Alternatives to Growth Hormone for Increasing Height in Children
For children with growth failure who cannot use growth hormone therapy, anabolic steroids like oxandrolone may be considered as an alternative treatment option, though with careful monitoring for side effects.
Understanding Growth Failure and Treatment Options
Growth failure in children with chronic kidney disease (CKD) is a significant clinical concern that impacts quality of life and long-term outcomes. While growth hormone (GH) therapy is the primary pharmacological intervention, some children may not be candidates for GH therapy due to contraindications or poor response.
When to Consider Alternatives to GH
Alternatives to GH should be considered in the following scenarios:
- Patients with known hypersensitivity to GH or its excipients 1
- Patients with closed epiphyses 1
- Patients with active malignancy 1
- Patients with severe secondary hyperparathyroidism 1
- Patients with acute critical illness 1
- Non-responders to GH therapy after at least 6 months of treatment 1
Alternative Pharmacological Options
1. Oxandrolone (Anabolic Steroid)
Oxandrolone is an anabolic steroid that can be used to promote growth in children with certain growth disorders.
Dosing and Administration:
- Administered orally
- Requires careful dose adjustment and monitoring
Important Considerations:
- May accelerate epiphyseal maturation more rapidly than linear growth 2
- Therapy should be monitored by X-ray studies at 6-month intervals to avoid compromising adult height 2
- Should only be used by specialists aware of effects on bone maturation 2
Potential Side Effects:
- Drug interactions with oral anticoagulants (especially warfarin) requiring close INR monitoring 2
- Interactions with oral hypoglycemic agents 2
- May increase edema when used with adrenal steroids or ACTH 2
- Can affect laboratory test results including thyroid function tests 2
- Long-term risks include potential liver cell tumors with high-dose, long-term therapy 2
2. Steroid Minimization in Transplant Recipients
For children with growth failure after renal transplantation:
- Steroid minimization or avoidance protocols have shown significant increases in height SDS (mean difference of 0.38; 95% CI 0.07–0.68) 1
- Particularly effective within the first year after steroid withdrawal (mean difference of 0.22; 95% CI 0.10–0.35) 1
- Most beneficial in prepubertal patients (mean difference of 0.60; 95% CI 0.21–0.98) 1
Non-Pharmacological Approaches
1. Nutritional Optimization
Adequate nutrition is essential for growth, particularly in infants and young children with CKD:
- Ensure adequate caloric intake
- Optimize protein intake
- Address specific nutritional deficiencies
- Consider enteral feeding support when necessary
2. Management of CKD-Related Metabolic Abnormalities
Addressing underlying metabolic issues can improve growth potential:
- Control metabolic acidosis
- Manage mineral and bone disorders
- Optimize dialysis adequacy in patients on renal replacement therapy
- Treat secondary hyperparathyroidism
3. Timing of Renal Transplantation
Early renal transplantation may improve growth outcomes in children with end-stage renal disease:
- Consider pre-emptive transplantation when possible
- Optimize post-transplant management to support growth
Monitoring and Follow-up
Regular monitoring is essential for all children with growth disorders:
- Height velocity measurements every 3-6 months
- Bone age assessment annually
- Pubertal staging in children older than 10 years
- Laboratory monitoring specific to the underlying condition and chosen therapy
Important Caveats and Considerations
- The evidence base for alternatives to GH therapy is less robust than for GH itself 3
- Treatment decisions should prioritize long-term morbidity, mortality, and quality of life outcomes
- Anabolic steroids should be used very cautiously in children due to potential effects on bone maturation 2
- The risk-benefit ratio differs significantly between treatment options
- Early intervention generally yields better outcomes than delayed treatment 4
Treatment Algorithm
- First-line approach: Optimize non-pharmacological management (nutrition, metabolic control)
- If growth failure persists and GH is contraindicated:
- Consider oxandrolone in selected cases with careful monitoring
- For transplant recipients: implement steroid minimization/avoidance protocols if immunologically feasible
- Monitor response: Assess height velocity after 6-12 months of intervention
- If inadequate response: Re-evaluate underlying factors and consider alternative or combination approaches
While alternatives to GH exist, they generally have a less favorable efficacy and safety profile, making the management of growth disorders in children who cannot receive GH therapy particularly challenging.