Short and Tall stature Growth in Children

Definition

• Short stature is defined as a height more than two standard deviations below the mean for age (less than the 3rd percentile).
• Tall stature is defined as a height more than two standard deviations above the mean for age (greater than the 97th percentile).

Phases of childhood growth

• Infancy: Birth to 2-3 years: Fastest period of growth determined by nutrition
• Childhood: Age 2-3 to Puberty: Determined by hormones. GH, T3/4, Insulin
• Adolescent growth: onset of puberty to fusion of epiphyses. Determined by GH and Androgens/Oestrogens

Fusion of Epiphyses

• Gradual process initiated by oestrogen from male adrenal and female ovaries
• This controls the final height of the person

Growth Charts: Age X axis and Height is Y axis

• Ensure you can plot the age/height of a child
• RCPCH Girls 0-4
• RCPCH Boys 0-4
• RCPCH Girls 2-18
• RCPCH Boys 2-18

Centiles

• Centile lines show the expected range of weights and heights (or lengths).
• Centiles are the number of children expected to be BELOW that line
• 50% of all children are below the 50th
• 91% of all children are below the 91st

Clinical

• Initial evaluation of short and tall stature should include a history and physical examination, accurate serial measurements, and determination of growth velocity, midparental height, and bone age.
• Dysmorphic characteristics suggest a genetic disorder
• Midline defects suggest an abnormality of the growth hormone axis.
• Inspection, measurements, manoeuvres, examination.

Midparental height

• Girls : [Sum of Parental height (cm)] 2 - 7 cm
• Boys : [Sum of Parental height (cm)] 2 + 7 cm
• This calculation is not appropriate if either natural parent is not of normal stature.

Growth Velocity

• Birth to 12 months: 23 to 27 cm (9.06 to 10.63 in)
• 12 months to 1 year: 10 to 14 cm (3.94 to 5.51 in)
• 2 to 3 years: 8 cm (3.15 in)
• 3 to 5 years: 7 cm (2.76 in)
• 5 years to puberty: 5 to 6 cm (1.97 to 2.36 in)
• Puberty: Girls: 8 to 12 cm (3.15 to 4.72 in).
• Puberty: Boys: 10 to 14 cm (3.94 to 5.51 in)

Bone age

• Bone age should be compared with chronologic age to narrow the differential diagnosis of short stature.
• Compare X ray of left wrist and hand to a database of norms, although various methods are now available
• Children with normal variations of growth may have advanced or delayed bone age, but a bone age that is more than two standard deviations from the mean for age is likely due to a pathological condition

Common causes Short Stature

• Physiological
  • Familial short stature
  • Constitutional delay of growth and puberty
  • Idiopathic short stature
• Pathological
  • Chronic diseases
  • Growth hormone deficiency
  • Dysmorphic: Prader-Willi syndrome, Noonan syndrome, Turner syndrome.
  • Hypothyroidism, Hypopituitarism, Pseudohypoparathyroidism
  • Cystic fibrosis
  • ADHD
  • Chronic steroid usage or radiation
  • Cardiac disease - congenital heart disease
  • Respiratory disease
  • Chronic kidney disease
  • Gastrointestinal disease - Inflammatory bowel disease, Coeliac disease

Common causes Tall Stature

• Physiological
  • Familial tall stature
• Pathological
  • Obesity
  • Klinefelter syndrome
  • Marfan syndrome
  • Precocious puberty.
  • Growth hormone excess

Investigations for short stature

• FBC, U&E, LFT, ESR, CRP
• Follicle-stimulating hormone, karyotyping if possible Turner syndrome
• Insulin like growth factor 1 if suspected Growth hormone deficiency
• Thyroid-stimulating hormone, free thyroxine (T4) for Hypothyroidism
• Tissue transglutaminase and total immunoglobulin A for Coeliac disease
• Urinalysis: Renal disease

Investigations for tall stature

• FBC, U&E, LFT, ESR, CRP
• Insulin like growth factor 1 if Growth hormone excess
• Karyotyping for Klinefelter syndrome (XXY)
• Serum luteinizing hormone, follicle-stimulating hormone, testosterone for Precocious puberty
• Thyroid-stimulating hormone, free thyroxine (T4) for Hyperthyroidism

References

• Evaluation of Short and Tall Stature in Children