1. SHORT STATURE
Karen Estrella H.
PGY-1

2. Is she short?

3. Definition
Standing height > 2SD below the mean (< 2.5 percentile) for gender and chronological age.
Compare the child’s height with that of a larger population of a similar background and mid-parental target height.

5. How to measure Ht? Ideally with calibrated stadiometer
Wall mounted
Tabletop recumbent (length)< 2 yrs old
Children who can’t stand:
Arm span
should approximate the height (>8yrs old)
**Consider: a decrease of 1.25cm in Ht measurement when standing

6. Aspects to consider: FHx: PMHx: Development Nutrition
Parents’ and siblings’ heights,
onset of puberty
medical problems
PMHx:
Birth Hx
Known diseases
Development
Nutrition
Age of pubertal development
Boys: testes > 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

7. Dysmorphic features Complete PE Body proportions: Arm span:
European origin: the arm span should approximate the height (>8yrs 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)

8. Target height of the child
BOYS:
[Father’s ht (cm)+ (mother’s Ht (cm)+ 13)] 2
GIRLS:
[(Father’s ht (cm) -13) + mother’s Ht(cm)] 2
Inches: change 13 for 5’’

10. 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: cm

11. Bone age (skeletal maturation)
Greulich and Pyle (compare epyphiseal centers in hand and wrist)

12. Greulich & Pyle Atlas

13. Causes:

14. Appropiate target height
Common causes:
Familiar (genetic)
Constitutional
BA=CA
BA<CA
N growth veloc
Appropiate target height

17. Causes:

18. Additional workup

19. Deceleration in a well-nourished or obese child:
GHD, hypothyroidism, glucocorticoid excess:
TSH, T4
Karyotype
IGF1, IGFBP3
GH stimulation tests
ACTH test

20. 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 < 10 ng/ml

21. Indications for GH therapy
GH deficiency
Turner
Renal insufficiency
Prader-willi
SGA who haven’t 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

22. Deceleration in a thin child:
GI, nutritional, renal or
chronic systemic disease
CBC , ESR
Antiendomysial, transglutaminase, antigliadin
Sweat chloride testing
Electrolytes
Albumin, transferrin UA

23. Dysmorphic features: Genetic: Karyotype Geneticist referral
Skelelal dysplasia radiography survey

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

25. Kaplowitz, (AAP news, 2005)Be prudent in referring short stature to the endocrinologist
At or > 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

26. Educate the family and the child about short stature

27. Questions

28. 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

29. 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 child’s groth is the comparison of the child’s 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.

30. You are evaluating a 6yo girl for short stature
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