Which growth chart should be used?• The growth charts compiled by Agarwal, et al. These charts provide information on growth from birth to 18 years. In the present circumstances, these charts remain best option for growth monitoring in Indian children and are recommended for use by the Growth Monitoring Guidelines Consensus Meeting of the IAP. (INDIAN PEDIATRICS VOLUME 44__MARCH 17, 2007, 188)• WHO recommends WHO growth charts should be used in all childrens <5yrs . (IJPP 2011;13(4) ,396)
1)Confirm short stature by serial height monitering inrelation to target height2) Height Velocity. When height velocity observed over a period of6mths or more falls below 25th percentile on velocity chart isabnormal.
Etiological diagnosis is based ondetailed history, physicalexamination and investigation
Clue from history1)When does short stature starts? By ICP model of Growth Infancy: Malnutrition Childhood: Hypothyroidism and GH deficeincy Puberty: Disorders of puberty most comman cause is constitutional delay of growth and puberty (CDGP)2)H/o Delayed puberty in parents in CDGP3)H/o poor dietary intake in undernutrition.4) Social history.
• Others: Clue to etiology of short stature History Etiology LBW SFA Polyuria CRF, RTA Diarrhoea, offensive stools Malabsorption Neonatal GH deficiency hypoglycaemia,jaundice,micropenis Headache, Visual problems Pituitary/hypothalamic SOL Lethargy, constipation, wt gain Hypothyroidism
Physical examination• Anthropometry 1)Wt for age. 2)Ht for age. 3)Crown rump length/Sitting height 4)Sub ischial leg length 5)Wt for height 6)upper segment : lower segment• Look for dysmorphic features.• Head to toe examination.
What is disproportionate short stature?When the disproportion between sub ischial leglength and Sitting height is more than 2SD the childis considered disproportionate. (IJPP 2011;13(4) ,396)
When to suspect disproportionate shortening?Disproportionate shortening of the limbs: If the upper limbs do not reach the mid pelvis in infancy or the upper thigh after infancy.Disproportionate shortening of the trunk is indicated by a short neck, small chest, and protuberant abdomen ( Nelson 19th edi)
Short child with distinguishing feature proportionate disproportionate syndrome Russell- silver Short legs Short trunk syndrome Down,Turner,Noonan Achondroplasia, SpondyloepiphysealHypochondroplasia and MPS Ricket
Short child looks normalNormal growth velocity Low growth velocity Chronic disease LBW Endocrine disease Short parents psychological Growth delay
Clues on physical examinationExamination finding EtiologyDysmorphology syndromeFrontal bossing, depressed nasal bridge, GH deficiencymicropenisPallor CRF, chronic anaemiaHypertension CRFGoitre and coarse skin Hypothyroidismobesity Cushing syndrome Tanner sexual maturity ratings should be done in all children who present with short stature.
Level 1 investigation for short stature1) Complete blood count and ESR2)Bone age3)Urinanalysis including microscopy, osmolality, pH4)Stool examination for Steatorrhea and occult blood (Malabsorption)5)Blood- urea ,creatinine,venous gas(CRF, RTA) Calcium, phosphate and ALP (RIcket) Fasting glucose Albumin and LFT (CLD)Level 2 investigationsSerum T4 and TSHKaryotypingLevel 3 investigationsCeliac serologyGrowth hormone stimulation test, IGF-1 level
Bone Age• It shoud be done in all patients of short stature.• When bone age is retarded by 2 or more year is abnormal• BA<CA in all causes of short stature except 1)FSS (BA = CA) 2)Precocious puberty and obesity (BA > CA)• BA markedly less than CA in Endocrine diseases and marginally less than in other chronic diseases and malnutrition.
• In children with skeletal dysplasias and other disproportionate short stature Skeletal Survey should be done.
Growth formulae• A combination of chronological age(CA), Height age(HA),weight age(WA)And bone age(BA) can help in reaching in many childrens. CA>HA>WA = Malnutrition/ Chronic disease (Mild bone age retardation) CA<HA<WA = Exogenous obesity (BA mildly advanced) CA<WA<HA = precocious puberty (BA significantly advanced) WA>CA>HA = Endocrine obesity (BA significantly retarded)