Michael Kleerekoper, MD, MACE, has joined the faculty at the University of Toledo Medical School where he is Professor in the Department of Internal Medicine and section chief of the Endocrinology Division. The author of numerous journal studies, Dr. Kleerekoper serves on the editorial boards for Endocrine Today, Endocrine Practice, Journal of Clinical Densitometry, Journal of Women's Health, Osteoporosis International and Calcified Tissue International. Dr. Kleerekoper is also a founding board member of the newly formed Academy of Women’s Health.

Not a tall tale

Adam was born five minutes after his twin sister and sadly he was born deaf. That did not stop him excelling as a student; when I first met him as a high school senior at age 17 he had just been accepted to a prestigious college in the Northeast.

Adam’s father was 6'3" and his sister 5'7" - Adam was 5'1"!

It is shameful that no attention had been paid to his obvious short stature and delayed development during all of his pediatric care. It was his sister, not his parents, who eventually went with him to one of the doctor visits and insisted that something had to be done. (Whatever happened to routinely plotting height and weight on growth curves?)

His bone age was delayed by 2.5 to 3 years and he failed to respond to provocative testing for growth hormone. Not only was he short, but he had no evidence of puberty and physical examination revealed only one small testis in the scrotum. The second testis was found on ultrasound, but the urologist was unable to relocate it to the scrotum so it was removed.

After discussion Adam elected to complete at least one year of GH replacement therapy before beginning testosterone therapy, and he has grown almost 4 in. He continues on GH and testosterone therapy has been started. At college he remains a straight-A student.

Jeff provides a different story. By age 8 years, his parents were concerned about his growth, which had been steady just above the 25th percentile for height and weight. He was an only child; his father was 5’11”; and mother was 5’6”. Because of his short stature relative to his parents, his pediatrician was able to prescribe GH replacement without provocative testing but over the next two years he did not grow at all and was falling off the growth curve. Subsequent testing confirmed that he had Laron syndrome - GH insensitivity.

This autosomal recessive disorder is due to an abnormality in the GH receptor, such that there is normal production of GH but failure to generate insulin-like growth factor-I and its IGFBP3. As with Jeff, GH replacement is ineffective. Mecasermin (Increlex) is a recombinant human IGF-I that is FDA approved as a treatment for this genetic disorder.

Why am I, an endocrinologist who infrequently cares for pediatric patients, involved with this uncommon pediatric problem? The pediatric endocrinologist caring for Jeff thought that it would be wise to monitor his BMD as well as his growth and growth velocity.

What should be monitored? There are conflicting opinions on this but my bias is to monitor total bone mass and not regional BMD. The total body approach also provides valuable information about body fat and lean mass which are important to monitor in this case. Moreover it would be difficult, if not near impossible, to decide which age group to use as the reference population if one were to focus on spine or hip T-scores. Finally, as Jeff’s bone size is likely to increase in advance of bone mass, serial monitoring of regional (2-D) BMD is likely to result in misleading serial data.