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:
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
29 SPECIAL Types of Growth Turner syndrome, Achondroplasia, Down syndromespecial 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]2Boys:=[Mother’s Height + Father’s Height + 13]2
36 Causes: Most common. Normal Growth Velocity. Non Pathologic. Normal VariantsMost common.Normal Growth Velocity.Non Pathologic.
37 Familial Short Stature Causes:Normal VariantsFamilial Short StatureConstitutional Growth Delay
38 Familial Short Stature Causes:Normal VariantsFamilial Short StatureShort parents.Born short.Bone age (X-ray): Chronological age.Puberty occurs at time.No treatment is indicated.
39 Constitutional Growth Delay Causes:Normal VariantsConstitutional Growth DelayBone age is delayed.Puberty is delayed.Hx. of delayed puberty in parents.Normal adult height.May require short term therapy with androgens/estrogens.
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
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.
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
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 epiphysesTurner syndrome, Noonan syndrome, chronic renal failure.