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

Growth hormone treatment in children in Israel: A large-scale retrospective database study

AIM

To evaluate the indications, population characteristics and latency between short stature diagnosis to treatment with recombinant growth hormone (GH) therapy in a large cohort of children in Israel.

METHODS

We performed a retrospective medical chart review of all children treated with GH for conditions associated with short stature in three central districts in Israel from 1 January 2010 to 31 December 2021. Data extracted from the medical files included demographics, time to diagnosis, treatment indications and GH therapy duration.

RESULTS

The study group comprised 5148 children aged 1 day to 17 years. A total of 64.1% were diagnosed with idiopathic short stature (ISS), 31.1% with GH deficiency (GHD) and 2.5% with small-for-gestational age (SGA). Males were treated more than females (58.9% vs. 41.1%). The mean age at first documentation of short stature was 6.9 ± 3.5 years. GH therapy was initiated at a mean age of 9.8 ± 3.3 years. A total of 51.2% were of high socio-economic status (SES); 78.2% were non-ultraorthodox Jews, 13%, ultraorthodox Jews, and 8.8% were Arabs.

CONCLUSION

Meticulous growth follow-up from early childhood for all children, specifically females, those of low SES, and minorities is important to provide appropriate referral, treatment and final adult height outcomes.

BMI z-score as a prognostic factor for height velocity in children treated with recombinant human growth hormone due to idiopathic growth hormone deficiency

PURPOSE

Growth hormone deficiency (GHD) causes growth disturbances during childhood. The most recommended treatment of GHD is the administration of recombinant human growth hormone (rhGH). Recent studies have proved that well-nourished GHD children respond better to rhGH therapy compared to undernourished individuals. The aim of this study was to analyze nutritional status along with height velocity in GHD children during the first two years of rhGH therapy, and to estimate the optimal BMI z-score range in which these children achieve the best growth results.

METHODS

This retrospective analysis included 80 prepubertal idiopathic GHD children treated with rhGH. Anthropometric data were obtained from medical records made at an initial visit and then follow-up visits after 12 and 24 months of treatment. The body mass index (BMI) was calculated and standardized into z-score, basing on Cole's LMS method. Then, the BMI z-score was analyzed in relation to the parameters of growth response.

RESULTS

The higher the BMI z-score at treatment entry, the greater the increase in height during the first twelve months of rhGH therapy. BMI z-score ≥0 noted at the beginning of each year of the treatment are associated with significantly better growth increments throughout the first and the second years of the therapy.

CONCLUSION

Prepubertal idiopathic GHD children with BMI z-score below 0 would probably benefit from the improvement of their nutritional status prior to the rhGH treatment beginning. It seems that increasing BMI z-score to obtain values between 0 and 1 would be optimal for the growth process.

Effect of recombinant human growth hormone plus vitamin D on development and lipid metabolism in children with growth hormone deficiency

The combination of rhGH and vitamin D has been suggested as a potential therapeutic approach for children with GHD. This retrospective study aimed to investigate the impact of recombinant human growth hormone plus vitamin D on development and lipid metabolism in children with growth hormone deficiency. A total of 198 children treated in our hospital from December 2011 to December 2021 were recruited. The study assessed development-related indices, lipid metabolism indices, growth factor indices, thyroid indices, and adverse reactions. After treatment, the development-related indices of children in both groups improved (P < 0.05), but the experimental group showed significantly better HtSDS and annual height growth rate (P < 0.05). Moreover, the experimental group had lower levels of TG, T-CHO, and LDL-C versus the observation group (P < 0.05), while no significant difference was observed in HDL-C levels between the two groups before and after treatment (P > 0.05). Moreover, patients receiving recombinant human growth hormone plus vitamin D had significantly higher IGF-1 and IGFBP-3 levels than those receiving recombinant human growth hormone alone (P < 0.05). The T3, T4, and TSH levels of children in both groups increased after treatment (P < 0.05). The incidence of adverse events did not significantly differ between the two groups (P > 0.05). In conclusion, our findings suggest that recombinant human growth hormone plus vitamin D effectively improves the development and lipid metabolism of children with growth hormone deficiency. Additionally, it increases growth factor levels without compromising thyroid function or increasing the risk of adverse drug reactions.

Key elements of Korean medicine treatment for idiopathic short-stature: A qualitative SWOT analysis based on Korean medicine doctors' views

The objective of this study was to explore the key elements of Korean medicine (KM) treatment for idiopathic short stature (ISS) by analyzing the strengths, weaknesses, opportunities, and threats (SWOT). This was a qualitative study of interviews with 7 KM doctors who had at least 3 years of experience in KM treatment for ISS. Based on the content, a SWOT and a cross-SWOT analysis were conducted. A SWOT of KM treatment for ISS was derived as follows: Strengths included the additional positive health promotion effects and fewer possibilities of adverse effects. Weaknesses included insufficient long-term evidence on the effect and safety and difficulty in predicting prognosis for ISS treatment in KM. Opportunities included a growing interest in height growth in general and the need for parental involvement in children height growth. Threats included the limited use of diagnostic devices and relatively high medical costs due to non-coverage by national health insurance. This study suggests that the safety and clinical effectiveness evidence of KM treatment for height growth should be guaranteed through well-designed large-scale long-term studies. Various strategies are needed to promote the use of diagnostic and evaluation devices for ISS treatment in KM clinical settings.

Therapeutic efficacy of recombinant human growth hormone in children with different etiologies of dwarfism from a pharmacoeconomic point of view

Treatment outcomes for different causes of childhood dwarfism vary widely, and there are no studies on the economic burden of treatment in relation to outcomes. This paper compared the efficacy and healthcare costs per unit height of recombinant human growth hormone (rhGH) for the treatment of growth hormone deficiency (GHD) and idiopathic short stature (ISS) with a view to providing a more cost-effective treatment option for children. We retrospectively analyzed 117 cases (66 cases of GHD and 51 cases of ISS) of short-stature children who first visited Weifang People's Hospital between 2019.1 and 2022.1 and were treated with rhGH for 1 to 3 years to track the treatment effect and statistically analyzed by using paired t tests, non-parametric tests, and chi-square tests, to evaluate the efficacy of rhGH treatment for GHD and ISS children and the medicinal cost. The annual growth velocity (GV) of children with GHD and ISS increased the fastest during 3 to 6 months after treatment and then gradually slowed down. The GV of the GHD group was higher than that of the ISS group from 0 to 36 months after treatment (P < .05 at 3, 6, 9, and 12 months); the height standard deviation scores (HtSDS) of the children in the GHD and ISS groups increased gradually with the increase of the treatment time, and the changes in the height standard deviation scores (ΔHtSDS) of the GHD group were more significant than those of the ISS group (P < .05 at 3, 6, 9, and 12 months). (2) The medical costs in the pubertal group for a 1-cm increase in height were higher than those of children in the pre-pubertal group at the same stage (3 to 24 months P < .05). The longer the treatment time within the same group, the higher the medical cost of increasing 1cm height. RhGH is effective in treating children with dwarfism to promote height growth, and the effect on children with GHD is better than that of children with ISS; the earlier the treatment time, the lower the medical cost and the higher the comprehensive benefit.

Diagnosis and treatment of growth hormone deficiency in children on the ketogenic diet: A case series

The ketogenic diet (KD) can have a negative impact on the linear growth and body composition of children. The aims of this study were to review two centers' experience with children who developed height deceleration on the KD and determine if the height deceleration was secondary to growth hormone deficiency (GHD), and if growth hormone therapy (GHT) would be effective and safe (not altering ketosis or seizure frequency). Retrospective chart reviews were performed on patients with KD referred to Endocrinology between 2013 and 2018. Seventeen children were identified. Data reviewed included: demographics, growth velocity, KD ratio, protein/calorie intake, lab results, GH dosage, Tanner stage, and seizure frequency, and endocrine recommendations. Descriptive statistics were performed. Of the 17 children referred to the Endocrine Division, seven children were growth hormone deficient and began GHT. Data were provided for six patients (2 males, 4 females; age 2-7 years at the start of KD) on the KD for >6 years and on GHT for >4 years. Growth for all patients stabilized or increased. IGF-1 z-scores normalized. GHT did not affect seizure frequency or ketosis. GHT in those with GHD can be an appropriate option allowing better growth while still maintaining ketogenic therapy and seizure control. PLAIN LANGUAGE SUMMARY: The KD can be an effective treatment for difficult-to-control epilepsy and some disorders of carbohydrate metabolism. The KD can adversely affect the linear growth (height) of children. This case series reviewed six patients who had slow linear growth. It was found that all six children had growth hormone deficiency, grew better with growth hormone treatments, and that their seizures and ketone levels were not affected.

Beyond the bias! Sex distribution in paediatric growth hormone deficiency reexamined

OBJECTIVES

Various biases pertaining to stature account for a male sex predominance in growth hormone deficiency (GHD) cases diagnosed by endocrinology clinics. This manuscript will assess the sex distribution when biases are minimised.

METHODS

Retrospective chart review was conducted on patients diagnosed with GHD between 3 and 16 years of age. The sex distribution of cases was ascertained according to: (1) peak GH (pGH) by groups; based on growth hormone provocative testing, (2) pituitary gland imaging results, and (3) isolated GHD (IGHD) versus multiple pituitary hormone deficiencies (MPHD). The relative frequency of each sex was compared according to these subgroups with significance evaluated at α = .05 level.

RESULTS

Of the 5880 clinic referrals for short stature, there were 3709 boys (63%) and 2171 girls (37%). Of these, 20% of boys (n = 745) and 15.3% of girls (n = 332) underwent provocative testing for GHD. Of those tested, 39.2% of boys (n = 292) and 32.2% of girls (n = 107) were diagnosed with GHD, all p < .001. There was a male predominance in GHD cases based on pGH or GHD severity. Though not significant, girls were more likely than boys to have MPHD (p = .056), even across pGH groups (p = .06). Both boys and girls had a similar distribution of imaging abnormalities.

CONCLUSION

Stratifying by sex, we found similar percentages of pituitary imaging abnormalities (including tumours) and the number of pituitary hormone deficiencies in boys and girls as the cause of GHD. For these classifications, we did not find the historically reported male sex predominance.

Beyond Growth Hormone: Association of Short Stature Types and Growth Hormones With Scoliosis

STUDY DESIGN

Cross-sectional and retrospective cohort study.

OBJECTIVE

We investigated the effect of 3 types of short stature [partial growth hormone deficiency (GHD), GHD, and idiopathic short stature (ISS)] and recombinant human growth hormone (rhGH) therapy on scoliosis.

SUMMARY OF BACKGROUND DATA

In short stature, rhGH is widely used and the concentration of growth hormone varies among types. The epidemiologic characteristics of scoliosis and the role of rhGH in scoliosis remain unclear.

PATIENTS AND METHODS

A cross-sectional study was conducted among 3896 patients with short stature (partial GHD, GHD, and ISS), and a 1:1 age and sex-matched control group with preexisting whole-spine radiographs. The cohort study included 2605 subjects who underwent radiography more than twice to assess scoliosis development, progression, and the need for bracing and surgery. Adjusted logistic regression was used to assess differences in the prevalence of scoliosis among patients with partial GHD, GHD, ISS, and controls. The Kaplan-Meier method was used to analyze the time course of scoliosis development and progression. Cox regression was applied to assess the independent factors related to scoliosis development and progression. Mendelian randomization analyses were also performed.

RESULTS

Compared with controls, patients with short stature had a higher incidence of scoliosis (34.47% in partial GHD, 31.85% in GHD, 32.94% in ISS vs . 8.83% in control, P < 0.001), a higher risk of scoliosis development [hazard ratio (HR) = 1.964 in partial GHD, P < 0.001; HR = 1.881 in GHD, P = 0.001; HR = 1.706 in ISS, P = 0.001), but not a higher risk of progression, brace, or surgery. Among the 3 types of short stature, there were no differences in the incidence, development, and progression of scoliosis or the need for bracing or surgery. RhGH treatment increased the risk of scoliosis development in each short-stature group (HR = 2.673 in partial GHD, P < 0.001; HR = 1.924 in GHD, P = 0.049; HR = 1.564 in ISS, P = 0.004). Vitamin D supplementation was protective against scoliosis development (HR = 0.456 in partial GHD, P = 0.003; HR = 0.42 in GHD, P = 0.013; HR = 0.838 in ISS, P = 0.257).

CONCLUSIONS

More attention should be paid to the spinal curve in patients with partial GHD, GHD, or ISS. For short stature treated with rhGH, the risk of scoliosis development was increased. Vitamin D supplementation may be beneficial for prevention.

LEVEL OF EVIDENCE

Level III.

Growth Hormone Treatment for Non-GHD Disorders: Excitement Tempered by Biology

The success of growth hormone (GH) replacement in children with classical GH deficiency has led to excitement that other causes of short stature may benefit similarly. However, clinical experience has shown less consistent and generally less dramatic effects on adult height, perhaps not surprising in light of increased understanding of GH and growth plate biology. Nonetheless, clinical demand for GH treatment continues to grow. Upon the 20th anniversary of the US Food and Drug Administration's approval of GH treatment for idiopathic short stature, this review will consider the factors underlying the expansion of GH treatment, the biological mechanisms of GH action, the non-GH-deficient uses of GH as a height-promoting agent, biological constraints to GH action, and future directions.

The Effects of Natural Product-Derived Extracts for Longitudinal Bone Growth: An Overview of In Vivo Experiments

Approximately 80% of children with short stature are classified as having Idiopathic Short Stature (ISS). While growth hormone (GH) treatment received FDA approval in the United States in 2003, its long-term impact on final height remains debated. Other treatments, like aromatase inhibitors, metformin, and insulin-like growth factor-1 (IGF-1), have been explored, but there is no established standard treatment for ISS. In South Korea and other Asian countries, East Asian Traditional Medicine (EATM) is sometimes employed by parents to potentially enhance their children's height growth, often involving herbal medicines. One such product, Astragalus membranaceus extract mixture HT042, claims to promote height growth in children and has gained approval from the Korean Food and Drug Administration (KFDA). Research suggests that HT042 supplementation can increase height growth in children without skeletal maturation, possibly by elevating serum IGF-1 and IGF-binding protein-3 levels. Preclinical studies also indicate the potential benefits of natural products, including of EATM therapies for ISS. The purpose of this review is to offer an overview of bone growth factors related to ISS and to investigate the potential of natural products, including herbal preparations, as alternative treatments for managing ISS symptoms, based on their known efficacy in in vivo studies.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Youth and Parent Perceptions of Youth Decision-Making Roles Regarding Evaluation for Short Stature

Youth decision-making involvement (DMI) in medical treatment associates with greater adherence and feelings of self-efficacy. However, little is known about youth DMI regarding medical evaluation and diagnostic procedures. Using thematic analysis of semi-structured interviews, we explored parent (n=24) and youth (n=24) perceptions of youth roles in the decision to undergo evaluation for short stature. Five themes emerged about evaluation decisions including: parents/providers were gatekeepers, some parents sought youth agreement, conversations focused on logistics, some parents gave limited information, and youth expressed anxiety. Results suggest that including youth in discussions about evaluation may alleviate anxiety and uncertainty about upcoming procedures.

MRI Findings of Pituitary Gland in Growth Hormone-Deficient Children and Their Correlation with Growth Hormone Peak during Growth Hormone Stimulation Tests

This study aims to explore the magnetic resonance imaging (MRI) findings of the pituitary gland (PG) in children with growth hormone deficiency (GHD) and their correlation with the growth hormone (GH) peak during clinical GH stimulation tests. Sixty-one children with GHD diagnosed and treated between December 2018 and December 2021 were retrospectively analyzed in terms of clinical and pituitary morphological MRI data. MRI measurements of various diameters of the adenohypophysis (AH) were obtained to analyze the differences of the measured values in different genders and age groups, as well as their relationship with the GH peak in GH stimulation tests. Among the 61 children with GHD, the superior PG margin was protuberant in 2 cases, flat in 13 cases, and concave in 46 cases. The three age groups showed similar pituitary morphology and stalk (P > 0.05). On T1-weighted images, the proportion of isointensity was lower while the proportion of slightly-low signal intensity was higher in the anterior pituitary gland (APG) of children aged >10 compared with those aged 7–10. The comparison of AH linear parameters and GH peak values of male patients among different age groups showed that the anteroposterior (sagittal) diameter of AH and GH peak were the highest in the >10-year-old group and the lowest in the ≤6-year-old group, with those of the 7–10-year-old group in between (P < 0.05). In females, the anteroposterior (sagittal) diameter and GH peak were higher in the 7–10-year-old group and >10-year-old group compared with the ≤6-year-old group (P < 0.05). The MRI coronal and sagittal heights of PG in children with GHD were positively correlated with the GH peak value. In conclusion, in GHD patients, the coronal and sagittal heights as well as the coronal width of AH do not change with sex or age, but the coronal and sagittal heights of PG are positively correlated with the GH peak of GH stimulation tests, which has high application value in the diagnosis of children with GHD.

Polyethylene glycol recombinant human growth hormone in Chinese prepubertal slow-growing short children: doses reported in a multicenter real-world study

BACKGROUND

To evaluate the effectiveness of individualized-dose polyethylene glycol recombinant human growth hormone (PEG-rhGH) for short stature.

METHODS

This real-world study enrolled children with short stature in 19 hospitals throughout China. They were treated with PEG-rhGH for 6 months. The starting dosage ranged from 0.10 to 0.20 mg/kg/week. The primary outcome was the change in height standard deviation score (ΔHt SDS).

RESULTS

Five hundred and ten patients were included and grouped based on dosage as A (0.10-0.14 mg/kg/week), B (0.15-0.16 mg/kg/week), C (0.17-0.19 mg/kg/week), and D (0.20 mg/kg/week). The mean 6-month ΔHt SDS for the total cohort was 0.49 ± 0.27, and the means differed among the four dose groups (P = 0.002). The ΔHt SDS was lower in group A than in groups B (LSM difference [95%CI], -0.09 [-0.17, -0.01]), C (LSM difference [95%CI], -0.10 [-0.18, -0.02]), and D (LSM difference [95%CI], -0.13 [-0.21, -0.05]) after adjusting baseline covariates. There were no significant differences among groups B, C, and D. When the baseline IGF-1 was < -2 SDS or > 0 SDS, the △Ht SDS was not different among the four groups (P = 0.931 and P = 0.400). In children with baseline IGF-1 SDS of -2 ~ 0 SDS, a higher dosage was associated with a better treatment effect (P = 0.003), and the △Ht SDS was lower in older children than in younger ones (P < 0.001).

CONCLUSIONS

PEG-rhGH could effectively increase height in prepubertal short children. When the baseline IGF-1 was < -2 SDS, 0.10 mg/kg/week could be a starting dose. In other IGF-1 statuses, 0.15-0.20 mg/kg/week might be preferred.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03249480 , retrospectively registered.

Clinical Indications for Growth Hormone Therapy

Growth hormone (GH) is an injectable medication originally used to replace the deficiency of the hormone, but has expanded to treating conditions that may reduce growth and adult height even when the body maintains endogenous GH production. In the United States, there are 8 Food and Drug Administration (FDA)-approved indications for pediatric GH therapy: GH deficiency, Prader-Willi Syndrome, small for gestational age (SGA) without catch-up growth, idiopathic short stature, Turner syndrome, SHOX gene haploinsufficiency, Noonan Syndrome, and chronic renal insufficiency. We characterize the growth patterns and effects of GH treatment in each of these indications. We also review patterns of growth that warrant referral to a pediatric endocrinologist, as well as safety updates. This review is intended to guide practitioners on the initial evaluation and management of patients with short stature, and the indications for GH therapy.

Integrative traditional Korean medicine treatment for children with idiopathic short stature: A STROBE-compliant case series

Integrative traditional Korean medicine (TKM) treatment including herbal medicine and acupuncture has been used frequently by parents in South Korea for the treatment of children with idiopathic short stature (ISS). We aimed to report the TKM treatments currently being used for children with ISS and explore their therapeutic effects. The medical records of children who met the criteria for ISS and who had been treated with TKM for the management of ISS were retrospectively reviewed. In total, 116 patients (mean [standard deviation] age, 8.07 [3.08] years; 52.6% girls) enrolled in the study. Their mean height percentile was 1.45 and body mass index was 16.19 kg/m2. During the study period of 5 years, participants visited the outpatient clinic an average of 2.93 times; the mean number of days to the next visit was 101 days. All patients received herbal medicine treatment, and the formulation was mainly decoction type. Additional treatments including ear acupuncture and moxibustion were also used. After treatment with TKM, the height percentile and standard deviation scores increased in both girls and boys (P < .001 and P < .01, respectively). Additionally, the predicted adult height, estimated based on bone age, increased in girls (P < .05). This study provided preliminary data for future research in TKM use in children with ISS.

Metabolomic Differential Compounds Reflecting the Clinical Efficacy of Polyethylene Glycol Recombinant Human Growth Hormone in the Treatment of Childhood Growth Hormone Deficiency

Understanding metabolite profiles may aid in providing a reference for individualized treatment using PEG-rhGH. Therefore, this study aimed to evaluate the clinical efficacy of PEG-rhGH in treating GHD patients by using a metabolomic approach. Fifty-seven pediatric participants treated with PEG-rhGH were enrolled (28 GHD patients with high clinical efficacy and 29 GHD patients with lower clinical efficacy). Serum samples from all patients were first collected at baseline for biochemical detection; then metabolite levels were measured using gas chromatography time-of-flight mass spectrometry. The candidates included heptadecanoic acid, stearic acid, 2-hydroxybutyric acid, myristic acid, palmitoleic acid, D-galactose, dodecanoic acid, and oleic acid. The related metabolic pathways involved fatty acid metabolism and energy metabolism. This study suggested that growth gains of PEG-rhGH treatment might be differentiated by altered serum levels of fatty acid. Collectively, the metabolomic study provides unique insights into the use of PEG-rhGH as a therapeutic strategy for individualized treatment.

Appearance and Performance Enhancing Drugs and Substances: The Role of the School Nurse

The purpose of this article is to provide the school nurse with the ability to recognize performance and appearance enhancing substance use and understand treatment and prevention strategies to reduce associated health risks. The use of appearance and performance enhancing drugs and substances, also known as "doping," has been an ethical and health issue in sports for many years. It is vital that school nurses learn to recognize performance and appearance enhancing substance use to ensure student athletes and exercisers receive the care and education they need. Commonly used performance and appearance enhancing substances include anabolic-androgenic steroids, stimulants, diuretics, growth hormone, and supplements. Signs and symptoms that may look similar to other health concerns include palpitations, stunted growth, acne, severe headaches, muscle cramps, dizziness, and dehydration, but some long-term severe complications occur as well. Doping can lead to severe and sometimes permanent organ damage, including liver, kidney, and heart disease. The school nurse can play a key role by working with parents, coaches, school counselors, and educators to foster an anti-doping culture.

Adherence and quality of life in children receiving rhGH treatment

Short stature may have a major impact on quality of life (QoL), not only during adulthood but also during childhood. Treatment by growth hormone may induce improvement in QoL through height gain, as shown in recent articles, with an increase in general health-related and also height-specific QoL assessed by self-reports and parental reports. In a paper published by our team, we show altered general-health QoL in patients with very short stature (≤ -3 SD) and an improvement in general and height-specific scales in the complete population (≤ -2 SD) after one year of recombinant human growth hormone (rhGH) treatment, perceived both by children and their parents, with a moderate positive correlation with height gain. Adequate results in terms of height gain depend on different factors: the patient's age, underlying condition for which rhGH is prescribed and dose of rhGH treatment, among others. Daily injections may cause a significant burden for the child and family, and may alter adequate adherence to treatment. Identifying positive and negative factors in the patient and in the healthcare providers-patient team and encouraging a shared decision-making process are important for improving the patient's adherence to treatment. New long-acting forms of rhGH that will be available in the next few years may play an important part in improving treatment-related QoL and adherence to treatment. © 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

Cardiac functions in children with growth hormone deficiency: Effects of one year of GH replacement therapy

INTRODUCTION

Children with Growth Hormone deficiency (GHD) are prone to heart dysfunction and, if left untreated, will result in marked cardiac dysfunction in adulthood. The aim was to evaluate the effect of GHD and growth hormone (GH) therapy on cardiac structure in children and adolescents, and to investigate the role of insulin like growth factor-1 (IGF-1) in this.

METHODS

M-mode, pulse-wave Doppler echocardiography and tissue Doppler imaging (TDI) were performed in 49 children with GHD who were divided into those with a peak GH response < 7 μg/L and 7-10 μg/L after two GH stimulation tests, aged 8-16 years at baseline and at six and 12 months after GH initiation, and 49 healthy peers. IGF-1 concentration was measured.

RESULTS

Although the left ventricular end diastolic and systolic diameters in both GH deficient groups were significantly lower than controls (p < 0.01), both diameters increased significantly with one year of treatment and achieved normal values (p > 0.05). Using TDI in both two patients group revealed increased E/A, prolonged isovolumic relaxation time, shortened ejection time, and a significant increase in myocardial performance index compared to controls (p < 0.001). Significant improvement was observed in these parameters from the sixth month of GH treatment (p < 0.001), this improvement does not match parameters measured in healthy peers, even after one year of treatment in both patients group. (p < 0.001). No correlation was found between IGF-1 concentration and any echocardiographic parameter.

CONCLUSION

Echocardiographic parameters were similar in children with a GH peak < 7 μg/L and 7-10 μg/L. In TDI, both systolic and diastolic function was impaired in GHD children compared to controls. These parameters improved after one year of GH therapy but did not recover to healthy control levels.

Racial and Ethnic Disparities in the Investigation and Treatment of Growth Hormone Deficiency

OBJECTIVE

To determine if the racial/ethnic inequity in growth hormone (GH) use is due to differences in GH stimulation testing and/or prescribing patterns in children referred for endocrine evaluation of short stature.

STUDY DESIGN

Retrospective chart review was performed including children aged 2-16 years, height z-score of ≤-1.5, and of non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic race/ethnicity, referred for endocrine growth evaluation between January 2012 and December 2019.

RESULTS

This study included 7425 children (5905 NHW, 800 NHB, and 720 Hispanic). GH stimulation testing was performed in 992, and 576 were prescribed GH. NHW children were 1.4 (95% CI, 1.04-1.8) times more likely than NHB children and 1.7 (95% CI, 1.2-2.2) times more likely than Hispanic children to undergo GH stimulation testing. GH-treated NHB children had (1) a lower median peak GH concentration when compared with NHW (P = .02) and Hispanic (P = .08) children (NHB 4.7 ng/mL [95% CI, 1.2-8.3 ng/mL] ng/mL, NHW 7.2 ng/mL [95% CI, 4.9-9.7 ng/mL], Hispanic 7.1 ng/mL [95% CI, 4.3-11.9 ng/mL]); (2) lower median height z-scores than NHW (P = .01) but not Hispanic children (P = .5); and (3) a greater height deficit from midparental height when compared with NHW (P = .01) and Hispanic (P = .002) children.

CONCLUSIONS

Racial and ethnic disparities exist in the evaluation and treatment of children with disordered growth. This likely results from both overinvestigation of NHW children as well as underinvestigation and undertreatment of children from minority communities. The evaluation and treatment of children with short stature should be determined by clinical concern alone, but this is not current practice.

Provocative growth hormone testing in children: how did we get here and where do we go now?

OBJECTIVES

Provocative growth hormone (GH) tests are widely used for diagnosing pediatric GH deficiency (GHD). A thorough understanding of the evidence behind commonly used interpretations and the limitations of these tests is important for improving clinical practice.

CONTENT

To place current practice into a historical context, the supporting evidence behind the use of provocative GH tests is presented. By reviewing GH measurement techniques and examining the early data supporting the most common tests and later studies that compared provocative agents to establish reference ranges, the low sensitivity and specificity of these tests become readily apparent. Studies that assess the effects of patient factors, such as obesity and sex steroids, on GH testing further bring the appropriateness of commonly used cutoffs for diagnosing GHD into question.

SUMMARY AND OUTLOOK

Despite the widely recognized poor performance of provocative GH tests in distinguishing GH sufficiency from deficiency, limited progress has been made in improving them. New diagnostic modalities are needed, but until they become available, clinicians can improve the clinical application of provocative GH tests by taking into account the multiple factors that influence their results.

Growth Hormone Stimulation Testing Patterns Contribute to Sex Differences in Pediatric Growth Hormone Treatment

INTRODUCTION

Males are twice as likely as females to receive pediatric growth hormone (GH) treatment in the USA, despite similar distributions of height z (HtZ)-scores in both sexes. Male predominance in evaluation and subspecialty referral for short stature contributes to this observation. This study investigates whether sex differences in GH stimulation testing and subsequent GH prescription further contribute to male predominance in GH treatment.

METHODS

Retrospective chart review was conducted of all individuals, aged 2-16 years, evaluated for short stature or poor growth at a single large tertiary referral center between 2012 and 2019. Multiple logistic regression models were constructed to analyze sex differences.

RESULTS

Of 10,125 children referred for evaluation, a smaller proportion were female (35%). More males (13.1%) than females (10.6%) underwent GH stimulation testing (p < 0.001) and did so at heights closer to average (median HtZ-score -2.2 [interquartile range, IQR -2.6, -1.8] vs. -2.5 [IQR -3.0, -2.0], respectively; p < 0.001). The proportion of GH prescriptions by sex was similar by stimulated peak GH level. Predictor variables in regression modeling differed by sex: commercial insurance predicted GH stimulation testing and GH prescription for males only, whereas lower HtZ-score predicted GH prescription for females only.

CONCLUSIONS

Sex differences in rates of GH stimulation testing but not subsequent GH prescription based on response to GH stimulation testing seem to contribute to male predominance in pediatric GH treatment. That HtZ-score predicted GH prescription in females but not males raises questions about the extent to which sex bias - from children, parents, and/or physicians - as opposed to objective growth data, influence medical decision-making in the evaluation and treatment of short stature.