Apprach to short stature when ,what,how

04/11/2023

Dr. vijay jaiswald

1

APPROACH TOSHORT

STATURE

DR. VIJAY JAISWAL ASSISTANT PROFESSOR , DEPT . OF PEDIATRICSLLRM MEDICAL COLLEGE, [email protected]

04/11/2023 Dr. vijay jaiswal 2

NOTICED SINCE LONGTIME……………..


•Family seeks medical attention for their short child

Shorter than their younger sibling•Shortest in their class•Gets teased •Bullied /treated differently in school•Size not meet expectations•Impediment to sports•Want to be sure nothing WRONG•SHORT STATURE CAUSING DISTRESS•Severity of height deficit•Degree of tolerance/ acceptance•Child’s coping skills


“HOW TALL ARE YOU ?” instead of “WHAT IS YOUR HEIGHT”

Sandy allen (7ft ½ inch) never marriedGeorge W. Bush only the fourth major

presidential candidate to succeed over a taller opponent

Girls referred half as boys and were significantly shorter

Americans specialists prescribed 13x more GH to boys for identical case scenarios


•Short stature imposes psychosocial stress

• How short is too short ???• Does short stature warrant medical treatment?

• A treatment approach based on suffering , rather than height , has been proposed

• CAUTION whether rhGH treatment for healthy short stature children construes medical or cosmetic treatment

• Whether this is an appropriate means of resource allocation on a societal

level !


A child with growth retardation

• Height below 3rd percentile or -2SD to avg population

• Excessively short for MPH/ target height• GV <25th centile,not 3rd even if height is within

normal percentile


GROWTH VELOCITY

Ideally should be observed over 12 months


NORMAL GROWTH VELOCITY

• Intrauterine pd is the pd. Of most rapid growth• 1st year – 25cm• 2nd year - 12.5 cm• 3rd-4th year – 6-7 cm• 5-9 year – 5 cm per year• Pre pubertal nadir –4 cm per year • Pubertal growth spurt 10-20 cms • Peak gain 10-12 cms boys, 7-9 cms girls


• Body proportion changes from 1.7 at birth to 0.98 – 1 by 13-14 years and to 1 in adulthood

• KEY to initial evaluation is• history • auxological parameters• Detailed clinical examination• Careful balance not to miss pathologIcal disorder

without over evaluation


CAUSES OF SHORT STATURE

• Physiological short stature familial constitutional delay of growth and pubertyPathological short statureSystemic diseases

Chronic anaemia congenital heart diseaseChronic renal failure chronic severe infectionChronic asthma malabsorption RTA chronic liver disease

• Undernutrition• Psychosocial dwarfism• Endocrine disorders

growth hormone deficiency /insensitivity hypothyroidism cushing syndrome pseudohypoparathyroidism

• Intrauterine growth retardation• Skeletal dysplasias and rickets• Genetic syndrome and enborn error of metabolism


Facts to be elicited in history(etiology)

• Age at onset – since when the child is not growing• Previous growth records at school, home or

physician• Records of previous height and weight must be

sought and charted on growth charts• Ante natal history birthweight/gest.age/IUGR• H/O birth asphyxia (hypopituitarism), breech

delivery, neonatal hypoglycemia, prolonged neonatal hyperbilirubinemia(hypothyroidism)


Symptoms pertaining to illness

• Shortness of breath, cyanosis, cough, fever, • Diarrhea, steatorrhoea, abdominal pain• Headache, vomiting, visual problems• Constipation, lethargy, feeding difficulty• Polyuria• H/O hepatitis , abdominal distention, malena• Recurrent blood transfusions• Dieatry history complementary feeding, calculate

calorie and protein intake


• Drug history prolonged use of corticosteroids ,amphetamine derrivatives

• Family history of SS in 1st/2nd degree relative (FSS), delay in puberty in one or both parent(CDGP)

• Social history , child abuse , family discord, emotional deprivation (psychosocial dwarfism)


1 -ANTHROPOMETRY

• Measurement is the basis of growth assessment• accurate , precise and correctly interpreted

measurements are more specific than single hormone assay

• Measurements should be accurate and reproducible with <0.1% of coe. Of variation

• Appropriately designed equipment and preferably by same person to eliminate interpersonal errors


HeightFor children < 2 years : Supine length by

infanto meter , two person required > 2 years standing height by stadiometer Plot the value on a reference curveCalculate the height ageCorrelate the height to MPH range in children

> 2 yearsTarget height range MPH+/- 8.5 cm


2- body proportions• US:LS ratio- vertex to pubis :pubis to sole of foot

birth 1.7:1,3yrs 1.4:1,5yrs 1.3:1,6yrs 1.2:1,at 8 yrs 1.1:1, 10 yrs 0.98:1)

• LS longer than US >5 cms after puberty is considered disproportinate

• Arm span /total height arm span is usually within 5 cm of height

• Weight, head circumference, and chest circumference are the other parameters which needs to be measured.




CLINICAL EXAMINATION

• Dysmorphism,cong. Malformations – genetic syndrome

• Midline defects, single upper central incisor• Micropenis/labia – GHD, hypopituitarism• s/o vit def. , malabsorption rickets• Jaundice, clubbing – ch. Liver disease• Central obesity, striae,proximal weakness

cushing’s syndrome


• Hypertension CRF• Goitre, coarse dry skin, hypothyroidism• Round face, short 4th metacarpal PHP• Pubertal staging – delayed puberty• Webbed neck, wide spaced nipple, increased

carrying angle – turner syndrome

04/11/2023 Dr. vijay jaiswal

MUST DO SMR




BONE AGE

X ray left hand wrist to tips of fingers TW3 GP ATLAS GILSANZ and RATIB

x no . Of carpal bones


WHY BONE AGE ?

• Skeletal maturity• Correlates closely with SMR• Speaks for remaining growth potential• Helps in adult height prediction• Delay of > 2 SD ie ~ 2 years is significant


ESR

• SCREENING STAGE 1• Hemogram, ESR• LIVER and KIDNEY functions tests• Ca, phosph, alk. Phosph.• Antigliadin and transglutaminase antibodies• Karyotype in a girl and pelvic ultrasound• Thyroid function test• Bone age

HOW TO INVESTIGATE ?


STAGE 2 SCREENING

• IGF- 1• IGF binding protein 3( IGFBP-3)• GROWTH HORMONE and other dynamic

stimulation test• Neuro imaging• Best to be done at SPECIALISED CENTRES


child referred for growth retard. anthropomettry growth charting , H/E

NORMAL SHORT

REASSURE AND ADVISE ROUTINE HEIGHT AND WEIGHT

MONITOIRING YEARLY

presentabsent

Confirmatory test and treatment

Bone age

BL STATUREN bone age

SIGNIFICANT

SHORT/ DELAYED

BA

CLUES TO ETIOLOGY FROM H/E


BL SIGNIFICANT SHORT,DELAYED BA

OBSERVE GV FOR 1 YR

NORMAL

PHYSIOLGICAL SS

REASSURE AND ADVISE

GROWTH MONITORING

ABNORMAL

SCREENING INVESTIGATIONS

ABNORMAL

TREAT THE CAUSE

NORMAL

ABNORMAL

TREAT CAUSE

NORMAL

ISS

KARYOTYPE IN GIRLS,TEST FOR GHD ,RTA, MALABSORPTION



TAKE HOME MESSAGE

1 •Take height and weight properly and plot it•Use growth charts (appropriate one)

2 •Growth velocity to be measured 6 monthly •Systemic approach and simple test first

3 •DYNAMIC STIMULATION TESTS AT SPECIALISED CENTRES

THANK YOU


Familial short stature

• One of the MC cause of short stature• Ht <3rd percentile but N against MPH• GV normal, growth curve follows parallel to 3rd

centile line• BA= HA, with N body proportion• Child achieve puberty at appropriate age• Adult stature is below normal• Heritable causes of pathological short stature

with mild phenotype may actually responsible


Constitutional delay of growth and puberty (CDGP)

• More frequently encountered in boys• Born with normal weight and length • Grow normally in the 1st year, decelerates during 2nd -

3rd year to reach just below 3rd cen• Continue to grow parallel to 3rd percentile with normal

GV throughout the childhood• Puberty delayed with growth spurt delayed and

attenuated• BA=HA < CA• H/O delayed puberty in either parent often

Health & Medicine

Apprach to short stature when ,what,how