growth failure in children

2. Growth
• Growth refers to an increase in physical size of
the whole body or any of its parts.
• It is simply a quantitative change in the child’s
body.
• It can be measured in Kg, pounds, meters,
inches, ….. etc

3. Development
• Development refers to a progressive increase
in skill and capacity of function.
• It is a qualitative change in the child’s
functioning.
• It can be measured through observation.

4. Introduction
• Growth failure is one of the most
common presentation to a pediatrician .
• Most short children have physiological
causes not requiring evaluation .
• The aim of evaluation of growth failure is
to avoid unnecessary work - up in children
with physiological causes while not
missing a pathological cause .

5. • Short child: Any child whose height falls below
the 3rd centile for his/her community.
• Failure of physical growth
• The term ‘Dwarfism’ is no longer used for short
stature
• Approximately 3% children in any population will
be short .

6. PATHOPHYSIOLOGY
• An understanding of growth physiology is
of most importance for successful
management of growth disorders .

7. • GROWTH PATTERN:
• Growth is characterized by phases of rapid
growth ( intrauterine , infancy and puberty )
interspersed with reduced growth ( childhood )
• Maximum linear growth happens in the fetal period
with increase of 50 cm .
• Fetal growth is regulated by intrauterine
environment with limited impact of growth
hormone and thyroxine .
• Infancy is associated with gain of 25 cm in first
year and 12 cm in the second.
• Growth during this period is largely driven by
nutrition.

8. • Childhood growth contributes
significantly to adult height and occurs at a
steady rate of 5-6 cm per year .
• Puberty accounts for 20-25 cm of growth .
• Pubertal growth spurt starts at breast
stage II in girls and testicular volume of 10
ml in boys and lasts for two years .
• It peaks at breast stage IV 6 months prior
to menarche with a rate of 9 cm / year in
girls and a testicular volume of 15 ml with
a rate of 11 cm / year in boys .

9. GROWTH REGULATION
• Final height is determined by genetics explaining 60-80 % variation .
• Within this framework growth represents an interaction of nutrition
and endocrine factors .
• Nutrition plays vital role in growth regulation .
• Type 1 nutrients ( vitamins , calcium , iodine and magnesium ) play
a role in specific processes . There deficiency disrupts a unique
facet with normal overall growth .
• Type II nutrients are the building blocks of body ( proteins ,
electrolytes , zinc , phosphorus and sulfate ) . Their deficiency
causes global reduction in growth .

10. ENDOCRINE REGULATION
• Growth is regulated by the GHRH - GH -
IGF1 axis with inputs from nutritional signals ,
sex steroids and thyroxine .
• Growth hormone - IGF1 axis
• Hypothalamic GHRH acts on pituitary to
produce growth hormone .
• Growth hormone is secreted in pulsatile
fashion with maximum release at night .
• Growth hormone acts on the liver to produce
IGF I , which acts on the type I IGF receptor
on the growth plate to induce growth .

12. • Nutritional influence
• Malnutrition is a growth hormone resistant
state with high GH and low IGF1 levels.
• GHD may therefore be missed in children
with malnutrition .
• Overnutrition is a growth hormone sensitive
state with high IGFI and low growth hormone
levels .
• This may lead to erroneous diagnosis of
growth hormone deficiency in obesity.
• Increased insulin in obesity stimulates growth
by raising free IGF1 levels and acting on the
type I IGF receptor .

13. CRITERIA
• Growth failure evaluation is required for children
who are:
 very short ( height less than 1st percentile) ,
 short and not growing ( height between 1 to
3rd percentile and
 not growing at all ( crossing two or more major
percentile lines between the age of 2 years and
puberty ) .
• Growth velocity should be measured over a period
of at least 6 months to one year with age specific
cutoff for identification of disorder .

14. ETIOLOGY
• Growth is controlled by multiple factors and abnormality in any of
these may cause growth failure .

15. Short child
• Six GOLDEN POINTS
• 1- Accurate & Serial measures.
• 2-Pubertal assessment
• 3- Mid Parental Height (MPH).
• 4- Height age.
• 5- Bone Age.
• 6- appropriates Investigations.

16. Important definitions
• Chronological age – Actual age of the child.
• Height age – it’s the age at which the height of the
child is at 50th centile.
• Bone age - is an indicator of skeletal maturation.
• Target MPH: F+M/2 +6.5 for boys and -6.5 for girls.
• Then plot the result on Growth Chart at Age 20 to
form Family chart ±10 to form centile

17. Assessment of a child with short
stature
• Accurate height measurement& height velocity
• Height plotted on appropriate growth chart.

18. Normal Measuring
• Supine length < 2 y of age
• For measurement of supine
length it is best to use a firm
box with an inflexible board
against which the head lies,
with a movable footboard on
which the feet are placed.
• Erect height > 2 y
• The head is held in a horizontal
plane
• Upward pressure is applied to
the mastoid processes in order
to encourage the child to stand
up straight.

19. Growth charts
• The key aspects to look in a growth chart include
• absolute status compared to population (
percentile ) ,
• effect of parental height ( growth chart for the
family ) and relative impact on height and weight
( height age and weight age ) .
• Greater compromise of weight than height in a
short child suggests nutritional cause (
malnutrition , infection , renal tubular acidosis or
celiac disease ) while height is more affected in
endocrine causes .

20. Pubertal
assessmen

21. Pubertal assessment
• Breast stage II ( elevation of papilla ) suggests that a
girl has entered puberty and marks the initiation of
growth spurt .
• Thelarche should be differentiated from lipomastia by
palpating breast tissue between thumb and index
finger .
• Breast stage IV ( secondary mound ) and vaginal
discharge predict menarche within the next six months
.
• Post menarchal growth is limited to 5-8 cm .

22. • First sign of puberty in boys is increase in
testicular size followed by appearance of pubic
hairs and increase in penile length and thickness .
• Pubertal onset is marked by a testicular volume
of 4 ml with growth spurt starting at 10 ml .
• Importantly growth velocity is lowest just before
the onset of puberty .
• This results in frequent presentation of
prepubertal boys with short stature .
• Spermarche is a terminal event indicating limited
growth potential .

23. Mid parental height (MPH)
• Comparison with child’s own genetic potentia
• Mid parental height for boys
• MPH = mother's height + father's height /2 + 6.5cm
• Mid parental height for girls
• MPH = mother's height + father's height /2 – 6.5cm
• Then plot the result on Growth Chart at Age 20 to
form Family chart ±10 (6)

24. Family Chart
• Example: 3 Y – girl –
• Ht=85 cm --Wt=10 Kg
• Father Ht= 165 cm
• Mother Ht= 155 cm
• MPH= 160-6.5=
• 153.5
• Plot on age 20
• 153.5 ±10
• 143.5 – 163.5
3rd
MPH= 153.5±10

25. Height age
• Height of a person at the 50th percentile
for their age.

26. Height age
• Examples:
• Girl- Age = 5 y
• Ht= 95 cm
• Height age= ?

27. Bone age assessment
• X ray of the non - dominant ( conventionally left ) hand and
wrist is used for bone age assessment .
• The fingers should be widely spread to allow visualization
of all bones separately .
• Given the difficulties of formal bone age assessment for
busy physicians , practical method has been devised to
provide quick overview of skeletal maturation .
• This involves selection of area of interest , comparison of
different areas and overall estimation of bone age .
The Greulich and Pyle Method The Tanner–Whitehouse Method
Computerized Automatic Systems

28. • Carpal bones are preferred in infancy ( up to 10
months in girls and 14 months in boys ) followed by
phalangeal epiphysis ( till 2 years in girls and 3 years in
boys ) .
• Comparison of the size of epiphysis to metaphysis is
indicated in pre - puberty to early / mid puberty .
• Epiphyses are smaller than metaphysis till seven years
of age in girls and nine years in boys .
• They become equal to metaphysis by 10-12 years ,
bigger beyond 12 years with capping and fusion by 14
years of age.
• Fusion of distal epiphysis is assessed during late
puberty ( 13-15 years in girls and 14-16 years in boys
with focus on long bones subsequently .

29. epiphysis to metaphysis

30. PHYSIOLOGICAL CAUSES
• These represent the vast majority of children with growth failure .
• Their identification limits unnecessary work - up for causes of growth
failure

31. Familial Short Stature
• In contradistinction to CDGP , children with
familial short stature have normal bone age
and puberty .
• The disorder is characterized by early onset
growth failure , family history of short stature ,
normal growth velocity and compromised
final height .
• Consideration for genetic cause of short
stature should be given if either of the parent
is very short ( height below -3 SDS ) or has
characteristic clinical picture.

32. Is she short?
• Example: 3 Y – girl –
• Ht=85 cm --Wt=10
Kg
• Father Ht= 165 cm
• Mother Ht= 155 cm
• MPH= 160-6.5=
• 153.5
• Plot on age 20
• 153.5 ±10
• 143.5 – 163.5
• Bone Age = normal
50th
3rd
MPH= 153.5±10
Familial short stature

33. Constitutional Delay Of Growth &
Puberty ( CDGP )
• CDGP is one of the commonest cause of growth failure .
• It is due to delayed onset of puberty due to genetic factors .
• Growth is normal in the initial phase with faltering by seven
years of age .
• The child remains behind his peers despite a normal growth
rate .
• Final height is normal as bone age is delayed and growth
continues for a longer period than other children .
• Family history of delayed puberty ( delayed menarche in
mother ; delayed onset of shaving and continued growth in
college years in father ) is present .
• CDGP is common in boys but also frequently observed in
girls.

34. Is she short?
• Example: 5.5 Y – girl
• Ht= 98 cm --Wt=13
Kg
• Father Ht= 175 cm
• Mother Ht= 165 cm
• MPH= 170-6.5=
• 163.5 ±10
• HT Age=3.5 years
• Bone Age=3.5 years
50th
3rd
MPH= 163.5 ±10
Constitutional short stature

35. Is she short?
• Example: 5 Y – girl –
• Ht= 98 cm --Wt=15 Kg
• Father Ht= 175 cm
• Mother Ht= 165 cm
• MPH= 170-6.5=
• 163.5 ±10
• HT Age=3.5 years
• Bone Age=1 year
50th
3rd
MPH= 163.5 ±10
Pathological short stature

36. PATHOLOGICAL CAUSES

37. Endocrine Causes
• Endocrine causes of growth failure include
hypothyroidism , growth hormone deficiency ,
pseudohypoparathyroidism and Cushing syndrome .
• These children have preserved weight with delayed
bone age and puberty .
• Hypothyroidism-
• Pseudohypoparathyroidism
• Cushing syndrome
• GH - IGF1 axis disorders

38. ASSESSMENT
• Key aspects of evaluation of a short child
is to confirm short stature , exclude
physiological causes , differentiate
nutritional from endocrine etiology and
identification of the cause .
• IS IT PHYSIOLOGICAL OR
PATHOLOGICAL?

39. Investigations
• Screening tests include
• complete blood count, erythrocyte sedimentation rate
• Electrolytes, calcium , phosphorus and alkaline phosphatase
• blood sugar
• creatinine ( chronic kidney disease )
• alanine transferase ( liver disease )
• free T4 , TSH levels ( hypothyroidism )
• celiac disease screening
• chest X ray
• blood gas ( renal tubular acidosis )
• Karyotype with 50 metaphases should be done in short girls with no
apparent abnormality on screening tests to identify Turner
syndrome .

40. Assessment of GH - IGF1 axis
• GH - IGF1 axis evaluation should be done only
after exclusion of all other causes of growth
failure .
• Basal GH has no role in diagnosing GHD but
can help in screening for GH resistance .
• Normal thyroid and cortisol levels are
essential to elicit growth hormone response .

41. • Growth hormone stimulation test is considered
the gold standard for identifying GHD .
• Sex steroid priming is recommended in girls older
than 10 years and boy above 11 years who are
pre - pubertal and have predicted adult height in
the normal range .
• 17 beta estradiol ( Progynova , 2 mg for two days)
can be used in both boys and girls .

42. • Commonly used stimuli include:
• clonidine ( 5 mcg / kg to a maximum dose of 200
mcg ) ,
• glucagon ( 30 mcg / kg with a maximum dose of 1
mg ) and
• insulin ( 0.1 unit / kg to induce hypoglycemia ) .
• Complete GHD is defined as peak stimulated
growth hormone lower than 5 ng / mL and partial
GHD as levels between 5-10 ng / ml .
• Children with abnormal response to one test
should have another dynamic test to establish
the diagnosis .

43. • GH dependent peptides
• IGF 1 and IGFBP3 are secreted in response to GH and provide
information about GH effect .
• These peptides are used for screening for GHD and monitoring
response to GH therapy .
• IGF 1 is an unreliable marker before two years of age and in those
with malnutrition and liver disease .
• IGFBP3 is a better marker of growth hormone status in younger
children including neonates .

44. MANAGEMENT
• General measures include nutrition ( protein ,
zinc , iron and calcium supplementation ) and
physical activity .
• Specific measures include gluten free diet in
celiac disease , alkali in RTA , thyroxine in
hypothyroidism and supplements and
infection control in cystic fibrosis .

45. MANAGEMENT
• Growth hormone therapy is indicated in children with:
• GHD ( benefit of 20-25 cm ) ,
• Turner syndrome ( 10-15 cm ) ,
• SGA without catchup ( gain 7-10 cm ) ,
• chronic kidney disease planned for renal transplant and
• Prader Willi syndrome with growth failure .
• GH therapy is being increasingly used in children with
idiopathic short stature with height below 1st
percentile .

46. THANKS FOR YOUR ATTENTION