Should Short Kids Take Growth Hormones?
The FDA seems to think so.
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Five men stand behind a two-way mirror, police lineup style. They're about the same age, all casually but neatly dressed. One of the men, Stu, is five feet tall. All of the other men, who vary in height, are taller. Stu has thick black hair and smiles warmly as he stands in the lineup. On the other side of the mirror are several women, average but pleasant-looking, like the men. They are each asked by a host which of the men they would want to date. The contest is rigged to give Stu a perceived leg up on the other men: Stu, they are told, is highly successful, a millionaire. But no one picks him. When asked why, all the women point to his height as the reason. What would it take for Stu to win the lineup, the host asks? "Maybe the only thing you could say is maybe the other four are murders," one of the women says quietly, arms crossed.
The idea that height is important for finding love and earning money, to succeeding in life and being taken seriously, has been hammered into many of us since we were kids. Arbitrary height requirements show up all the time in Western society. Many sperm banks have a robust height requirement for donors of 5'11", despite an average male height in the US of 5'9". To become a fashion model, a woman must be at minimum 5'8", with most models clocking in around 5'10", when the average American woman is a more modest 5'4". Much like the experiment above, done for the show 20/20 back in 1996, dating profiles allow anyone searching for a potential mate to create an arbitrary height cut off. Adding fuel to the fire, studies linking height to greater earning potential regularly make headlines. Being short, especially for men, comes with a price, it seems.
Now imagine you are the parent of a short child and your pediatrician tells you that your son or daughter will always be drastically shorter than the other kids and eventually, shorter than the other adults. What if they told you that there was a way to game the system, at least a little, and give your child a couple of extra inches? The long-term health effects of the treatment are not known, and it will require your child to inject themselves regularly. Would you take the gamble?
In 2003, the FDA approved the use of synthetic growth hormone for idiopathic short stature. Before that, growth hormone was only prescribed for children with a demonstrated deficiency, who were not thriving. Since 2003, growth hormone can be prescribed for any child that is simply very short—to be exact, over-two-standard-deviations-below-the-mean short, or about a projected adult height of 5'3" for a boy and 4'11" for a girl. Since being short for no medical reason is not a disease, use of synthetic growth hormone for children with idiopathic short stature is not always covered by insurance, so extra height can come at a very high cost, around $52,000 an inch. Because short kids with no growth hormone deficiency are genetically predisposed to be short, synthetic growth hormone can usually only add around one to three inches to their adult height. Some kids don't respond to it at all. Even with the best medicine, you can't completely win a fight with genetics.
That has not stopped parents from asking for treatment for their children. A review of US growth hormone registries in 2012 showed that 18 percent of patients were being treated for idiopathic short stature—for simply being very short. The ability to treat a physical characteristic in children with no underlying pathology has created controversy in the medical community. "Does a poorly defined, unpredictable benefit suffice to warrant subjecting a healthy child to years of nightly injections with a medication that may carry risk of adverse effects, albeit small? Now factor in the high cost of growth hormone treatment, and the controversy moves from the individual to the societal level," says Adda Grimberg, scientific director of the Diagnostic and Research Growth Center at the Children's Hospital of Philadelphia and chair of the task force that recently updated physician guidelines for the use of growth hormone treatment.
In the absence of physical health issues, the psychological distress associated with being very short is used as one reason to justify treatment. "Parents are frequently concerned about the psychological implications of being shorter than average," says David Sandberg, director of the Division of Pediatric Psychology at the University of Michigan Medical School. Taller height is used as a proxy for quality of life, he says. But he argues that while short kids may experience bullying, how parents frame that bullying can send an important message to children about height. If a child gets off the school bus crying because someone called him 'shorty,' says Sandberg, and the parent gets very upset, starts crying and vows to speak to the teacher, "that says to the child that being short is the end of the world," he explains. "Parents need to understand the downside of communicating that something is wrong because of a physical characteristic," he adds. The motivation for the bullying may not be a child's height, explains Sandberg, and the bully simply uses height as an easy way to insult the child.
It is difficult to tease out how often the decision to seek treatment is motivated by distress experienced by a child or by parental concerns. "We are not privy to the conversations in the home before a family decides to seek medical care," Grimberg says. "Even observations at the clinic visit are ambiguous. Commonly, the children say they're cool with their height, they have friends, etc, but then their parents will jump in to remind them of that time they complained they couldn't go on the amusement park ride or were teased in school. It's hard to tease out if the child is too shy to bring up their concerns at the doctor's office or if the parents are pushing them to get treatment."
Most of us will never be models for many reasons and don't have any interest in becoming sperm donors. While childhood bullies may target smaller kids who are less physically intimidating, emotional and social outcomes for shorter kids are no different from those for their average-height peers. In a hypothetical world where we could all be in the top quartiles for height, another arbitrary physical characteristic would simply replace height for bullies and picky daters. As for the studies correlating height and earning potential, subsequent studies have found cognitive ability to be the mediating factor predicting success. Discrepancies in maternal and childhood health and nutrition impact both cognitive abilities and adult height.
Whether or not Stu from 20/20 ever found dating success is a question lost to time, but other markedly short men who are over two standard deviations from the norm have fared well, including 4'11" former Secretary of Labor under the Clinton administration, Robert Reich, whose wife was 9" taller. Or take beloved 4'10' or 5' (depending on who you ask) actor Danny DeVito, who has been married for over forty years, or the 5'2" tall ladies' man Prince. All three fall under the height guidelines that would make them eligible for treatment for idiopathic short stature. Being 4'11" never stopped Veronica Lake from being a sex symbol in the 1940s, or Lil'Kim from being a rap revolutionary, though it too would have made both of them eligible for growth hormone.
Society may continue to favor taller height, especially for men, but that does not mean short stature should be pathologized. While there is discretion for doctors when to suggest treatment, Grimberg recommends it in cases where an underlying growth problem is suspected but "diagnostic tests are unable to capture that problem." For physicians, abnormal growth patterns imply health issues, while height is a variable physical characteristic. When two short parents bring in a healthy, well-adjusted short child on the other hand, "my job is not to treat someone who is fine with themselves just because the FDA picked a line on the growth chart."