4/23/2015. Pediatric Growth Hormone Deficiency: Identification, Diagnosis, & Management. Conflict of Interest. Objectives THANK YOU!

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1 Pediatric Growth Hormone Deficiency: Identification, Diagnosis, & Management Kent Reifschneider, MD CHKD / EVMS Norfolk, VA Conflict of Interest Speaker bureau and advisor for Pfizer Board member of The Human Growth Foundation THANK YOU! Objectives Review the literature regarding measurement accuracy Discuss accurate measurement techniques Identify normal verse abnormal growth patterns Review differential diagnosis for poor growth Case studies 1

2 Importance of Accurate Growth Measurement Incorrect measurements = Inaccurate assessment A 2004 study showed growth to be measured accurately in only 30% of children 1 1. Lipman TH et al. Arch Dis Child. 2004; 89: Accurate Height Measurement Technique No shoes, hair ornaments, braids, etc 1 Heels together, legs straight, arms at sides, shoulders relaxed 1 Patient should inhale deeply and stand fully erect 1 Height should be potted on patient s chart at each visit 1. Lipman TH et al. Arch Dis Child. 2004; 89: Accurate Length Measurement Technique 2

3 Evaluating Growth (cont d) Normal growth velocity: Most rapid in first year of life (up to 22 cm/yr) 1 Slows to 7-9 cm/yr, ages 2-4 years 2 Declines further to ~ 5-7 cm/yr, mid-childhood 1 Increases to cm/yr, during pubertal growth spurt 1 Serials measurements over at least 6 months are required for growth velocity calculation Velocity standards are required for correct evaluation of data 1 1. Lipman TH et al. Arch Dis Child. 2004; 89: CDC growth chart Causes of Abnormal Growth Normal Variants Endocrine - Familial Short Stature - Hypothyroidism - GH deficiency - Constitutional Delay - Cushing Syndrome Prenatal Factors Postnatal Growth - Early or late puberty - Low Birth Weight (SGA) Genetic Syndromes -Down - Congenital Anomalies - Turner Nutritional Deficiency - Prader-Willi - GER, FTT, Eating Disorders - Pseudohypoparathroidism - Russell-Silver Chronic Disease Bone Disorders - Common - GI, Renal, Neurologic - Achondroplasia, etc - Less Common - Cardiac, Pulmonary Medications -Steroids, Stimulant medications Normal Variants Short Stature with normal growth rate Familial Short Stature Short stature with normal onset of puberty FH of short stature BA = CA Final height short but within target range Constitutional Delay Short stature with delayed puberty (late bloomer) FH of slow growth and delayed puberty in ~50-75% BA < CA Final height normal or low normal 3

4 Auxological Signs of Pediatric GHD 1 Short stature 1 Low growth velocity for age (<25 th % for bone age) 2 Crossing centiles in a downward direction Auxology is helpful as an indication for evaluation for pediatric GHD; however it doesn t differentiate children with pediatric GHD from other causes of growth problems 1 Screening tests can help differentiate endocrine from non-endocrine causes of growth failure 1. Growth Hormone Research Society. J Clin Endocrinol Metab. 2000;85: Wilson TA et al. J Pediatr. 2003;143: Etiologies of Pediatric GHD - Congenital Multiple genetic causes of pediatric GHD have been identified 1,2 Examples include abnormalities of the GH gene, the GHRHR gene, or the Pit-1 gene (POI1F1 gene) May be associated with structure defects 3 : Agenesis of corpus callosum Hydrocephalus Sept-optic dysplasia May be associated with midline facial defects 3 : Cleft lip/palate Single central incisor 1. AACE Growth Hormone Task Force. Endocr Pract. 2003;9: Camocho-Hübner C et al. Pediatric Endocrinology. 3. Cowell CT. Clinical Paediatric Endocriniology. 1995: Etiologies of Pediatric GHD - Acquired Trauma 1 CNS infection 1 Hypophysitis 2 Primary or secondary CNS tumors, particularly of the hypothalamus or pituitary (eg, craniopharyngioma, glioma, germinoma, histiocytosis) 2 Cranial irradation 3,4 1. Ronsenfeld RG et al. Pediatric Endocrinology. 2. Cowell CT. Clinical Paediatric Endocriniology. 3. Rappaport R et al. Pediatric Res. 1989;25: Shalet SM et al. Ballieres Clin Endocrinol Metab. 1992;6:

5 Idiopathic Pediatric GHD Majority of pediatric GHD cases Presentation may be in early childhood with severe growth failure and other clinical features of GHD Affected infants usually have a normal weight and length at birth, but impairment of linear growth may occur within the first 2 years of life 1 This growth pattern 2 suggest that GH may not be an essential growth factor in utero History may include difficult deliver, recurrent hypoglycemia, and/or prolonged jaundice 1,3 1. Camocho-Hübner C et al. Pediatric Endocrinology. 2. Goossens M. J Clin Endocrinol Metab. 1986;62: Craft WH et al. J Pediatr. 1980;96: Auxological Criteria for GHD Evaluation Investigation should be initiated if a child exhibits one or more of these features: Severe short stature 1 Height >2.25 SD below the mean for age or >2 SD below the midparental height percentile 2 Midparental height = (father s height + mother s height)/2; cm for boys, cm for girls 3 Growth velocity <25 th % for bone age 3 1. AACE Growth Hormone Task Force. Endocr Pract. 2003;9: Wilson TA et al. J Pediatr. 2003;143: Rosenfeld RG et al. Pediatric Endocrinology. Conclusions Pediatric GHD is defined as short stature or slow growth caused by the absence or inadequate production of GH in children Multiple etiologies have been identified; may also be idiopathic Diagnosis is complex 1 Based on clinical, auxological, biochemical, and radiological evaluations GH therapy is proven to improve growth in children with pediatric GHD 2 Routine follow-up of patients receiving GH therapy should be performed by a pediatric endocrinologist 3 1. Growth Hormone Research Society. J Clin Endocrinol Metab. 2000;85: Bierich JR. Acta Paediatr Scan. 1987;337(suppl): Wilson TA et al. J Pedatr. 2003;143:

6 Management of Short Stature in Children Born Small for Gestational Age Objectives of Presentation Define small for gestational age (SGA) Review the etiology of SGA Discuss methods of identifying children who are born SGA Review evidence for the use of growth hormone (GH) in children who are born SGA and fail to manifest catch-up growth by 2 years of age Discuss assessment and monitoring of children who are candidates for GH therapy Etiology of SGA 6

7 SGA: Pathophysiology (Hypothesis) Fetal response to prolonged nutrient deficiency late in gestation may be permanently reset to a slow growth rate, with a degree of resistance to GH, insulinlike growth factor (IGF-I), and insulin Therefore, a subset of children born SHA may have: Slow growth rate as a manifestation of a degree of GH or IGF-I resistance Increased risk of cardiovascular and metabolic diseases in later life Gluckman PD, Harding JE. Hom Res. 1997;48(suppl 1): Identifying Children Born SGA For correct diagnosis of SGA, birth length must be measured precisely 2 people required for accuracy Infant on back, centered on board, lying straight with shoulders and buttocks flat against surface Infant s eyes looking straight up and toes pointing upward with feet flat against footpiece, both legs fully extended Pomerance JJ. Pediatrics. 2003; 112(1 pt 1): Catch-up Growth in Children Born SGA ~90% of children who are born SGA experience catch-up growth by age 2 years and will achieve a height greater than -2 SDS (~3 rd percentile) 1,2 80% or more of infants caught up in the first 6 months of life 1,2 1. Albertsson-Wikland K, Karlber J. Acta Paediatr Suppl. 1997;423: Karlberg JPE et al. Hom Res. 1997;48(suppl 1):

8 Growth Failure in Children Born SGA In some children born SGA, the growth pattern falls away from age- and genderspecific growth curves National Center for Health Statistics and National Center for Chronic Disease Prevention and Health Promotion (2000). Rationale for GH Evaluation Children who have not experienced catch-up growth by age 2 years have higher risk of short stature (less than - 2SDA) as adults, especially those with low birth weight. Age (mo) Albertsson-Wikland K, Karlberg J. Acta Paediatr Suppl. 1997; 423: Conclusions: Management of Short Stature in Children Born SGA Children born SGA who fail to exhibit catch-up growth by 2 years of age are unlikely to catch up, and may be candidates for GH therapy1 Treatment of children with GH for up to 6 years has been effective and well tolerated in clinical trials2 Early initiation of therapy may result in better growth response3 1. Albertsson-Wikland K, Karlberg J. Acta Paediatr Suppl. 1997; 423: De Zegher F et al. J Clin Endocrinol Metab. 2000; 85: Bogusewski M et al. iacta Paediatr. 1998; 87:

9 What is Normal Growth? It depends! Important Questions Accuracy of measurement Reference point (gender, MPH) Hx: Birth, PMH (trauma, meningitis) & FH Medications Activities ROS: Hass, vision, hearing or signs of hypothyroidism P.E: arm span, tanner, skeletal exam, & growth velocity 9

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11 What if this was a girl? Turner Syndrome Clinical Features % Short Stature ~100 Gonadal failure >95 Characteristic facies 60 micrognathia, high-arched palate, low-set ears Cardiovascular anomalies Renal abnormalities 40 Skeletal abnormalities short metacarpals cubitus valgus, scoliosis Endocrine abnormalities autoimmune thyroiditis Type 2 diabetes Webbed neck 25 Edema of hands/feet 25 11

12 Evaluation Confirm accurate measurements Compare to genetic potential and Hx Follow growth velocity Similar to FTT plus hormones & Bone age CBC - CMP UA - ESR TSH/T4 - IGF-1/IGF-BP3* IgA with TTG abs - Bone age* Nutrition ALL JUICE IS BAD! LOW FAT MILK IS GOOD! Diet soda? N.E.A.T. vs Exercise 12

13 References 1. Lipman TH et al. Arch Dis Child. 2004; 89: Growth Hormone Research Society. J Clin Endocrinol Metab. 2000;85: Wilson TA et al. J Pediatr. 2003;143: AACE Growth Hormone Task Force. Endocr Pract. 2003;9: Camocho-Hübner C et al. Pediatric Endocrinology. 6. Cowell CT. Clinical Paediatric Endocriniology. 1995: Ronsenfeld RG et al. Pediatric Endocrinology. 8. Rappaport R et al. Pediatric Res. 1989;25: Shalet SM et al. Ballieres Clin Endocrinol Metab. 1992;6: Goossens M. J Clin Endocrinol Metab. 1986;62: Craft WH et al. J Pediatr. 1980;96: AACE Growth Hormone Task Force. Endocr Pract. 2003;9: Bierich JR. Acta Paediatr Scan. 1987;337(suppl): Wollmann HA. Horm Res. 1998;49(suppl 2) Neerhof MG. Clin Perinatol. 1995;22: Gluckman PD, Harding JE. Hom Res. 1997;48(suppl 1): Pomerance JJ. Pediatrics. 2003; 112(1 pt 1): Albertsson-Wikland K, Karlber J. Acta Paediatr Suppl. 1997;423: Karlberg JPE et al. Hom Res. 1997;48(suppl 1): Albertsson-Wikland K, Karlberg J. Acta Paediatr Suppl. 1997; 423: De Zegher F et al. J Clin Endocrinol Metab. 2000; 85: Bogusewski M et al. iacta Paediatr. 1998; 87: