Threshold of evaluation for short stature in a pediatric endocrine clinic: differences between boys versus girls?

Efficacy, safety, and patient satisfaction of norditropin and sogroya in patients with growth hormone deficiency: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Growth hormone deficiency occurs when the pituitary gland does not produce enough growth hormone. Norditropin®, a recombinant human growth hormone, and Sogroya®, an albumin-binding growth hormone derivative, are prescribed for patients with growth hormone deficiency. This systematic review assesses the efficacy, safety, and patient satisfaction associated with Norditropin and Sogroya.

METHODS

We systematically searched PubMed, Web of Science, and Scopus databases to identify eligible comparative studies. All studies published until June 2023 were included in our analysis. Our outcomes for children included height velocity and height velocity standard deviation score. In contrast, adult outcomes included adverse events, insulin-like growth factor 1-standard deviation score (IGF-1 SDS), and the Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9). Results are reported as odds ratio (OR) and mean difference (MD) with a 95% confidence interval (95% CI).

RESULTS

Ten studies involving 1058 participants (665 children and 393 adults) were included in the meta-analysis. In children, Norditropin at doses of 0.034 and 0.067 mg/kg/day was compared to Sogroya at doses of 0.04, 0.08, 0.16, and 0.24 mg/kg/week. The results showed that 0.034 mg/kg/day Norditropin had a favorable impact on height velocity (MD -2.01, 95% CI -3.7 to -2.12, p < 0.00001) and height velocity standard deviation score (Mean Difference -3.61, 95% CI -5.06 to -2.16, p < 0.00001) when compared to Sogroya 0.04 mg/kg/day. Other doses showed comparable results. In adults, the only significant side effect noted was rash, which favored Sogroya (OR 0.1, 95% CI 0.04-0.27, p < 0.00001). Additionally, IGF-1 SDS was significantly higher in the Sogroya group than in the Norditropin group (MD 0.25, 95% CI 0.02-0.48, p = 0.03). Furthermore, the overall score of the TSQM-9 questionnaire, which includes three domains: convenience, effectiveness, and satisfaction, was significantly higher in the Sogroya group compared to the Norditropin group (OR 6.36, 95% CI 3.92-8.8, p < 0.00001).

CONCLUSION

Norditropin and Sogroya showed comparable efficacy and safety profiles, except for the prevalence of rash in the Norditropin group, and Sogroya has higher satisfaction among adults. More high-quality studies with more patients are required to confirm these results.

The Boy:Girl Ratio of Children Diagnosed with Growth Hormone Deficiency-Induced Short Stature Is Associated with the Boy:Girl Ratio of Children Visiting Short Stature Clinics

BACKGROUND

About twice as many boys as girls undergo growth hormone (GH) therapy in GH deficiency (GHD). However, this sex difference may not correctly reflect a real incidence.

OBJECTIVES

We analyzed the evidence of a selection bias whereby more boys seek treatment at short stature clinics.

SUBJECTS AND METHODS

The present study included 3,902 children who visited 17 short stature clinics with a height SD score of -2 SD or less. The percentage of children who underwent the GH stimulation test was compared between boys and girls, as was the percentage of children ultimately diagnosed with GHD.

RESULTS

The children comprised 2,390 boys (61.3%) and 1,512 girls (38.7%), with a boy:girl ratio of 1.58:1. The percentage of children who underwent the GH stimulation test did not differ between boys (45.7%) and girls (49.8%). Among the children who underwent the GH stimulation test, the percentage diagnosed with GHD did not differ significantly between boys (22.0%) and girls (20.1%). The boy:girl ratio of children diagnosed with GHD was 1.59:1.

CONCLUSIONS

The boy:girl ratio of children with short stature (1.58:1) did not differ significantly from that of children diagnosed with GHD (1.59:1). These results indicate that the predominance of boys in GHD does not reflect a real incidence, but rather a selection bias whereby a higher proportion of boys with short stature seek treatment at clinics. This difference arises because parents are more concerned about boys' height, and because boys reach adult height at an older age.

Questioning the Value of Brain Magnetic Resonance Imaging in the Evaluation of Children with Isolated Growth Hormone Deficiency

BACKGROUND

Isolated growth hormone deficiency (IGHD) is a relatively common disorder. Current diagnostic protocol requires a brain magnetic resonance imaging (MRI) study of the hypothalamus and the hypophysis to determine the cause after establishment of the diagnosis. This study aimed to examine the yield of brain MRI in the evaluation of children with IGHD and to define clinical and laboratory parameters that justify its performance.

METHODS

A retrospective chart review of all children (<18 years) diagnosed with IGHD was conducted at 3 pediatric endocrinology units between 2008 and 2018.

RESULTS

The study included 192 children (107 boys) with confirmed IGHD. The mean age ± standard deviation (SD) at diagnosis was 8.2 ± 3.7 years (median 8.5 years, range 0.8-15.9). The mean height SD score (SDS) at diagnosis was -2.25 ± 0.73. The mean height deficit SDS (defined as the difference between height SDS at diagnosis and mid-parental height SDS) was -1.7 ± 0.9. Fifteen children (7.8%) had pathological MRI findings. No space-occupying lesion was detected. Children with pathological MRIs had greater height deficit SDS and lower peak growth hormone levels on provocative tests compared to children with normal MRIs: -2.3 ± 1.2 vs. -1.6 ± 0.8 (p = 0.02) and 4.4 ± 1.9 vs. 5.7 ± 1.3 (p = 0.01), respectively.

CONCLUSION

Our preliminary data indicate that most brain MRIs performed for routine evaluation of children with IGHD are not essential for determining cause. Further studies with larger cohorts are needed in order to validate this proposed revision of current protocols.

Pattern and Features of Pediatric Endocrinology Referrals: A Retrospective Study in a Single Tertiary Center in Italy

Introduction: The knowledge of the pattern and the features of pediatric endocrinology referrals is crucial to optimize resources and guide public health interventions. We explored the numbers and the reasons for referral to a pediatric endocrinology outpatient clinic and investigated their features in terms of assignment of priority ranks, sex, age differences, the prevalence of pathological findings among referred cases, and the agreement among referrals, final diagnosis, treatment, and follow-up. Methods: Retrospective study with data collection for pediatric endocrinology first visits between November 2012 and February 2019 in a tertiary center. Results: A total of 1930 first visits were performed with an overall number of referrals of 2,165, and an increasing trend over the years. The most frequent referral reasons were slow growth, precocious puberty, and obesity; 14% of visits were classified as "urgent" (<7 days), 35% as "deferrable" (<30 days), and 51% as "planned" (<180 days). Sex and age differences among referrals were detected, with criticality in the appropriate timing for referral. Thirty-eight percent of patients had pathological findings. In 4% of the cases the final diagnosis was not concordant with the reason for referral. Treatment was prescribed in 35% of cases, and 67% returned at least for one follow-up visit. Conclusion: The study highlighted the need to target medical education of primary care on the definition of priority ranks, the need for more extended observation periods for subclinical or para-physiological conditions, the appropriate timing for referral, based on the definition of conditions or the best window of intervention.

Evaluation of referrals for short stature: A retrospective chart review

Background

Referrals to paediatric endocrine clinics for short stature are common. Height velocity (HV) is an essential component of the evaluation of short stature as growth deceleration often reflects an underlying paediatric endocrine diagnosis (PED). Access to previous measurements facilitates prompt calculation of HV.

Objective

To determine the availability of previous measurements at time of referral for short stature and to determine predictors of a PED.

Methods

A retrospective chart review was performed on all referrals for short stature to a single paediatric endocrinologist between January 2008 and December 2014. Standard practice following receipt of a referral for short stature included repeated requests to the referring physician for previous measurements.

Results

A total of 324 charts of patients aged 11 months to 18 years were reviewed and 286 were eligible for inclusion. Previous measurements were available in 72.4%, and 44.8% of these were found to have a PED. There was a significant relation between HV<25th percentile and a PED (P<0.0001) and between height deficit (HD) and a PED (P<0.0001). Logistic regression analysis showed that a HV<25th percentile and a HD>2 standard deviations, increased the odds of PED by a factor of 5.12 (P<0.001) and 1.39 (P<0.005), respectively.

Conclusion

HV is a significant predictor of a PED. Our higher rate of previous measurement availability is likely due to our effective referral screening protocol. The availability of these measurements, which are essential for HV calculation, are likely to reduce delays in diagnosis and management.

Initiation of growth hormone therapy in idiopathic short stature: do gender differences exist?

BACKGROUND/AIMS

Growth hormone (GH) registries indicate that boys receive preferential GH treatment for idiopathic short stature (ISS). The aim was to determine whether age, auxological parameters, pubertal status, and target height differ between genders at GH initiation.

METHODS

Review of the computerized files of the endocrine department of a tertiary pediatric medical center identified 184 patients who started GH therapy for ISS between 2003-2011. Data on auxologic parameters, predicted height, parental height, and pubertal status were collected and compared between boys and girls.

RESULTS

Boys accounted for a significantly higher percentage of the study group (65.8%, p<0.001). At onset of GH therapy, there were no significant differences between boys and girls in age (10.2±3.1 vs. 9.9±2.4 years), height-standard deviation score (SDS) (-2.64±0.5 vs. -2.79±0.5), body mass index-SDS[(-0.65±1.01) vs. (-0.80±1.13)], or pubertal status (66% vs. 63.5% prepubertal). Predicted height-SDS was significantly higher in boys (-1.95±1.05 vs. -2.56±0.73, p<0.001). Midparental height-SDS was similar in the two groups, as were paternal and maternal height.

CONCLUSIONS

The similar age, height deficit, and pubertal status at onset of GH treatment in boys and girls suggests that gender differences do not exist. Male predominance may stem from family preferences to treat boys. Future studies are warranted to assess the psychosocial aspects in the decision to initiate therapy.

Early recognition of growth abnormalities permitting early intervention

Normal growth is a sign of good health. Monitoring for growth disturbances is fundamental to children's health care. Early detection and diagnosis of the causes of short stature allows management of underlying medical conditions, optimizing attainment of good health and normal adult height.

CONCLUSION

This review summarizes currently available information on monitoring for short stature in children and conditions usually associated with short stature and summarizes the authors' conclusions on the early recognition of growth disorders.

Characteristics of the short children referred to an academic paediatric endocrine clinic in Greece

AIM

To describe the characteristics of short children in relation to gender and the various diagnoses.

METHODS

All new patients of Greek origin that were referred to our institution in the years 2007 and 2008 for evaluation of short stature were included in the study. Children were categorized according to the severity of their short stature in those with height standard deviation score (HSDS) ≤ -3 and HSDS > -3.

RESULTS

Two hundred ninety-five children (162 boys and 133 girls, ratio 1.2) were referred. HSDS of boys was -2.3 (0.6) and of girls -2.1 (0.5), P= 0.004. Girls had shorter parents, and the predicted adult HSDS was also shorter for girls -1.7 (0.8) than for boys -1.35 (0.76), P= 0.003. Seventy per cent of the children of both sexes had familial short stature (FSS), constitutional delay of growth or a combination of the two conditions. About 10% presented the auxological and biochemical criteria for growth hormone deficiency (GHD). In addition, 11.8% had a HSDS ≤ -3, the most common diagnosis being GHD (36.1%); the less severely short children most commonly presented FSS (41.2%).

CONCLUSIONS

There is no gender bias in referrals for short stature in Greece. About 70% of children of both sexes presented FSS or constitutional delay of growth or a combination of the two conditions, whereas GHD was diagnosed in about 10% of the children. Normal variants of growth were present in about 80% of children with HSDS > -3, but in only 40% when HSDS was ≤ -3.

A comparison of referral patterns to the pediatric endocrine clinic before and after FDA approval of growth hormone for idiopathic short stature

BACKGROUND

Short stature is a common reason for referral to the pediatric endocrine clinic. In 2003, the US Food and Drug Administration (FDA) approved the use of growth hormone (GH) for the treatment of children with idiopathic short stature (ISS).

OBJECTIVE

To explore if this indication changed referrals for short stature (SS).

DESIGN/METHODS

A retrospective chart review of children seen for SS in the pediatric endocrine clinic between July 1998 and June 1999 (interval one, n=138) and July 2005-June 2006 (interval two, n=268) was performed. Variables collected included age, gender, height (h), and parental heights.

RESULTS

Average height standard deviation score (HT-SDS) was -2.11 +/- 0.9 in interval one and -2.14 +/- 0.83 in interval two (p=ns). No differences in age, gender distribution, relationship between child and parental heights, the proportion of subjects started on GH for ISS or in the HT-SDS of those treated between the two intervals were identified. Nearly half of all children referred in each interval did not meet the technical criteria for short stature.

CONCLUSIONS

No differences in referral patterns for SS in our area following FDA approval of GH for ISS were identified. Although referrals appear unchanged, additional investigation of GH prescribing patterns before and after this new indication is needed. Continued education of primary care physicians and the general public regarding the definition of SS and the eligibility for GH therapy should be pursued.

The influence of secular trend for height on ascertainment and eligibility for growth hormone treatment

OBJECTIVE

Assessment of short stature in many instances is based on a comparison with the Centers for Disease Control's (CDC) growth curves. The secular trend for height may limit the utility of CDC data for contemporary populations. We investigate the effect of the secular trend on Australian and US populations.

DESIGN

Describe CDC-defined height SDS distributions of contemporary populations for different ages and genders. Compare observed means and standard deviations (SDs) to expected values of 0 and 1. Compare frequency of individuals shorter than the CDC-1st centile to those shorter than 1st centile defined empirically from the contemporary population.

SUBJECTS

Healthy Kids Queensland Survey 2006: 1686 boys, 1822 girls. Australian National Children's Nutrition and Physical Activity Survey 2007: 2415 boys, 2379 girls. US National Health and Nutrition Examination Survey 2005-2006: 2160 boys, 2118 girls.

MEASUREMENTS

Means, SDs and normality of CDC-defined height SDS distributions. Frequency of individuals shorter than the CDC-1st centile and shorter than an empirically defined 1st centile.

RESULTS

In Australia, means of CDC-defined height SDS distributions are always greater than 0 and the CDC-1st centile identifies only the shortest 0·5% of children. Means may vary with age and occasionally between genders in contemporary populations. Normality and SDs of 1 are retained.

CONCLUSIONS

The secular trend has resulted in an underestimate of the number of Australian children eligible for GH treatment using the CDC-1st centile cut-off. Contemporary, local data should be used to construct standards. Using the 2nd CDC centile would approximate the 1st local centile until new standards are constructed. The secular trend does not account for the gender bias in GH therapy.

Gender bias in children receiving growth hormone treatment

BACKGROUND

About twice as many boys than girls are treated with GH. Ascertainment bias is a possible explanation.

HYPOTHESES

For ascertainment bias, the gender least frequently treated should be relatively shorter, and in an unbiased population sample, equal numbers of boys and girls should be eligible for GH treatment.

SUBJECTS AND SETTING

In 2007 a total of 1485 Australian children received GH (OZGROW database). Heights were also obtained from two recent unbiased surveys consisting of 3596 and 4794 Australian children.

METHODS

Numbers of boys and girls treated with GH were determined for each treatment indication. Height sd scores (SDS) at first presentation for GH-treated boys and girls were assessed. Frequency of boys and girls from two unbiased populations with height SDS less than -2.326 were recorded.

OUTCOMES

OUTCOMES included gender frequencies and height SDSs. HYPOTHESES were formed before interrogation of preexisting databases.

RESULTS

More boys than girls received GH (P = 3.68 x 10(-20)). By indication: biochemical GH deficiency (P = 0.001), cranial irradiation (P = 0.002), slow growing (P = 2.09 x 10(-16)), and chronic renal failure (P = 0.061). Approximately equal numbers of girls and boys were treated for hypoglycemia (P = 0.543). Slow-growing girls were relatively shorter than boys for ages spanning 4.50-8.49 yr (P = 3.80 x 10(-4)), but boys were relatively shorter in the 6.00- to 17.99-month age group (P = 0.011). Biochemical boys were relatively shorter than girls (P = 0.023). In the two unbiased surveys, boys outnumbered girls 11 to six and 16 to eight for height SDS less than -2.326.

CONCLUSIONS

There is a gender bias in this GH-treated population. Ascertainment bias does not appear to be the major cause.

Short stature in a population-based cohort: social, emotional, and behavioral functioning

OBJECTIVE

The goal was to determine whether there were significant differences between children of normative versus short stature in behavioral functioning and peer relationships, according to teacher and child reports.

METHODS

The study included 712 boys and girls in the sixth grade, from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main outcome measures included Achenbach Teacher's Report Form internalizing, externalizing, and total scores; Children's Depression Inventory scores (child report); Life Orientation Test-Revised scores (child report); Child Behavior with Peers questionnaire asocial with peers, excluded by peers, and peer victimization subscale scores (teacher report); peer social support and victimization scores (child report); and relationships with peers score (teacher report). In bivariate comparisons, these outcomes were compared for children of relatively short (height of <10th percentile) versus nonshort (height of > or =10th percentile) stature, and effect sizes were calculated. Multivariate linear regression models adjusted for maternal education, income/needs ratio, race, and gender.

RESULTS

Effect sizes ranged from 0.00 to 0.35. Short children reported marginally higher levels of self-perceived peer victimization, compared with their nonshort peers. There were no significant differences in the rest of the outcomes for children of short versus nonshort stature, in either unadjusted or adjusted models.

CONCLUSION

Although short children from a population-based sample reported marginally higher levels of self-perceived peer victimization, they did not differ from their nonshort peers in a range of social, emotional, and behavioral outcomes.