Beyond growth velocity: a dual-criterion framework for selective recombinant human growth hormone combination therapy in girls with idiopathic central precocious puberty

Gonadotropin-releasing hormone analog (GnRHa) serves as the first-line therapy for girls with idiopathic central precocious puberty (ICPP). Treatment-related growth deceleration is a predictable pharmacological consequence of GnRHa administration; however, clinicians frequently rely solely on this single observation to justify adjunct recombinant human growth hormone (rhGH) therapy. Accumulated meta-analytic evidence indicates unselected ICPP patients derive minimal clinically meaningful final adult height benefits from combination treatment, with most girls achieving final adult heights consistent with their genetic targets following GnRHa monotherapy. We hypothesize that incremental height benefits are restricted to a high-risk subgroup characterized by persistent growth deceleration and substantially reduced predicted adult height (PAH). Current clinical guidelines lack standardized therapeutic criteria, resulting in overreliance on isolated growth velocity cutoffs and empiric overtreatment. This Perspective argues that rhGH initiation may be better guided by comprehensive residual growth potential than by short-term growth deceleration alone. Existing clinical guidelines prioritize PAH, while routine clinical practice emphasizes growth velocity, with no unified strategy integrating both metrics. We therefore propose a dual-criterion, risk-stratified framework to define concurrent sustained growth slowing and composite PAH deficits relative to population normative standards and individual genetic target heights. Crucially, this “both-and” criterion is proposed strictly as a research enrichment tool to identify a phenotypically homogeneous subgroup for future prospective trials, rather than as a clinical screening rule for routine practice. Prospective validation, particularly among East Asian ICPP cohorts, is essential.