Health is a vital sign. It is an important thing we monitor at well visits, which is why routine check-ups are important. But when is growth a concern? Tune in to hear me talk with Dr. Sarah Hart-Unger, a Pediatric Endocrinologist, about height and kids. We discuss:

• How percentiles play a role in height
• Average growth trajectory for kids
• Workup if height trajectory is a concern including imaging and labs
• When Growth Hormone is Recommended

You can find Sarah’s Podcasts ‘The Best of Both Worlds‘ and ‘Best Laid Plans‘ and lots more at theshubox.com

00;00;01;02 – 00;00;17;09

Dr. Sarah Hart-Unger

Believe it or not, your kid grows really fast when they’re younger, like a baby and a toddler, and then it slows way down and then it picks back up again. There’s another bump around puberty, and that bump is going to depend on the child. And when puberty hits, and that can be based on gender, family history and more.

 

00;00;17;12 – 00;00;45;03

Dr. Mona

Hello everyone, and welcome back to the show. Thank you so much for tuning in every week. All of your reviews and just all of your love for the podcast. This is how the podcast continues to grow and I’m so excited I get to connect with parents from the community that I get to give you some solo parenting mindset guidance every month, and that I get to invite the most amazing guests on this podcast, including today’s guest, who I actually know professionally because we practice in the same area.

 

00;00;45;05 – 00;01;06;24

Dr. Mona

It is Sarah Unger, who is a pediatric endocrinologist in Florida with me, and I have referred my patients to her, and we are talking today about children’s height. I wish my kid was a little bit taller. All about your questions and comments and concerns about if your child is not meeting height, trajectory, everything you’d want to know and I cannot wait to talk to Sarah.

 

00;01;06;24 – 00;01;08;22

Dr. Mona

Thank you so much for joining us today.

 

00;01;08;24 – 00;01;13;03

Dr. Sarah Hart-Unger

Thank you so much for having me on. It’s so fun to have a conversation with you outside of work.

 

00;01;13;05 – 00;01;36;00

Dr. Mona

Yes, and I am so excited about this topic because we get so many questions in our general pediatrics offices, and I’m sure a lot of the parents listening are concerned. Maybe even in that early pediatric years. But of course, when that child is going through puberty, is my child growing okay? And, you know, I’m so excited we’re having this conversation because I feel like we often focus on weight, which is important.

 

00;01;36;00 – 00;01;55;21

Dr. Mona

But people also should be focusing on height. And I am really, really big on monitoring height, making sure that we’re not over evaluating, but also making sure that we’re not under evaluating if a child is not meeting certain height trajectory. And we’ll talk all about that. So thank you for joining us. And tell us again what you do as a pediatric endocrinologist.

 

00;01;55;24 – 00;02;15;19

Dr. Sarah Hart-Unger

Yeah. So I work at Joe DiMaggio Children’s Hospital in Hollywood, Florida, which is part of where Doctor Mona doctor referral population would go. And I’ve been there for about ten years, and I take care of children with all kinds of endocrine disorders, from growth issues to thyroid to diabetes and many more.

 

00;02;15;19 – 00;02;33;24

Dr. Mona

I love it. And again, we’re focusing on height today because I haven’t had someone come on the podcast to talk about this yet. So this is going to be great. So talking about growth, like I said, we often focus on weight percentiles, right? I think that’s what parents normally expect at those early visits. Right. We’re talking about the baby growing in weight.

 

00;02;33;24 – 00;02;56;22

Dr. Mona

All of that. But length is important. And also as a child gets older, we’re measuring height because they’re standing. So that’s kind of how we use the terminology. But what do we want to see in height trajectory, I guess throughout the ages, if you want to kind of sum it all up, because of course we were expecting to see different things based on a toddler versus a school age kid versus someone who’s gone through puberty.

 

00;02;56;25 – 00;03;18;13

Dr. Sarah Hart-Unger

100%. There are different expected growth rates based on your age. And there’s a really interesting chart not to get too into the weeds that graphs growth velocity, like how fast you expect a child to go based on age. And it’s really, really interesting. Believe it or not, your kid grows really fast when they’re younger, like a baby and a toddler, and then it slows way down and then it picks back up again.

 

00;03;18;13 – 00;03;39;11

Dr. Sarah Hart-Unger

There’s another bump around puberty, and that bump is going to depend on the child. And when puberty hits, and that can be based on gender, family history and more. But one cool rule of thumb that I remember learning in fellowship, this goes back to Duke’s chair of endocrinology. Doctor Michael Freemark, taught me that babies grow about 20in in their first year, meaning that counts the in utero part, right?

 

00;03;39;11 – 00;03;56;06

Dr. Sarah Hart-Unger

So when you come out and they’ve been like gestating for 40 weeks or so, maybe less in some cases, of course, but they come out around 20in. So they’ve grown, oh my gosh, like 20in a year. Like think about that right. Yeah. And then in the next year of life they grow approximately ten inches and then it’s five.

 

00;03;56;11 – 00;04;06;14

Dr. Sarah Hart-Unger

And then every year after that is about two inches a year until puberty. And then you hit your growth spurt. So really like wrapping your mind around that. Babies and toddlers grow really.

 

00;04;06;14 – 00;04;06;27

Dr. Mona

Really.

 

00;04;06;27 – 00;04;26;17

Dr. Sarah Hart-Unger

Really fast. Like they should. You know, in pediatrics we think about vital signs, right? We think about how rapid is the heart rate and how is the kid breathing. But height and weight are really, really important vital signs to look at as well. Although they have to be taken into context to generally assess how a child’s health is going.

 

00;04;26;20 – 00;04;44;01

Dr. Mona

Love it. And like I said, we both are so important and we tend to only focus when I say we. Pediatricians are focusing on both. But parents usually listen to that weight, especially because they’re that’s what they’re used to for newborns, right? Like, oh, your baby’s gaining weight. You know, breastfeeding formula, feeding all of that. But like you said, both are really important.

 

00;04;44;01 – 00;04;54;00

Dr. Mona

And I love this. So 20in goes down to ten inches a year or five inches a year or two inches a year. To clarify, for people listening, the 20in a year is in that first year. So up until one. Right?

 

00;04;54;04 – 00;05;11;00

Dr. Sarah Hart-Unger

Yes, 20in a year. I mean, that’s kind of an estimate. It’s exactly it’s probably slightly more than that really, because if you’re starting from zero and then you’re pregnant for nine months and your baby is 20in at birth, they’re probably a couple more inches by the time they are two months old. And so yeah, just think about that growth rate.

 

00;05;11;00 – 00;05;12;11

Dr. Sarah Hart-Unger

It’s pretty astounding.

 

00;05;12;16 – 00;05;30;21

Dr. Mona

Yeah. And so when we are looking at all this, when should a parent evaluate their child for height if it’s not meeting that certain trajectory or other besides those, you know, the ballpark numbers that you gave, are there other things that you know a parent should be talking with their pediatrician about in terms of high trajectory and growth?

 

00;05;30;24 – 00;06;04;03

Dr. Sarah Hart-Unger

Yes. So that is where percentiles become really, really important. There’s nothing inherently better about a child growing along the 10th percentile versus a child growing along the 90th percentile. And I want to emphasize that as that’s something we’ll talk about later in the episode as well. But it is concerning if a child initially is at the 90th percentile, let’s say, for the first year of life, and then all of a sudden is dropping down, crossing multiple percentile lines, crossing a percentile line, between visits isn’t necessarily something to get totally freaked out about.

 

00;06;04;03 – 00;06;22;03

Dr. Sarah Hart-Unger

In fact, sometimes kids grow more related to their nutrition in the first year of life and then they kind of follow more of a genetic trajectory. So if parents are pretty small, but you’ve got like these big, chunky big eater babies, they might be expected to be a little bit bigger as babies and then kind of fall in line into their familial growth curve.

 

00;06;22;10 – 00;06;42;21

Dr. Sarah Hart-Unger

And for that to happen, you’re going to see some gradual dropping in percentiles, but it shouldn’t be multiple percentiles being crossed over between visits, like between that six month checkup and like that nine month checkup or whenever the next one is. You would get alarmed if you saw the baby go from 70th to 30th. However, there’s nothing alarming at all for a baby that’s on the 25th staying on the 25th.

 

00;06;42;23 – 00;06;44;01

Dr. Sarah Hart-Unger

So it’s all relative.

 

00;06;44;05 – 00;06;46;20

Dr. Mona

It’s that big drop from percentile.

 

00;06;46;22 – 00;07;11;12

Dr. Sarah Hart-Unger

Yes, a big drop in percentile and conversely a big increase in percentile can actually be concerning as well depending on the age. Like if we’re talking about a school age population in a child that hasn’t not really in the age where you’d expect them to be hitting puberty yet, a really big increase in height percentile could mean that they’re experiencing signs of early puberty, or that something else is going on more rare, like a thyroid condition could present with that.

 

00;07;11;12 – 00;07;12;09

Dr. Sarah Hart-Unger

For example.

 

00;07;12;11 – 00;07;30;13

Dr. Mona

I love it, and we’re going to go over the workup and all of that and things that we’re kind of looking for from a medical standpoint, when height is not being met in terms of the trajectory that we’re looking for, what about like a lower percentile child? So I know you said that we’re okay if a child is like on the 10th and tracking there, but what about if a child is under the third or fifth percentile.

 

00;07;30;17 – 00;07;39;03

Dr. Mona

But they’re, you know, happy developing great overall things are good. Do we get concerned of lower percentile children even if they’re trending? Okay?

 

00;07;39;05 – 00;07;56;12

Dr. Sarah Hart-Unger

I think we definitely have to take things into context. And that means looking at a number of things. First of all, what’s the kid’s health background like? Is this a baby with a congenital heart defect where we kind of understand why they might have started out smaller and are growing more slowly. In that case, following the third might be awesome for that child.

 

00;07;56;15 – 00;08;20;02

Dr. Sarah Hart-Unger

I’m also looking at the parents you know, is mom five feet and dad five five. In that case, I wouldn’t expect their kid to be hitting the 50th percentile. That would be weird. That kid might be expected to grow at the fifth or even third percentile. So if there’s a genetic component that makes sense. Or maybe you have, you know, five kids and all of them have been late bloomers and they’ve been kind of trailing the bottom of the growth chart, then I wouldn’t worry.

 

00;08;20;02 – 00;08;38;23

Dr. Sarah Hart-Unger

However, I would say even if they’re growing at a normal rate, if it just doesn’t seem to make much sense, then I think some evaluation does need to happen. And I have seen in my practice, I can think of one patient in particular that I followed for a few years. Mom was very tall, like 511 and I think was like 62.

 

00;08;38;23 – 00;08;56;07

Dr. Sarah Hart-Unger

And this little boy was kind of tracking basically like on the growth chart, but barely keeping up with the fifth. And at some point I was just like, you know, let’s just do a test to look for this child’s growth hormone production. And that child did turn out to be growth hormone deficient. And then as we’ll talk about later, received some treatment.

 

00;08;56;07 – 00;09;19;21

Dr. Sarah Hart-Unger

So in that particular case it wasn’t just late bloomer although that can be it too, especially if there’s a family history of one of the parents going through late puberty or having a late growth spurt. But if it just doesn’t fit with the picture that you’d expect, and especially looking at the parents and any other family members, then I think it warrants at least some investigation, either by your general pediatrician or referral to a specialist, like an endocrinologist.

 

00;09;19;21 – 00;09;42;14

Dr. Mona

I love it, and I know we’ll get into like when that referral should take place. But what is done? I guess maybe at the pediatrician’s office? I know it depends on maybe people who are listening depending on your pediatricians capability or, you know, a referral process. What is that workup that’s done? Then if we see that, okay, there’s a concern here in terms of any imaging labs where would we kind of start with the evaluation.

 

00;09;42;16 – 00;09;58;05

Dr. Sarah Hart-Unger

Yeah. So first of all, I’ll say as a specialist I’m totally fine. Either way. If the pediatrician just feels like, you know what, I’m concerned enough. I just want to send this child to be seen and I’ll let them order what they want to order. That’s completely fine with me. All I really need is an accurate growth chart.

 

00;09;58;05 – 00;10;20;03

Dr. Sarah Hart-Unger

That’s the most important thing. And then other pediatricians might be more interested in doing part of the work up to kind of decide whether the child needs to be referred. And if you’re in an area like ours where unfortunately, there’s kind of like a long waiting list for appointments, sometimes it can be useful for the pediatrician to do the work up to make sure there’s nothing glaring that would make them want to call the office and get the child in a little bit earlier.

 

00;10;20;06 – 00;10;39;01

Dr. Sarah Hart-Unger

So what that workup often looks like is an X-ray of the hand. Parents call it all kinds of different things. Parents will call it a bone scan or a bone density, but that’s not what it is. It’s actually called a bone age. And what we’re looking at in that X-ray is not how big is the hand? Or like, do the bones look weird?

 

00;10;39;01 – 00;10;59;07

Dr. Sarah Hart-Unger

But we’re looking at the growth plates. Well, growth plates are a little basically lines of cartilage because baby’s hands are not made of mostly bone. The bones in their hands are like tiny, and then the edges of it are all cartilage. So they show up as clear on an X-ray. And so you can basically look at the image of a hand and see how far along that child is in their growth.

 

00;10;59;10 – 00;11;15;19

Dr. Sarah Hart-Unger

And it’s given an age. Now, I also want to do a little bit of damage control here, because parents will come in freaked out, like, oh my gosh, they’re seven and they’re bony. Just five. Like something’s terribly wrong. But that’s not the right way to interpret things because you have to think that bone age is just an average.

 

00;11;15;22 – 00;11;35;12

Dr. Sarah Hart-Unger

The way the standards were determined was like a 1930s foreign population. And they took a million X-rays of a bunch of kids and they said, okay, on average, kids who have lived for seven years have hands that have looked like this. And then so your bone age would get rad is seven. But just because your kid isn’t seven and they’re reading it as looks like seven doesn’t necessarily mean something’s off.

 

00;11;35;12 – 00;11;59;00

Dr. Sarah Hart-Unger

It’s just kind of one tool in the toolbox to understand where your child’s growth is. For example, they look like a late bloomer. We expect them to have a delayed bone age. That doesn’t mean something’s wrong. It can just mean that they’re likely to grow late, go through puberty late, etc. A severely delayed bone age and a poor growth rate can point to issues like hypothyroidism, celiac disease, or growth hormone deficiency.

 

00;11;59;03 – 00;12;23;03

Dr. Mona

I love it, and we’ll get into more of the labs that are done. But let’s talk about that delayed bone age. So just say we have a child who again, is maybe not meeting that trajectory that we would expect, or maybe they dropped a little bit on percentiles. And so you do a bone age and it shows that their chronological age so that the age of the child is eight, but that their bone age is actually a five, which means that they are still going to grow.

 

00;12;23;03 – 00;12;32;00

Dr. Mona

So that’s how we kind of know that they’re still going to grow. Their growth plates are not closing. We’d be more concerned if an eight year old had a bone age of 12, correct?

 

00;12;32;03 – 00;12;51;27

Dr. Sarah Hart-Unger

Well, yes, unless that eight year old is very, very tall. Yes. So yeah we do. Bone age is looking at both ends of the spectrum. And I guess I would just say that like let an endocrinologist or your pediatrician like interpret whether it be concerned about the bone age, because I think this is a fairly nuanced conversation and there’s so many variables there.

 

00;12;52;00 – 00;13;06;09

Dr. Sarah Hart-Unger

But the takeaway for me is it’s a really useful tool to predict future height, and that just because the number you get isn’t exactly the same as your child’s is, isn’t a reason to panic. But ask whoever ordered the bone age to explain what it means in terms of growth and whether to be concerned.

 

00;13;06;14 – 00;13;24;03

Dr. Mona

And also what the future workup would be like. Just say they do a bone age and things seem okay. Let’s say like, okay, there’s a late bloomer kind of situation. The child’s still going to grow. Maybe they did some labs and it was normal. Have the conversation with the ordering provider, whether that is the pediatrician or the endocrinologist on when we need to follow up.

 

00;13;24;03 – 00;13;28;20

Dr. Mona

Again, in terms of the height or, you know, is it going to be a few months, six months, one year, correct?

 

00;13;28;22 – 00;13;46;20

Dr. Sarah Hart-Unger

Yes. So in bony just are moving targets. I like to tell patients that too. Sometimes I have someone come in and they had a bone done on them two years ago and they’re like, well, why do I need that? I had that I’m like, right, well, and that can change with time. And so it’s one kind of like piece of the puzzle we use to put things together.

 

00;13;46;20 – 00;14;03;24

Dr. Sarah Hart-Unger

But just because it looks great one time doesn’t mean we’ll never need to do it again. And usually they will tell you, okay, we’ll need to repeat this in six months or a year. Look at height, etc.. Now, a condition where a bone age might be reassuring and help you not have to do further workup would be in a child.

 

00;14;03;24 – 00;14;21;18

Dr. Sarah Hart-Unger

Perhaps that is kind of on the late side for puberty. So we often get boys who are like 12 who have no signs of puberty on exam, and maybe they have a family history of later puberty, and it looks like they’re falling percentiles on the growth chart. And the reason it looks like that is because a lot of their peers are starting to have their pubertal growth spurts.

 

00;14;21;18 – 00;14;43;07

Dr. Sarah Hart-Unger

On average, the chart goes up. And so if they’re still growing at a normal pre puberty rate, their position on the chart is going to go down. And in that case if they have no puberty on exam and you get a bone age and it’s ten, that can be very, very reassuring because it’s like, okay, this picture fits beautifully with the fact that you’re just following your family’s footsteps and we have your whole growth spurt ahead of you.

 

00;14;43;07 – 00;14;52;28

Dr. Sarah Hart-Unger

So your position on the chart now doesn’t necessarily reflect where you’re going to land as an adult. Just because you’ve dropped to the 10th percentile doesn’t mean you’re going to be a 10th percentile adult.

 

00;14;53;01 – 00;15;11;29

Dr. Mona

Yeah. And like you said, it’s such a nuanced discussion looking at the big picture of an exam, right. Like you said, like you need to know what age is a child, what is their pubertal status. Like if we’re talking about like, you know, certain developmental characteristics there, because that does play a role in the big picture of evaluating, hey, do I need to be concerned more or do I need to evaluate further and all of that?

 

00;15;12;01 – 00;15;28;10

Dr. Sarah Hart-Unger

Yes, exactly. And family history can be really, really helpful too. I worry a lot less about delayed puberty when I hear the parent say, oh yes, I had my growth spurt in 12th grade and the mom says, I had my period at age 16, and then you’re like, okay, well, you came into this honestly and that’s okay.

 

00;15;28;13 – 00;15;35;28

Dr. Mona

I love it. And so you mentioned already some of the medical stuff you mentioned celiac, thyroid, what labs would be done in a workup of any high concern?

 

00;15;36;00 – 00;16;05;27

Dr. Sarah Hart-Unger

Yeah. So the general kind of screening panel that I typically order or tell the community pediatricians to order is a complete blood count, just to kind of look for anything like iron deficiency or just go to sort of something unexpected, a BMP, at least to look at kidney function, thyroid function tests. So usually a TSH and free T4, a celiac panel, something called a Sadri, which just looks for generalized inflammation that might be helpful to figure out if somebody had like a rheumatology disease or inflammatory bowel disease.

 

00;16;06;00 – 00;16;31;19

Dr. Sarah Hart-Unger

And then two growth factors called IGF one and IGF three. These are both made in the liver in response to the growth hormone that’s produced from your body in the pituitary. Now parents often say, well, why. If you’re worried about growth hormone problem, why didn’t you just measure growth hormone and the reason is because growth hormone is released in kind of a secretory pattern throughout the day, meaning some minutes of the day it’s going to be really high and many other minutes it’s going to be zero.

 

00;16;31;24 – 00;16;50;11

Dr. Sarah Hart-Unger

And so you can’t count on any one blood draw, capturing really the essence of what’s going on with a child’s growth hormone status. So these growth factors are released kind of in proportion to how much growth hormone is being released. So they’re more stable surrogate factors that we can look at to kind of gauge if that is a diagnosis in question.

 

00;16;50;13 – 00;17;06;07

Dr. Mona

Very good. And I love having this conversation so that people know why it’s important that we’re monitoring these things. Right. Like we’re not talking about weight, but if a child’s weight is going out of their trajectory, right. Like maybe they were on the 20th percentile, now they’re on the 90th or we’re talking about height here. Same thing jumping.

 

00;17;06;07 – 00;17;22;06

Dr. Mona

Jumping like across the multiple percentiles. It is so important that we know and are monitoring these things. And I go back to this because that’s why. Well visits are so important. Like I have some families who are like, oh, you know, things are well, I’m going like I have no questions, so why do I need to bring my child in for checkups?

 

00;17;22;06 – 00;17;48;13

Dr. Mona

And I’m like, because we have the graph. Like we see everything to look at that big picture, to know that everything’s going okay, because I have had it where sometimes children will come in and they missed three well visits, whatever reason, right? Like maybe family was moving around or whatever. And then we missed maybe like a prime opportunity, maybe that pubertal age where we could have maybe intervene, which we’ll talk about things like growth hormone because that kind of stuff like may need to be done earlier than later, right.

 

00;17;48;13 – 00;17;58;02

Dr. Mona

Like if a family decides to do something like growth hormone, if their child is not meeting certain height trajectory that we want, that needs to be done before their growth plates close, correct?

 

00;17;58;04 – 00;18;29;01

Dr. Sarah Hart-Unger

Yes. I just want to be very careful because you said if the parents want to do growth hormone, and that’s not exactly the wording I would use. Yeah. If a child needs growth hormone or qualifies for growth hormone, I can definitely go into detail of what conditions would warrant that. Then yes, you would need to treat prior to growth plates closing and just as important, although sometimes I feel like parents forget we don’t want to miss the condition that could affect the child health in other ways, such as, again, celiac worst case of brain tumor hypothyroidism.

 

00;18;29;01 – 00;18;43;27

Dr. Sarah Hart-Unger

Like when I say growth is a vital sign. Yes, one thing that can cause poor growth is growth hormone deficiency. And growth hormone can be a helpful Band-Aid. But not every kid who’s growing slow, that’s not always the reason we need to look for other underlying reasons why that might be the case.

 

00;18;43;29 – 00;19;02;09

Dr. Mona

Well, yes, thank you for that clarification, but I’ve had some situations where a family, even if they qualify for like seeing an endocrinologist and working on their height, they don’t want to see one because they’re like, hey, I’m fine. Like they see you. So that’s what I’m saying. Like a family wants to pursue that. Is that yes, you’re right that there are guidelines to growth hormone and all that.

 

00;19;02;09 – 00;19;06;03

Dr. Mona

But some people refuse care and so just wanted. Yeah I’m just I wish they.

 

00;19;06;03 – 00;19;27;18

Dr. Sarah Hart-Unger

Wouldn’t though because again like we’re not necessarily going to recommend treatment. Right. But you want to do the work up to make sure there’s no underlying health issue. Although I get it, if parents are both short and the child is just very short and is growing appropriately, then that’s another story. And growth hormone can be used and non growth hormone deficient individuals if they meet certain criteria.

 

00;19;27;18 – 00;19;54;06

Dr. Sarah Hart-Unger

So I think that’s more what you’re referring to like a child with what we call idiopathic short stature. That’s kind of growing at a normal rate but a very low percentile. And I guess I will just clarify what that is. So technically ES is approved for children beneath the -2.25 standard deviations for height, which equates to about the first percentile and a predicted adult height for girls below 411 and for men below about five four.

 

00;19;54;09 – 00;20;09;03

Dr. Sarah Hart-Unger

I think it’s sometimes important to actually share where those cutoffs are, because in some communities, I think people get the idea that growth hormone should be given to every kid who’s like below average or something like that. Again, it can be used in kids who are not deficient, but they really should be quite small.

 

00;20;09;06 – 00;20;15;16

Dr. Mona

Love it. And yeah, if we can elaborate more on the current guidelines on when growth hormone is FDA authorized or approved.

 

00;20;15;18 – 00;20;39;20

Dr. Sarah Hart-Unger

Yeah. So that was the idiopathic short stature guideline or indication. Other indications include growth hormone deficiency. So this would be tested for in the situation where the child is not growing at a normal rate and then has low growth factors, we can do something called a growth hormone stimulation test to formally figure out if the child does have true growth hormone deficiency, and if they do, then that would qualify them for treatment.

 

00;20;39;27 – 00;21;03;17

Dr. Sarah Hart-Unger

In addition, there’s other conditions such as Noonan syndrome, Turner syndrome. Those are both genetic syndromes where a growth hormone is approved for treatment. And then finally, one that I think people kind of forget about is that children who are born small for gestational age so below the ten percentile for their gestational age, if they don’t catch up to the 10th percentile by age two, then they would qualify for treatment.

 

00;21;03;17 – 00;21;07;21

Dr. Sarah Hart-Unger

Or they’re approved on the FDA label for treatment with growth hormone as well.

 

00;21;07;24 – 00;21;31;10

Dr. Mona

I love this. And like Doctor Sarah said, if you are concerned about your child’s height, it doesn’t necessarily mean that there’s going to be this big intervention that needs to get done. But at the very least, we need to monitor the height or at the very least, we need to do imaging lab work. But that’s all discussed in a clinician patient relationship discussing high trajectory what’s going on familial high, which we talked about already asking the parents height.

 

00;21;31;10 – 00;21;59;14

Dr. Mona

And, you know, when they went through puberty and all of that. So it is so important. It is a big conversation to be had with a lot of nuance like we’ve already discussed. So I love this conversation. And obviously, just to be completely clear, if you’re going into growth hormone, you are by then probably seeing an endocrinologist. I know there’s some doctors maybe in rural settings that prescribe it as a general pediatrician, but typically pediatric endocrinologist is the one managing growth hormone and all of that in the United States is from, you know, my experience as well.

 

00;21;59;14 – 00;22;10;21

Dr. Sarah Hart-Unger

Yes. And there’s actually even guidelines put out by the piece in our society. Well, maybe they’re biased, but they do suggest that growth hormone management should be done by a pediatric endocrinologist. So that would be the specialty you would go to for that.

 

00;22;10;26 – 00;22;28;22

Dr. Mona

Yeah. And you already mentioned, you know obviously one that we would evaluate things like that. But you also briefly alluded to when a family would see an endocrinologist. But to kind of reiterate that. So if a family is concerned, when should they see their pediatrician? When is it time, in your opinion, to say, hey, a pediatrician, we should take a look now.

 

00;22;28;25 – 00;22;54;02

Dr. Sarah Hart-Unger

Yeah. So if the child’s percentiles continue to drop and you feel like that doesn’t make sense, or if you notice your kid is routinely the smallest child among their peers and it just doesn’t make sense for your family, I think it’s worth it to go see a pediatric endocrinologist, even if it’s just for reassurance. Because one thing that we’re a little bit more equipped to do than general pediatricians is do a predicted adult height, looking at bone age and the growth rate and the child.

 

00;22;54;02 – 00;23;13;26

Dr. Sarah Hart-Unger

And so sometimes that can be really helpful for families. Maybe the pediatrician has said, I think you’re fine. I think you’re fine, and maybe they are fine, but we actually have an algorithm that we use pretty commonly where we look at the bone age and the child’s height, and we can actually say point blank to the family, okay, your kid might be at the fifth percentile right now, but she actually has a predicted height of around five four.

 

00;23;13;29 – 00;23;33;02

Dr. Sarah Hart-Unger

And for your family’s genetics, I would expect five 3 to 5 seven. So, you know, this is normal. And then the parents are often really, really relieved to get like a more specific prediction as well as just like a more thorough just to make sure that, like, nothing’s being missed. So we see that all the time. We expect to see it and we don’t mind it at all.

 

00;23;33;02 – 00;23;42;06

Dr. Sarah Hart-Unger

So if you’re just worried, visit after visit with your PCP. Just don’t worry. We have a lot of self referred parents and we are happy to do an initial evaluation.

 

00;23;42;09 – 00;24;02;08

Dr. Mona

Yes, have the conversations. Advocate for your child and like Doctor Sarah said, if anything you’re just getting reassurance if it’s not anything that needs to be done. But I do think this is a very important conversation. Height monitoring. Weight monitoring is all part of, like you said, vital signs and can really give us insight into if this is something that needs intervention.

 

00;24;02;09 – 00;24;22;29

Dr. Mona

Like you said, I want to reiterate again, going back into is there something medical that needs to be evaluated that we’ve missed? I have some celiac disease from lack of growth. And so I think yes, a very important conversation. And that’s something we caught as general pediatricians that we didn’t actually need to send to an endocrinologist. We were actually just sent to GI, confirm the celiac disease and manage that.

 

00;24;23;04 – 00;24;34;28

Dr. Mona

And then we saw growth come back. So it’s really a fascinating thing. And it’s so important like we’ve talked about already, to have that sort of discussion and the big picture analysis of what’s going on when we approach height.

 

00;24;35;00 – 00;24;52;08

Dr. Sarah Hart-Unger

Yes. Yeah. And seriously, if it just bothers you visit after visit, I say just book that specialist appointment. And I think that’s true for anything people understand if you just want another opinion, especially if you’re very honest about not coming in, seeking some answer that you’ve decided already, but you’re open to actually hearing what the specialist has to say.

 

00;24;52;14 – 00;24;54;06

Dr. Sarah Hart-Unger

We absolutely welcome that.

 

00;24;54;09 – 00;25;13;23

Dr. Mona

Well, yeah, I mean, I know you deal with this and I’ve dealt with it to like parents who are adamant that their child is taller, even if they’re doing fine, like me, to be honest. Like I have children who are trending beautifully. They’re on the 30th percentile, meaning they’re meeting their percentiles. The family is not like tall basketball players.

 

00;25;13;23 – 00;25;30;13

Dr. Mona

Like it all makes sense. But then the parent really wants the child to be taller for whatever reason. Societal expectation culture. I see it a lot and I’m sure you do as well. Parents coming in saying I want growth hormone or I want my child to be taller and you’re like, well, this is all on track, right?

 

00;25;30;15 – 00;25;48;03

Dr. Sarah Hart-Unger

Right. I mean, we’re very clear about like that little speech I did about what the indications are. Yes, I gave that one a lot. And I always tell parents, look, I’m happy to look for a reason that your child needs treatment, but if I can’t find one, then you know it’s not to your child’s benefit to be given a medicine for years.

 

00;25;48;03 – 00;26;04;13

Dr. Sarah Hart-Unger

That is most likely safe, but which we don’t have long, long, long term large population data on, especially for kids. You know, all the studies are done on kids that qualify for treatment. So it’s not necessarily fair to extrapolate a child who doesn’t qualify and assume that it’s safe for them as well. So.

 

00;26;04;16 – 00;26;11;23

Dr. Mona

You know, I don’t know the answer to this because I don’t have a patient on growth hormone currently in my practice, surprisingly. But how often are they taking the injections?

 

00;26;12;00 – 00;26;30;02

Dr. Sarah Hart-Unger

Oh, that’s a great question. So it’s every night. It’s a tiny needle like the size of an insulin needle. And most of them have really fancy nice pen devices. And there is one weekly growth hormone that was just FDA approved. It is not covered by every insurance plan, but I do have a couple patients on that as well.

 

00;26;30;06 – 00;26;45;01

Dr. Sarah Hart-Unger

It’s a bigger needle. So my patients tell me that that one hurts more with each shot. But then you’re only giving shots once a week. But that’s a very new one. It’s called Sky trova. And that just came out. Most of the conventional growth hormones are nightly doses.

 

00;26;45;04 – 00;27;04;16

Dr. Mona

Well, this is another reason I love having specialists on my podcast, because you all are up to date on the new meds, right? Like you just taught me something because I didn’t know that there was a new weekly med because unless I have a patient, a general, pediatricians kind of know when to be concerned. And then we utilize the resources of our specialists if we need that more personalized care of something like this.

 

00;27;04;16 – 00;27;19;18

Dr. Mona

So I love it. I just learned something new and I appreciate that. This was an amazing conversation. I know you’re going to come on again, because I have a lot of other endocrine topics to discuss. Yeah. What would be your final message again for everyone listening today regarding this topic or anything in general? Yeah.

 

00;27;19;22 – 00;27;48;28

Dr. Sarah Hart-Unger

Well, about growth, I’d say if you’re worried, definitely seek out that opinion. And that tall isn’t necessarily better than small, especially when it’s within a normal range. So be careful about assigning value judgment to height. If your child’s growing normally is going to reach a reasonable height, then you should love them for whatever they’re worth. And this is coming from a short female, married to a tall husband who already knows that I’m sure my son will be shorter than dad, but yeah, that’s okay.

 

00;27;49;00 – 00;28;06;17

Dr. Mona

Wow, what a great final message because I going back to parental stress about height, like the genetics are just not there. Like it’s okay, that’s who we are. And it’s sad. I mean, even for more so males and females, there’s a gender kind of expectation of like okay well males you know, they need to be this height. And I see that often.

 

00;28;06;17 – 00;28;21;16

Dr. Mona

And it’s a sad reality. And I love that final message because it’s an important one to know for all things related to our kids, not just height. We get these children and they are who they are. And we really have to kind of recognize that accepting them for what they are and what they bring to the table, and that includes how they look and their height and their weight.

 

00;28;21;16 – 00;28;26;03

Dr. Mona

And knowing when to be concerned is so important, which I know we talked about in detail on this episode.

 

00;28;26;05 – 00;28;27;23

Dr. Sarah Hart-Unger

Oh my gosh, I love that.

 

00;28;27;26 – 00;28;41;23

Dr. Mona

And where can everyone find you? Because I know that you also have your own podcasts that have nothing to do with anything. But tell us more where people can stay connected not only about endocrine stuff, but just about everything that you put out into the world. Because I would love to hear more about that too.

 

00;28;41;25 – 00;29;01;14

Dr. Sarah Hart-Unger

Yeah. So if you happen to be in South Florida, you can see me as a patient. I am at Joe DiMaggio Children’s Hospital and the group there, and I’d love to have any of you come, but then I’m actually part time currently, and I have a two podcast, actually, one conversely planned about all things planning and planning adjacent.

 

00;29;01;14 – 00;29;17;11

Dr. Sarah Hart-Unger

And then another one I do with a time management expert called Best of Both Worlds about making work and life fit together. And I’ve been blogging for 18 years. Yes, 18 years at the Shoe box.com shoe box.com. So you can find me at any of those places.

 

00;29;17;14 – 00;29;28;01

Dr. Mona

Well, we will attach everything you just mentioned to our show notes. And again I want to thank you for joining us today. This was such an awesome conversation and I cannot wait to have you on again for another episode.

 

00;29;28;03 – 00;29;32;14

Dr. Sarah Hart-Unger

Awesome, I can’t wait. We can talk puberty period. Anything you want.

 

00;29;32;16 – 00;29;44;29

Dr. Mona

Yes. And for everyone listening today, make sure if you love this episode to leave a review. Thank Doctor Sarah for her time and all the valuable information, and I cannot wait to talk to another guest next week.

 

00;29;45;00 – 00;30;00;21

Dr. Mona

Thank you for tuning in for this week’s episode. As always, please leave a review. Share this episode with a friend. Share it on your social media. Make sure to follow me at PedsDocTalk on Instagram and subscribe to my YouTube channel, PedsDocTalk TV. We’ll talk to you soon.