Friday, January 2, 2015

Approach to a Child with Short stature

Short Stature-

Height Below 3rd Centile or more than -2 SD height for Age and Gender for the standard population.
When height is > -3 SD its most likely pathological.

Assessment of Short stature-

1. Accurate height measurement using Stadiometer for <2yrs and on Frankfurt plane for older children.

2.Assess height velocity-  cm/year

3. Mid-parental height-
Estimated Final Height = 
(Ht of father in cm  + height of mother in cm + 13 cm)/2 in Males
(Ht of father in cm  + height of mother in cm - 13 cm)/2 in Females 
 Also see Assessment of height.

4. Assessment of Body Proportion- Upper segment Lower segment ratio- Normal, low or high

5. Sexual Maturity Rating- Normal, Delayed or Advanced

Etiological Assessment and Classification-

Click on the chart to enlarge-

Legend- CDGP: Constitutional delay in Growth and puberty

Can be classified on the basis of Upper:Lower segment ratio, then Physiological and pathological causes.

Keeping in mind the causes, 
history should be sought for-
- history of Low birth weight, IUGR
- family history of short stature ( Achndroplasia, Familial short stature), delayed puberty and menstruation ( CDGP) , bowing legs and skeletal deformities ( Skeletal dysplasias)

Symptoms - systemic
- Renal- polyuria, Hypertension, Pallor, hematuria
-CNS- Cerebral palsy, 
- history of jaundice, white stool, bulky stool
- Recurrent UTI

Neonatal history- hypoglycemia, jaundice, micropenis
Any chronic illness, drug or hormone intake
Social environment

Body Proportions, Skeletal ratios- Rhizomelia, phocomelia etc
Skeletal abnormalities
Pallor, Hypertension, Jaundice, abdominal distension
Frontal bossing, depressed nasal bridge, Webbed neck
Goitre, corase hair, 
Central obesity, striae


1. Assess Bone Age and tally with Chronological age-

Bone age is asses by- Tanner's and Whitehouse method or Gruelich-Pyle atlas

Delayed Bone age compared to Chronological age-
All organic cases 
Bone age proportionate to height age
  • CDGP
  • Malnutrition and Systemic Illness- 

Bone age is less than height age-

  • Growth Hormone Deficiency
  • Hypothyroidism
  • Delayed Pubertry  

Bone age is Normal for Chronological Age-
Familial Short stature

Advanced Bone Age -
Cushing Syndrome
Precocious Puberty


If Height is  not below 2 SD, no evaluation- weight and watch 3-6 monthly

If Height < -2 SD, look for SD score-
If > 1 SDS- Physiological varaint
If <-1 SDS- look for Facies, proportions- if abnormal - Genetic, skeletal dysplasias

If Normal Proceed with-

Level I-
Complete blood count, ESR
Bone Age
Renal function test ( CKD)
Urine specific gravity, pH ( RTA, CKD)
Stool RME, Culture, occult blood, pH -( GI inflammations, celiac, malabsorptions)
Liver function test ( CLD, Hepatitis, Obstructive jaundice)
ABG- ( RTA, Barter and Gittelman syndrome, CKD, Any metabolic acidosis)
Blood Sugar- (GH deficiency, Diabetes type I, Addisons disease, Metabolic disorders)

Level II-
Thyroid function Tests

Level III-

Celiac - TTG for > 2yrs child, Antigliadin Ab for < 2yrs
GH stimulation assay
IGF1 and IGF-BP3 assessment
MRI brain

Managment -

For CDGP and Familial- Counselling

GH therapy for GH deficiency, failure to catch-up Low birth weight children, 
GH is currently approved in the United States for treating children with growth failure as a result of Turner syndrome, end-stage renal failure before kidney transplantation, Prader-Willi syndrome, intrauterine growth retardation, and idiopathic short stature

As per pathology for other causes.

Nelson Textbook of Pediatrics
OP Ghai Essentials of Pediatrics
Review articles


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