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SPECIAL ARTICLE |
* Pennsylvania State University College of Medicine, Hershey Medical Center, Hershey, Pennsylvania
Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
Sophia Children’s Hospital, Erasmus University of Rotterdam, Rotterdam, the Netherlands
|| University Saint-Louis Lariboisière, Hôpital Robert Debré, Paris, France
Objective. To provide pediatric endocrinologists, general pediatricians, neonatologists, and primary care physicians with recommendations for the management of short children born small for gestational age (SGA).
Methods. A 13-member independent panel of pediatric endocrinologists was convened to discuss relevant issues with respect to definition, diagnosis, and clinical management of short children born SGA. Panel members convened over a series of 3 meetings to thoroughly review, discuss, and come to consensus on the identification and treatment of short children who are born SGA.
Conclusions. SGA is defined as birth weight and/or length at least 2 standard deviations (SDs) below the mean for gestational age (
–2 SD). Accurate gestational dating and measurement of birth weight and length are crucial for identifying children who are born SGA. Comprehensive pregnancy, perinatal, and immediate postnatal data may help to confirm the diagnosis. Maternal, placental, and fetal causes of SGA should be sought, although the cause is often not clear. Most children who are SGA experience catch-up growth and achieve a height >2 SD below the mean; this catch-up process is usually completed by the time they are 2 years of age. A child who is SGA and older than 3 years and has persistent short stature (ie, remaining at least 2 SD below the mean for chronologic age) is not likely to catch up and should be referred to a pediatrician who has expertise in endocrinology. Bone age is not a reliable predictor of height potential in children who are SGA. Nevertheless, a standard evaluation for short stature should be performed. A diagnosis of SGA does not exclude growth hormone (GH) deficiency, and GH assessment should be performed if there is clinical suspicion or biochemical evidence of GH deficiency. At baseline, insulin-like growth factor-I, insulin-like growth factor binding protein-3, fasting insulin, glucose, and lipid levels as well as blood pressure should be measured, and all aspects of SGA—not just stature—should be addressed with parents. The objectives of GH therapy in short children who are SGA are catch-up growth in early childhood, maintenance of normal growth in childhood, and achievement of normal adult height. GH therapy is effective and safe in short children who are born SGA and should be considered in those older than 2 to 3 years. There is long-term experience of improved growth using a dosage range from 0.24 to 0.48 mg/kg/wk. Higher GH doses (0.48 mg/kg/wk [0.2 IU/kg/d]) are more effective for the short term. Whether the higher GH dose is more efficacious than the lower dose in terms of adult height results is not yet known. Only adult height results of randomized dose-response studies will give a definite answer. Monitoring is necessary to ensure safety of medication. Children should be monitored for changes in glucose homeostasis, lipids, and blood pressure during therapy. The frequency and intensity of monitoring will vary depending on risk factors such as family history, obesity, and puberty.
Key Words: small for gestational age • intrauterine growth retardation • catch-up growth • short stature • growth hormone
Abbreviations: SGA, small for gestational age • SD, standard deviation • GH, growth hormone • AGA, appropriate for gestational age • SDS, standard deviation score • IUGR, intrauterine growth retardation • IGF-I, insulin-like growth factor-I • IGFBP-3, insulin-like growth factor binding protein-3
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