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


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


Evaluation-

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


Investigations-

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
Karyotyping

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.

References-
Nelson Textbook of Pediatrics
OP Ghai Essentials of Pediatrics
Review articles



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