4. Factors affecting height
Intra FSH
uterine Nutrition LH
Growth Hormone
Growth Thyroid harmone GH
factors Thyroid
Birth 1 year 2 years 4years 8years Puberty Adult
5. Normal height pattern
Birth length 50cm
One year 75 cm
Two yrs 87.5 cm
Three yrs 93.75 cm growth
4 yrs 100 cm velocity
8 yrs 125 cm 6 cm
12 yrs 150 cm per year
7. Definition
A child whose height is below 2 standard deviations
for age and gender
Males
200 78
190 +2
+1
74 Generally
180 0 70 accepted
170 -1
160
-2
66
-2.0 SD (2.3 percentile) definition of
62
normal range
Height (cm)
150
Height (in)
58
140
54
130
50
120
46
110
42
100
38
90
34
80
30
70
2 4 6 8 10 12 14 16 18 20
Age (y )
8. Etiology of short stature
Physiological
– Familial or genetic
– Constitutional short stature
Pathological
– Malnutrition
– Chronic systemic illness
– Hormonal deficiency states
10. Most parents contribute short stature to
hormonal def. large randomized trials have
shown only 5% cases are attributed to hormones
Most common cause is malnutrition in
developing countries
Familial or constitutional is the leading cause in
developed countries
11. Approach to a child with short stature
History
Physical examination
Height of the child
Height of parents
Plotting on growth chart
workup
13. Physical examination
Weight measurement (fat & short….endocrine,
thin & short……under nutrition or chronic illness
Systemic examination to rule out systemic illness
skeletal system examination including spine
Dysmorphic features
Tanner staging
14. Height measurements
Without footwear
Heels & back touching
the wall
Looking straight ahead
Gentle but firm
pressure upwards
applied to the mastoids
from underneath
US/ LS ratio
Total Arm span
15. Target height
Target height in cm for a girl = [mother's height in
cm + (father's height in cm - 13)] /2
Target height in cm for a boy = [(mother's height
in cm + 13) + father's height in cm)] /2
17. Workup for short stature
Rule out chronic disease (Hemoglobin, hepatic
and renal profile)
Rule out malabsorption (esp. if history is
suggestive)
Karyotyping for all females with short stature to
rule out turner syndrome
X-ray for bone age (usually left wrist)
20. Familial Vs Constitutional
hallmarks of familial (genetic) short stature is normal
bone age, normal growth velocity, and predicted adult
height appropriate to the familial pattern
By contrast, constitutional growth delay is characterized
by delayed bone age and predicted adult height
appropriate to the familial pattern
Patients with constitutional growth delay typically have a
first or second-degree relative with constitutional growth
delay (menarche older than 15 y, adult height attained in
male relatives when older than 18 y)
21.
22. Growth hormone actions
Growth Hormone GH receptors Liver
Metabolic effects
Metabolic effects
(Anabolic)
Synthesis of IGF1
GH receptors
IGF receptors
Proliferation of Cells
Linear Growth
Linear growth
Cellular growth
23. Workup for GH def
endogenous GH is secreted in a pulsatile
fashion. These intermittent peaks are greatest
after exercise, meals, and during deep sleep.
Therefore, measuring a single random serum
GH value is of no use in the evaluation of the
short child.
random serum GH value of more than 10 mg/dL
generally excludes GHD, a random low serum
GH concentration does not confirm the diagnosis
24. GH stimulation test
Insulin-induced hypoglycemia is the most
powerful stimulus for GH secretion; however,
this test also carries the greatest potential for
harm.
Alternate GH stimulants used successfully are
arginine, levodopa, propranolol with glucagon,
exercise, clonidine, or epinephrine.
GH provocative testing should be done under
the supervision of a pediatric endocrinologist
25. IGF-1 and IFGBP-3 measurement
IGFBP-3 and IGF-1 serum levels represent a
stable and integrated measurement of GH
production and tissue effects
IGF-1 have superior diagnostic sensitivity and
specificity compared with IGFBP 3.
The combination of IGF-1 and IGFBP-3
measurements appears superior to determining
either analyte alone in the diagnosis of growth
hormone (GH) related disorders
26. Interpretation of results
If IGF-1 and IGBP-3 level are normal then it shows
that GH level is also normal (no need for GH testing)
If IGF-1 and IGBP-3 level are low then it may be due
to GH def or GH resistance-----go for GH basal level
and after stimulation
If GH also low then GH def, if normal or high then GH
resistance ( Primary IGF-1 def)
27. Take Home Message
Take height properly along with the height of parents
Plot on Growth Charts and find out the target centile
Determine the growth velocity by follow up at least after 6
months
A systematic approach and simple tests like bone age
usually reduce the need & hence cost of further
investigations
For dynamic stimulation tests refer the child to specialist
centres
