Brief Answer:
GH deficiency vs Constitutional delay

Detailed Answer:
Good evening,

Thank you for posting the question.

I have noted the X-ray reports, IGF-1, and GH stimulation tests. These are cumulative evidences of GH deficiency in the child. I would like to know what method was used for GH stimulation testing? Clonidine?/Arginine?/Exercise??

Do you have a growth chart which your doctor plotted in the last one year time? If so, could you attach it?

Let me tell you few facts. It is often very difficult to distinguish between constitutional delay in puberty from true GH deficiency in this age. There are limitations for GH stimulation tests and no one method is accurate compared to other.

Some children ( especially teenage children) with a constitutional delay in growth and puberty (CDGP) often exhibit very low GH secretion following stimulation while still prepubertal or in early puberty, but show a normal increase as puberty progresses. This is due to lack of sex hormone priming prior to testing. Sex hormone priming is typically done in peri pubertal children. I agree that, your son probably didn't require a sex hormone priming prior to GH stimulation testing.

In constituitional delay of puberty, usually there is a family history of delayed growth (+/- delayed puberty) and finally these kids reach their target height.

I can see that, your son has grown 6.5 cm in last one year ( growth velocity of 6.5 cm per year) which is not bad. The GH peak in the child ( during GH stimulation test) was 5.54 ng/ml which is sub optimal, but not too bad.

I presume your endocrinologist has considered a number of factors before considering GH treatment. MAY I KNOW WHO WAS THE PAEDIATRIC ENDOCRINOLOGIST IN XXXXXXX WHOM YOU CONSULTED? I can suggest a very good Paed endo in XXXXXXX

Now coming to your questions.

1) Is there an alternative to these injections? like medicines, naturopathy etc?
Modern medicine doctors can't answer this question as we are not trained in naturopathy or other alternative medicines. A good nutrition and exercise, vitamin D, calcium can help often to a certain extent.

2) What if we do not go forward with the therapy as prescribed (injections), what would be the risk?

If he has true GH deficiency, there may be a risk of sub-optimal height gain if we start GH later in age. The earlier, the better the response.

3) Are these injections safe? do they have side effects (short term and long term)?
Modern GH preparations are quite safe. It can be injected under the skin using a pen device. They need monitoring to look for possible side effects which are very very rare. There are possible side effects, but very very rare. The doctors closely follow up the child and thus adverse effects can be prevented.

4) Is this the right age to start the therapy? Could we wait to see his growth for another couple of years?
It is the right age. To answer the question properly, I need to look at his Growth chart. As I said earlier, if he has true GH deficiency, it is better to start treatment early.

5) Can the duration of the therapy be reduced after observation for couple of years? what happens if we stop the injections after let's say 2 yrs noting considerable increase in his height/growth?

If there is true GH deficiency, we can't stop the treatment in between. There will not be good benefit. I mean final height can be very low.


6) how do we distinguish constitutional growth delay vs GH deficiency? for ex: I am about 176 cms tall and my wife is about 158 cms tall, but when I was about 8 yrs old, I was about the same height as my son, but it was around 14-16 yrs is when I shot up with my height?

I have explained this part.

In summary, it is often difficult task to pinpoint GH deficiency at this age. His GH peak value during stimulation test was low, but not too low. He has low IGF-1 ( which can also be seen if there is malnutrition). His bone age is delayed. These points favor possible Gh deficiency.

However, his height velocity was 6.5 cm last year which is good. And there is family history of constitutional delay and these points may favor constitutional delay. I am sure your endocrinologist would have decided to start treatment considering a number of factors and it is difficult for me to question his decision without seeing and examining the child. However, if you are reluctant, You may wish to post pone the treatment for six months and carefully plot his height in growth chart.

Regards
Binu

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Brief Answer:
Endocrinologist in XXXXXXX

Detailed Answer:
Good day.
1) Yes, it is essential to do a Vtamin D and calcium tests iwhen we evaluate for growth disorders. Besides, we also do simple tests like CBC and electrolytes to address common prolems first. I would always do these simple tests firts.

2) Usually, wellbeing and mood improves with GH treatment. Even in adults with GH deficiency, general well being improves after starting GH.

3)ESI corporation employees get GH free from ESI hospitals. Some insurance companies also give cover for GH deficiency. You need to confirm the GH deficiency first.
I can refer two endocrinologists in XXXXXXX Dr XXXXXXX Sarathi, who is a consultant in Vydehi Hospital ( vydehi Institute of medical sciences) and in Manipal hospital, Whitefeld.

Or Dr XXXXXXX XXXXXXX She works in St.Johns. They have an exclusive paediatric endocrine clinic in St.Johns on saturdays between 10 am to 12 noon. You can walk in.

You have to carry all old details including the Growth charts, hand xrays and tests reports.
Regards
Binu

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