Skeletal accrual in pediatric growth hormone deficiency: a narrative review

Growth hormone deficiency (GHD) is a frequent cause of impaired linear growth and may also affect skeletal development and bone mass acquisition. This narrative review summarizes the current evidence on bone health in pediatric GHD, with a focus on clinical findings, response to recombinant human growth hormone (rhGH) therapy, and practical approaches to bone assessment. Available pediatric studies consistently show decreased BMD and bone mineral content at diagnosis, often involving the lumbar spine and total body, together with alterations in bone structure. During rhGH treatment, gradual improvements in bone turnover markers and BMD are generally observed, although responses are variable and may depend on age, growth response, and treatment intensity. Full normalization is achieved only in a subset of patients, highlighting heterogeneity in skeletal recovery. Given these findings, a structured clinical approach is recommended. An integrated algorithm for bone health evaluation in children with GHD should include biochemical assessment (IGF-1, calcium-phosphate metabolism, vitamin D status, and bone turnover markers) plus imaging evaluation, primarily using dual-energy X-ray absorptiometry (DXA) with appropriate pediatric and size-adjusted interpretation. Early initiation of rhGH therapy, alongside optimization of calcium and vitamin D intake, is essential to support bone accrual. Overall, pediatric GHD is associated with impaired skeletal development, but timely diagnosis and standardized monitoring through a combined clinical, biochemical, and imaging algorithm can improve the final bone outcomes. Further prospective studies are needed to refine assessment tools and optimize long-term management strategies.