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Growth disturbances
Knut Dahl-Jørgensen
Unit for Endocrinology and Diabetes Pediatric Dept.
Ullevål University Hospital
Simple guidelines by short stature
• Examined by the doctor:– All children below 2.5 height percentile– All children decreasing more than two centile chanals
• Refer to Pediatric Dept. by increasing deviation• Enclose by referal :
– Family history (growth and puberty)– History of birth, development and diseases– Growth chart– Eventually Bone age and laboratory test results
Differential diagnoses by short stature
Constitutional Growth DelayFamily Short StatureCombination of the previousNutritional
HypocaloricChronic inflamatory bowel diseaseMalabsorption , Coeliac disease
EndocrineHypothyroidismGrowth Hormone DeficiencyHypopituitarismExcessive cortisolPrecosious puberty
Chromosome defectsTurner Syndrome
Maternal deprivation
Low birth weightSmall for gestagional age
Prematurity
Fetal alcohol syndrome
Bone development disordersRickets
Sceletal dysplasias
MetabolicKidney failure
Hypoxic, Cardiac
Liver diseases
Inborn errors of metabolism
SyndromesNoonans
Aarskog
Routine examinations 1
Family history growth and puberty, growth treatment, syndromes
NeonatalGetational age, birth weight, birth length, forceps,
Hypoglycemia, hyperbilirubinemia, mikropenis
Gatrointestinal symptoms
Neurological symptoms
Psycosocial problems
Routine examinations 2
• Physical examination– Height
– Weight
– Growth velocity (cm per year)
– Tanner stages
– Teticular volume
– Dysmorphology (evt. sitting height, arm span)
– Blood pressure
– General physical examination
– Neurological examination
Routine examinations 3
Bone age and final height prediction
Clinical chemistry– TSH and free thyroxin
– GH, IGF-1, IGF-BP3
– At puberty: LH, FSH, estradiol or testosteron
– Coeliac screening
– Hemoglobin, ferritin, CRP
Chromosomes (girls)Evt. Metabolic screen, liver, kidney, bone (PTH, Vit.D)
Prediction of final height
Bone age estimation: Greulich & Pyle Atlas
Prediction: Bailly and Pinneau Tables
Causion ! Variability in bone age estimation by different radiologists
Great SD in reference material
Total variability: Young child + 5 cm, Late puberty + 3 cm
If unpredicted early puberty: Height prediction will decrease.
Other method: Tanner Whitehouse
Normal growth patterns
Normal early puberty
Normal late puberty
Familial (genetic) short stature
Constitutional delay of growth and puberty
Obesity
Pathological growth patterns
Growth hormone deficiency
Clinical appearancePuppy child
Hypoplastic midface ?
Evt. Hypoglycemia, hyperbilirubinemia, mikropenis
AuxologyDrop in height percentile
Growth velocity (cm per year) < 10 perc.
Delayed Bone Age
Causes of Growth hormone deficiency
CNS malformations (midline defects)
Hydrocephalus
CNS injuries (birth, forceps)
Meningitis, brain edema
Congenital infections
Hypothalamic or hypophyseal tumors
Cranial radiation
Congenital, genetic
Indications for Growth hormone treatment
Main indicationGrowth Hormone Deficiency
Other indications:Turner Syndrome
Kidney failure
Prader-Willi Syndrome
Small for gestagional age without catch-up growth ?
Testing Growth hormone secretion
Physiological testsOne random samplePhysical activityContinuous overnight samplingContinuous 24 hours sampling
Stimulation tests (allways two tests)Insulin iv (hypoglycemia)Arginine ivGlucagone iv or imClonidine (oral)GHRH
IGF-1, IGF-BP3
Growth hormone treatment
Daily subcutaneous injections
Injection pens
Disposable prefilled syringes
Autoinjection systems
Dosage: 0.033 mg/kg/day (0.1 U/kg/day)