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SHORT STATURE <ul><li>Dr SANJAY KALRA, D.M. [AIIMS] </li></ul>
OUR VISION To  be a globally-acknowledged centre of excellence  for clinical care,  education &   training , and research ...
Height is important <ul><li>Personal health </li></ul><ul><li>Professional health </li></ul><ul><li>Social health </li></u...
QUADRUPLE OF ATREYA  (CHARAK SANHITA) DOCTOR PATIENT DRUG ATTENDANT
Defining short stature <ul><li>According to growth charts </li></ul><ul><ul><li>ICMR </li></ul></ul><ul><ul><li>Aggarwal <...
Measuring stature  <ul><li>Stadiometer  </li></ul><ul><li>Barefeet </li></ul><ul><li>Four points touching the wall </li></...
Anthropometry  <ul><li>US: LS ratio </li></ul><ul><li>Arm span </li></ul><ul><li>SE: EMC ratio </li></ul><ul><li>Sitting h...
Growth patterns <ul><li>Growth velocity charts </li></ul><ul><li>Growth is not a steady continuous process but occurs by e...
Growth velocity 9 – 10.3 mid-puberty 5 7 - puberty 6 5, 6 7 3, 4 10 2 25 1 Increment in cm year
Anthropometry  <ul><li>CA  chronological age </li></ul><ul><li>HA  height age </li></ul><ul><li>BA  bone age </li></ul><ul...
Bone age <ul><li>Tanner-Whitehouse atlas  </li></ul><ul><li>GP atlas </li></ul><ul><li>20 bone method </li></ul><ul><li>Mo...
Differential diagnosis <ul><li>Constitutional growth delay CGD </li></ul><ul><ul><li>Delayed puberty/ Late bloomer </li></...
Non-pathologic short stature <ul><li>Familial short stature FSS </li></ul><ul><ul><li>Family history </li></ul></ul><ul><u...
PATHOLOGICAL SHORT STATURE <ul><li>ENDOCRINE </li></ul><ul><li>METABOLIC </li></ul><ul><li>GENETIC </li></ul><ul><li>PSYCH...
ENDOCRINE CAUSES <ul><li>GHD/Panhypopit </li></ul><ul><li>Diabetes insipidus </li></ul><ul><li>Hypothyroidism </li></ul><u...
GENETIC SYNDROMES <ul><li>Turner’s syn </li></ul><ul><li>Noonan’s  </li></ul><ul><li>Russel Silver </li></ul><ul><li>Secke...
SYSTEMIC ILLNESSES <ul><li>Chronic anaemia </li></ul><ul><li>CRF </li></ul><ul><li>RTA </li></ul><ul><li>Asthma </li></ul>...
Differential diagnosis <ul><li>ENDOCRINOPATHY </li></ul><ul><li>Bone age retarded </li></ul><ul><li>History  </li></ul><ul...
GHD: PHYSICAL FEATURES <ul><li>Cherubic face; fair complexion </li></ul><ul><li>Normal IQ </li></ul><ul><li>Frontal bossin...
GHD: PROVOCATIVE TESTS <ul><li>Needed because normal range is wide </li></ul><ul><li>Basal GH of no help </li></ul><ul><li...
Growth hormone therapy <ul><li>EVOLUTION: </li></ul><ul><li>1958 -  pituitary GH </li></ul><ul><li>1978 - Creutzfeld- Jaco...
Growth hormone therapy <ul><li>Available only as injection </li></ul><ul><li>Subcutaneous </li></ul><ul><li>Administer aft...
Growth hormone therapy <ul><li>Effect reduces with time; esp after 3 years </li></ul><ul><li>?Formation of antibodies </li...
Growth hormone therapy <ul><li>Response better if started earlier </li></ul><ul><li>Average increment = 10 cm/year </li></...
Indications  <ul><li>GH Deficiency </li></ul><ul><li>IUGR </li></ul><ul><li>Non-GH deficient short stature </li></ul><ul><...
Side effects <ul><li>Edema </li></ul><ul><li>Arthralgia  </li></ul><ul><li>Myalgia  </li></ul><ul><li>Muscle stiffness </l...
 
Who Moved My    Cheese ? ? WHO KEPT ME SHORT ?
 
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FTT

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Transcript of "FTT"

  1. 1. SHORT STATURE <ul><li>Dr SANJAY KALRA, D.M. [AIIMS] </li></ul>
  2. 2. OUR VISION To be a globally-acknowledged centre of excellence for clinical care, education & training , and research in diabetology and endocrinology.
  3. 3. Height is important <ul><li>Personal health </li></ul><ul><li>Professional health </li></ul><ul><li>Social health </li></ul><ul><li>Sexual health </li></ul><ul><li>Self-confidence </li></ul><ul><li>Physical health </li></ul>
  4. 4. QUADRUPLE OF ATREYA (CHARAK SANHITA) DOCTOR PATIENT DRUG ATTENDANT
  5. 5. Defining short stature <ul><li>According to growth charts </li></ul><ul><ul><li>ICMR </li></ul></ul><ul><ul><li>Aggarwal </li></ul></ul><ul><ul><li>Western </li></ul></ul><ul><ul><li>Below 3 rd %ile or 5 th %ile </li></ul></ul><ul><li>Growth velocity </li></ul><ul><li>mid-parental height </li></ul><ul><ul><li>FH + MH + 6.5 cm for boys </li></ul></ul><ul><ul><li>FH + MH _ 6.5 cm for girls </li></ul></ul>
  6. 6. Measuring stature <ul><li>Stadiometer </li></ul><ul><li>Barefeet </li></ul><ul><li>Four points touching the wall </li></ul><ul><li>Frankfurt plane [line joining inferior orbital margin to ext auditory meatus] paralel to ground </li></ul><ul><li>Serial measurements better </li></ul>
  7. 7. Anthropometry <ul><li>US: LS ratio </li></ul><ul><li>Arm span </li></ul><ul><li>SE: EMC ratio </li></ul><ul><li>Sitting height </li></ul><ul><li>Supine length [if age< 2 years] </li></ul>
  8. 8. Growth patterns <ul><li>Growth velocity charts </li></ul><ul><li>Growth is not a steady continuous process but occurs by episodic saltatory increments </li></ul><ul><li>More in spring, summer </li></ul>
  9. 9. Growth velocity 9 – 10.3 mid-puberty 5 7 - puberty 6 5, 6 7 3, 4 10 2 25 1 Increment in cm year
  10. 10. Anthropometry <ul><li>CA chronological age </li></ul><ul><li>HA height age </li></ul><ul><li>BA bone age </li></ul><ul><li>WA weight age </li></ul><ul><li>DA dental age </li></ul>
  11. 11. Bone age <ul><li>Tanner-Whitehouse atlas </li></ul><ul><li>GP atlas </li></ul><ul><li>20 bone method </li></ul><ul><li>Most accurate </li></ul><ul><li>Predicts adult height </li></ul><ul><li>Useful for D/D </li></ul>
  12. 12. Differential diagnosis <ul><li>Constitutional growth delay CGD </li></ul><ul><ul><li>Delayed puberty/ Late bloomer </li></ul></ul><ul><ul><li>BL normal [upto 3 years] </li></ul></ul><ul><ul><li>BA = HA < CA </li></ul></ul><ul><ul><li>GV normal for BA </li></ul></ul><ul><ul><li>AH normal </li></ul></ul>
  13. 13. Non-pathologic short stature <ul><li>Familial short stature FSS </li></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>BL small </li></ul></ul><ul><ul><li>BA, GV normal </li></ul></ul><ul><ul><li>HA < CA </li></ul></ul><ul><ul><li>AH = MPH < normal </li></ul></ul>
  14. 14. PATHOLOGICAL SHORT STATURE <ul><li>ENDOCRINE </li></ul><ul><li>METABOLIC </li></ul><ul><li>GENETIC </li></ul><ul><li>PSYCHOSOCIAL </li></ul><ul><li>SYSTEMIC </li></ul><ul><li>NUTRITONAL </li></ul><ul><li>IUGR </li></ul><ul><li>SKELETAL </li></ul><ul><li>IDIOPATHIC </li></ul>
  15. 15. ENDOCRINE CAUSES <ul><li>GHD/Panhypopit </li></ul><ul><li>Diabetes insipidus </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Cushing’s </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Hypogonadism </li></ul>
  16. 16. GENETIC SYNDROMES <ul><li>Turner’s syn </li></ul><ul><li>Noonan’s </li></ul><ul><li>Russel Silver </li></ul><ul><li>Seckel’s </li></ul><ul><li>Down’s </li></ul>
  17. 17. SYSTEMIC ILLNESSES <ul><li>Chronic anaemia </li></ul><ul><li>CRF </li></ul><ul><li>RTA </li></ul><ul><li>Asthma </li></ul><ul><li>congenital heart disease </li></ul><ul><li>Chronic infections </li></ul><ul><li>Chronic bowel disease </li></ul><ul><li>Steroid therapy </li></ul>
  18. 18. Differential diagnosis <ul><li>ENDOCRINOPATHY </li></ul><ul><li>Bone age retarded </li></ul><ul><li>History </li></ul><ul><ul><li>Birth asphyxia/breech </li></ul></ul><ul><ul><li>Headache/vomiting </li></ul></ul><ul><ul><li>Polyuria/polydipsia </li></ul></ul><ul><ul><li>Weight gain/obesity </li></ul></ul><ul><ul><li>Delayed milestones </li></ul></ul><ul><li>Physical features </li></ul><ul><li>NON-ENDOCRINOPATHY </li></ul><ul><li>Bone age normal </li></ul><ul><li>History </li></ul><ul><ul><li>Weight loss/anorexia </li></ul></ul><ul><ul><li>Chr diarrhea </li></ul></ul><ul><ul><li>Chr cough/dyspnea </li></ul></ul><ul><ul><li>Low birth weight </li></ul></ul><ul><ul><li>Poor intake </li></ul></ul><ul><li>Physical features </li></ul>
  19. 19. GHD: PHYSICAL FEATURES <ul><li>Cherubic face; fair complexion </li></ul><ul><li>Normal IQ </li></ul><ul><li>Frontal bossing </li></ul><ul><li>Midfacial crowding </li></ul><ul><li>Pallor </li></ul><ul><li>Micropenis </li></ul><ul><li>Truncal obesity </li></ul>
  20. 20. GHD: PROVOCATIVE TESTS <ul><li>Needed because normal range is wide </li></ul><ul><li>Basal GH of no help </li></ul><ul><li>Insulin tolerance test is gold standard </li></ul><ul><li>Exercise test </li></ul><ul><li>Sleep test </li></ul><ul><li>Clonidine stimulation test: 0.15 mg/m2 clonidine given orally in morning </li></ul><ul><li>IV line must be in place </li></ul><ul><li>Sample for GH at 0’, 30’, 60’ and 90’ </li></ul><ul><li>GH must rise to > 10 ng/ml </li></ul><ul><li>Value of > 7 ng/ml indicates partial deficiency </li></ul>
  21. 21. Growth hormone therapy <ul><li>EVOLUTION: </li></ul><ul><li>1958 - pituitary GH </li></ul><ul><li>1978 - Creutzfeld- Jacob disease </li></ul><ul><li>1985 - approval for biosynthetic hGH </li></ul>
  22. 22. Growth hormone therapy <ul><li>Available only as injection </li></ul><ul><li>Subcutaneous </li></ul><ul><li>Administer after 8.00 pm </li></ul><ul><li>3 to 7 times a week </li></ul><ul><li>0.15 to 0.3 mg/kg/week </li></ul><ul><li>Effect is dose-dependent </li></ul>
  23. 23. Growth hormone therapy <ul><li>Effect reduces with time; esp after 3 years </li></ul><ul><li>?Formation of antibodies </li></ul><ul><li>?Hypothyroidism </li></ul><ul><li>Side effects more common in adults </li></ul>
  24. 24. Growth hormone therapy <ul><li>Response better if started earlier </li></ul><ul><li>Average increment = 10 cm/year </li></ul><ul><li>Better response in classic GHD </li></ul><ul><li>Higher dose needed in Turner syndrome </li></ul>
  25. 25. Indications <ul><li>GH Deficiency </li></ul><ul><li>IUGR </li></ul><ul><li>Non-GH deficient short stature </li></ul><ul><ul><li>FSS </li></ul></ul><ul><ul><li>CGD </li></ul></ul><ul><li>Chronic renal failure </li></ul><ul><li>Burns </li></ul><ul><li>Steroid therapy </li></ul><ul><li>Osteoporosis </li></ul><ul><li>HIV-associated cachexia </li></ul><ul><li>Sports </li></ul>
  26. 26. Side effects <ul><li>Edema </li></ul><ul><li>Arthralgia </li></ul><ul><li>Myalgia </li></ul><ul><li>Muscle stiffness </li></ul><ul><li>Paresthesias </li></ul><ul><li>Carpal tunnel syn </li></ul><ul><li>Hypertension </li></ul><ul><li>Melanocytic nevi </li></ul><ul><li>Hypothyroidism </li></ul>
  27. 28. Who Moved My  Cheese ? ? WHO KEPT ME SHORT ?
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