Short stature

 

Defined as a height below 2nd centile; or below 2 SD of mean for the population.

– Height measurement should be accurately recorded using standard technique

– A single height measurement is less valuable than monitoring serial measurements to know height velocity.

Concern is often raised if height measurements fall to lower centiles than before.

Most school-age children grow 5 to 6 cm/year; and more rapidly at 8 to 14 cm/year during pubertal growth spurt

Chronic illness or under-nutrition initially affects weight & then height, so these children have a disproportionately lower weight centile.

Hormonal causes affect height more than weight.

 

Causes

– Familial short stature

– Constitutional growth delay

– IUGR

– Malnutrition / Rickets

– Chronic Diseases: Coeliac, Chronic Renal Disease, IBD, Rheumatoid Arthritis, etc

– Dysmorphic Genetic Syndromes: Downs, Turner, Russell-Silver, Prader Willi etc

– Skeletal Dysplasia: Achondroplasia, etc

– Endocrine causes: GH Deficiency, Hypothyroidism, Cushing’s Syndrome

 

History

– Detailed antenatal history-any illnesses / medications / alcohol in pregnancy? Prematurity? IUGR?

– Birth weight, length, HC; early feeding and growth

Early development, school progress

– Any illnesses, medications or significant past medical complication?

– Review record of previous growth

– Current dietary intake satisfactory? Is weight satisfactory?

– Family h/o chronic illnesses, endocrine disorders or short stature

 

Examination

Accurate measurement and plotting of weight, height & HC on appropriate chart

Obtain previous measurements to plot height  centiles

Measure body proportion (Upper segment:Lower segment ratio);

Upper body segment =sitting height

    increased in Turner synd, Achondroplasia, Hypothyroidism etc

    decresased in Morquio synd

    normal in GH deficiency

Arm span is less than height before puberty; but greater after midpuberty.

 

Puberty staging (Tanner)

General exam- pallor, angular cheilosis, rickets, jaundice etc?

Any features of systemic illness? Obesity? Heart murmur?

Any dysmorphism? Syndromic facies? Midline defects like micropenis?

Obtain height of father & mother to calculate MPH

 

Investigation

Test if suspecting an underlying cause (dysmorphism, disproportionately short, obese, delayed puberty or slow height velocity)

– U&E, LFT, Bone profile, T3/T4/TSH, Vit D, Coeliac screen, Karyotype (Microarray), FBC, Ferritin, ESR, Serum IGF-I & IGFBP-3

– Urinanalysis

Selectively test:

– Xray left wrist (Bone Age)

– MRI Brain (pituitary stalk)

– GH provocation test

 

If all INV normal, check bone age

      Bone age normal = Familial short stature

      Bone age minimally delayed  = Constitutional growth delay

If INV abnormal (even if bone age normal) = further tests for systemic cause

If INV abnormal & bone age significantly delayed = Endocrine / systemic illness

 

Management

Monitor height in 6 months without investigations if not suspecting any underlying significant cause

Obtain previous growth measurements & parental heights

Ensure good nutrition & correction of any deficiency

Predicted Adult Height

    Boy: (Father’s Height + Mother’s Height + 13) / 2

    Girl: (Father’s Height + Mother’s Height – 13) / 2

– No specific management in Familial SS, as bone age is normal but final height will be expected to be short. Child’s projected height is within 2 SD of MPH

– In constitutional growth delay, there is delay in bone age and puberty but height velocity is appropriate for bone age, so final adult height is normal.

– Most IUGR babies show a ‘catch-up’ in height within first 2 – 3 years, but some continue to grow along lower centiles.

– Specific therapy for aetiology if there is chronic medical condition.

– In genetic syndromes, growth potential is affected. Some conditions have ‘syndrome-specific’ growth charts, but sometimes GH is beneficial.

– Growth Hormone replacement is used in GH deficiency, but also in some syndromes and chronic illnesses. These involve daily injections until epiphyseal closure.

[Seek specialist support from paediatric endocrinologist]