Short stature

or Stunting

dr. Kurniawati Arifah, M.Sc, Sp.A

KSM Ilmu Kesehatan Anak RSUD Prof. Dr.

Margono Soekarjo Purwokerto/ FK Unsoed
 Normal Growth

– Growth that follows established patterns based on studies of

several different populations and that follows the trajectories of
standard growth charts

– Normal growth falls between the 3rd and 97th percentiles of

all children à the shortest and tallest 3% fall outside the
bounds of “normal” stature
Phases of Normal Growth

– Intrauterine
– Growth strongly influenced by intrauterine
environment
– Insulin, IGFs, and their binding proteins play
important roles in fetal growth
– GH, thyroid hormone not very important
– Infantile
– Rapid but decelerating growth during first 2 years
of life
– Infants often cross percentile lines during the first
24 months as they grow toward their genetic
potential and get further away from the excesses
or constraints of the intrauterine environment
Phases of Normal Growth

– Childhood
– Growth at a relatively constant velocity of 4.5 to 7 cm/year (1.8
to 2.8 cm in/year)
– Perhaps some slight slowing just prior to adolescence
– Pubertal
– Characterized by a growth spurt of 8 to 14 cm/year (3.2 to 5.5
in/year) because of the synergistic effects of increasing gonadal
steroid and growth hormone secretion
Growth failure and short
stature

– Short stature: height more than 2.0 SD below the mean for
age and gender; strictly statistical convention
– Growth failure: decline in rate of linear growth (cross
channels). Slowly growing children are usually short
– There are many non-endocrine and endocrine causes of
growth failure and short stature
Diagnostic approach

– Anthropometric measurement : Evaluate further if HAZ < -

3SD, Growth velocity is under 25th percentile or
<5cm/year, Projected adult height below potential height,
Growth faltering
– Laboratory work for short stature evaluation : Complete
blood count, Thyroid hormone level, Bone age, Karyotipe,
Growth hormone and IGF-1 level
Algorithm
for
diagnostic
approach
in short
stature
children
 Pituitary Gland
Pituitary Gland
Adenohypophysis Neurohypophsis
Anterior lobe Middle Lobe Posterior Lobe
Somatotrophs MSH & Endorphins AVP
Growth hormone
Oxytocin

Thyrotrophs
TSH

Lactotrophs
Prolactin

Gonadotrophs
LH & FSH

Corticotrophs
ACTH
Hypothalamic-Pituitary GH-IGF1 Axis
Growth Hormone Secretion
GH measurement

§ IGF-1 & IGFBP-3

§ More reproducible, longer half-lives, little diurnal variation.
Acceptable sensitivity and specificity
§ No age- , sex- and puberty - related standards
§ Unreliable <5 yrs. Discriminate better >8 yrs
§ IGF-1 or IGFBP-3 > -1 SDS essentially rules out classic GHD.
Practical application – exclude pts unlikely GHD and identify pts
further work up should be performed
§ Pitfalls – cannot discriminate completely GHD and short normal;
cannot predict long-term response to GH
§ GH provocation test
 IGF deficiency
1. GHD due to hypothalamic dysfunction
2. GHD due to pit dysfunction
3. GH insensitivity (GHI)
A. Primary GHI
a. GH receptor def –mutations/deletions
b. Abn GH signal transduction – post-receptor
B. Secondary GHI
a. malnutrition
b. hypothyroidism
c. chronic ds – liver ds, DM, infection
d. drugs- chemoPx, steroids, psychotropic drug
4. Primary defects of IGF synthesis
5. Primary defects of IGF transport/clearance
6. IGF resistance
Growth hormone deficiency

– Height < - 3 SD
– Growth Velocity < 25 %
– Delayed bone age (< -2 SD)
– PAH substantially < mean parental Height (< -1.5 SDS)
– IGF1 and IGFBP3 < -1 SDS
– Impaired peak GH response to 2 provocation tests
– +/- MRI or genetic abnormalities
Treatment

– GH replacement therapy
– Pediatric endocrinologist