socioeconomic status (standardized regression coefficient b = 2.6, 95% CI 1.6-3.6, P < 0.0001). Height at age 13 was also a significant predictor of IQ after adjusting for socioeconomic status (b = 3.4, 95% CI 2.3-4.4, P = 0.001), and explained an additional 2.5% of the variation in IQ scores to that already explained by socioeconomic status and height at age nine.

CONCLUSIONS

These results suggest a continuing effect of post-natal growth on childhood cognition beyond the age of 9 years. Post-natal growth, which may be influenced by genetic factors and nutrition and socioeconomic circumstances in childhood, may be more important than fetal growth in terms of childhood cognition.

Psychological adaptation in children with idiopathic short stature treated with growth hormone or placebo

The influence of short stature on psychological adaptation in childhood and adolescence is controversial. GH is currently used to treat children with idiopathic short stature (ISS, also known as non-GH-deficient short stature). This study represents the first double-blind, placebo-controlled trial of the effects of GH on the psychological adaptation of children and adolescents with ISS, treated with GH until adult height was attained.Sixty-eight children (53 males, 15 females), 9-16 yr old, with marked ISS (measured height or predicted adult height -2.5 sd or less) received either GH 0.074 mg/kg or placebo sc three times per week until height velocity decreased to less than 1.5 cm/yr. Parents completed the Child Behavior Checklist (CBCL) and children the Self-Perception Profile (SPP) and Silhouette Apperception Technique at baseline and annually thereafter. Baseline behavioral/emotional adjustment (CBCL) and self-concept (SPP) scores for children with ISS were within the normative range. The two study groups exhibited similar behavioral and self-concept profiles (CBCL) during the first 2 yr of the study. However, CBCL behavior problems (internalizing, externalizing, and total problems) appeared to decline, in yr 3 and 4, in the GH-treated group relative to the placebo-treated group. Group differences in CBCL competency domains and the SPP were not observed at any point during the study. Short stature among children with ISS enrolled in this long-term, placebo-controlled study was not associated with problems in psychological adaptation or self-concept with the psychological instruments employed. GH treatment was associated with a trend toward improvement in problem behaviors, as measured by questionnaires (CBCL) completed by study participants' parents. It remains to be determined whether GH treatment significantly impacts adaptation, psychosocial function, or quality of life in children with ISS.

Personality functioning: the influence of stature

BACKGROUND

The Wessex Growth Study has monitored the psychological development of a large cohort of short normal and average height control participants since school entry.

AIMS

To examine the effect of stature on their personality functioning now that they are aged 18-20 years.

METHODS

This report contains data from 48 short normal and 66 control participants. Mean height SD score at recruitment was: short normals -2.62 SD, controls -0.22 SD. Final height SD score was: short normals -1.86, controls 0.07. The Adolescent to Adult Personality Functioning Assessment (ADAPFA) measures functioning in six domains: education and employment, love relationships, friendships, coping, social contacts, and negotiations.

RESULTS

No significant effect of recruitment height or final height was found on total ADAPFA score or on any of the domain scores. Socioeconomic status significantly affected total score, employment and education, and coping domain scores. Gender had a significant effect on total score, love relationships, coping, and social contacts domain scores. Salient aspects of daily living for this sample were identified from the interviews (prevalence%): consuming alcohol (94%), further education (63%), love relationships (55%), current drug use (29%), experience of violence (28%), parenthood (11%), and unemployment (9%). Stature was not significantly related to behaviour in any of these areas.

CONCLUSIONS

Despite previously reported links between short stature and poorer psychosocial adaptation, no evidence was found that stature per se significantly affected the functioning of the participants in these areas as young adults.

Early childhood stunting and later behaviour and school achievement

BACKGROUND

Stunting in early childhood is common in developing countries and is associated with poorer cognition and school achievement in later childhood. The effect of stunting on children's behaviours is not as well established and is examined here.

METHOD

Children who were stunted at age 9 to 24 months and had taken part in a 2-year intervention programme of psychosocial stimulation with or without nutritional supplementation were reexamined at age 11-12 years and compared with non-stunted children from the same neighbourhoods. Their school and home behaviours were assessed using the Rutter Teacher and Parent Scales and school achievement was measured using the Wide Range Achievement Test (WRAT) and the Suffolk Reading Scales.

RESULTS

No significant intervention effects were found among the stunted groups. Thus data from the four intervention groups were aggregated for subsequent analyses, comparing all 116 stunted children with 80 non-stunted children. Controlling for social background variables, the stunted group had more conduct difficulties (p < .05) as rated by their parents. They also had significantly lower scores in arithmetic, spelling, word reading and reading comprehension than the non-stunted children (all p < .001). Conduct difficulties and hyperactivity were related to poorer school achievement. Controlling for the children's IQ, the stunted children's arithmetic scores remained significantly lower than those of the non-stunted children, but reading and spelling scores were not different.

CONCLUSIONS

Previously stunted children had more conduct difficulties at home, regardless of their social background, than non-stunted children. Their educational attainment was also poorer than non-stunted children and these results are suggestive of a specific arithmetic difficulty. Children with behaviour problems performed less well at school.

The psychosocial consequences of short stature: a review of the evidence

The advent of biosynthetic growth hormone (GH) has been accompanied by a transformation in the clinical management of youths with short stature. An important--if not always explicitly stated--goal of endocrine therapies is an improvement in the psychological adaptation of individuals with short stature. Negative stereotypes regarding short stature constitute a potential source of psychosocial stress for the affected child and, in turn, the entire family. Nevertheless, studies have demonstrated that the psychological adaptation of individuals who are shorter than average is largely indistinguishable from others, whether in childhood, adolescence or adulthood. "Short stature" as an isolated physical characteristic appears to hold little value as a predictor of the individual's psychological adaptation or quality of life. In order to avoid the unwarranted medicalizing of healthy short stature, clinicians would be well advised to incorporate factors beyond auxology in the decision-making algorithm when selecting and preparing patients for possible growth-promoting therapies.

Quality of life and self-esteem in children treated for idiopathic short stature

OBJECTIVE

Changes in health-related quality of life (HRQOL) and self-esteem were studied in children with idiopathic short stature (ISS) participating in a study on the effect of growth hormone treatment.

STUDY DESIGN

Prepubertal children (n = 36) with ISS were randomly assigned to a treatment or control group. Children with ISS, their parents, and the pediatrician completed HRQOL and self-esteem questionnaires 3 times in 2 years.

RESULTS

At the start, children with ISS did not have lower scores than the norm population, except for social functioning HRQOL. The pediatrician reported an improvement of HRQOL in the treatment group, the parents reported no change, and the children in the treatment group reported the same, or sometimes even worse, HRQOL or self-esteem than the control group. Changes related to the child's satisfaction with height and hardly to growth itself.

CONCLUSION

The assumption that growth hormone treatment improves HRQOL in children with ISS could not be supported in this study.

Secular growth and its harmful ramifications

Secular growth has been occurring in Europe for about 150 years. In the USA, since 1900, each new generation has increased by an average of 1in (2.54cm) in height and about 10lb (4.54kg) in weight. This trend has generally been viewed as favorable and tallness is admired, with the current ideal height for a man in the Western world being 6ft 2in (188cm). The Japanese have increased in height since the end of the Second World War by about 5in (12.7cm) in height and the Chinese have been growing at the rate of 2.54cm/decade since the 1950s. In spite of admiring greater height, a world population of increasing height and body-weight is a major threat to our environment, health and survival. Based on more than two decades of research, quantitative data are given for increased use of resources, and increased pollution, energy and fiscal costs resulting from a population of larger people. The laws of scaling are described to show why the impact of increasing stature has a non-linear impact on consumption, body-weight, strength, pollution and economic costs. Paleontological findings indicating that larger body size increases the risk of extinction are also discussed. Various studies indicate a loss of 0.47 year of longevity for each cm increment of height. Caloric restricted diets are also reviewed for their applicability to humans. Recommendations are made for dietary practices to moderate growth in our youth and to postpone development of chronic or degenerative diseases.

Optimizing gh therapy in adults and children

Until the advent of modern neuroradiological imaging techniques in 1989, a diagnosis of GH deficiency in adults carried little significance other than as a marker of hypothalamo-pituitary disease. The relatively recent recognition of a characteristic clinical syndrome associated with failure of spontaneous GH secretion and the potential reversal of many of its features with recombinant human GH has prompted a closer examination of the physiological role of GH after linear growth is complete. The safe clinical practice of GH replacement demands a method of judging overall GH status, but there is no biological marker in adults that is the equivalent of linear growth in a child by which to judge the efficacy of GH replacement. Assessment of optimal GH replacement is made difficult by the apparent diverse actions of GH in health, concern about the avoidance of iatrogenic acromegaly, and the growing realization that an individual's risk of developing certain cancers may, at least in part, be influenced by cumulative exposure to the chief mediator of GH action, IGF-I. As in all areas of clinical practice, strategies and protocols vary between centers, but most physicians experienced in the management of pituitary disease agree that GH is most appropriately begun at low doses, building up slowly to the final maintenance dose. This, in turn, is best determined by a combination of clinical response and measurement of serum IGF-I, avoiding supraphysiological levels of this GH-dependent peptide. Numerous studies have helped define the optimum management of GH replacement during childhood. The recent requirement to measure and monitor GH status in adult life has called into question the appropriateness of simplistic weight- and surface area-based dosing regimens for the management of GH deficiency in childhood, with reliance on linear growth as the sole marker of GH action. It is clear that the monitoring of parameters other than linear growth to help refine GH therapy should now be incorporated into childhood GH treatment protocols. Further research will be required to define the optimal management of the transition from pediatric to adult GH replacement; this transition will only be possible once the benefits of GH in mature adults are defined and accepted by pediatric and adult endocrinologists alike.