Infant, Small for Gestational Age Clinical Trial
Official title:
An Observational Phase IV Study for Prospective Follow-up to Adult Height of a Cohort of Subjects Born Small for the Gestational Age and Treated With Growth Hormone
This non-interventional study for prospective follow up of a cohort of 220 subjects born small for gestational age (SGA) is planned for the purpose of finding out if normalisation of adult height is associated or not with metabolic alterations and if true, their magnitude and relevance as well as to detect warnings throughout the treatment period that may be useful for prevention or therapy. This study would help in answering the question if the SGA and growth hormone (GH) association results in insulin resistance and if affirmative, who develops it as well as its impact on other metabolic parameters that precedes type 2 diabetes.
The small for gestational age (SGA) concept includes babies born to term whose weight and/or
height is lower than two standard deviations (SD) below the mean. Pathologically short
stature is understood as a stature of 2.5 SD below the mean for their age and an expected
adult height adjusted to the parental height of one SD below the mean. These SGA children
with a pathological short stature after four years of age are unsuitable for GH treatment. In
fact, there is no other efficient treatment for short stature and insufficient development of
these children other than GH. In addition to short stature, the SGA syndrome also includes
resistance to insulin with the consequent risk of developing type 2 diabetes and other
interrelated metabolic alterations like dyslipidemia and hypertension; and the
glucose-insulin-insulin growth factors (IGFs)-proteins transport axis regulate growth as well
as foetal metabolism and development. Independent from the possible maternal environmental
causes, those born with SGA have low levels of somatomedin C (IGF-I) and its transport
protein [Insulin-like growth factor binding protein 3 (IGFBP-3)] as well as fasting
hyperinsulinemia. The low levels of IGF-1 and IGFBP-3 persist in those that do not present a
catch-up growth and the insulin resistance is secondary to the somatotrope axis. Treatment
with GH increases IGF-I and IGFBP3 levels but also the plasmatic level of fasting insulin and
the long term net result of this combination is unknown.
An analysis has shown, that although during the first 2 years of GH treatment, there are no
signs of glucose intolerance even though there is less sensitivity to insulin, there could be
a greater incidence of type 2 diabetes in deficient children that have been treated with GH
for a longer period. Treatment with GH, of children born SGA that have not caught-up their
growth at 4 years of age, in the majority of cases achieves a good initial growth speed
increase in order to continue to grow within normal limits and end up with an adult height
that falls within normal. This is achieved with an authorised daily dose of 0.035 mg/kg (1
mg/m2/day). However, the question regarding the possible metabolic consequences of GH
treatment of those born SGA remains unanswered in both forms, to find out if GH treatment
increases or reduces resistance to insulin and other associated metabolic parameters and
therefore, the risk of developing type 2 diabetes. Continued monitoring to adult height of a
cohort of subjects born with SGA and treated with GH is the most efficient, easy and
comfortable tool for answering that question.
OBJECTIVES
Primary objective:
- To quantify the evolution of insulin sensitivity from the start of treatment with GH
until adult stature is reached. Sensitivity or resistance to insulin is calculated using
the HOMA-IR model (Homeostasis Model Assessment for Insulin Resistance) which is a
reliable and easy mathematical model that uses the following formula: insulinemia
(μU/ml) x glycemia (mmol/l)/22.5.
Secondary objectives:
- To find predictive factors for the possible changes in insulin sensitivity and its
complex associated obesity, hypertension and high triglycerides type dyslipidemia with
low high density lipoprotein (HDL)-cholesterol. For this, a relation between these
metabolic factors and auxological parameters is to be identified.
a. The following are considered independent or predictive variables:
- Speed of growth in cm/ year
- Standard deviations of height
- IGF-I in ng/ml
- IGFBP-3 in ng/ml b. The dependent variables will be:
- HOMA-IR value
- Triglycerides rate in mg/dl / HDL-cholesterol in mg/dl
- Blood pressure in mmHG
- Body mass index
This is an observational study of a single cohort, without the possibility of a control group
because those born with SGA, who experience a catch-up growth and enter normal auxology
within the first four years of life are not subjected to a paediatric follow-up similar to
those that do not catch-up to normal auxology and are treated with GH. Therefore, the same
auxological and metabolic test results are not available in standard care. The collection of
said parameters requires an "ad hoc" intervention and the study would be experimental or
interventional. The observation period of this study encompasses from the start of treatment
with GH up to a year after finishing the treatment for any reason. The starting age as well
as the time treatment is ended will vary per subject. However, most subjects finish treatment
once adulthood is reached. In accordance with clinical studies, the average observation
period will probably be about 10 years. After the basal data is made available, the
collection of data afterwards will be carried out once a year per subject.
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