Ethical Issues Regarding Treatment Of Shortstatured Children

There is agreement about the treatment of the short-statured GH deficient child. What is controversial is the use of recombinant hGH in the treatment of the non-GH deficient child. This discussion is separate from the problems inherent in diagnosing GH deficiency as previously reviewed in this chapter. In the United States, Food and Drug Administration-(FDA) approved indications for hGH treatment at the time of preparation of this chapter include: GH deficiency, growth failure associated with chronic renal failure and Turner Syndrome, wasting in AIDS and GH-deficient adults.

The treatment practices in non-GH-deficient, short-statured children by U.S. pediatric endocrinologists were recently reported in the Journal of the American Medical Association (130). Because of the controversial nature of this common practice among pediatric endocrinologists, this article was accompanied by an editorial (131). An arbitrary definition of non-GH-deficient children with short stature would include otherwise healthy children with heights <3 SD below the mean for age, abnormal growth velocity (<25th percentile for bone age), and normal provocative testing with peak GH >10 ng/L (using a polyclonal radioimmunoassay). Parental pressure to mitigate short stature in their children is driven by a cultural "heightism" that permeates American society. Taller college graduates make more money, and most (80%) presidents have been the taller candidate (132). Being teased or bullied, having poor self-esteem, feeling athletically incompetent, and being treated as younger than their chronological age by older people are frequent concerns of short children or their parents (133). There are several psychological studies that indicate that short stature per se does not result in negative psychological adaptation (134). To date, there are no completed long-term controlled studies of GH therapy in non-GH-deficient children who have been followed to final height. The international uncontrolled observations of this heterogeneous group is mixed with about one-third of the patients achieving final heights greater than predicated heights (135,136). In one study, the authors demonstrated an average mean gain in height of 3-5 cm (37). Data presented at recent scientific meetings report conflicting results, with one study showing no improvement (138), whereas another showed about an 8.5 cm increase (139); both studies compared treated to untreated patients.

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