Apprach to short stature when ,what,how
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approach to short stature, not all require treatment but thorough systematic approach is the key
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Apprach to short stature when ,what,how
- 1. 2/26/2014 DR. VIJAY JAISWAL ASSISTANT PROFESSOR , DEPT . OF PEDIATRICS 1 LLRM MEDICAL COLLEGE, MEERUT kinjalvijay@yahoo.com
- 2. NOTICED SINCE LONGTIMEâŚâŚâŚâŚâŚ.. 2/26/2014 Dr. vijay jaiswal 2
- 3. â˘Family seeks medical attention for their short child Shorter than their younger sibling â˘Shortest in their class â˘Gets teased â˘Bullied /treated differently in school â˘Size not meet expectations â˘Impediment to sports â˘Want to be sure nothing WRONG â˘SHORT STATURE CAUSING DISTRESS â˘Severity of height deficit â˘Degree of tolerance/ acceptance â˘Childâs coping skills 2/26/2014 Dr. vijay jaiswal 3
- 4. âHOW TALL ARE YOU ?â instead of âWHAT IS YOUR HEIGHTâ Sandy allen (7ft ½ inch) never married George W. Bush only the fourth major presidential candidate to succeed over a taller opponent Girls referred half as boys and were significantly shorter Americans specialists prescribed 13x more GH to boys for identical case scenarios 2/26/2014 Dr. vijay jaiswal 4
- 5. ⢠Short stature imposes psychosocial stress ⢠How short is too short ??? ⢠Does short stature warrant medical treatment? ⢠A treatment approach based on suffering , rather than height , has been proposed ⢠CAUTION whether rhGH treatment for healthy short stature children construes medical or cosmetic treatment ⢠Whether this is an appropriate means of resource allocation on a societal level 2/26/2014 ! Dr. vijay jaiswal 5
- 6. A child with growth retardation ⢠Height below 3rd percentile or -2SD to avg population ⢠Excessively short for MPH/ target height ⢠GV <25th centile,not 3rd even if height is within normal percentile 2/26/2014 Dr. vijay jaiswal 6
- 7. GROWTH VELOCITY Ideally should be observed over 12 months 2/26/2014 Dr. vijay jaiswal 7
- 8. NORMAL GROWTH VELOCITY ⢠⢠⢠⢠⢠⢠⢠⢠Intrauterine pd is the pd. Of most rapid growth 1st year â 25cm 2nd year - 12.5 cm 3rd-4th year â 6-7 cm 5-9 year â 5 cm per year Pre pubertal nadir â4 cm per year Pubertal growth spurt 10-20 cms Peak gain 10-12 cms boys, 7-9 cms girls 2/26/2014 Dr. vijay jaiswal 8
- 9. ⢠Body proportion changes from 1.7 at birth to 0.98 â 1 by 13-14 years and to 1 in adulthood ⢠KEY to initial evaluation is ⢠history ⢠auxological parameters ⢠Detailed clinical examination ⢠Careful balance not to miss pathologIcal disorder without over evaluation 2/26/2014 Dr. vijay jaiswal 9
- 10. CAUSES OF SHORT STATURE ⢠Physiological short stature familial constitutional delay of growth and puberty Pathological short stature Systemic diseases Chronic anaemia Chronic renal failure Chronic asthma RTA ⢠⢠⢠congenital heart disease chronic severe infection malabsorption chronic liver disease Undernutrition Psychosocial dwarfism Endocrine disorders growth hormone deficiency /insensitivity hypothyroidism cushing syndrome pseudohypoparathyroidism ⢠⢠⢠2/26/2014 Intrauterine growth retardation Skeletal dysplasias and rickets Genetic syndrome and enborn error of metabolism Dr. vijay jaiswal 10
- 11. Facts to be elicited in history(etiology) ⢠Age at onset â since when the child is not growing ⢠Previous growth records at school, home or physician ⢠Records of previous height and weight must be sought and charted on growth charts ⢠Ante natal history birthweight/gest.age/IUGR ⢠H/O birth asphyxia (hypopituitarism), breech delivery, neonatal hypoglycemia, prolonged neonatal hyperbilirubinemia(hypothyroidism) 2/26/2014 Dr. vijay jaiswal 11
- 12. Symptoms pertaining to illness ⢠⢠⢠⢠⢠⢠⢠⢠Shortness of breath, cyanosis, cough, fever, Diarrhea, steatorrhoea, abdominal pain Headache, vomiting, visual problems Constipation, lethargy, feeding difficulty Polyuria H/O hepatitis , abdominal distention, malena Recurrent blood transfusions Dieatry history complementary feeding, calculate calorie and protein intake 2/26/2014 Dr. vijay jaiswal 12
- 13. ⢠Drug history prolonged use of corticosteroids ,amphetamine derrivatives ⢠Family history of SS in 1st/2nd degree relative (FSS), delay in puberty in one or both parent(CDGP) ⢠Social history , child abuse , family discord, emotional deprivation (psychosocial dwarfism) 2/26/2014 Dr. vijay jaiswal 13
- 14. 1 -ANTHROPOMETRY ⢠Measurement is the basis of growth assessment ⢠accurate , precise and correctly interpreted measurements are more specific than single hormone assay ⢠Measurements should be accurate and reproducible with <0.1% of coe. Of variation ⢠Appropriately designed equipment and preferably by same person to eliminate interpersonal errors 2/26/2014 Dr. vijay jaiswal 14
- 15. Height ďźFor children < 2 years : Supine length by infanto meter , two person required ďź> 2 years standing height by stadiometer ďźPlot the value on a reference curve ďźCalculate the height age ďźCorrelate the height to MPH range in children > 2 years ďźTarget height range MPH+/- 8.5 cm 2/26/2014 Dr. vijay jaiswal 15
- 16. 2- body proportions ⢠US:LS ratio- vertex to pubis :pubis to sole of foot birth 1.7:1,3yrs 1.4:1,5yrs 1.3:1,6yrs 1.2:1,at 8 yrs 1.1:1, 10 yrs 0.98:1) ⢠LS longer than US >5 cms after puberty is considered disproportinate ⢠Arm span /total height arm span is usually within 5 cm of height ⢠Weight, head circumference, and chest circumference are the other parameters which needs to be measured. 2/26/2014 Dr. vijay jaiswal 16
- 19. CLINICAL EXAMINATION ⢠Dysmorphism,cong. Malformations â genetic syndrome ⢠Midline defects, single upper central incisor ⢠Micropenis/labia â GHD, hypopituitarism ⢠s/o vit def. , malabsorption rickets ⢠Jaundice, clubbing â ch. Liver disease ⢠Central obesity, striae,proximal weakness cushingâs syndrome 2/26/2014 Dr. vijay jaiswal 19
- 20. ⢠⢠⢠⢠⢠Hypertension CRF Goitre, coarse dry skin, hypothyroidism Round face, short 4th metacarpal PHP Pubertal staging â delayed puberty Webbed neck, wide spaced nipple, increased carrying angle â turner syndrome 2/26/2014 Dr. vijay jaiswal 20
- 21. MUST DO SMR 2/26/2014 Dr. vijay jaiswal
- 24. BONE AGE X ray left hand wrist to tips of fingers ďź TW3 ďź GP ATLAS ďź GILSANZ and RATIB x 2/26/2014 no . Of carpal bones Dr. vijay jaiswal 24
- 25. WHY BONE AGE ? ⢠⢠⢠⢠⢠Skeletal maturity Correlates closely with SMR Speaks for remaining growth potential Helps in adult height prediction Delay of > 2 SD ie ~ 2 years is significant 2/26/2014 Dr. vijay jaiswal 25
- 26. ESR HOW TO INVESTIGATE ⢠⢠⢠⢠⢠⢠⢠⢠? SCREENING STAGE 1 Hemogram, ESR LIVER and KIDNEY functions tests Ca, phosph, alk. Phosph. Antigliadin and transglutaminase antibodies Karyotype in a girl and pelvic ultrasound Thyroid function test Bone age 2/26/2014 Dr. vijay jaiswal 26
- 27. STAGE 2 SCREENING ⢠IGF- 1 ⢠IGF binding protein 3( IGFBP-3) ⢠GROWTH HORMONE and other dynamic stimulation test ⢠Neuro imaging ⢠Best to be done at SPECIALISED CENTRES 2/26/2014 Dr. vijay jaiswal 27
- 28. child referred for growth retard. anthropomettry growth charting , H/E NORMAL SHORT CLUES TO ETIOLOGY FROM H/E REASSURE AND ADVISE ROUTINE HEIGHT AND WEIGHT MONITOIRING YEARLY absent present Bone age Confirmatory test and treatment 2/26/2014 Dr. vijay jaiswal BL STATURE N bone age SIGNIFICA NT SHORT/ DELAYED 28 BA
- 29. SIGNIFICANT SHORT,DELAYED BA BL OBSERVE GV FOR 1 YR NORMAL PHYSIOLGICAL SS REASSURE AND ADVISE GROWTH MONITORING 2/26/2014 ABNORMAL SCREENING INVESTIGATIONS ABNORM AL TREAT THE CAUSE NORMAL KARYOTYPE IN GIRLS,TEST FOR GHD ,RTA, MALABSORPTION ABNORMAL NORMAL TREAT CAUSE Dr. vijay jaiswal ISS29
- 31. TAKE HOME MESSAGE 1 2 ⢠Take height and weight properly and plot it ⢠Use growth charts (appropriate one) ⢠Growth velocity to be measured 6 monthly ⢠Systemic approach and simple test first ⢠DYNAMIC STIMULATION TESTS AT SPECIALISED CENTRES 3 2/26/2014 Dr. vijay jaiswal 31
- 32. THANK YOU
- 33. Familial short stature ⢠One of the MC cause of short stature ⢠Ht <3rd percentile but N against MPH ⢠GV normal, growth curve follows parallel to 3rd centile line ⢠BA= HA, with N body proportion ⢠Child achieve puberty at appropriate age ⢠Adult stature is below normal ⢠Heritable causes of pathological short stature with mild phenotype may actually responsible 2/26/2014 Dr. vijay jaiswal 33
- 34. Constitutional delay of growth and puberty (CDGP) ⢠More frequently encountered in boys ⢠Born with normal weight and length ⢠Grow normally in the 1st year, decelerates during 2nd -3rd year to reach just below 3rd cen ⢠Continue to grow parallel to 3rd percentile with normal GV throughout the childhood ⢠Puberty delayed with growth spurt delayed and attenuated ⢠BA=HA < CA ⢠H/O delayed puberty in either parent often 2/26/2014 Dr. vijay jaiswal 34