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Since the mid-80’s synthetic growth hormone is used in the treatment of children who have growth hormone (GH) deficiency and other conditions causing short stature. It is a safe and effective treatment. There are a few side effects. Fortunately, serious side effects are rare.
Although infrequent, there are some possible side effects that you should be aware of. They are:
·Allergic reaction, including swelling at the injection site or rash.
·Hip, knee, or other joint pain.
·Headache
·Progression of spine curvature in patients with scoliosis
The side effects are more pronounced in people who obtain injectable HGH for off-label purposes (uses for which it was not approved by the FDA) and through Internet pharmacies, anti-aging clinics, and web sites.
Growth hormone is not given to people who have tumours or cancer. Sometimes kids may require growth hormone if they have deficiency after receiving cranial radiation or after surgeries of the skull. In these cases, the endocrinologist will be in touch with the neurosurgeon before starting growth hormone to make sure that there is no additional risk. Contact your treating endocrinologist for the expert advice and treatment options with Growth hormone.

Author
Dr Tittu Oommen

GH is given as injections. It is given subcutaneously (below the skin) just as insulin is injected. Once a decision is taken to start GH, the endocrinologist will discuss various options: this will include liquid GH preparations and those with lyophilised powder which needs to be reconstituted before injection. Various kid friendly injection devices are available in the market. GH must be stored in the refrigerator between 2 and 8 degrees.
Despite being an injection, we have never seen kids refusing growth hormone after the initial few days.

Author
Rejitha Jagesh

Adequate nutrient intake and good health is undoubtedly an indicator for appropriate growth. Nutritional growth retardation and delayed puberty is more prevalent among population who are malnourished. The distinctive feature of malnutrition is low weight for height. By improving their nutritional status, these kids can achieve catch-up growth. Studies have shown that there is lower intake of proteins, fats, calcium, and iron in children with short stature. Hence nutritional assessment is important while evaluating a child with poor growth. Even in kids on growth hormone treatment, an appropriate intake of nutrients is encouraged.
Sometimes kids have malabsorption resulting in poor absorption of food. Children may have poor absorption of food related to various problems like celiac disease, chronic bowel diseases, worm infestations, and pancreatic disease. Various kidney related diseases, heart diseases, and diseases of thyroid and adrenal may further reduce appetite. A possibility of food fads, poor calcium intake (due to lactose intolerance) or eating disorders (e.g. anorexia nervosa) should also be considered in the appropriate circumstances.

Author
Rejitha Jagesh

No. Short stature can be a sign of various diseases as we have discussed earlier. Most of these children can be managed without the use of growth hormone. For example, a slowly growing kid with chronic bronchial asthma can achieve good growth when asthma is controlled. Many children have constitutional delay in growth and puberty which may improve spontaneously or with minimum medicines.
Some children can have normal growth hormone levels but can have improved heights with the use of growth hormone. These include:
A) Turner syndrome
B) Idiopathic Short stature
C) Small for Gestational Age who fail to have catch up growth
D) Prader Willi Syndrome
E) Chronic Kidney Disease
F) SHOX gene deficiency
So, do not be surprised when your endocrinologist may discuss growth hormone therapies with you even if your kid has normal growth hormone levels

Author
Dr Mathew John

If a child is suspected to have short stature the first step is to document the height and weight in a growth chart and assess the position on the chart with respect to the height of the parents and children of same age and sex.
Once short stature is established, it is always better to get evaluated by an endocrinologist who will proceed ahead with complete medical history and physical examination. Based upon relevance the child maybe advised investigations like:
· Xray of the hand which will help in assessing the bone age of the child (also to determine maturity and growth potential of bones).
· Blood tests (to rule out hormone or other disorders associated with growth failure)
· Chromosome/Genetic tests
· Examining the functions of the pituitary gland, which produces and secretes the growth hormone.
· Growth hormone stimulation tests: these are done under observation of the kid in the clinic.
· Imaging if necessary, to look for pituitary gland or brain tumours.
Depending on the degree of stunting, the doctor may decide on watching your kid for 6-12 months before deciding to investigate him/her.

Author
Dr. Titto Oommen

This is a particularly important question that need answers. There are growth charts which help to understand if a child is short in comparison to children of the same age and sex. Since children in different ethnicities have different growth rates, it is important that we compare children with other children of the same ethnicity. Some clues to understand if your child is growing normally is to
1. See if he/she is outgrowing his/her clothes
2. Is he/she significantly shorter than other kids of his/her age and class
3. Was he/she smaller than other kids at birth (say birth weight less than 2.8 kg)?
4. Is he/she funny looking? (as commented by others)
5. Their height is not in keeping with parent’s height
5. You have a gut feeling that he/she is not normal
Yes, it is important to get kids checked out for height. Although poor height apparently is a cosmetic problem, it could also be an important sign of many diseases. This could be related to nutrition, gastrointestinal diseases, kidney diseases, respiratory or cardiac diseases, thyroid diseases, growth hormone related problems or even a brain tumor. Most of these are uncommon. The most common reason is a constitution delay in growth and puberty. It is not only important to get the child examined by an endocrinologist, but also a 6-12 month follow up to understand the growth velocity. More delayed the visit for medical care, the lesser the options for treatment.

Author
Dr. Mathew John

Obesity causes a variety of problems like cardiovascular disease, respiratory problems, sleep apnea, musculoskeletal problems, varicose veins, gallbladder disease. The aim of bariatric surgery is to halt the progression or revert the same with weight loss. Surgical procedures can help more significant weight loss than other procedures. A BMI of more than 35 qualifies for surgery even in the absence of any other complications. A person with BMI > 30 in the presence of 2 or more complications also qualifies for surgical management. Some patients with uncontrolled type 2 diabetes mellitus and BMI > 27.5 may be considered for surgical weight loss. These criteria are applicable to people of Indian origin. For westerners, a higher threshold of BMI is considered.

Surgical weight loss is associated with improved lifespan, reduced risk of cardiac disease, improvement in hypertension and cholesterol problems and reversal of diabetes. Depending on the type of surgery, the complications are extremely low especially in experienced surgical hands.

The goal of obesity treatment is to reach and stay at a healthy weight. You may need to work with a team of health professionals — including a dietitian and obesity specialist — to help you understand and make changes in your eating and activity habits. In addition to a healthy diet and regular exercise, weight-loss medication may help in certain situations. The main purpose of anti-obesity medications is to help you to stick to the advised low-calorie diet. This is achieved by stopping the hunger and lack of fullness signals that appear when trying to lose weight. Before selecting a medication for you, your doctor will consider your health history, as well as possible side effects.

Anti-obesity medications approved by the Food and Drug Administration (FDA, USA) include Orlistat, Phentermine/topiramate, Bupropion/naltrexone, and Liraglutide. Of these, medications, orlistat and liraglutide are available in India. Orlistat is an oral medication that acts by preventing the absorption of fats from the diet. Liraglutide is an analog of the intestinal hormone GLP-1 ( a protein produced by the intestine), which delays gastric emptying and promotes a feeling of satiety. It must be injected daily. Some medicines are used by physicians to help people with obesity lose weight even if they are not approved for the same. These are called “off-label use. Metformin and SGLT2 inhibitors are medicines that are sometimes used in this manner. As of date, no ” herbal” medicines are approved for weight loss and some have even been associated with liver toxicities.

It is important that the patients have realistic expectations about the weight loss that can be achieved with medications.

Exercise, a subcategory of physical activity, refers to planned, structured, and repetitive- activities aimed at improving physical fitness and health. Exercise results in energy expenditure. Increased energy expenditure leads to weight loss. In addition to weight loss, regular exercise will help control diabetes, hypertension, and dyslipidemia in people with obesity.
300 minutes per week of moderate physical activity (or 150 minutes of high-intensity exercise) is recommended for weight loss. Resistance exercises 2 days a week will be an added benefit. Exercise plans combined with calorie curbed diet plans will work better. All attempts should be made to reduce physical inactivity time (sitting time). People with obesity should be examined by a cardiologist before doing intensive exercise. Clinicians should also address physical limitations while recommending exercise. It is also important to discuss “cardiorespiratory fitness” as an attainable goal than significant weight loss. People with obesity with good cardiorespiratory fitness have less mortality than normal-weight individuals. Any increase in physical activity should be appreciated and encouraged.

Various studies have indicated that increased consumption of unhealthy food is one of the major factors contributing to obesity. So, it is logical that making changes in diet will help reduce weight. But before modifying the diet, various factors such as BMI, weight loss goals, comorbidities, and socioeconomic status need to be considered. Individualizing the diet will cater to the person’s needs, making it easier for them to achieve long-term weight loss.
Different dietary approaches lead to weight loss if people adhere to them since they are all calorie deficient. Some of these diets reduce carbohydrates and some reduce fat. It is still not clear if one is truly better than the other in long term. In most cases, weight loss of approximately 0.5 kg per week can be achieved with a 500 kcal deficit diet that is adequate in carbohydrates and proteins, low in fat, and high in fiber. Individuals will find this diet effective as it is easier to follow in the long run, but this may not be applicable for those with higher degrees of obesity (say BMI of > 35).

For people with a BMI of > 35, a much more intensive diet restriction under the regular supervision of a dietitian is required. This would mean a higher restriction of calories (mainly from carbohydrates) replacing it mostly with proteins and lesser so with fat. These diets must be supervised by a dietician.

Another restrictive diet is the ketogenic diet which consists of high fats (55-60%), moderate proteins (30-35%), and a very low content of carbohydrates (5-10%). The ketogenic diet is superior in producing rapid weight loss in otherwise healthy patients with obesity. The clinical impacts, safety, tolerability, efficacy, and duration of treatment with these diets and potential for weight regain after discontinuation is not well understood. A ketogenic diet may be followed for a minimum of 2 to 3 weeks up to 6 to 12 months. Close monitoring of renal functions while on a ketogenic diet is imperative, and the transition from a ketogenic diet to a standard diet should be gradual and well-controlled. Your dietician is the best person to help you understand the diet and suggest appropriate personalized modifications.