A substantial portion of children born small for gestational age (SGA) fail to catch up height, despite normal or even elevated insulin-like growth factor (IGF1) serum levels. In most cases, the etiology of the apparent IGF1 resistance is regarded as idiopathic. However, the recent identification of human IGF1 and IGF1 receptor (IGF1R) mutations, as well as information obtained from transgenic animals, points to a strong genetic component being of pivotal importance in the development of growth retardation. These findings direct attention to molecules downstream of the IGF1R, which have both growth-promoting and, to a lesser extent, metabolic functions. Therefore, defects in these molecules are likely to participate in the etiology of human SGA.