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Suggest treatment for growth hormone deficiency

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Posted on Sat, 26 Jul 2014
Question: My son is 13 years old. 6/11/2001. We have been to an endocrinologist who ordered a hgh stimulation test. Arginine stim test showed a peak increase to 8.8 with a BMI of 17.4. Chlonidine test showed peak of 17.3 although based on tests hgh went from 3.3 to 17.3 in 20 mins. He was at the 50th percentile on 4-4-2010 at 51.49 inches. Currently at 69.25 inches and at the 24th percentile on 6-26-2014. His testosterone level is 7. The doctor says he is not hgh deficient but per the results of the arginine test along with very slowed growth, still a few baby teeth and no sign of puberty, we are concerned. Bone age scan showed less than 1 year behind. I think I have covered all necessary details for your expert opinion. Please let us know if we should get a second opinion.
doctor
Answered by Dr. Binu Parameswaran Pillai (33 minutes later)
Brief Answer:
Hello

Detailed Answer:
Hello,
Good day.
Noted the case history and the results of tests.
growth hormone deficiency needs atleast 2 tests to prove it and there are dificulties and short falls in all tests. If the stimulated GH is less than 5, we consider as GH deficiency. If it is between 5 to 10, then doubtful and if it is > 10, no GH deficiecy. Arginine stimulation test and Clondidine stimulation tests both proved that, he doesnt have deficiecy of growth hormone. I presume his puberty has atleast in stage 3 ( testes volume atleast 4 ml) and LH > 0.6. Otherwise we need to prime him with 3 doses of testosterone before testing. However, since both tests are negative, i think he doesnt have GH deficiency. The gold standard is insulin induced hypoglycemia stress test. This is dangerous and difficult to do. Most centers do not do it.

1 year delay of bone age is not pathological. More than 2 years delay is considered abnormal.

What was his IGF-1 level ( please mention the lab specefic range for hi age as well. this will be there in his report).

There are number of causes of short stature apart from GH deficiency. I am sure that your endocrinologist would have rule out all of them. It seems that his puberty is little slow. Most likely he has CDGP ( constitutional delay in growth and puberty). Difficult to prove it, but these kids eventually enter puberty and there wiill be a growth spurt during puberty.

Need bit of history. Any facial assymetry, cleft lip or cleft palate? How is his Thyroid function tests like ? What about IGF-1 level ? I would appreciate if you could attach the reports.

Any family hisory of short stature?
Could you provide his height in centi meters, date of birth, both parent's height in centimeters. I need them to calculate his height potential.

Regards
Binu
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (2 hours later)

Thank you. I have attached labs and a summary. I
Chase still has baby teeth, sleeps 11-12 hours a day, testosterone level of 7, LCMSM level of 5, DHEA level 123, TSH level of 1.25, did not do IGF-1 only IGF-3 which is 5.8, hemoglobin 5.4.

Chase 150.49 cm. CURRENT height
Dad 180.34
Mom 160.22
Paternal grandfather 182.88
Maternal grandfather 183.51
Maternal grandmother 167.64
Paternal grandmother 162.56

Chase has 14 year twin sisters..
1. 162.56
2. 160.02

Notes: last week the orthodontist had to extract 2 of Chases baby teeth (still baby teeth at 13).
Bone age x ray at 10.1 years old showed bone age of 8. Bone age at 12 years old showed bone age of 11. But no significant growth.
doctor
Answered by Dr. Binu Parameswaran Pillai (2 hours later)
Brief Answer:
Not to worry.

Detailed Answer:
Hi,
Got all the reports.

Sorry for the delay. I Was busy in clinic.

His height was 147.32 cm in November 2013 and 7 months later in XXXXXXX 2014 he is 150.495, that is increment of 3.175. This is not great, but not bad either. You can see that he is nearly on 25th centile. This is not the pattern seen in GH deficiency.

According to his parent's height, Chase's achievable height potential (prediction) is 176.78 cm +/- 10 cm. He is already 150.49 cm at 13 years. He is just in to puberty. I do not know what is his testicular volume now. When his testicular volume is around 4 ml, he will start growing in a faster pace. I believe his final height is easily achievable.

Given that he has normal GH levels and that there is no structural deformities in him + no history of familial short stature + considering his growth pattern in growth chart, there are 2 possibilities

1) CDGP ( constitutional delay in growth and puberty)
2) Idiopathic short stature

There are lots of other tests like 17 hydroxyl progesterone and Deoxycorticosterone etc were done. But I can't understand the relevance of these test in Chase's situation. Those are done to rule out rare forms of congenital adrenal hyperplasia where patients will have accelerated/early puberty . They were normal anyway.

We could certainly wait for him to enter puberty. By 14 years, if no signs of puberty, we can kick start puberty by some medicines and observe growth pattern.

Hope this help. Please feel free to discuss further

Regards XXXXXXX
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (4 hours later)
Thank you. That is helpful. One final question for you. I am considerably shorter than any of my siblings or mother...they are all around 170 cm. i had a fairly tramatic fall from a bridge when i was 12 and have not grown since. I am assuming based on his tests that he could not have inherited an issue from me? And lastly, even reaching his potential of 176.78, is there a possibility that growth hormone, say at 14 or 15, could accelerate his growth a couple of inches and, if he were your son, would you give him that chance? Could i get contact information to follow up with you in 6 months or so?
Respectfully,
XXXX
doctor
Answered by Dr. Binu Parameswaran Pillai (3 hours later)
Brief Answer:
Hello

Detailed Answer:
Hi ,

Even if the traumatic fall which you had at 12 years of age theoretically would have caused some GH deficiency due to pituitary injury, that was an acquired one. Not genetic. That wouldn't change the genes which you carry. Hence there is no question of passing that " acquired" cause to your son.

I calculted that, he has a genetic potential to grow up to 176.78 cm +/- 10 cm ( so the range is 166.7 cm to 186.7 cm). So he can grow taller than 176.78 and vice versa... I DONT KNOW IF YOU ARE GETTING MY POINT.

Certainly, if he is not having a catch up growth at puberty ( atleast 8-12 cm per year during early pubertal years), a trial of GH treatment is worth. If he was my son, i would certainly want him to get that extra advantage.

I can see that his DHEA-S level is just 60 mcg/dl. This means that he has just started to get his adrenarche ( production of adrenal androgens). This is slightly delayed too. He would have started getting pubic hair by now. Adrenarche is followed by Puabrche ( pubic and axillary hair growth) , then proper Pubertal events. Adrenarche is followed by testicular androgen production. This is the time, a boy develops many changes. There will be a GH surge in puberty and sudden growth spurt. IF HIS PUBERTY IS GETTING DELAYED BEYONG 14 YEARS, I WOULD TRY A SHORT COURSE OF ANDROGEN THERAPY (3 months) TO BOOST HIS PUBERTY.

I noted your concern that his elder sisters are taller. Please understand that puberty start earlier in girls compared to boys. ( you would have noticed that at around 9-11 years of age, suddenly the girls in a school , grow taller than boys of same class, but then after 1 to 1.5 years, boys will become taller than girls).

I am sort of confident that Chase will eventually get his puberty soon. And you may notice that, there is suddenly a growth spurt in him and will grow taller than his sisters. I beleive he may get a catch up growth too. If that is sluggish, we may consider a trial of GH treatment at that point of time.

At this point of time, all you need to do is optimise his calcium and vitamin D intake and the general nutrition. MAke him to do exercise too. These external factors would surely boost growth potential. We would keep monitoring his height every six months and plot it in the growth chart and observe.

You can certainly contact me after 6 months by either reactivating this thread or by directly asking a question to me ( if you can bear with my english, ha ha). I would be interested to follow his case .I will store our discussions so that i remember his case.

You are welcome to ask more questions. But if you feel that there is nothing more to ask, you may close the query .

I wish Chase good health and success.

Regards
Binu




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Binu Parameswaran Pillai (1 hour later)
Understood. Just a final note that the labs you have read were from march of 2013 so a little over a year ago. I am requesting the pediatricia to do a new blood workup and if any major changes i will reopen with you. Until then, with much respect.
XXXX
YYYY@YYYY
doctor
Answered by Dr. Binu Parameswaran Pillai (3 minutes later)
Brief Answer:
Yes

Detailed Answer:
Noted that. Even the xray you sent was doone last year. It may be a good idea to get the bloood works. Avoid a randoom GH test. It has no value. I guess a fasting Testosterone, LH, DHEA-S, IGF-1, calcium and Vitamin D and CBC , Thyroid functions would be great.
Take care XXXXXXX

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Binu Parameswaran Pillai

Endocrinologist

Practicing since :2003

Answered : 1435 Questions

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Suggest treatment for growth hormone deficiency

Brief Answer: Hello Detailed Answer: Hello, Good day. Noted the case history and the results of tests. growth hormone deficiency needs atleast 2 tests to prove it and there are dificulties and short falls in all tests. If the stimulated GH is less than 5, we consider as GH deficiency. If it is between 5 to 10, then doubtful and if it is > 10, no GH deficiecy. Arginine stimulation test and Clondidine stimulation tests both proved that, he doesnt have deficiecy of growth hormone. I presume his puberty has atleast in stage 3 ( testes volume atleast 4 ml) and LH > 0.6. Otherwise we need to prime him with 3 doses of testosterone before testing. However, since both tests are negative, i think he doesnt have GH deficiency. The gold standard is insulin induced hypoglycemia stress test. This is dangerous and difficult to do. Most centers do not do it. 1 year delay of bone age is not pathological. More than 2 years delay is considered abnormal. What was his IGF-1 level ( please mention the lab specefic range for hi age as well. this will be there in his report). There are number of causes of short stature apart from GH deficiency. I am sure that your endocrinologist would have rule out all of them. It seems that his puberty is little slow. Most likely he has CDGP ( constitutional delay in growth and puberty). Difficult to prove it, but these kids eventually enter puberty and there wiill be a growth spurt during puberty. Need bit of history. Any facial assymetry, cleft lip or cleft palate? How is his Thyroid function tests like ? What about IGF-1 level ? I would appreciate if you could attach the reports. Any family hisory of short stature? Could you provide his height in centi meters, date of birth, both parent's height in centimeters. I need them to calculate his height potential. Regards Binu