A challenging case of Growth hormone deficiency (GHD) during the neonatal period

Fawzia Alyafei; Noor Hamed; Nada Alaaraj; Shayma Ahmed; Ashraf Soliman

Introduction: Growth Hormone Deficiency (GHD) can manifest at birth with hypoglycemia, micropenis, or prolonged conjugated hyperbilirubinemia. While neonatal length is often normal, early post-natal growth failure can be significant.

Case Report: A 2-week-old girl born to a Type 2 diabetic mother (HbA1c 7% at end of pregnancy) via elective LSCS presented with normal birth metrics but was admitted to NICU due to hypoglycemia. On day 11, she exhibited hypoactivity, poor feeding, hypothermia (35.5 °C), weak pulse, delayed CRT, mottled cold skin, and severe hypoglycemia. She received emergency resuscitation, oxygen, IV dextrose, saline, and antibiotics (ampicillin and cefotaxime). Blood sugar improved, but the infant tested positive for COVID-19 and was transferred to PICU. Despite 1.5 maintenance fluids with D10% and tube feeding, hypoglycemia recurred. Tests revealed extremely low cortisol and growth hormone levels. Further examination was unremarkable. ACTH and cortisol levels were significantly low, necessitating an ACTH stimulation test.

Table 1: Critical sample
Critical sample	Results	Normal value	Interpretation
Serum Ketone	<0.10 mmol/L	0.4 - 0.5	(low)
C peptide	0.37 ng/ml		(low)
Insulin	1.7 mcunit/ml		(low)
Cortisol	<1.5 nmol/L	>500 nmol/l	(extremely low)
HGH	0.04 mcg/L	>7 mcg/L	(extremely low)

Table 2: Standard dose ACTH Stimulation test
ACTH Stim test	Result	Normal value	Comment
ACTH	<1.5 pg/ml	7.2-63.3	LOW
Cort Stim Baseline	2 nmol/L	> 150	LOW
Cort Stim 30	22 nmol/L	> 500	LOW
Cort Stim 60	27 nmol/L	> 500	LOW A challenging case of Growth hormone deficiency (GHD) during the neonatal period

Treatment included hydrocortisone and levothyroxine, alongside blood sugar monitoring. MRI revealed right thalamocapsular acute focal ischemic infarction, ectopic posterior pituitary gland, and atrophic anterior pituitary gland. The neonate received high-caloric formula and polyose with overnight NGT feed, achieving a total energy intake of 127 kcal/kg/d. At 3 weeks, she developed hypoglycemia (2.1 mmol/L), prompting an increase in polyose. However, hypoglycemia recurred at 25 days with poor weight gain. An IGF1 generation test showed low baseline IGF1 (9.6 mcg/ml), which improved post-treatment. Growth hormone injections (0.03 mg/kg/day) resolved hypoglycemia and improved weight gain, leading to a diagnosis of panhypopituitarism (Central Adrenal Insufficiency, Central Hypothyroidism, GHD, and Hypogonadotropic Hypogonadism). MRI pituitary showed right thalamocapsular acute focal ischaemic infarction with an Ectopic posterior pituitary gland and atrophic (hypoplastic) anterior pituitary gland in the sellar cavity.

Conclusion: Diagnosing GHD in neonates is challenging. It is crucial to correct hypocortisolism and hypothyroidism before evaluation. The IGF1 Generation test may be a valid diagnostic tool for suspected neonatal GHD.

ESPE Abstracts

P3-127