GH secretion is the result of a complex series of interactions occurring both in peripheral tissues and in the central nervous system (CNS). Although our knowledge of these detailed interactions continues to grow, it is interesting to note that this knowledge does not have as much clinical application to the growing organism as one might expect. Despite our knowledge of neurotransmitter control and the impact of specific pharmaco-logic agents, physiologic and pathophysiologic entities, we still lack a specific gold standard to identify those subjects that may benefit from exogenous GH therapy (140).

The use of overnight and 24-h GH secretory profiles, along with standard GH provocation testing and accepted markers of GH secretory "sufficiency," including IGF-1 and its binding proteins, supplement physical findings and growth velocity. Together, this information allows the clinician an educated guess in selecting subjects for GH therapy, thus enabling us to maneuver through the confusing and complex biochemical events described previously. In this manner, we can deliver this therapeutic modality to those who can benefit the most. These decisions must be made in the context of the physician's understanding of the psychological and ethical issues in the treatment of these short-statured children.

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