Since my 3-year-old son is shorter than 99% of boys his age, the doctor recommended growth hormones. Here's what I discovered about the therapy.
"He's in the 1 % range," my wife reported. SR9011 raw powder
Though our 3-year-old son Nicholas is certainly bright, I knew she wasn't referencing his IQ. No, Nicholas is one in 100 for another reason: At 33½ inches tall and 26 pounds, he's smaller than over 99% of boys his age.
"She brought up growth hormones," she continued.
Cue parental paranoia. A flurry of Googling and link sharing ensued as my wife and I wandered down a cyber rabbit hole—familiar surroundings for any medically alarmed mom or dad. What are growth hormones and what is the best age to start growth hormone treatment?
Human growth hormone is a natural hormone produced by your pituitary gland. It promotes growth in children. Growth hormone (GH) therapy became available in the late 1950s for children with severe growth hormone deficiency. During therapy, a synthetic GH shot is injected into the body daily to help promote growth. Children are usually on growth hormone therapy for several years. Some children with growth hormone deficiency may need the shot for life.
In 2003, the FDA approved a synthetic human growth hormone for idiopathic short stature (ISS), a term describing children who are short for no known cause. Research shows an estimated 500,000 kids in the U.S. meet qualifying criteria for potential treatment. GH therapy can also be used for children with a medical condition that is causing their short stature.
Some children are below average height without a medical reason. That can be because of genetics or they didn't catch up after being small for their gestational age at birth. But short height can also be a result of human growth hormone deficiency or conditions like these below:
The success of GH therapy depends on various factors, such as when the child starts treatment, how long it lasts, what conditions they may have, and their height potential. But research shows it can in fact increase the adult height of children with idiopathic short stature.
Growth hormone treatment can begin once there is evidence of growth issues, which typically is noticed when puberty begins. It may begin even earlier if the child has a diagnosed condition. Keep in mind, growth hormone therapy can not be initiated after a child's growth plates fuse, which is around 14 in girls and 16 in boys.
There's a lot for parents to consider, especially since besides being expensive, GH shots won't help in every case despite daily injections and regular endocrinologist visits. Varying reasons for treatment lead to wide-ranging success rates, with more exacting models for predicting GH therapy's effectiveness continuously being improved. Before considering growth hormone therapy for your tiny tot, here are a few factors to consider.
Though synthetic-sounding, growth hormone is a natural bodily substance produced in the pituitary gland, which is located in the brain.
"In any scenario where growth hormones become an option, the first action is determining whether the child has a clinical growth hormone deficiency, as opposed to being at the bottom of the growth chart organically," says Sarah Nielsen, MD, a pediatrician at Verona Pediatrics in Verona, New Jersey. In other words, there's a difference between being naturally small and un-naturally small.
If GH stimulation testing reveals inadequate levels of growth hormone, says Dr. Nielsen, "then intervention becomes a far easier choice."
Elizabeth Burtman, MD, of Pediatric Endocrinology Associates in Tenafly, New Jersey, agrees. "Being significantly below average in growth hormone levels is just like being deficient in any hormone, and therapy becomes a fairly obvious choice," says Dr. Burtman, who is double board-certified in pediatric endocrinology and pediatrics.
It also makes it far likelier that the treatment will be covered by health insurance—a key factor as treatment can cost tens of thousands of dollars a year. According to Dr. Burtman, due in part to the imperfections of GH testing and the cost of the treatment, there are other criteria that usually must be met for insurers to cover the therapy, including a child's likely "potential height" pitted against his parents' height.
Dr. Nielsen also notes it isn't just the tiniest tots who should be tested for sufficient GH levels. "If a child is in the 50th percentile for a while, but then suddenly slips into the 20th, that's a potential red flag of a compromised GH level," she says.
In Nicholas' case, his growth curve is normal from a consistency standpoint, reassuring on one level, but also adding to concerns that he'll be substantially smaller than his peers forever.
If your child's GH levels are normal, deciding whether to pursue growth hormone therapy becomes a bit more complicated. Not surprisingly, among the factors that come into play is family height history.
"What we try to determine is whether the child is growing to his or her full height potential," says Dr. Nielsen. "Obviously, if a child's parents and grandparents are on the small side, the likelihood he'll be short is higher. Ethnicity is also a consideration." My wife and I are a mixed bag here: I'm 6-foot-tall and Caucasian, while my wife is a towering 4-foot-11 and Chinese. And since Nicholas is an only child, there are no siblings for useful comparison.
"Family is a factor, but not the factor," says Dr. Burtman. "There's so much variability within families that it simply can't provide a slam-dunk answer."
So unless it's abundantly clear that smallness aligns with family history, says Dr. Nielsen, what becomes advisable at this point is a bone age study, an X-Ray of the child's growth plates, which are softer bones consisting of special cells responsible for growth. This is intended to provide an educated approximation of adult height.
But as with GH stimulation testing, we run again into the challenge of the testing itself being imperfect. "Bone age studies can differ in terms of their accuracy. Reading them is as much an art as a science, with some subjectivity involved," says Dr. Burtman. "It's really just another tool but shouldn't be relied upon as the sole determining factor."
Society can be tough on shorter men. "Studies have shown that shorter men have a harder time finding a partner or performing well on a job interview," says Dr. Nielsen. "It shouldn't be the case, but that's the society in which we live."
Depending on the severity, I fear Nicholas' shortness could be a significant hindrance socially and professionally.
The downsides of shortness are, typically, less harrowing for women, which may be a reason why boys make up the majority of patients who receive growth hormone therapy. But it shouldn't be ignored in girls either.
"If I see 10 patients in a day, seven or eight of them are usually boys," says Dr. Burtman. "Though it's easy to dismiss shortness in women as less of a long-term social inconvenience, it's best to at least have preliminary tests performed for all children in the third percentile of growth or lower."
From there, according to Dr. Burtman, a child's rate of growth must also be monitored. "Growing less than two inches per year before puberty, and less than three inches per year in puberty, is considered less-than-normal growth and should be explored," she says.
Growing less than two inches per year before puberty, and less than three inches per year in puberty, is considered less-than-normal growth and should be explored.
Psychological factors may come into play. According to a 2014 study led by Emily C. Walvoord, MD, a professor of clinical pediatrics at the Indiana University School of Medicine, short but healthy children who are treated with growth hormone therapy may become more depressed and withdrawn than peers the same height who do not undergo the treatment.
"Daily injections, frequent clinic visits, and repeated discussions about height might exacerbate instead of improve psychosocial concerns in children with idiopathic short stature who are otherwise healthy, and give them no cognitive improvements," lead author Dr. Walvoord said in a statement.
A child's proclivity for depression or anxiety is made higher when close relatives have similar maladies. For Nicholas, the child of a clinically depressed recovering alcoholic with an anxiety disorder (me), this may provide particular pause in our decision-making.
Dr. Burtman sees adverse psychological effects as the exception rather than the rule. "A small percentage of children who are treated may show some emotional sensitivity to it, but for kids who gain height, the process can certainly add confidence and self-esteem," she adds.
According to Cincinnati Children's Hospital, growth hormone is considered safe and side effects from it are rare but, like the effectiveness of the therapy itself, run a range of potency. For one, headaches can occur as a result of increased pressure on the brain.
Accelerated growth also can cause a hip problem called slipped capital femoral epiphysis, in which the upper part of the thighbone shifts. This can cause considerable knee or hip pain, is often accompanied by a limp, and may need surgery to correct.
Due to GH therapy's relative newness, less is known about the long-term risks. But there is concern it may increase the risk of stroke and bone and bladder cancer. Yet, according to Dr. Burtman, these risks are only slightly higher compared to the general population.
If you are concerned about your child's short stature, it's OK to bring up conversations with their health care provider. You may be concerned if you notice their height is below the growth curve, their height percentile is different than that of family members, or they have a very slow growth rate.
Dr. Burtman thinks a parent's intuition can be a useful tool in topics as potentially subjective as short stature and growth hormone therapy. "If the parent feels there's something wrong, and the pediatrician doesn't agree, parents should press the issue," says Dr. Burtman. "In my experience, parents really do know best in these gut feeling situations."
As for Nicholas, the two-person jury of my wife and I is still out. We haven't had him officially tested for GH deficiency yet; should that show a measurable lack of growth hormone, we will certainly move forward with therapy.
If it doesn't, well, we'll see. Nicholas is only 3, meaning we have time to conduct our own research and, hopefully, wait for a game-changing growth spurt. Whatever we decide, it will add another shade of gray to the seldom black-and-white duties of childrearing.
Growth Hormone and Health Policy. J Clin Endocrinol Metab. 2010.
Growth hormone significantly increases the adult height of children with idiopathic short stature: comparison of subgroups and benefit. Int J Pediatr Endocrinol. 2014.
Predicting Growth Hormone Treatment Success. BioMed Central. 2017.
Gender Bias in U.S. Pediatric Growth Hormone Treatment. Sci Rep. 2015.
Growth hormone treatment for children may exacerbate feelings of depression. Endocrine Society. 2014.
Growth Hormone Therapy. Cincinnati Children's Hospital. 2023.
Growth Hormone Treatment Tied to Increased Risk of Stroke. American Academy of Neurology. 2014.
Cancer Risks in Patients Treated With Growth Hormone in Childhood: The SAGhE European Cohort Study. GCEM. 2017.
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