Specialty: Pediatric endocrinology
Title: Chief of Diabetes and Endocrine Center for Children and Young Adults, Boston Children’s Health Physicians at Phelps Memorial Hospital
Hospitals: Maria Fareri Children’s Hospital
Dr. Richard A. Noto remembers the day 9-year-old Adam* visited his office, accompanied by his parents. “He was off the growth charts, below the fifth percentile,” Noto recalls. An exam and diagnostic tests revealed the child was growth-hormone deficient. Left untreated, “He would probably end up being five-foot-three-inches tall,” he says. He prescribed injectable growth hormones.
Adam grew to 5’ 10” and in adulthood became a world champion of tae kwon do. For Noto, 68, it’s one of many success stories: “I’m best known for helping kids grow,” says Noto, who works at Maria Fareri Children’s Hospital, as well as Boston Children’s Health Physicians at Phelps Memorial Hospital. It’s a personal mission: “I’m five-foot-four inches tall myself, and I was always the shortest kid in my class,” he recalls. “I call myself the advocate for all short kids.”
When assessing a new patient, blood tests to check for growth-inhibiting conditions, such as celiac disease, are a must. “In addition, we assess the child’s sex hormones, to see if they will be a late developer,” Noto adds. He’ll also determine a child’s bone age — the number of years a child has left to grow — via a hand X-ray. “Kids should grow at least two inches a year between ages three and puberty,” he says. In some cases, Noto will prescribe medication that suspends puberty, giving children a chance to grow further before their bones fuse.
Though today’s pediatricians are more attuned to their undersized patients than ever, sometimes “they don’t understand,” Noto laments. “The thing that drives me crazy is when a child is short, and a parent is short too, and the pediatrician says to the parent, ‘Well, you’re short, so what do you expect?’ Well, if the father is five-foot-two, don’t you think he’s got a problem? He’s probably growth-hormone-deficient himself. Many tall people don’t think it’s so important to be tall, but they don’t live in short people’s shoes.”
“I was always the shortest kid in my class… I call myself the advocate for all short kids.”
Some pediatricians and parents also are hesitant to intervene in a child’s growth pattern due to ‘tall tales’ about growth hormones. “Everyone thinks kids on growth hormones grow more than other children, but that’s not true,” Dr. Noto says. “The average kid on growth hormones goes from the bottom percentiles [of the growth charts] to the 50th percentile. They take off and reach their percentile.”
Myths about side effects also abound. Though it’s true that a small percentage of kids on growth hormones may initially experience headaches due to fluid retention, or have joint pain due to fast growth, “in those cases the growth hormone can be temporarily halted,” Noto shares. As for more serious consequences, “The only thing they’ve come up with is a European study showing a slightly increased risk of strokes and heart disease,” he says. “People are concerned that growth hormones will make tumors grow, but we have no data. The cancer risk is not there. So far, it’s been very clean.”
Noto spearheads research into short stature. Along with the late researcher Marion Kessler, he performed a study showing that short children have smaller-than-average pituitary glands. Several years ago, he had a paper published in the Journal of Pediatric Endocrinology, showing the link between insufficient growth and pituitary gland size.
The intrepid doctor also receives kudos from former patients. “I can’t tell you how many times I get stopped in an airport and kids recognize me and say, ‘Hey, do you remember me?’” Noto says. Perhaps it’s because the gift he’s given them is priceless. “I asked a bunch of patients whether they’d rather have an extra three-quarters of an inch of height or a brand-new Porsche in the driveway. Every single one said they’d rather have the three-quarters of an inch. As one commented, ‘The Porsche will rust, but my height will always be there.’”
*Name changed for privacy.