From the Guidelines
Tanner clinical judgment should be prioritized in assessing growth hormone treatment in children with chronic kidney disease, focusing on bone age, pubertal stage, and potential contraindications such as papilledema or active tumors, as emphasized in the 2019 study published in Nature Reviews Nephrology 1. When considering growth hormone therapy, it is crucial to assess the patient's bone age through radiography of the left wrist and evaluate their pubertal stage according to Tanner stages for patients older than 10 years of age. Key considerations include:
- Fundoscopic examination to rule out pre-existing papilledema, which could suggest intracranial hypertension that might progress during GH therapy.
- Assessment of pubertal stage using Tanner stages to understand the child's physical development and its implications for growth potential.
- Evaluation of bone age to determine the degree of maturation of the child's bones and potential growth potential. The most recent and highest quality study, published in 2024 in Nature Reviews Endocrinology 1, supports the use of serum IGF1 levels and GH suppression tests in diagnosing GH excess, with considerations for age, sex, and Tanner stage. Important points from this study include:
- Elevated serum IGF1 levels in relation to age-adjusted, sex-adjusted, and Tanner stage-matched normal ranges support a diagnosis of GH excess.
- GH suppression tests, although challenging in adolescents due to physiological variations, can aid in diagnosing GH excess, with a cut-off of 1 μg/l after an oral glucose load.
- The interpretation of biochemical results should be within the context of clinical assessment, including height velocity, pubertal stage, and bone age. In clinical practice, prioritizing Tanner clinical judgment and adhering to the guidelines outlined in the 2024 study 1 can lead to more accurate diagnoses and effective management of GH excess in children, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Tanner Clinical Judgment
- The concept of Tanner clinical judgment is related to the assessment of growth and development in individuals, particularly in the context of hormone replacement therapy 2.
- Clinical judgment and reasoning in nursing are critical skills that have been studied extensively, with researchers building on Tanner's original model to improve our understanding of these skills 2.
- In the context of hormone replacement therapy, clinical judgment is essential for determining the optimal dose and monitoring treatment efficacy, as seen in studies on growth hormone replacement therapy in adults 3.
- The use of hormone testing, such as testosterone levels, is also an important aspect of clinical judgment in the diagnosis and evaluation of hypogonadism and monitoring of testosterone therapy 4.
- Other studies have explored the relationship between hormone replacement therapy and quality of life outcomes, highlighting the importance of clinical judgment in tailoring treatment to individual needs 5, 6.
Key Findings
- A systematic review of clinical judgment and reasoning in nursing found that experience plays a role in clinical reasoning and judgment, although the exact nature of this relationship is not well understood 2.
- Studies on hormone replacement therapy have shown that clinical judgment is critical for determining the optimal dose and monitoring treatment efficacy, with serum markers such as IGF-I, IGFBP-3, and ALS used to assess treatment response 3.
- The use of hormone testing, such as testosterone levels, is an important aspect of clinical judgment in the diagnosis and evaluation of hypogonadism and monitoring of testosterone therapy, although adherence to guidelines for hormone testing is suboptimal 4.
- Gender-affirming hormone therapy has been shown to improve quality of life outcomes, including reduced levels of depression, anxiety, and suicidal ideation, highlighting the importance of clinical judgment in tailoring treatment to individual needs 5.