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).
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.
SGA is defined as birth weight and/or length at least 2 standard deviations (SDs)
below the mean for gestational age (<or=-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.