Approach to the child with short stature

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Approach to the child with short stature

• Eva Tsalikian, M.D.
• Stead Family Department of Pediatrics
• Pediatric Endocrinology
• 4/16/14

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Objectives

• Short stature
• a. General
• b. Familial
• c. Constitutional growth delay
• d. Growth hormone deficiency

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Names associated with delayed growth

• Intrauterine growth retardation
• Failure to thrive
• Short stature
• Growth and pubertal delay

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Times of growth

• Intrauterine growth
• growth in Infancy
• toddlers and preschool children
• childhood - preadolescents
• puberty- adolescents
• adults

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Prenatal and Postnatal growth velocity
Birth
10
8
Crown-Heel length Velocity (cm/4wk)
6
4
2
2
20
0
18
10 20 30 40

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Postmenstrual age (wk)
Height Velocity (cm/yr)
14
12
10
8
6
4
2
Age (yr)
0
0 2 4 6
8 10 12
14 16 18
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Diagnostic Evaluation of short stature

• HISTORY
• birth weight and length
• growth pattern to date and previous records
• family heights

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Parental heights
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Midparental height calculation
girls
Fathers height- 5 inches mothers height
2
boys
Mothers height 5 inches Fathers height
2
Midparental height Target
Midparental height 2SD(2inches)
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Diagnostic evaluation of short stature

• PHYSICAL EXAM
• accurate measurements
• facies, body proportions
• body fat distribution
• pubertal staging

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Height measurementages 2-18yrs
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Growth velocity
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Tanner I Breast Development
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Tanner II Breast Development
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Female Genitalia
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Tanner Staging -- Boys
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Male Genitalia
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Diagnostic evaluation (continued)

• LABORATORY TESTS general screening tests (CBC
  differential, chemistry panel, ESR)
• RADIOGRAPHIC EVALUATION (bone age)
• HEIGHT PREDICTION
• from parental heights
• from bone age

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Bone Age 9 years
Bone Age 14 years
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SHORT STATURE

• Common complain
• Symptom not a disease
• Important to differentiate
• Normal variant
• Pathologic short stature

Genetic/familial
Constitutional delay of growth
Proportionate
Disproportionate
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SHORT STATURE

• NORMAL VARIANTS
• Familial short stature
• Family history of short stature
• Normal growth velocity
• Normal bone age
• Constitutional delay of growth and puberty
• Family history of similar growth
  pattern but average to tall final height
• Low normal growth velocity
• Delayed bone age

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Growth patterns
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SHORT STATURE

• PATHOLOGIC
• Disproportionate
• Uncommon, mostly due to skeletal dysplasias
• achondroplasia or
  dyschondroplasia
• hypophosphatemic rickets
• Proportionate Short stature
• Most common, etiology prenatal or postnatal

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Growth chart for children with Achondroplasia
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Proportionate Short StatureEtiology

• Prenatal disorders
• Intrauterine growth retardation
• Dysmorphic syndromes
• Chromosomal anomalies

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Turner syndrome growth chart
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PROPORTIONATE SHORT STATURE Etiology

• Postnatal disorders
• Undernutrition
• Psychosocial dwarfism
• Chronic diseases
• Drugs
• Hormones

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Undernutrition and short stature

• Low caloric intake
• famine-feeding problems
• Celiac Disease
• Crohns disease

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Growth pattern of a child with psychosocial
dwarfism
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Hormonal disturbances responsible for short
stature

• Hypothyroidism
• Congenital/Acquired
• Hypercortisolism
• Cushing disease/ syndrome
• Growth hormone deficiency
• Sex steroids/Pubertal delay

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HYPOTHYROIDISM
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97
PE Child small for age, Proportionate, no
abnormal features, wears glasses, rest of exam WNL
26 months old boy
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3
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Prevalence of growth hormone deficiency Utah
Growth Study

• 114,881 children studied
• GHD height gt2 SD below mean,
• growth ratelt5 cm/yr,
• delayed bone maturation,
• peak GHlt10ng/mL
• 16 new cases identified
• Prevalence 13480
• Lindsay R. J. Pediatr 199412529-35

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Growth hormone deficiency

• 1 in 4000 children, 1 of short children
• Clinical characteristics
• -short stature
• -chubby face, truncal obesity
• -delayed skeletal maturation
• -high-pitched voice
• Etiology idiopathic vs organic

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Growth Hormone Deficiency Diagnosis

• No gold standard exists
• -Short stature, slow growth,
• compatible physique
• -Low IGF-I, IGF BP-3
• -insufficient rise in serum GH following
• provocative stimuli
• -Deficiencies of other pituitary hormones

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Take Home Message

• Short stature is a symptom not a disease
• Etiology could be normal variant or
  pathologic
• Careful and specific H/P and laboratory testing
  will guide you to the diagnosis and appropriate
  management
• Growth rate determination and accurate
  measurements important

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