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Short stature
- 1. SHORT STATURE NUR IZZATUL NAJWA -36 NUR FARRA NAJWA -35
- 2. LEARNING OBJECTIVES • DEFINE SHORT STATURE • KNOW THE ASSESSMENT OF SHORT STATURE • CLASSIFY SHORT STATURE BASED ON ETIOLOGY • DESCRIBE EACH TYPES OF SHORT STATURE • UNDERSTAND THE DIFFERENTIAL DIAGNOSIS OF SHORT STATURE • ENUMERATE THE MANAGEMENT OF SHORT STATURE • APPROACH TO THE CASE SCENARIO
- 3. DEFINITION SHORT STATURE IS DEFINED AS HEIGHT BELOW THIRD CENTILE OR MORE THAN 2 STANDARD DEVIATIONS (2SDs) BELOW THE MEDIAN HEIGHT FOR AGE AND GENDER (<-2SDs) ACCORDING TO THE POPULATION
- 4. CHART
- 5. TABLE
- 6. ASSESMENT TO SHORT STATURE 1. ACCURATE HEIGHT MEASUREMENT 2. ASSESSMENT OF HEIGHT VELOCITY 3. COMPARISON WITH POPULATION NORMS 4. COMPARISON WITH CHILD’S OWN GENETIC POTENTIAL 5. ASSESSMENT OF BODY PROPORTION 6. SEXUAL MATURITY RATING (SMR)
- 7. 1. ACCURATE HEIGHT MEASUREMENT ABOVE 2 YEARS • Using stadiometer • Standing upright which heels, buttocks, shoulder blades and back of heads are in contact with vertical surface • Head piece is kept firmly over the head to compress BELOW 2 YEARS • Using infantometer or measuring table • Holding the infant straight on horizontal board in supine position • Knees and legs keep straight • Bulky diapers, harpin, braids, are removed!
- 8. 2. ASSESSMENT OF HEIGHT VELOCITY • Rate of increase in height over a period of time expressed as cm/year AGE AVERAGE OF HEIGHT VELOCITY 1ST YEAR 25cm/yr 4-9 year ( prepubertal children) 4-6cm/yr During puberty 10-12cm/yr • If the velocity is lower than expected age, child is suffering from pathological stature
- 9. 3. COMPARISON WITH POPULATION NORMS • Height must be plotted on growth chart and expressed in centiles or standard deviation score
- 10. 4. COMPARISON WITH CHILD’S OW GENETIC POTENTIAL • Parents height affects child’s height • Estimation of child’s genetic potential is by mid parental height (MPH) • Value is plotted on chart to observe whether the target will be reached or not MPH BOYS = MOTHER’S + FATHER’S HEIGHT (CM) + 6.5CM 2 MPH GIRLS = MOTHER’S + FATHER’S HEIGHT (CM) - 6.5CM 2
- 11. 5. ASSESSMENT OF BODY PROPORTION • Assessed by upper segment(US) and lower segment(LS) ratio and comparison of arm span with height • US from sitting position, LS by subtracting • Increase ratio is seen in rickets, achrondroplasia and congenital hypothyroidism Age US:LS Ratio Birth 1.7 3yr 1.3 6yr 1.1 10yr 1 Adults 0.9
- 12. 6. SEXUAL MATURITY RATE (SMR) • Assessed in older age children • Also known as Tanner stage with 5 stages according to gender
- 14. CLASSIFICATION SHORT STATURE PHYSIOLOGICAL - FAMILIAL - CONSTITUTIONAL PATHOLOGICAL - UNDERNUTRITION - CHRONIC SYSYEMIC ILLNESS - ENDOCRINE CAUSES - PSYCHOSOCIAL DWARFISM - CHILDREN BORN SMALL FOR GESTATIONAL AGE - SKELETAL DYSPLASIA - GENETIC SYNDROME
- 16. FAMILIAL SHORT STATURE • Child is short as per definition but normal according to genetic’s potential determines by parents height. • Catch down growth (birth-2years), so that height and weight lies normal within MPH • Subsequently growth velocity is normal • Body proportionate, bone age are equals to chronological age • Born small and remain small
- 17. CONSTITUTIONAL SHORT STATURE (IDIOPATHIC) • Born with normal height and weight for first 6-12 months of life • Then shows deceleration • By 3yr of age, normal height velocity is resumed and continue to grow just below or parallel to 3rd centile • Onset of puberty and adolescent growth is delayed, but final height is normal • Bone age is lower than chronological age • History of delayed puberty from one or both parents
- 18. DISTINCTION BETWEEN FAMILIAL AND CONSTITUTIONAL SHORT STATURE FEATURE FAMILIAL CONSTITUTIONAL GROWTH DELAY HEIGHT SHORT SHORT HEIGHT VELOCITY NORMAL NORMAL FAMILY HISTORY SHORT STATURE DELAYED PUBERTY BONE AGE NORMAL LESS THAN CHRONOLOGICAL AGE PUBERTY NORMAL DELAYED FINAL HEIGHT LOW BUT NORMAL FOR TARGET HEIGHT NORMAL
- 20. UNDERNUTRITION • Stunted growth due to chronic undernutrition • Detailed diet history and US:LS can suggest the diagnosis • Eg : Kwashiorkor
- 21. ENDOCRINE • Growth hormone deficiency, insensitivity • Hypothyroidism • Cushing syndrome • Pseudohypothyroidism • Precocious or delayed puberty
- 22. SKELETAL DYSPLASIA • Inborn error in the formation of bone and cartilage • Can be sporadic or inherited • Associated with abnormal skeletal proportion ans severe short stature (except hypchondroplasia) Warwick Davis
- 23. GENETIC SYNDROMES • Turner syndrome ( 1:2000 live birth) • Down syndrome • Prader- Willi syndrome • Russell-Silver syndrome
- 24. PSYCHOSOCIAL DWARFISM • Also known as emotional deprivation dwarfism, maternal deprivation dwarfism or hyperphagic short stature • Seen in children with unhappy homes • Characterized by functional hypopituitarism indicated by low IGF-1 and inadequate response of GH stimulation • Need to be nurtured with love and affection
- 25. CHILDREN BORN SMALL FOR GESTATIONAL AGE ( SGA) • Birthweight below the 10th centile for gestational age can be caused by maternal, placetal or fetal factor • Most of them shows catch up at age of 2yrs • 20-30% of babies born SGA fail to show improvement and remain short • Subtle defect in growth hormone and insulin like growth hormone ( GH-IGF) axis are considered responsible
- 27. CLUES TO ETIOLOGY OF SHORT STATURE FROM HISTORY HISTORY ETIOLOGY LOW BIRTHWEIGHT SMALL FOR GESTATIONAL AGE POLYURIA CHRONIC RENAL FAILURE, RENAL TUBULAR ACIDOSIS CHRONIC DIARRHEA, GREASY STOOLS MALABSORPTION NEONATAL HYPOGLYCEMIA, JAUNDICE HYPOPITUITARISM HEADACHE, VOMITING, VISUAL PROBLEM PITUITARY LETHARGY, CONSTIPATION, WEIGHT GAIN HYPOTHYROIDISM INADEQUATE DIETARY INTAKE UNDERNUTRITION SOCIAL HISTORY PSYCHOSOCIAL DWARFISM DELAYED PUBERTY IN PARENTS CONSTITUTIONAL DELAY OF GROWTH AND PUBERTY
- 28. CLUES TO ETIOLOGY OF SHORT STATURE FROM EXAMINATION EXAMINATION FINDING ETIOLOGY DISPROPORTION SKELETAL DYSPLASIA, RICKETS, HYPOTHYROIDISM DYSMORPHISM CONGENITAL SYNDROMES PALLOR CHRONIC ANAEMIA, CHRONIC RENAL FAILURE HYPERTENSION CHRONIC RENAL FAILURE FRONTAL BOSSING, DEPRESSED NASAL BRIDGE, CROWDED TEETH, SMALL PENIS HYPOPIUITARISM CENTRAL OBESITY, STRIAE CUSHING SYNDROME
- 29. MANAGEMENT
- 30. • GENERAL – Counseling of parents – Dietary advice • SPECIFIC – Physiological : reassurance, annual monitoring of height and weight, dietary rehabilition – Pathological : limb lengthening procedure for skeltal dysplasia, levothyroxine replacement, daily subcutaneous injection of growth hormone
- 31. CASE SCENARIO
- 32. CASE APPROACHES • A 8 year old boy, parents complains that he is the shortest boy in his class. • He has a normal past medical history and although always a bit small for his current age, he noticed that he has fallen behind his peer in the last 2 years. • He is at the 3rd percentile for height. • His father began puberty at age of the 16 and complete his growth at the age of 19, he is now 6 feet. • His mother began pubertal development at the age of 13, her height is 5 feet.
- 34. HISTORY TAKING Presenting a case of, an eight year old boy, named Shankar, sex- male, religion- hindu, born on 22/4/2009 • Shankar • 8 year old • Male • Hindu • Weight : 30kg • Height : 110cm
- 35. CHIEF COMPLAIN • Fallen behind his peer in the last 2 years. HISTORY OF PRESENTING ILLNESS • Shankar a 8 year old boy is lagging behind compared to his peers of same ages for 2 year, he also had difficulty to play together with them. • His clothes also still the same for past 2 years and not outwear. • He also the shortest child in his classroom. • Friend also make fun of him of his height. • His academic performances and appetite is normal . • Recently during fitness checkup at school, his height is 110cm and referred to nearest hospital.
- 37. PAST HISTORY • Before 2015, he was having normal growth, as mother say there is a change is clothing size in average 3 to 4 times since birth and can catch up with friends with his age. • Last time his shoe size change when he was 6 • No history of congenital heart diseases, gastrointestinal disease such as celiac diseases, inflammatory bowel diseases and no history of renal diseases • No history of any surgical procedure
- 38. FAMILY HISTORY • He is the only son of a non consanginuine marriage between a 40 year old father and 34 old mother. • Father’s family had history of down syndrome, which is father’s sister • No family history of congenital anomalies
- 39. Cont. • Fathers was diagnosed with constitutional short stature during his childhood, as on examination his bone age is lower than his chronological age and had attained puberty by age 16 ( delayed puberty) • Currently father height is normal that is 160 cm for typical Asian man • Mother was normal in height for typical Asian women that is 145 cm, and shes been diagnosed with diabetes mellitus at age of 30
- 40. BIRTH HISTORY Antenatal • She was a booked case • Pregnancy was normal • She is having pregnancy induce hypertension during last trimester but resolve after delivery • All routine check up was done and also ultrasonography • She taking Iron Folic Acid supplement • She received TT injection
- 41. Cont. Natal • Mode of delivery is normal • Baby is born on term (37-41 weeks) • Baby cries soon after birth • Length and weight is normal (length = 52 cm, weight = 3 kg) • normal head circumference (32 cm) • No history of asphyxia recorded
- 42. Postnatal • There is history of admission to NICU for jaundice for 2 days • But no history of neonatal hypoglycemia or prolonged jaundice or cyanosis or fever convulsion • Baby was breast feed after 3 hours for 15-30 minutes with gap of 3 hours after discharge from NICU • During NICU stay there is mixed breast milk with formula milk for 2 days.
- 43. Immunization history • The immunization schedule is up to date
- 44. DEVELOPMENTAL HISTORY • Boy start to stand when he is 1 year old • He start to walk when he 2 and a half year • He start to speak at age of 4 year • All milestone was up to date to his age
- 45. Diet history Breakfast Idly (1) Milk (100ml) 50kcal 67kcal 2g 3.3g Lunch Rice (100 gram) Paneer Vegetables Banana Egg 111kcal 64kcal 35kcal 105kcal 70kcal 2.2g 4g 3g 1.29g 6g Dinner Rice (100g) Curd Vegetables Egg 111kcal 67kcal 105kcal 70kcal 2.2g 3.3g 1.2g 6g Snack Biscuit 132kcal 1g Total calorie: 987kcal Total protein: 35.49g
- 46. Weight of child is 20kg Calorie requirement • 10kg = 1000kcal • 10kg = 500kcal • Total needed = 1500kcal • Calorie deficit = 513 kcal Protein requirement • 20kg x 1.5g/kg/day = 30 g/ day • Protein deficit = 5.49g/day
- 47. SOCIOECONOMIC HISTORY Mothers • Name : Sumitha • Age : 34 • Occupation : teacher • Education : degree Father • Name : Sharhul • Age : 40 • Occupation : businessman • Education : diploma Income = 15000 / month Income per capita = 5000/ person Kuppuswamy score : education : graduate (6) businessmen : (6) income : (10) Total score : 22 from upper middle
- 48. Cont. • They live in a pukka house, embassy height apartment with 1 hall, 3 bedroom, kitchen(gas) and attached bathroom • 3 person in a home with good ventilation and lighting • Waste product are manage properly, sources of water is from filter • No pets no smoker in family • Living environment is far from main city and housing area is well equip with facilities such as playground for child and small lake for elderly activities.
- 49. SUMMARY This is a case of an 8 year old boy, whose brought by mother with complain of growth lagging 2 year behind his peer. He was born with normal weight, length, head measurement and non other congenital anomalies seen. At 8 year, his height is below normal compared to other child but has no difficulty in learning. The child was healthy and active. Family history was normal except there is history for delayed puberty in fathers.
- 50. Cont. • Development is up to date and the socioeconomic is upper middle according to kuppuswamy scale. • Immunization is up todate based on IAP schedule however he has calorie deficit by 513kcal and protein execess by 5.49g.
- 51. PROVISIONAL DIAGNOSIS • Constitutional short stature • Pathological short stature probably due to genetics
- 52. PHYSICAL EXAMINATION • Weight measurement : 20 kg • Height measurement : 110 cm • Ratio of US:LS = 1:1 • Normal systemic examination • Normal facial features • H/A > W/A, but both below chronological ages ( thin/short )
- 54. GENERAL EXAMINATION Anthropometry • Height : 110 cm (between 3rd – 15th percentile) • Weight : 20 kg • MPH : mother’s height + father’s height + 6.5 cm = 152 + 182 + 6.5 = 173.5 cm SMR : tanner stage ( not done, will be assessed next checkup – older child) 2 2
- 55. COUNSELLING • GENERAL - Parent should be explain about the situation of the child, that everything about their child is normal for his condition. - Emphasizes to parent more on the child diet so it is planned to meet with his age requirement to support his growth and development by suggesting what combination of diet is good. - Advised the parent on the personality building of child despite of worrying about his stature, this can help him to catch up with his peers.
- 56. Cont. • SPECIFIC - Reassure the parents that the child height will be normal when he reached for puberty. They can be advised to always monitor the child height and weight, if he reached the target height , with the help of physician. - Suggest the best treatment needed which is affordable for parents, explain all the pros and cons and explain also the complication that may arise from the treatment.
- 57. Q & A • How short stature is define? • How to assess short stature? • Under short stature classification of pathological, children born small for gestational age (SGA) is ? • Explain the general management of short stature and perform it? • For the cases scenario, which is the most significant issue that point to constitutional short stature?
- 58. REFERENCES • Ghai, Essential Pediatric, Eight Edition • Clinical Pediatrics,Aruchamy Lakshmanaswamy • https://www.ncbi.nlm.nih.gov/pmc/articles/P MC4028640/ • http://emedicine.medscape.com/article/9244 11-clinical