Short Stature

PRESENTER: DR VISHNU S
MODERATOR : DR S R KESHAVMURTHY
Definition

 Short stature is defined as height below third

centile or more than 2 standard deviations
(SDs) below the median height for age and
gender ( <-2 SD) according to the population
standard.
 Children whose stature is more than 3 SD
below the population mean for age and
gender ( <-3 SD) are more likely to be
suffering from pathological short stature,
 As compared to those with stature between -
2 and -3 SD, who are more likely to be
affected by physiological, i.e. familial or
constitutional short stature.
Steps in Assessment

1. Accurate height measurement.

 For children below 2 yr, supine length should
be measured using an infantometer.
 For older children, height should be
measured with a stadiometer,
2. Assessment of height velocity.
 Height velocity is the rate of increase in
height over a period of time expressed as
cm/year.
 The average height velocity is 25 cm/yr in
the first year,
 declines to 4-6 cm/yr in prepubertal children
between 4 and 9 yr of age and
 increases during puberty to a peak height
velocity of 10-12 cm/yr.
3. Comparison with population norms.
The height should be plotted on appropriate
growth charts and expressed in centile or as
standard deviation score
4. Comparison with child's own genetic potential.
 Parents' height significantly affects the child's height.
 Mid parental height (MPH) gives an approximate estimate
of the child's genetically determined potential.
 MPH for boys = Mother's+ Father's height (cm)/2 +6.5cm
 MPH for girls = Mother's+ Father's height (cm)/2-6.5 cm
 This value is then plotted on the growth chart at 18-20 yr
(adult equivalent) of age. This gives an estimate of the
target height for the child and the percentile that he/she
is likely to follow.
5. Assessment of body proportion
Short stature can be proportionate or
disproportionate. The proportionality is assessed by
upper segment (US): lower segment (LS) ratio and
comparison of arm span with height
 Normally, US: LS ratio is 1.7 at birth, 1.3 at 3 yr,
1.1 by 6 yr, 1 by 10 yr and 0.9 in adults.
 Increase in US: LS ratio is seen in rickets,
achondroplasia and untreated congenital
hypothyroidism.
 Decrease in US : LS ratio is seen in
spondyloepiphyseal dysplasia and vertebral
anomalies. Arm span is shorter than length by 2.5
cm at birth, equals height at 11 yr and thereafter
is slightly (usually 1cm ) greater than height
6. Sexual maturity rating (SMR)
 Height spurt is seen in early puberty in girls
and mid-puberty in boys.
 Precious puberty can lead to early height
spurt followed by premature epiphyseal
fusion and ultimate short stature.
 On the other hand, delayed puberty can also
present with short stature in adolescents as
the height spurt is also delayed.
 Bone age assessment should be done in all
children with short stature. The appearance
of various epiphyseal centers and fusion of
epiphyses with metaphyses tells about the
 Skeletal maturity of the child. Bone age is
conventionally read from radiograph of the
left hand and wrist using either Gruelich-Pyle
atlas or Tanner-Whitehouse method.
Specific Etiologies

1. Familial short stature

The child is short as per definition but is normal
according to his own genetic potential
determined by the parents' height

These children show catch-down growth

between birth and 2 yr of age, so that the
height and weight come to lie on their target
(mid-parental) centiles by the age of 2 yr.
Subsequently, the growth velocity remains
normal throughout childhood and adolescence
 The body proportion is appropriate and bone
age equals the chronological age.
 Puberty is achieved at appropriate age and
final height is within their target range
2. Constitutional growth delay
 These children are born with a normal length
and weight and grow normally for the first 6-
12 months of life. Their growth then shows a
deceleration so that the height and weight
fall below the 3rd centile.
 By 3 yr of age, normal height velocity is
resumed and they continue to grow just
below and parallel to the 3rd centile with a
normal height velocity.
 The onset of puberty and adolescent growth
spurt is also delayed in these children but
final height is within normal limits.
 Bone age is lower than chronological age and
corresponds to the height age.
 History of delayed puberty and delayed
height spurt is usually present in one or both
parents
3. Undernutrition
 Stunted growth caused by chronic
undernutrition is one of the commonest
cause for short stature in our country.
 A detailed dietary history and presence of
other features of malnutrition such as low
mid upper arm circumference and low weight
for height suggest the diagnosis.
4. Endocrine causes
5. Skeletal dysplaslas
6. Genetic syndromes -Down, Prader-Willi,
Russell-Silver and Seckel syndromes, Turners
syndromes
7. Psychosocial dwarfism
 known as emotional deprivation dwarfism,
maternal deprivation dwarfism or
hyperphagic short stature, is seen in children
in unhappy homes where the emotional
needs of the child are totally neglected.
 It is characterized by functional
hypopituitarism indicated by low IGF-1 levels
and inadequate response of GH to
stimulation.
 Therapy with GH is however, not beneficial.
Good catchup growth is usually seen when
the child is placed in a less stressful
environment and nurtured with love and
affection
8. Children born small for gestational age (SGA)
 Birth weight below the 10th centile for
gestational age can be caused by maternal,
placental or fetal factors.
 Most of these infants show catchup growth
by 2yr of age.
 However, an estimated 20-30% of babies
born SGA fail to show catchup growth and
remain short.
 Subtle defects in the growth hormone and
insulin like growth factor (GH-IGF) axis are
considered responsible for the short stature
Normal Growth Patterns

 0–1 year: 25 cm/year

 1–2 years: 12 cm/year
 2–4 years: 6–7 cm/year
 4 years to puberty: 5–6 cm/year
 Puberty: Girls 8–10 cm/year; Boys 10–12
cm/year
Causes of Short Stature

 A. Normal Variants:
 • Familial Short Stature (FSS)
 • Constitutional Growth Delay (CGD)
 • Idiopathic Short Stature (ISS)
 B. Pathological Causes:
 • Endocrine, Chronic diseases, Skeletal,
Genetic, Psychosocial
Endocrine Causes

 GH deficiency
 Hypothyroidism
 Cushing syndrome
 Poorly controlled diabetes
Chronic Diseases & Other
Causes

 Chronic renal failure, cardiac disease

 Malnutrition, Celiac disease
 Rickets, Achondroplasia
 Turner, Noonan, Russell-Silver syndromes
 Psychosocial dwarfism
Evaluation - History

 Birth and developmental history

 Family and pubertal history
 Nutritional and systemic illness
Evaluation - Physical Exam

 Accurate anthropometry: Height, Weight,

Arm span
 Upper/lower segment ratio
 Pubertal staging
 Dysmorphism, goiter, cushingoid features
Growth Charts & Mid-Parental Height

 Use WHO/CDC charts

 Mid-Parental Height (MPH):
 Boys: [(Father + Mother) / 2 + 6.5cm
 Girls: [(Father + Mother) / 2 - 6.5cm
Bone Age & Labs

 X-ray left hand/wrist (Greulich & Pyle)

 Labs: CBC, ESR, LFT, RFT
 TSH, Free T4, IGF-1, GH stimulation test
 Anti-TTG, Karyotype (girls)
Management

 Reassurance for normal variants

 GH therapy for GH deficiency
 Levothyroxine for hypothyroidism
 Gluten-free diet for celiac disease
 GH + estrogen for Turner syndrome
 Manage chronic illness appropriately
Prognosis

 Good for normal variants

 Early diagnosis improves outcomes in
pathological cases
Summary

 Short stature: common pediatric concern

 Differentiate between normal and
pathological
 Timely evaluation and targeted therapy are
key
References

 Nelson Textbook of Pediatrics

 OP Ghai Essential Pediatrics 9th edition
Thank You
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