Growth is a sensitive marker of a child's over-all health. Although short stature frequently construes a variant of normal growth, multiple diseases can present with growth faltering alone. Thus, timely evaluation of growth faltering can have important consequences, not just for final height, but for morbidity and mortality. In 2003, the Food and Drug Administration approved growth hormone (GH) treatment for idiopathic short stature, the first indication that emphasizes height rather than underlying pathology as the qualifying criterion for treatment. Decades of literature support the observation that social pressures for tallness preferentially affect males. Consistent with this, GH registries show marked under-representation of female and racial minority patients, as do children who seek endocrine consultations for the evaluation of growth faltering. The gender, racial and socioeconomic disparities in the evaluation and treatment of growth faltering lead to two problematic outcomes: the inappropriate use of GH for socially driven height enhancement in healthy, primarily white boys, and the potential for unnecessary delays in the diagnosis of underlying disease in girls and children of racial and socioeconomic minorities. The proposed study will evaluate disparities in the management of growth faltering from two novel perspectives, the primary care pediatrician (PCP) and the patient-family. Growth studies have traditionally focused on the circumscribed populations of endocrine centers or GH registries, which are beset by ascertainment bias. By taking advantage of a powerful technological advance, the electronic health record (EHR) system, the proposed study will encompass all children aged 2 years to 15 (girls) or 17 (boys) in a demographically heterogeneous primary care pediatrics network that spans New Jersey, Pennsylvania and Delaware. The study seeks to evaluate PCPs'approach to the identification and evaluation of children with growth faltering, and test the efficacy of an electronic alert and decision support tool in improving the consistency of PCP growth evaluations. However, PCP management is often influenced by patient-family concerns and expectations. Thus, the study also aims to understand the complementary role of the patient- family in creating the disparities in the management of growth faltering. Using a combined qualitative- quantitative approach, the study will elicit, from parents themselves, the factors that affect their likelihood to obtain evaluation and treatment for growth faltering and analyze how gender, racial and socioeconomic factors associate with that likelihood. Only by understanding the roots of disparities can effective strategies be designed to eliminate them. This study serves the NIH goal, mandated by Congress in the Minority Health and Health Disparities Research and Education Act of 2000, of reducing and ultimately eliminating health disparities, and the goal of PA-07-392 to reduce health disparities among minority and underserved children. Beyond the specific issue of disparities in growth faltering, this study has the potential to significantly impact pediatric care and child health by demonstrating the power of the EHR in shaping physician practice patterns.

Public Health Relevance

Growth faltering is often the first or only sign of an underlying health problem in a child. However, due to social pressures for tallness, there are gender, racial and socioeconomic disparities in the children who receive specialist evaluation and growth hormone treatment. This study aims to understand the roots of those disparities - from the perspectives of both the primary care pediatricians and the parents - and to test the efficacy of an electronic alert and decision support tool in improving the consistency of pediatrician diagnostic testing and specialist referral for growth faltering.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Study Section
Kidney, Nutrition, Obesity and Diabetes (KNOD)
Program Officer
Winer, Karen
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Children's Hospital of Philadelphia
United States
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Grimberg, Adda; Lindberg, Anders; Wajnrajch, Michael et al. (2018) Racial/Ethnic Disparities in US Pediatric Growth Hormone Treatment. Horm Res Paediatr 90:102-108
Grimberg, Adda; Allen, David B (2017) Growth hormone treatment for growth hormone deficiency and idiopathic short stature: new guidelines shaped by the presence and absence of evidence. Curr Opin Pediatr 29:466-471
Lipman, Terri H; Cousounis, Pamela; Grundmeier, Robert W et al. (2016) Electronic Health Record Mid-Parental Height Auto-Calculator for Growth Assessment in Primary Care. Clin Pediatr (Phila) 55:1100-6
Hawkes, Colin P; Grimberg, Adda; Dzata, Vivian E et al. (2016) Adding Glucagon-Stimulated GH Testing to the Diagnostic Fast Increases the Detection of GH-Sufficient Children. Horm Res Paediatr 85:265-72
Grimberg, Adda; Cousounis, Pamela; Cucchiara, Andrew J et al. (2015) Parental Concerns Influencing Decisions to Seek Medical Care for a Child's Short Stature. Horm Res Paediatr 84:338-48
Hawkes, Colin P; Grimberg, Adda (2015) Insulin-Like Growth Factor-I is a Marker for the Nutritional State. Pediatr Endocrinol Rev 13:499-511
Grimberg, Adda; Huerta-Saenz, Lina; Grundmeier, Robert et al. (2015) Gender Bias in U.S. Pediatric Growth Hormone Treatment. Sci Rep 5:11099
Cousounis, Pamela A; Lipman, Terri H; Ginsburg, Kenneth et al. (2014) How Short is Too Short According to Parents of Primary Care Patients. Endocr Pract 20:1113-21
Hawkes, Colin Patrick; Grimberg, Adda (2013) Measuring growth hormone and insulin-like growth factor-I in infants: what is normal? Pediatr Endocrinol Rev 11:126-46
Cousounis, Pamela; Lipman, Terri H; Ginsburg, Kenneth R et al. (2013) Internet informs parents about growth hormone. Horm Res Paediatr 80:86-91

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