A presentation about Growth and Short stature , from students of University of duhok college of medicine , it will cover bellow ● Being familiar with Growth charts and related terms ●Growth physiology ●Factors affecting growth , Focusing on Hormones ●Definition and Types of Short Stature ●Causes of Short Stature ●Growth hormone deficiency as an endocrine cause ●Celiac Disease as a Chronic cause ●Clinical Assessment , Investigations ●Pitfalls of diagnosing Short Stature created by : Ammar abdulrahman Muhammad and Harman Fakhir abdulqadir Supervised by : dr.bayar ahmed qasim Refrences ●Nelson Essentials of Pediatrics 9th edition ●Volume 4 Nelson Textbook of Pediatrics ●Richard I.G. Holt, Neil A. Hanley - Essential Endocrinology and Diabetes-Wiley-Blackwell (2012) ●Carol mattson Porth essentials of pathophysiology 3rd edition

1. Prepared by :
Ammar Abdulrahman Muhammad
Herman fakhir abdulqadir
Supervised by : Dr.Bayar Ahmad Qasim
MRCP(London) , FKBMS , Endo diploma (UK) , SCE Endo/Diabetes(UK)
Endocrine lecturer at University of Duhok
Endocrine and Diabetes Tutor
Honorary lecturer at University Of South Wales (UK)
Growth and
Short Stature
University of Duhok
College of medicine
4th Stage / Group A
Endorenal Block

2. Learning Objectives
● Introduction , Be familiar with Growth charts and related terms
● Growth physiology
● Factors affecting growth , Focusing on Hormones
● Definition and Types of Short Stature
● Causes of Short Stature
● Growth hormone deficiency as an endocrine cause
● Celiac Disease as a Chronic cause
● Clinical Assessment , Investigations
● Pitfalls of diagnosing Short Stature

3. Growth
Charts
What we mean By
Percentile ?
E.g / if your score
on a test is on the
95th percentile, a
common
interpretation is
that only 5% of
the scores were
higher than yours
https://www.cdc.gov/growthcharts/clinical_charts.htm

4. Terms to be Familiar with
● Chronological age : Actual Age of The person
● Bone age : indicator of skeletal maturation
● Height age : the age that Corresponds to the child’s height at
50th percentile on a growth Chart
● Mid-parental height : child’s projected adult height based on the
heights of the parents
● Growth failure : slow growth rate regardless of stature. ( don’t
confuse it with Short stature)

5. GH hormone Secretion
Stimulated by : hypoglycemia, Protein rich diet , increased amino acid in blood ( as
Arginine) , Exercise , Stress , Sleep , Glucagon , Ghrelin
Inhibited by : Hyperglycemia, increased free fatty acids , Excess GH feedback to inhibit
its own secretion , Excess Cortisol

6. Effects of Growth Hormone
Childhood and Puberty
Linear Growth
Higher GH doses
Adulthood
Metabolic Effect
Lower GH doses
Transitional Peroid

7. GH
GHRH
Somatostatins
Amino acid uptake
Muscle size
O.B, O.C
(endochondral ossification)
Collagen type 1
Proteoglycans
Proliferation
Size
Differentiation
Lipolysis
Gluconeogenesis
IGF-1
Ghrelin
Amino acids
Exercise
Testosterone
estrogen
Deep sleep
Glucose
Free fatty acids
Obesity
Aging

8. Factors affecting growth
Intrinsic Factors
● Genetic / about 80 percent of an
individual's height is determined
by the DNA sequence variations
they have inherited
● Hormones /Growth Hormone ,
Androgens , T4 , Cortisol .
Extrinsic Factors
● Nutrition / Protiens,calcium, vitamins A
and D also influence height
● Excercise / stimulatory effects on
secretion of anabolic hormones like
growth hormone (GH)
● Socioeconomic factors /
Socioeconomic disadvantage is
associated with shorter adult stature

9. Hormonal effects on Growth
● Intrauterine period …. IGF-II ( not GH mediated ) , Insulin
● Infancy…. Nutrition
● Childhood ….Growth hormone , IGF-1 ( GH mediated) , Thyroid hormones , Insulin
● Adolescence… Sex steroid , Growth hormone

10. ● Height below 3rd percentile or Less than 2 Standard Deviation bellow the
median height for age and sex according to the population standard . [ Essential
Pediatrics 7th edition ]
● Subnormal height relative to other children of the same gender and age, taking
family heights into consideration.[ Nelson Essentials of Pediatric 9th Edition ]
Definition
Short Stature

11. Classification
Proportionate Short
stature
Disproportionate Short stature

12. Causes of Short stature
- Variations of Normal ( most common )
- Endocrine disorders
- Chronic diseases
- Skeletal Dysplasias and lysosomal Storage Disease
- Syndromes of Short Stature

13. Endocrine Disorders causing Short stature

14. Criterias that Support GH defeciency
● Height > 2.25 SD bellow mean for age and sex
● Growth Velocity < 25th Percentile for 6-12 Months
● Delayed bone age > 2 SD bellow mean for age
● Low Serum IGF-1 and/or IGFBP3
● Low Serum GH by 2 GH provocation tests
For Neonates
● Hypoglycemia
● Prolonged neonatal jaundice
● Micropenis
● Traumatic delivery
● Cranial Irradiation , Head Trauma or CNS infection
● An affected family member
● Craniofacial midline abnormalities

15. GH Diffeciency
● Start GH therapy As early as possible once
diagnosis established
●
● Daily subcutanous injections at bed
● Dose differ according to various indications
● Compliance is IMPORTANT
Normal at birth
Normal GV in infancy

16. Chronic diseases Causes
Short Stature + Underweight
Think of Chronic Disease

17. Celiac Disease
● Short Stature Could be the
only Presenting Symptom in
Celiac Disease ( Silent
Celiac Disease ) Making the
Diagnosis Challenging

18. Treatment of Growth Faliure in Celiac Disease
● Adhere to Gluten free Diet is Usually
associated with marked improvement
of Linear Growth
Indication of GH Therapy
● Only in Children with Celiac disease
and GHD with ShorOnly After 12
months of Gluten free diet

19. Syndromes causing Short stature
Turner S Noonan S LMBB S Prader-Willi S Russel-Silver S

20. Clinical assessment
History taking
● Date of birth
● perinatal history
● Nutritional status
● Chronic illness
● Drug history
● School performance
● Psychological status
● Family history
Anthropometric Assessment
● Height SD
● Weight for Height SD
● BMI SDS
● Growth Velocity (Cm/year)
● US:LS ratio
● Mid Parental Height
Puberty Assessment

21. Puberty Assessment

22. Bone Maturation test
Greulich-pyle Atlas Method

23. Investigation
Baseline investigations
● CBC , ESR
● Electrolytes
● LFT, RFT , Ca+2 , Phosphorus , ALP
● Urine and Stool Examination
● Endomysial antibodies: Antitissue Transglutaminase IGA
● Karyotype for All Short girls
Endocrine Investigations
● Free T4 , TSH
● GH Provocation test ( 2 different tests )
● Serum IGF-1
● Serum IGF-BP3
● Cortisol and ACTH
● Prolactin
CT scan or MRI of Sella Turcica
if needed

25. Pitfalls in Diagnosing Short Stature
● Avoid basal GH Measurements
● Two GH provocation tests are needed for Diagnosis of GHD ( GH < 7ng/ml)
● TFT Should be done prior to GH Provocation test
● Karyotype Should be done to All Short girls
● Bone age doesn’t indicate definite Diagnosis
● MRI for sella turcica should be done if more than one pituitary hormones
deficiency
● Exclude Normal variants , nutritional and Chronic illness before jumping to
endocrine causes

26. Refrences
● Nelson Essentials of Pediatrics 9th edition
● Volume 4 Nelson Textbook of Pediatrics
● Richard I.G. Holt, Neil A. Hanley - Essential Endocrinology and Diabetes-
Wiley-Blackwell (2012)
● Carol mattson Porth essentials of pathophysiology 3rd edition

27. Thank you