Dr.Mohamed Ahmed Fouad

Lecturer of Pediatrics

Jazn Faculty of Medicine

Objectives

Define short stature .

Distinguish normal growth from pathological short stature.

Identify key components in the history and physical exam in the evaluation of short stature.

construct an effective management plan to acase of short stature.

Phases of growth

Normal growth Facts It is dynamic process.

It is not only gaining Height!

Appropriate wight,hight,HC for age.

Normal growth pattern: between the 3rd and the 97th percentiles

Very important to measure each visit and exam (make it routine!)

Height growth charts

Analysis of the Growth Curve Absolute Height

Growth Velocity

Mid-parental hieght

Weight-for-Height Ratio

How to measure height Less than 2 years use prone mat on firm surface(infantometer)

Standing height over 2 yrs use wall mounted stadiometer

Precautions during measuring

*Without footwear

*Heels & back touching the wall

*Lower border of the eye socket in the same

horizontal plane as external auditory meatus

*Looking straight ahead

*A right angled block slides down until touches

the head

US/LS ratio :

Lower body segment:

Length from the symphysis pubis to floor

Upper body segment:

(Ht – lower body segment)

US/LS ratio :

At birth – 1.7

At 3 years - 1.3

After 7 years – 1.0

Growth Velocity:??????

Growth is not a steady continuous process but occurs by episodic increments

Growth Velocity :

“Change in standing height over six months in children or in length over at least four months in infants.”

More sensitive index than single measurement

Poor linear growth:

Linear growth velocity <2 SD the mean for gender, and chronological age.

Example

A boy grows from 119 to 122 cm from 9 to 9.5 years

He has grown 3 cm in 1/2 year

3/ (1/2) = 6 cm = annual growth velocity

Between 75th and 90th percentiles

Normal Growth Velocity 24 = 1st y, 12= 2nd y, 6= 3rd y , 5 there after

until puberty

NB: Children who grow ~5 cm / yr between 3 yrs of age & puberty usually do not have an endocrinopathy or

underlying pathologic disorder

Velocity Charts

Why are boys taller than girls after Puberty? Growth Spurt : boys enter this spurt 2 years later than girls

During 2 year period, boys grow at 5cm/y (10cm total) ; girls grow at 8cm/y (16cm total)

Age 14 : girls stop growing; boys now growing 8cm/ year (16 cm)

Because boys stop growing 2y later, (5cm/year) they are at least 10cm taller

Mid parental height&Target height

Target height in cm for a GIRL :

mother’s Ht in cm + (father’s Ht in cm -13) +/- 8cm 2

Target height in cm for a BOY :

(mother’s Ht + 13 cm) + father’s Ht in cm +/- 8 cm 2

For both girls and boys, 8 cm on either side of the MPH represents the 3rd-97th percentiles and represent the target height

Mother

Father

Target Height

Mother

Father

Correction for Mid Parental (Target) Height

Male 9 years

Height 119 cms and weight 20 kg

Father is 157 cms, mother is 150 cms,

Formula for target height in boys: (MH+FH+13)/2

Target Height is 160 (152-168)

Target range is 168-152

(8cm above and below TH)

Bone age What does bone age tell you?

Skeletal maturity

Speaks for remaining growth potential

Methods of bone age assessment

Tanner White House

Greulich and Pyle

G& P Method compare epyphiseal

centers in hand and wrist

Patient’s film is compared

with the standard of the

same sex and nearest

age

It is next compared with

adjacent standard, both

older and younger to get

the closest match

Short stature

Defenetions Height < 3rd centile for age and sex

A predicted height less than the mid-parental target height.

Deceleration in growth velocity

1-Normal variant(mostcommon A)Familial short stature .

B)Constitutional delay of growth and adolescence

Normal variant short stature describes a child whose height is below

the third percentile but is growing with a normal growth velocity.

Pathologic short stature describes a child whose height is below the third percentile (often more than 3 SDs below the mean) but is growing with a suboptimal growth velocity.

familial (genetic or intrinsic) short stature (FSS) childhood growth is at or just below the 3rd percentile, but

the velocity is generally normal.

bone age is concordant with chronologic age.

Parental height is short (both parents are often below the 10th percentile) .

pubertal maturation is normal.

Final heights in these individuals are short and in the target zone for the family.

Constitutional delay of growth and adolescence

More in males

Normal or near normal growth velocity, with height below but parallel to the 3rd percentile during prepubertal years .

Delayed BA and pubertal maturation

Adult height usually within the normal range,

No history of systemic illness

Normal physical examination, including body proportions

History of delayed puberty in the father

Pathological Short stature

Proportionate Disproportionate

Proportionate short stature:

is defined as short stature with a normal U/L

ratio

1: Proportionate and Heavy Congenital GH deficiency (?midline defects, perinatal

asphyxia)

Acquired GH def. (tumors, trauma, post-infectious)

Hypothyroidism

Cushing syndrome

Testing

TSH, FT4, GH level (provocation test), Bone Age

For Cushing’s eval. consider overnight Dex supression test or 24 hour urinary Cortisol

Growth chart of a child with acquired GHD. Note the more profound effect on height growth compared with the lesser effect on weight

ACQUIRED HYPOTHYROIDISM

Growth chart of a child with acquired hypothyroidism. Note the severe deceleration of growth velocity as weight acquisition remains relatively constant

Cushing syndrome

Growth chart depicting declining growth velocity with acceleration of weight gain typical of cortisol excess.

2: Proportionate and Thin (the endless list…)

GI losses- malabsorbtion, IBD, celiac

Renal- RTA, nephrogenic DI, Chronic renal failure

CV- shunting, failure

Endo- Diabetes mellitus, Diabetes insipidus

Pulm- CF, Asthma

Severe Psycho-social deprivation & Poor nutrition

Testing

Good History and Physical examination

Chem , UA, CBC, and ESR

DISPROPORTIONATE SHORT STATURE Abnormal U/L segment ratio:

Increased U/L= long bone, Decreased U/L=spine

***Skeletal dysplasia

***Error of metabolism

SKELETAL DYSPLASIAS & Errors of metabolism Achondroplasia(US>LS)

Epiphyseal dysplasias

Osteogenesis imperfecta

Osteopetrosis

Mucopolysaccharoidosis(LS>US)

Rickets

Skeletal Dysplasia – Disproportionate short stature

Achondroplasia, Hypochondroplasia

short limbs -long narrow trunk

Large head, midfacial hypoplasia, prominent

forehead

Limb shortening is greatest in the proximal segments,

Short and Dysmorphic

Turner’s

Down’s

Prader-Willi

Testing

Karyotype

Skeletal Radiographic studies

Genetics evaluation

Syndromic causes of short stature

Turner : (45 XO & mosaic forms)

Low hairline, - webbing of the neck

Increased carrying angle - Lymphoedema

Cardiac- (coactation) - Renal anomalies

Broad chest (widely spaced

nipples)

Noonan : (Gene mutations)

Typical facies (hypertelorism, down-slanting eyes, low set ears)

Cardiac – (pulmonary stenosis)

Conclusion 1 Look at the growth chart!

Short + heavy = Endocrine (GH/Thyroid/Cortisol)

Short + thin = Systemic disease

Short with normal velocity = Con. Delay or FSS, sort out by Bone Age.

Always think of Turner’s in Girls!

Conclusion 2 Is the child very much below the 3rd percentile or just

below?

If just below and within Target range then watch growth velocity for 6 months to one year

If very much below the 3rd percentile and target range - investigate

Conclusion 3

Dysmorphic syndromes are suspected (Eg: Turner)

disproportionate US/LS ratio(Eg: Skeletal dysplasia)

Ht velocity is <25th centile over 1 year period

Underlying pathology identified in the history and the examination

Thank you