SHORT STATURE

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SHORT STATURE

• Karen Estrella H.
• PGY-1

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Is she short?
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Definition

• Standing height gt 2SD below the mean (lt 2.5
  percentile) for gender and chronological age.
• Compare the childs height with that of a larger
  population of a similar background and
  mid-parental target height.

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How to measure Ht?

• Ideally with calibrated stadiometer
• Wall mounted
• Tabletop recumbent (length)lt 2 yrs old
• Children who cant stand
• Arm span
• should approximate the height (gt8yrs old)
• Consider a decrease of 1.25cm in Ht
  measurement when standing

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Aspects to consider

• FHx
• Parents and siblings heights,
• onset of puberty
• medical problems
• PMHx
• Birth Hx
• Known diseases
• Development
• Nutrition
• Age of pubertal development
• Boys testes gt 2.5 cm
• Girls breast enlargement (growth spurt 2 yrs
  prior to boys, peak growth velocity of 8.5 cm/yr
• Any current symptoms
• Weight

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• Dysmorphic features
• Complete PE
• Body proportions
• Arm span
• European origin the arm span should approximate
  the height (gt8yrs old)
• Asian proportionally shorter arms
• Africans had significantly longer arms.
• Lower segment (LS)
• Measure from the symphysis pubis to the floor.
• Upper segment (US)
• Subtract the LS from the height.
• US/LS ratio is calculated by dividing the US by
  the LS.
• About 1.7 at birth and decreases to 1 at about
  age 10, where it remains throughout adulthood
  (may increase slightly in puberty)

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Target height of the child

• BOYS
• Fathers ht (cm) (mothers Ht (cm) 13)
• 2

• GIRLS
• (Fathers ht (cm) -13) mothers Ht(cm)
• 2
• Inches change 13 for 5

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Growth velocity

• Most important aspect of growth evaluation
• Change in standing Ht over
• Infants 4 mo
• Children 6mo

• Normal (cm/yr)
• 1y 25
• 2y 12
• 3y 8
• Then until puberty 4-7 cm

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Bone age (skeletal maturation)

• Greulich and Pyle (compare epyphiseal centers in
  hand and wrist)

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Greulich Pyle Atlas
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Causes
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Common causes
Familiar (genetic) Constitutional
BACA BAltCA
N growth veloc N growth veloc
Appropiate target height Appropiate target height

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Causes
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Additional workup
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Deceleration in a well-nourished or obese child

• GHD, hypothyroidism, glucocorticoid excess
• TSH, T4
• Karyotype
• IGF1, IGFBP3
• GH stimulation tests
• ACTH test

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GH stimulation test

• Insulin-induced hypoglycemia most powerful, but
  more risk.
• OTHER (2 serial tests)
• Arginine
• levodopa, propranolol with glucagon, exercise,
  clonidine
• GHD GH peak after stimulation lt 10 ng/ml

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Indications for GH therapy

• GH deficiency
• Turner
• Renal insufficiency
• Prader-willi
• SGA who havent reach the 5th percentile by 2
  years of age
• ISS and are not expected to reach an adult height
  in the normal adult height.
• HIV wasting syndrome

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Deceleration in a thin child

• GI, nutritional, renal or
• chronic systemic disease
• CBC , ESR
• Antiendomysial, transglutaminase, antigliadin
• Sweat chloride testing
• Electrolytes
• Albumin, transferrin
• UA

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Dysmorphic features

• Genetic
• Karyotype
• Geneticist referral
• Skelelal dysplasia radiography survey

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• Decelaration of linear growth in Adolescence
• Delayed puberty
• Hypogonadotropic Diseases(Klinefelter, Kallman)
• Serum gonadotropin levels

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Kaplowitz, (AAP news, 2005)Be prudent in
referring short stature to the endocrinologist

• At or gt 3 percentile and appear to be following
  an established channel on the growth chart
  remeasure in 6-12 mo
• WNL but 1 single measurement deviates for regular
  pattern of growth, remeasure and if confirmed
  value, check in 6 mo. If continue look for
  pathology
• Fall-off in Wt over time with normal linear
  growth look for GI problems
• Healthy but sustained fall-off in Ht and Wt in
  1st 2 yrs, follow and refer if persists
• Later pubertal children, physically mature and
  short and leveling off in the linear growth near
  to f of growth plates

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Educate the family and the child about short
stature
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Questions
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• In which of the following conditions is the BA
  consistent with chronological age (not delayed)?
• Acquired hypothyroidism
• Constitutional delay
• Familial short stature
• Glucocorticoid excess
• Psychological dwarfism

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• Which of the following statements regarding
  growth in children is true?
• Crossing percentiles in the first 3 yrs after
  birth can be normal
• The best indicator of the appropiateness of a
  childs groth is the comparison of the childs
  actual height with the target height.
• The pubertal growth spurt occurs later un puberty
  in girls than it does in boys
• The U/L body segment ratio is at its highest
  during puberty
• The wt-for ht ratio has little importance in the
  evaluation of a child who has short stature.

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• You are evaluating a 6yo girl for short stature.
  Her growth chart reveals a birth length at 60th
  percentile, and a current height at 5th
  percentile. Her growth velocity in the last 3 yrs
  has been 3cm/yr. Her weight is at the 50th
  percentile. On PE wnl, and her intelligence
  appears normal. There are no midline defects or
  dysmorphic features. Her BA is 4 yrs. What is the
  most llikely dx?
• Congenital hypothiroidism
• Crohn disease
• GH deficiency
• Spondilodysplasia
• Turner