To assess the relative determinants of growth rate, we measured serum levels of insulin-like growth factor-I (IGF-I), IGF-binding protein-3 (IGFBP-3), and GH-binding protein (GHBP) as well as IGF-I erythrocyte receptor specific binding (SB) in 14 prepubertal GH-deficient children before and during the first year of treatment with 0.043 mg/kg.day GH. Serum IGF-I and IGFBP-3 levels, measured by RIA, were significantly increased by 2 weeks and showed progressive increases throughout the year of GH therapy. Growth rate (height velocity SD score adjusted for bone age) correlated best with the 12 month changes in IGFBP-3 (r = 0.81; P < 0.001) and IGF-I (r = 0.72; P = 0.005), and to a lesser extent with the 12 month absolute IGFBP-3 (r = 0.58; P = 0.04) and the 6 month change in IGFBP-3 (r = 0.55; P = 0.05). The baseline IGF-I correlated inversely with the growth rate during GH therapy (r = -0.55; P = 0.05) and was the best pretreatment predictor of growth response. GHBP, as measured by ligand-mediated immunofunctional assay, showed no significant change during GH therapy and did not correlate with growth response. The baseline GHBP, however, did correlate with both the 12 month IGFBP-3 (r = 0.72; P = 0.006) as well as the 2 week change in IGFBP-3 (r = 0.63; P = 0.05). Erythrocyte IGF-I SB showed a significant decrease by 6 months secondary to a decrease in IGF-I receptor number, with no change in affinity. The 6 month IGF-I receptor binding correlated inversely with the increase in IGF-I (r = -0.88; P < 0.001). Erythrocyte IGF-I SB at baseline did not correlate with the growth response, although there was an inverse trend between the 6 month IGF-I receptor level and the growth rate. IGF-I and IGFBP-3 show progressive increases, whereas the erythrocyte IGF-I receptor-binding capacity decreases by 6 months, and GHBP shows little change during the first year of GH treatment. Data from this study suggest that changes in IGFBP-3 and, to a lesser extent, IGF-I are the major correlates of growth rate, and that down-regulation of the IGF-I receptor may have relatively little influence on growth rate compared with changes in IGFBP-3 and IGF-I.