SHORT STATURE Prof.Dr. Oya Ercan. Failure of physical growth an important sign of disease. Differential diagnosis of the short child is wide. Treatment.

SHORT STATURE

Prof.Dr. Oya Ercan

Failure of physical growth

an important sign of disease. Differential diagnosis of the

short child is wide.Treatment effective only before

the epiphyses fuse.

Short child: Any child whose height falls below the 3rd centile for his/her community.

The main reasons for differences in the mean heights of children in different populations are environmental

The head is held with the external auricular meatus and outer canthus of the eye in a horizontal plane.

Upward pressure is applied to the mastoid processes in order to encourage the child to stand up straight.

Measuring Stature

Expected or Target Height: Determined from the parents’ height centiles. +12,6 cm to the mother’s height on a boy’s chart. -12,6 cm from the father’s height on a girl’s chart.

Almost all (95%) normal children have a final height within 9 cm of the mid-parental centile.

Predicted height may be calculated from the present height, age and bone age.

If the predicted height falls more than 10cm below the expected height (mid-parental centile) growth is abnormal for the family.

1. The heights of the parents and the age at which they reached puberty.

2. The child’s weight and gestational age at birth and pattern of growth since then.

3. The appetite, energy and well-being of the child.

4. Any specific symptoms.

5. Social history (structure of the family, the quality of the relationships within it and the mother’s health and ability to cope)

Observation of the child’s proportions

Standard of nutrition The presence of any minor

abnormality or abnormal facies Routine examination of the urine

General physical examination should include:

1. Those who require further investigation immediately:

Height well below the 3rd centile,evidence of chronic ill health or, a growth velocity below the 25th centile over one year.

2. Those with genetic short stature:

Who are well, with heights near the 3rd centile, within the target or expected centile range, satisfactory growth velocity.

Make sure that the parent’s short statue is not the result of a pathology and that the child does not have a hereditary disorder affecting growth.

3. Those who are suffering as a result of social problems or deprivation.

Growth velocity is a more useful observation then actual height.

Because of seasonal variations in growth rate velocity must be assessed over a whole year.

FURTHER INVESTIGATION

Measurement of sitting as well as of standing height, assesment of fat and muscle development from mid-upper arm circumference and triceps skinfold thickness measurements, examination of the optic fundi and visual fields.

1. Radiographs of the skull and of the hand and wrist for bone age.

2. Chromosome analysis: Turner’s ?

3. Simple renal function tests: Urine culture, blood urea and creatinine.

4. Test of thyroid function, particularly thyroid stimulating hormone, free thyroxine.

5. Hb and blood folate estimations, malabsorption ?

Familial short stature – organic disorders identified

Various grades of GH insufficiency ?

Genetic delay ?

When GH insufficiency is considered possible:

Serum IGF-I (SM-C)GH response to exercise 10 min.A sleep GH level (in very young

children) 30 min. after onset of swsProvocative testing insulin, arginine, L-

Dopa clonidine 24 hr or overnight GH profile 20 min.

CAUSES OF SHORT STATURE

Bone Disease : Predominantly affect limb bones or spine → disproportionate short stature.

In some mild forms of bone disease

(hypochondroplasia, epiphyseal dysplasias) may not be apparent.

SKELETAL DYSPLASIAS OF UNKNOWN PATHOGENESIS

1. Dysostoses: Malformations of individual bones, singly or in combination.

2. Osteochondrodysplasias: Abnormalities of cartilage and/or bone growth and development :They affect stature especially defects of growth of tubular bones or spine or both (a)

Disorganized development of cartilage and fibrous component of the skeleton e.g. fibrous dysplasia and enchondromatoses

Abnormalities of density or of cortical diaphyseal structure and of metaphyseal modelling (e.g. osteogenesis imperfecta, osteopetrosis)

Other osteochondrodysplasias

Manifested at birth → achondroplasia

Manifested in later life → hypochondroplasia

Achondroplasia: Rhizomelic short limbs,

autosomal dominant (80% new mutations) most common genetic skeletal dysplasia. Bone lengthening (chondrodiatasis)

Osteochondrodysplasias(a)

DISEASES OF BONE WITH KNOWN PATHOGENESIS

1. Chromosomal aberrations

2. Primary metabolic abnormalities Calcium and phosphorus metabolism Mucopolysaccharidoses Mucolipidosis – lipidosis

3. Bone abnormalities secondary to disturbance of extraskeletal system.

Syndromes Any short child who has other

abnormalities such as old facies, mental retardation or low birth weight.

Most chromosomal abnormalities lead to short stature.

Trisomies 21, 18, 13 Partial deletion of a chromosome cri-du-

chat, 4p , 13q , 18p , 18q , 21q ⁻ ⁻ ⁻ ⁻ ⁻syndromes

Extra fragment of a chromosome e.g. the cat-eye syndrome

Some syndromes with severe short stature:

Aarskog’s syndrome, Bloom’s syndrome,

Cockayne’s syndrome, Russell – Silver syndrome, Seckel’s syndrome ...etc. → no consistent chromosomal abnormalities.

Turner’s Syndrome

Characteristically is associated with 45X chromosomes.

Neonatal lymphoedema Low posterior hairline Webbed neck

Their pattern of growth shows a combination of poor intrauterine growth, gradual decline in velocity during childhood and an absence of puberty growth spurt.

Diseases of a major organ or metabolism

Asthma Renal disease Congenital heart disease Diabetes mellitus Chronic anemia Mental retardation

Nutritional Disorders

Kwashiorkor Marasmus Inadaquate intake: Renal disease,

infections, pyschological disturbances such as anorexia nervosa and depressin

Chronic intestinal disease• Cystic fibrosis• Celiac disease

Growth retardation in undernutrition is a means of conserving nutrients for essential functions and keeping requirements to a minimum.

The finding of gross or multiple endocrine abnormalities in an undernourished patient must raise the possibility of organic hypothalamic disease with secondary malnutrition.

Low birthweight

AGA → usually normal stature (premature) normal statureSGA = Light–for-dates short statureShort stature: 1- Chromosomal disorders 2- Children who have been damaged in utero by some

recognised environmental insult e.g. Rubella, alcohol, anticonvulsants etc. (Impaired growth potential at cellular level)

3- Placental dysfunction4- Syndromes of unknown etiology of which low birth weight

is a feature (multifactorial?)

Endocrine Diseases 1)Thyroid Deficiency: GH response to stimulation tests may be clusterd

→Hypothyroidism should be excluded before GH tests are done. 2)Corticosteroid Excess:

- Cushing’s syndrome - High-dose steroids used over long periods of time (asthma,

rhematoid arthritis) - (Unhealthy skin) steroid creams - Prolonged treatment with ACTH

3)Growth hormone insufficiency

Complete deficiency: deletion of GH gene (very rare)GH insufficiency (usually isolated or with other pituitary

hormone deficiencies)Multiple deficiencies: Craniopharyngioma ? Neurosecretory dysfunction (physiological deficiency) Inability to generate IGF (Laron dwarfism)Defect in IGF receptors (African Pygmy)

Social Disorders

Emotional deprivation

GH insufficiency : 1/4000NSD : 1/4000 ?Thyroid deficiency : 1/3000 – 5000Turner’s syndrome : 1/3000 ♀Celiac disease : 1/2000

2-3 /1000 children have short stature caused by conditions for which specific treatment available and appropriate.

Genetic

Two groups of genes acquired from the parents affect the height of a child.

1- The group that determines the child’s final height

2- The group that determines the rate of maturation, the age of puberty and the age of cessation of growth

1. Familial short stature (genetic shortness)

2. Genetic delayed maturation

3. 1+2 (small / delay)

some of them NSD or NVSS