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beandoctor, Pediatrician
Category: Pediatrics
Satisfied Customers: 334
Experience:  Board Certified; Graduated from top 20 medical school
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10.10 year old son starting puberty but only in 15 perc for

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10.10 year old son starting puberty but only in 15 perc for height. Bone scan went from 8 yrs old to 11 year old in 11 months. Las Vegas ped endo won't prescribe lupron or growth hormone. Says he will be 5'5 or at best 5'6. Can you tell me a ped somewhere near las Vegas that will help.
Submitted: 4 years ago.
Category: Pediatrics
Expert:  beandoctor replied 4 years ago.

I'd love to try to help with your question... but unfortunately, there may not be an easy solution to this.


First, it sounds like your son's diagnosis is idiopathic short stature - is that what you've been told? Essentially, that just means that a person is short without a medical reason (like kidney disease or a hormone deficiency). Usually, kids with idiopathic short stature are shorter children because their parents are shorter adults - so it's sort of "in the cards" for them, genetically speaking.


For children with severe idiopathic short stature, many endocrinologists will prescribe recombinant human growth hormone injections, as you suggest.


These injections, though, have a downside. For one, although they're effective, they're only modestly effective for children with idiopathic short stature (compared to children with growth hormone deficiency, for example). Basically, at your son's age, you could probably hope for an improvement of only a few inches versus his height without growth hormone. Another disadvantage is that the medication must be administered as a daily injection. I emphasize daily, because if you only give the medication a few days a week, the body tends to not make growth hormone on the days you don't give it - so to attain a real improvement in height takes giving the medication every single day for a sustained period of time. The injections are not especially painful, but the fact that the medication must be administered as a "shot" can be a significant hurdle for some children and families. And finally, the medication is expensive.


Generally speaking, insurance companies will only cover growth hormone for children with idiopathic short stature whose height percentiles are much lower than your son's - usually less than 3rd percentile. That means that you'll end up having to pay for the medication out-of-pocket...


To give you an idea about how expensive that might be, I just looked up the cost of Genotropin. A 5 mg cartrige for injection costs $381.99... and I would ballpark that your son would need at least one of those every 4-5 days. There are other brands on the market, so you may be able to get the medication more cheaply... but I bring it up for the sake of example to give you a sense of just how expensive it might be unless your insurance covers it.


If the cost is not a concern for your family, then I think the best advice I can give you would be to obtain a second opinion from another pediatric endocrinologist. Unfortunately, I practice on the East Coast, so I can't recommend particular physicians - but your best bet would be to look at any children's hospitals or medical schools in your area (or surrounding areas). Another endocrinologist may be willing to prescribe the medication after discussing the risks and benefits with you.


I know this was not the answer that you were hoping to hear, but I hope that this information is helpful to you and helps to put this issue into perspective.


Best wishes to you and your son...

Customer: replied 4 years ago.
What about the possibility of delaying puberty? I know that this is done for children with rapid bone maturation due to puberty to give them more time to grow. Why would this not be an option based on the very low risk? And last, what about hgh releasers, or l larginine, are these safe options to help him in any way?
Expert:  beandoctor replied 4 years ago.

You are asking excellent questions!


There actually have been a couple of studies that looked at delaying puberty with medications like Lupron for children without precocious puberty (which is obviously the typical reason we would use medications to delay puberty). The results were somewhat mixed.


In children who were also treated with growth hormone, the results were good - an extra 8-14 cm of height (3-5 inches) were obtained, though puberty had to be delayed for at least 2 years. Unfortunately, for children with normally-timed puberty who did not also get growth hormone, the results weren't so good. Because of that, in 2009 the American Academy of Pediatrics did not include poor growth as a reason for prescribing Lupron in its most recent consensus statement.


In real life, I think that means two things. First, you almost certainly won't be able to get insurance to cover Lupron without a diagnosis of precocious puberty. And although Lupron is much cheaper than growth hormone, it's still expensive - the generic is around $350/month. Second, I think you'll be less likely to find a physician to prescribe Lupron than you would growth hormone, since the benefits are less clear.


Personally, I don't think I would prescribe Lupron in your son's case, for two reasons. The first one is that it's not clear how well it works unless you use growth hormone at the same time. The second one is that I'm not sure I entirely agree with you that delaying puberty is "very low risk." I say that because the risk of using medications to delay puberty could be adverse social consequences for your son. It's bad enough being the short kid - but it might be even worse to be the even shorter, pre-pubertal kid for the next several years. (For this reason, most endocrinologists stop Lupron by 12 years old for boys with precocious puberty.)


L-arginine could be helpful - but there really aren't any real clinical studies on using that for the situation your son is in. (The only articles I could find were negative ones, suggesting that oral supplementation with arginine does not cause a sustained increase in the level of growth hormone.) I don't think there is much downside - other than cost - to trying that, though.


Again, I know that this information is probably not what you were hoping to hear - but it's my honest opinion, and what I would say if one of my own family members were asking me the excellent questions that you are.


If I have answered your question, please click accept - and if you have any additional questions about any of this (or anything else in the future) please do not hesitate to ask.

Customer: replied 4 years ago.
I must say, although I was hoping for different answers, you have been fabulous. I have one final question and then I will let you move on and pay whatever I need to pay for your expertise.

If it were your son and you could give him 2 or 3 inches by buying the growing hormone (with the expected height of 5'5) which could mean the difference of being able to follow his dream of an MLB player and a more normal life, would you do so? There are no players in the MLB under 5'8.

I feel as if the cut off age of 5'4 for growth hormone, per much research,for boys and his expected height of 5'5 is truly a shame. If he is not reaching his mid parental height then there is some issue whether it be small or not. Why would I not give him every opportunity to reach his potential, even if I must do it on my own.

I have researched jintropin. Thank you and I look forward to your final thoughts. Pamela
Expert:  beandoctor replied 4 years ago.
Pamela, your questions get harder and harder! The sports issue does change things a bit, doesn't it?

I have a son of my own, actually. He's not quite 3, though, so he's not yet dreaming of playing in the MLB. But I thought about your question for a while, and this is what I think you should do.

1) I think you should get a second opinion from a new pediatric endocrinologist. The purpose of this will be twofold. The first thing will be to make sure that there isn't something that we've missed along the way that would explain your son's poor growth. As you suggested, it is a bit unusual for him to fall so far below what should be his genetic height potential... and if there is something that we're missing, now is the time to find it. The second reason will be so that you can find someone with whom you can have a frank conversation about starting growth hormone. (You mentioned that your son's endocrinologist was unwilling to prescribe it... and if you're unable to find an endocrinologist who will, the rest of this sort of becomes moot.)

2) Assuming that you find a doctor with whom you see eye-to-eye and his/her evaluation does not turn up anything else that we could work on to improve your son's growth, the next step is to get some real numbers to inform your decision-making. I looked up the cost of Genotropin just to give you a ballpark idea of what the cost might be... but there are half a dozen manufacturers of growth hormone at this point, and you may be able to find one at a lower cost where you live. (I just looked up Nutropin, for example, and it looked to be around $100 cheaper for the same dose compared to Genotropin.) Additionally, because the pharmaceutical companies want you to use their brand, most of them offer some kind of rebate program or coupon for people who have to pay out of pocket. There's a chance that something like that might be the difference between the medicine being affordable versus being out of the question.

The botXXXXX XXXXXne is, I think you'll have to have some real numbers to try to make this decision. If doing the growth hormone for a couple of years wouldn't be an unbearable hardship for your family, you may want to go for it. If it would mean forgoing every luxury, then obviously it's probably not the best idea. (Baseball camps and good coaches are also expensive, you know... and it's wise to save for his college education in case he doesn't get drafted or get a scholarship!) But once you have some real numbers, you can sit down and figure out how realistic committing to growth hormone for a couple of years might be. Without knowing that data and what the botXXXXX XXXXXne will be for your family, it's impossible to make that call.

If I can help with anything more as you work through all this, please let me know - and all my best to you and your son...

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