Neurokognitive und psychosoziale Entwicklung bei SGA im Kontext der Indikation zur Wachstumshormontherapie

Zusammenfassung

Die intrauterine Wachstumsretardation ohne postnatales Aufholwachstum stellt eine neue Indikation für Wachstumshormontherapie (GHT) ab dem vierten Lebensjahr dar. Die Beurteilung des Therapienutzens bei Kindern mit SGA (small for gestational age) erfolgt in der klinischen Praxis nicht alleine auf der Basis auxologischer Kriterien (erzielbare Wachstumsbeschleunigung, Endgröße). Vielmehr ist die Therapieentscheidung für Kinderärzte wie für Eltern eng mit der Frage verknüpft, ob SGA die neurokognitive, psychosoziale und schulisch-berufliche Entwicklung gefährdet und ob eine GHT solchen Risiken über eine Optimierung des Wachstumsverlaufs hinaus gegebenenfalls entgegenwirken kann. Die vorliegende Übersicht stellt dazu jüngste Ergebnisse klinischer wie populationsbasierter Studien vor. Auf der Basis der empirischen Literatur wird ein Bedingungsmodell zum neurokognitiven und psychosozialen Entwicklungsverlauf bei SGA abgeleitet, das drei Faktorengruppen integriert:

• Intrauterine pathologische Ursachen (genetische Aberrationen, maternale Grunderkrankungen, uterin-plazentare Faktoren), die sowohl eine Restriktion der Wachstumsentwicklung im Sinne einer intrauterinen Wachstumsretardation (IUGR) als auch eine Schädigung der ZNS-Reifung und damit der neurokognitiven Entwicklung bedingen,

• konstitutionelle Faktoren, die mit einer schichtspezifischen Verknüpfung von normvarianter Wachstumsretardation mit normvarianter kognitiver Retardation einhergehen,

• psychosoziale Risiko- und Schutzfaktoren, die die weitere postnatale Entwicklung steuern und somit wesentlich die klinische Variabilität im Entwicklungsergebnis bei SGA erzeugen.

Das Modell differenziert zwischen spezifischen psychischen Anpassungsproblemen an den Kleinwuchs versus globalen Verhaltensauffälligen mit einer kleinwuchsunabhängigen Genese. Es ist zu erwarten, dass der psychosoziale Therapienutzen einer GHT umso höher ist, je stärker eine spezifisch-kleinwuchsbezogene Anpassungsstörung beim Kind vorliegt bzw. zukünftig droht. Der Stellenwert kinderpsychologischer gegenüber endokrinologischer Intervention steigt dagegen bei Verhaltensstörungen mit kleinwuchsunabhängiger Genese.

Abstract

After recent approval of treatment indication for growth hormone therapy (GHT) in SGA (small for gestational age) treatment expectations do not only refer to improvement of growth parameters but also to enhancement of suspected impairments of neurocognitive, behavioural and educational development. Clinical prognosis, however, is difficult which specific developmental risks are to be expected in the individual case and if their course may response to GHT. The paper reviews recent findings of clinical and population-based studies on neurocognitive and psychosocial outcome in SGA and delineates an integrative framework on the emergence and course of potential developmental risk comprising three major causes:

• intrauterine pathological (fetal, maternal, placental) factors that include both a restriction of growth and of CNS maturation and hence neurocognitive development,

• constitutional factors comprising both a normvariant growth retardation and a normvariant cognitive retardation promoted by socio-economic disadvantage,

• psychosocial risk and protective factors moderating postnatal development and creating the high clinical variability in developmental outcome among SGA patients.

Conclusions are drawn for the clinical differentiation of specific adaptation difficulties towards short stature versus global, short stature independent behavioral disorders. Psychosocial outcome parameters can be expected to respond best to endocrinological growth stimulation in conditions with a high specific short stature related maladjustment; in turn, the relevance of child psychology interventions increases in conditions with global disturbance and short stature independent origin.

SGA - IUGR - Kleinwuchs - Wachstumshormontherapie - Adaptation

SGA - IUGR - short stature - growth hormone therapy - adjustment

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