This study from Leiden University in the Netherlands dealt with changes in health-related quality of life (HRQOL) and self-esteem in children with idiopathic short stature (ISS) participating in a study on the effects of growth hormone (GH) treatment.  There were 36 pre-pubertal children who were randomly assigned to a treatment or to a control group.  Children, their parents and their pediatricians completed a HRQOL and a self-esteem questionnaire, 3 times in 2 years.  The data indicated that children with ISS did not have lower scores at the start as compared with the normal population, except for social functioning. The pediatricians noticed an improvement in HRQOL in the children in the treatment group.  Those in the treatment group did grow significantly more than those in the control group.  However, the parents and the children being treated reported no change in HRQOL.  Indeed, in some instances they reported being worse than before. The child’s satisfaction with height was more related to HRQOL than was measured height.  The authors concluded that the assumption that growth hormone treatment improves HRQOL or self-esteem in children with short stature could not be supported by this study. 

First Editor’s Comments:  It is widely assumed that short stature may be a handicap and that this condition may result in psychosocial problems, such as ridicule, and mascotism.  Indeed, short people might be victims of discrimination and prejudice, often referred to as “heightism”.  For that reason, many have opted to receive GH with the intent to accelerate growth and improve the final adult height, and in that way improve their psychosocial status.  The response to GH treatment in these children appears to be modest, resulting in a possible gain in final height of 5–9 cm, after many years of treatment.  However, few studies have approached the concept of HRQOL as an outcome measure of this treatment.  In this study, children with a height of more than two standard deviations below the mean for age and sex, who were not GH deficient, were found to have appropriate HRQOL and self-esteem, and did not show improvements after GH treatment. The parent’s opinion about their social competence after treatment was also not changed.  Of interest was the lack of agreement between the informants, who were the patients and parents, with the pediatrician’s perception of the effects on quality of life after GH.  The relationship between stature, growth, HRQOL and self-esteem might be determined by the expectations of the participants rather than by the improvements in growth. These children, as well as their parents, might have had unrealistic expectations and, therefore, not be satisfied with the treatment, despite improved standard deviation scores for height.  Therefore, when we undertake treatment of a non-growth hormone deficient short child, we should consider aspects other than height. GH treatment should not be initiated just because the child is short.  An interesting editorial accompanied this article and was written by Basil J. Zitelli in the same issue of the journal, and the reader is encouraged to review that as well.  (Journal of Pediatrics 2002;140:493-495).

Fima Lifshitz, MD

Second Editor’s Comment:  Dr. Zitelli in his commentary points out with emphasis that offering children and parents therapy for short stature raises expectations of success.  Motivation to be included in GH trials frequently involved the hope of gaining height, yet if expectations were not met through therapy, poor self-esteem and parental anxiety and disappointment were acutely felt by the child.  With the variability and unpredictability of results for any particular child, GH therapy becomes an intervention that may be more detrimental than the original complaint of short stature.

Investigators have added another layer of therapy to enhance growth.  To delay epiphyseal fusion, gonadotropin releasing hormone agonists have been added to GH treatment regimens.  This may potentially compound the iatrogenically introduced fear in the normal short child of being abnormal or affected with a disease that requires 2 medications to treat.

The last issue (GGH 2002 Vol 18:3) has an abstract and commentary regarding the use of LHRHa in advanced puberty.  The conclusion of the authors was “these data suggest that advanced puberty (as differentiated from sexual precocity defined as sexual development in girls before the age of 8 years and boys below 9 years) decreases the growth potential by about 5 cm and that GnRHa therapy does not prevent this”.

Robert M. Blizzard, MD

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