1. Preseted by: Fahd Alareashi & ??????????
Pediatrics Seminar
Preseted by: Fahd Alareashi & ??????????

2. A 10-year-old girl presents to the clinic with her parents.
Her parents report that she is the shortest in her class.
However, they have become concerned because her 8-year-old sister is now the same height as she is.
The patient has not yet attained menarche and her mother reports no breast development.
She has been well with no chronic medical problems, no hospitalizations, and no surgeries.
Case Scenario:

3. Case Scenario: She lives with her mother, father, and sister .
She is currently in the fifth year elementary school and she always scores grade A.
Her mother is 173 cm (5'8") and weighs 68 kg (150 pounds). She had menarche at age 12.
The patient's father is 185 cm (6'1") and weighs 95 kg (210 pounds).
There is no family history of any medical problems.
Case Scenario:

4. On further history, you find that your patient was 43 cm (17 inches) long at term (average is 49.5 cm, 19.5 inches).
P/E:
General:
Conscious.
Looks girl.
No apparent distress.
Vital signs:
Temperature: 37◦ C.
Pulse: 90 bpm.
BP: 100/60 mmHg.
RR: 18 breaths/min.
Case Scenario:

5. Case Scenario: P/E: Growth Parameters: Height: 120 cm. Weight: 23 Kg.
Head Circumference: 52 cm.
Case Scenario:

6. Stature

7. Weight

8. H.C.

9. Wt-for-Ht.

10. Case Scenario: P/E: Head & Neck: Chest: Abdomen:
Neck is supple and webbed.
Low posterior hair line.
Chest:
Heart: Normal S1 & S2, No additional sound.
Lungs are clear.
Abdomen:
Soft.
No masses.
Case Scenario:

11. Case Scenario: P/E: Breast: Pubic Hair: Tanner I.
Wide spaced nipples are evident.
Pubic Hair:
Case Scenario:

12. Case Scenario: INVESTIGATIONS:
Her growth chart is reviewed which demonstrates:
an average growth velocity: 3cm/year.
Bone age:
8 years & 6 months.
CBC: normal.
ESR: normal.
TFT's: normal.
UA: normal.
Serum electrolytes: normal.
Case Scenario:

13. Case Scenario: INVESTIGATIONS: Chromosomal analysis:
45 XO.
► Diagnosis of Turner Syndrome is made.
She is referred for a renal ultrasound, cardiology evaluation, and a hearing screen.
She is also seen by the pediatric endocrinologist and is started on growth hormone.
Case Scenario:

14. An approach to short stature
Preseted by: Fahd Alareashi

15. Short Stature Outlines Definition Growth Charts Causes Approach
Management

16. Short Stature Outlines Definition Growth Charts Causes Approach
Management

17. A child whose height is below the 3rd percentile for age and sex.
Short Stature:
A child whose height is below the 3rd percentile for age and sex.

18. Slow growth rate regardless of the stature.
Growth Failure:
Slow growth rate regardless of the stature.
Ultimately, a slow growth rate leads to short stature.
A Growth Chart is used to show:
A child's current height.
Growth Velocity : how fast the child is growing.

19. Short Stature Outlines Definition Growth Charts Causes Approach
Management

20. Short Stature Outlines Definition Growth Charts Causes Approach
Management

21. Growth Charts

22. Growth charts are a standard part of any checkup.
They show health care providers how kids are growing compared with other kids of the same age and gender.

23. Different Types of Growth Charts:
Male
Growth
Charts
Weight-for-Age
Height-for-Age
Weight-for-Height
Different Types of Growth Charts:
HC-for-Age

24. Different Types of Growth Charts:
Female
Growth
Charts
Weight-for-Age
Height-for-Age
Weight-for-Height
Different Types of Growth Charts:
HC-for-Age

25. Growth Charts: Assessment: Short Stature: Height < 3rd percentile.
Growth Failure:
Height crossing 2 major percentiles.
Low growth velocity: Rate < 25th percentile.

26. Short stature with normal growth rate and delayed growth spurt with eventual achievement of normal adult stature.
“ CONSTITUTIONAL GROWTH DELAY “
Stature

27. Stature Normal growth rate. Short stature in childhood.
Short stature in adults.
“ Familial Short Stature“
Stature

28. “ Acquired Pathologic Short Stature“

29. SPECIAL Types of Growth
Turner syndrome, Achondroplasia, Down syndrome
special growth charts available for these conditions.
These children grow along percentiles specific to their condition.

30. Mid-Parental Height:
Children are usually in a percentile between their parents' height.
The Expected Height of the child as adult lies between ± 5 cm from the Mid-parental age:
Girls: =
[Mother’s Height + Father’s Height - 13] 2
Boys: =
[Mother’s Height + Father’s Height + 13] 2

31. CAUSES of: short stature

32. Short Stature Outlines Definition Growth Charts Causes Approach
Management

33. Short Stature Outlines Definition Growth Charts Causes Approach
Management

34. Causes:
Normal Variants
Pathologic

35. Causes:
Normal Variants
Pathologic

36. Causes: Most common. Normal Growth Velocity. Non Pathologic.
Normal Variants
Most common.
Normal Growth Velocity.
Non Pathologic.

37. Familial Short Stature
Causes:
Normal Variants
Familial Short Stature
Constitutional Growth Delay

38. Familial Short Stature
Causes:
Normal Variants
Familial Short Stature
Short parents.
Born short.
Bone age (X-ray): Chronological age.
Puberty occurs at time.
No treatment is indicated.

39. Constitutional Growth Delay
Causes:
Normal Variants
Constitutional Growth Delay
Bone age is delayed.
Puberty is delayed.
Hx. of delayed puberty in parents.
Normal adult height.
May require short term therapy with androgens/estrogens.

40. Causes:
Normal Variants
Pathologic

41. Causes:
Normal Variants
Pathologic

42. Prenatal “ Primordial “
Causes:
Pathologic
Prenatal “ Primordial “
Postnatal

43. Prenatal “ Primordial “
Causes:
Pathologic
Prenatal “ Primordial “
All parameters are affected; Height, weight, & head circumference.
IUGR.
Chromosomal: Down syndrome, Turner syndrome.
Skeletal dysplasia.
Proportionate

44. Psychosocial neglect:
Causes:
Pathologic
Postnatal
Endocrine:
GH deficiency.
Hypopituitarism.
Cushing syndrome.
Chronic Diseases:
Cyanotic congenital heart diseases.
Celiac diseases, IBD, cystic fibrosis.
Chronic infections.
Chronic renal failure.
Psychosocial neglect:
Height > Weight
“Short & Fat”
Weight > Height
“Short & Skinny”
Weight & Height are decreased
Proportionate

45. Causes: Disproportionate Postnatal Achondroplasia. Rickets.
Pathologic
Postnatal
Achondroplasia.
Rickets.
Hypothyroidism.
Disproportionate

46. Short Stature Outlines Definition Growth Charts Causes Approach
Management

47. Short Stature Outlines Definition Growth Charts Causes Approach
Management

48. Approach & Assessment of: short stature

49. Assessment
History Taking

50. History: Antenatal History: Delivery: IUGR?
Any complications: pre-eclampsia, hypertension, anemia, maternal history of smoking, alcohol & infections, drugs?
Delivery:
Gestational age?
Mode of delivery?
APGAR score.
Complications?
Hypoglycemia.

51. History: Nutritional History?
Symptoms suggesting systemic chronic diseases:
Dyspnea?
Sweating with feeding?
Recurrent respiratory infection?
Chronic diarrhea?
Fatigue, cold intolerance? “hypothyroidism”
Recent weight gain, acne, mood swing? “Cushing”

52. History: Syndromes? Family History? Down syndrome, Turner syndrome?...
Short stature?
Chronic illnesses.
Neglect? Starvation?

53. History: Drug History? Development History? Systemic Review:
Corticosteroids?
Insulin?
Development History?
Delayed?
Systemic Review:
A complete review of systems needs to be undertaken in order to help exclude an undiagnosed syndrome or chronic medical condition

54. Assessment
Physical Examination

55. Physical Examination:
Vital Signs.
Anthropometric Measurements:
Height:
Plotted on growth chart.
Height velocity growth chart in the 6 – 12 months.
Nutritional Assessment:
Mid arm circumference.
Weight for age and weight for height.

56. Physical Examination:
Vital Signs.
Anthropometric Measurements:
Proportionate / Disproportionate:
Upper / lower segment ratio.
Arm span minus Height.

57. Physical Examination:
Vital Signs.
Anthropometric Measurements:
Calculate Mid-parental Age:
Girls: =
[Mother’s Height + Father’s Height - 13] 2
Boys: =
[Mother’s Height + Father’s Height + 13] 2

58. Physical Examination:
Dysmorphic Features?
Down Syndrome? Turner Syndrome?
Single palmar crease, webbed neck, low hairline,..
Moon face “Cushing”?
Puberty Assessment (Tanner Staging):
Examinations for systemic illnesses.

59. Assessment
Investigations

60. Investigations: Bone age. Wrist X-ray for rickets:
Skeletal survey for skeletal dysplasia:
a series of X-rays of all the bones in the body, or at least the axial skeleton and the large cortical bones.
Karyotyping.

61. Investigations: Ca, P, Alkaline phosphatase. LFTs, RFTs. ESR.
Sweat chloride test for cystic fibrosis.

62. Investigations: Endocrinal studies: T4, TSH, GH: Basal level.
Level after pituitary stimulation: exercises, clonidin or arginin.

63. Short Stature Outlines Definition Growth Charts Causes Approach
Management

64. Short Stature Outlines Definition Growth Charts Causes Approach
Management

65. mANAGEMENT

66. Management: Non-pathological short stature: No treatment is required.
Pathologic short stature:
Manage the underlying cause.
Growth Hormone GH:
GH Therapy if the following criteria are met:
GH shown to be deficient by 2 different stimulation tests.
Patient is short, insufficent growth velocity, <3rd percentile.
Bone age x-rays show unfused epiphyses
Turner syndrome, Noonan syndrome, chronic renal failure.

67. THE END….