Fundamental Task: Growth is a fundamental aspect of childhood development.
Key Interactions: Adequate skeletal lengthening depends on a complex interaction of genetic, hormonal, nutritional, and psychosocial variables.
Health Professional Role: Ensuring children reach their maximum height potential is a crucial responsibility for healthcare providers.
Parental Concerns: Addressing parental expectations and anxieties is important when managing concerns about a child’s height.
Normal Growth Patterns
Greatest Growth Velocity: Occurs in late fetal life.
Decreasing Velocity: Growth velocity decreases after birth until adolescence, with the notable exception of the pubertal growth spurt.
Gender Differences: Growth rates are similar between genders until puberty.
Pubertal Growth Spurt: Occurs later and with higher velocity in males, resulting in average heights of 177 cm for males and 164 cm for females.
Identifying Growth Disorders
Key Distinction: Differentiate between a child who is short but growing well and one who is growing poorly.
Short Stature Definition: Defined as height below the 1st centile for age on growth charts.
Dynamic Process: Growth is dynamic and requires multiple height measurements over at least 6 months.
Normal vs. Pathologic Growth: Normal growth is parallel to the centiles; deviations may indicate pathological causes of growth failure.
Assessing Growth
Measurements:
Height: Plot against standard centile charts.
Weight: Plot against standard centile charts.
Body Proportions: Assess body proportions.
Growth Velocity: Plot against growth velocity centile charts.
Consistency in Measurement:
Ideally, one person should measure the patient at every visit to avoid inter-observer bias.
Measurement Techniques:
Children <2 Years:
Place on a supine table.
One measurer holds the child’s head.
Another performs the measurement.
Children ≥2 Years:
Use a stadiometer.
Child stands without shoes or socks.
Heels and back against the wall/board.
Head straight.
Gentle upward pressure applied to the mastoid process.
Normal Body Proportions:
Arm Span to Total Height Ratio: Around 1.0 at all ages.
Upper Segment to Lower Segment Ratio:
Approximately 1.7 as a neonate.
Decreases to 1.4 at age 4-5 years.
Just below 1.0 by age 10-12 years.
Growth Velocity Assessment:
Serial measurements are required, preferably over 1 year.
Calculate growth over time (convert to cm/year).
Growth velocity is a sensitive marker for growth slowing, even if not apparent on standard centile charts.
Repeated height values plotted on a standard chart usually give a good indication of current growth velocity.
Predicting Adult Height
Parental Heights: Mother’s and father’s heights are needed.
Female Child:
Subtract 13 cm from the father’s height.
Plot the adjusted paternal height on the female chart.
Plot the mother’s height on the female chart.
The midpoint between these two values is the mid parental height (MPH).
Male Child:
Add 13 cm to the mother’s height.
Plot the adjusted maternal height on the male chart.
Plot the father’s height on the male chart.
The midpoint between these two values is the MPH.
Range for Prediction: The 3rd and 97th centiles for the child are 10 cm to either side of the MPH.
Bone Age Assessment:
Perform an X-ray of the wrist and hand.
Determine bone age, chronological age, and current height.
Use the Bayley-Pinneau tables to predict the likely adult height.
Interpreting Growth Data – Normal Variants
Assessment Goal: Determine if short stature is a normal variant or due to a pathological condition.
Normal Variants:
Familial Short Stature: Short parents likely to have short children growing at a normal rate.
Constitutional/Maturational Delay:
Transient slowing of growth around 3 years and 11-12 years of age.
May have a family history of delayed growth and pubertal development.
Bone age, height age, and growth velocity help distinguish from familial short stature.
Bone Age: Delayed bone age reflects physiologically delayed growth.
Growth Chart: Use corrected growth charts for bone age to assess growth patterns.
Outcome:
Patients with familial short stature are likely to remain short adults.
Children with constitutional delay are likely to achieve a good height outcome as their growth catches up over time.
Interpreting Growth Data
Normal Variants vs. Pathology:
Familial Short Stature: Children grow at a normal rate but are shorter due to familial patterns; these children will be short adults.
Constitutional Delay: Children experience a temporary slowing of growth around ages 3 and 11-12, often with a family history of delayed growth and pubertal development. They typically catch up in height later.
Pathological Causes of Short Stature
Indicators of Pathology:
History and Examination:
Include birth weight
symptoms of chronic illness
psychosocial issues
physical examination for dysmorphic features.
Height Velocity: Falling off centiles is a key indicator of pathology.
Weight Changes: Weight falling off the centiles can indicate chronic illness, nutritional, or psychosocial causes.
Female Patients: All females with short stature (<1st centile) should have a karyotype to exclude Turner syndrome.
Mnemonic ‘Endocrine PICNICS’: Used to remember pathological conditions causing short stature:
Nutritional: Malnutrition, specific nutrient deficiencies.
Iatrogenic: Effects of certain medications like corticosteroids.
Congenital syndromes: Genetic syndromes like Turner syndrome, Down syndrome.
Skeletal dysplasias: Conditions like achondroplasia.
Treatment of Short Stature
Nonpathological Causes: Explanation and reassurance are crucial for both parents and child.
Boys with Constitutional Delay: May benefit from testosterone administration to induce puberty.
Catch-up Growth: Possible in some conditions once underlying issues are controlled, although may not reach premorbid height potential.
Referral: To a pediatric endocrinologist if a pathological cause is suspected.
Tall Stature
Less Common: Tall stature is less commonly a presenting problem.
Familial Tall Stature: Often familial, with serial measurements and parents’ heights used for assessment.
Endocrine and Syndromal Causes: Include hyperthyroidism, precocious puberty, growth hormone-secreting tumors, and syndromes like Klinefelter and Marfan syndrome.
Treatment: Usually reassurance; in rare cases, sex steroid administration may be used to reduce final height.
Conclusion
Accurate Assessment: Careful history, examination, and growth parameter assessment are essential.
Reassurance: Vital for non-pathological cases.
Referral: Required for complex or pathological cases.
Support: Medical and social support are crucial for managing growth disorders.
Additional Notes:
Constitutional Growth Delay: Transient slowing of growth at approximately 3 years and again at 11-12 years of age; may have a family history of delayed growth and pubertal development. Bone age, height age, and growth velocity can help distinguish this from familial short stature.
Growth Hormone Therapy: Considered for children who meet specific criteria; applications are made to a central governing body.
Tall Stature Syndromes: Klinefelter syndrome (47XXY), Marfan syndrome (autosomal dominant, fibrillin defect), Sotos syndrome (cerebral gigantism), Homocystinuria (autosomal recessive, similar to Marfan but with poor bone density and thrombosis tendency), Beckwith-Wiedemann syndrome (fetal overgrowth, risk of malignancy).
