Diagnostic approach of Short stature / Stunted (Jan 2015) - Prof Dr Jose Batubara

Diagnostic approach of

Short stature / Stunted

Jose RL Batubara

Pediatric Endocrinology, Dept of Pediatric

Faculty of Medicine, University of Indonesia

Outline

• Growth proses

• Short Stature

• Stunted

Growth mechanism

GROWTHHiperplasia

Hipertrofi

Deposisisi Matrix

Lingkungan

Well being

HormonGenetik

Nutrisi

GH – IGF axis

• A composite of living cells in combination of organic and inorganic materials

• Collagen matrix combine with hydroxyapatite mineral crystals form the majority of bone

• Mineral is 70% by weight, 50 %by volume

• Collagen and protein matrix 29.5% by weight and 50% by volume

• Remaining 0.5% by weight is made by cells

Long bones are divided

into 3 major regions

Diaphysis (shaft)

▪ cortical and cylindical

region of bone

Metaphysis :

▪ trabecular region of bone

just at the end of

diaphysis

Epiphysis :

▪ ends of bone, which are

highly trabecullar

The ephiphysis and

metaphysis are

separated by an

epiphysial growth plate

EPIPHYSEAL GROWTH PLATE

• Bone growth is a large part of overall body

growth

• Bones growth longitudinally and

circumferentially from embryonic to puberty

• After puberty growth predominantly

circumferential

• Protein accretion controll by 80 growth

regulators controll growth in the body

• They controll

• Cell division

• Cell hypertrophy

• Cell differentiation

• Cell migration

• Most important hormones for growth

• Growth hormone

• Thyroid hormone

• Insulin

• Testosterone

• Estrogen

• Growth factors

Hypothalamus

Anterior pituitary gland

+ GHRHSomatostatin -

GH

Liver

Cartilage and bone

growth

Muscle and other

organs:

-Protein synthesis

and growth

Adipose Tissue

-lipolysis

- release of FFAs

Most Tissues

â glucose utilization

-blood glucose

IGF-1

SomatomedinGH levels and effects are

most pronounced during

puberty

13

The roles of growth hormone (GH) and insulin-like growth factor-I (IGF-I) in promoting growth. GH stimulates IGF-I production in liver and epiphyseal growth plates. Epiphyseal growth is stimulated primarily by autocrine/paracrine actions of IGF-I. IGF-I produced by the liver accounts for growth in diameter of bones and acts as a negative feedback regulator of GH secretion. Liver is the principal source of IGF-I in blood, but other GH target organs may also contribute to the circulating pool.

FIGURE

11.5

16

GH signal transduction: other genes?

I-C-P Model

INFANT CHILDHOOD PUBERTAL

FASE INFAN (0-2 th)

•Penurunan kecepatan pertumbuhan

• Pertambahan berat dan tinggi yg cepat

•Proses Kanalisasi

FASE ANAk (2-11 yrs)

•Kecepatan pertumbuhan stabil

•Pertumbuhan sesuai kanal genetik

•GH dependent & thyroid hormone (partially)

FASE PUBERTAS

•Growth spurt / growth acceleration

•Dependent upon action of sex hormone and GH

•Deceleration and termination of growth

Pertambahan tinggi badan

1-6 bl : 18 - 22 cm/th

6-12 bl : 14 – 18 cm/th

1 th : 11 cm/th

2 th : 8 cm/th

3 th : 7 cm/th

4 – pubertas : 5 – 6 cm/th

Growth evaluation

• Antropometri: reliability

• training

• Equipment

• Plotting

• Absolute Height

• –2SD - -3SD: 80% normal variant

• < -3SD:80% patologis

Size - Stature

• Statistical concept

• Normal

• Tall > p97

• Short < p3

• Sex & ras

Growth evaluation

• Growth velocity

• Pengukuran TB dengan interval 6 bl

• Deselerasi / crossing centiles pada usia 3-12 th:

biasanya patologis sp dibuktikan lain

• Kecepatan pertumbuhan normal normal growth

• Hubungan BB dan TB

• BB/TB ratio: kasus endokrin

• BB/TB ratio: penyakit sistemik

Growth charts

Complete growth charts consist of

a series of charts

• Weight for age

• Height for age

• Weight for height

• Head circumference for age

• Body Mass Index for age

• Sitting height for age, SH/LL

• Arm span

• Skin fold thickness

• Waist circumference

• Growth Velocity for age

• etc

Which growth charts should be used

Country

(Year)

BH (boys)

cm

BH (girls) cm

p50 p97 p50 p97

The Netherlands (1985)

Germany (1992)

United Kingdom (1995)

USA (NHCS) (1977)

Denmark (1982)

Sweden (1976)

Mexico (1975)

182.0179.9

176.4

176.8

179.4

179.1

172.8

194.5

192.5

190.5

187.6

190.4

192.4

186.3

168.3

167.0

163.6

163.7

166.0

165.5

160.6

179.8

179.0

176.0

173.6

176.0

178.2

174.5

Korea (1979)

Singapore (1998)

Indonesia (2005)

170.2

171.5

168.2

180.0

183.6

179.8

157.6

152.5

150.0

166.5

165.6

162.4

Genetic height in different populations

Other Parameters for

growth evaluation

• Genetic Height Potential

• Boys = TBA +(TBI+13)

2

• Girls = (TBA-13)+TBI

2

Bone age

• Greulich & Pyle

• Comparison of left wrist

• Prediction of FH after 6 years

• Table Bayley & Pinneau

• Tanner Whitehouse II

• Maturation of ossification center

• More reliable : scoring system

• complicated

Body Proportion

• Measurement

• Sitting height and standing height

• Arm span

• Upper/lower segment ratio

• Lahir:1.7 dan 8 th : 1

• Disproportionate pada skeletal dysplasia

Body Proportion

Growth velocity

Diagnostic approach of

Short Stature

Short Stature

Abnormal

Normal

Constitutional DelayNormal Variant

Proportional Dysproportional

W/H W/H

Endocrine

Bone Dysplasia

Systemic diseases

How bad is it to be short ?

• Short stature is associated with

- low self-esteem

- poor school performance

- stigmatization and teasing

(esp. boys)

- other mental health problems

Short stature

• TB < 2SD untuk populasinya

• Sex, usia and ras

• Pola pertumbuhan lebih penting

dibanding posisi tinggi absolut pada

kurva pertumbuhan

Variants of normal

• Familial short stature• Parents height

• Genetically short

• Bone age normal

• pertumbuhan paralel dg kurve N

• Constitutional delay of growth & puberty / CDGP• Riwayat pubertas terlambat pada keluarga &

delayed bone age

• Kecepatan pertumbuhan normal spadolescent

• Tinggi akhir normal

Etiology of pathologic

short stature

• Primary disturbances of growth

• Skeletal dysplasias

• Chromosome abnormalities

• Metabolic abnormalities

• IUGR / PJT stunted

• Syndromes

• Genetics

Secondary growth disturbances

•Undernutrition stunted

•Abnormalities in GI tract, renal, heart, pulmonology

•Psychosocial deprivation

•Chronic infections Stunted

•Endokrin abnormalities

• Idiopathic growth delay

Stunted growth

• Definition

• World Health Organisation (WHO) is

• "height for age" value to be less than two standard deviations (< 2 SD) of the WHO

Child Growth Standards median

Stunted growth

• Stunted growth or stunting is a reduced

growth rate in human development. It is a

primary manifestation of malnutrition and

recurrent infections, such as diarrhea and helminthiasis in early childhood and even before birth, due to malnutrition during fetal development brought on by a malnourished mother

• WHO As of 2012 an estimated 162 million

children under 5 years of age, or 25%,

Anthropometric Indicators

• In children 3 most commonly used

anthropometric indices to assess

growth status are

• weight-for-height,

• height-for-age and

• weight-for-age.

Low Weight for Height

• Wasting

• Acute or severe proses ;of weight loss

• May also be the result of a chronic

disease

• prevalence of wasting is usually below

5%, even in poor countries

Low Height for Age

•Stunted growth

•Reflects a process of failure to

reach linear growth potential as a

result of suboptimal health and/or

nutritional conditions.

On a Population basis

•High levels of stunting are

associated with

•poor socioeconomic conditions

• increased risk of frequent and

early exposure to adverse

conditions such as illness

• inappropriate feeding practices

•a decrease in the national

stunting rate is usually

indicative of improvements in

overall socioeconomic

conditions of a country

Causes of Growth Stunting

• 1. Inadequate nutrition

• 2. Chronic or recurrent infections,

• 3. Intestinal parasites.

• 4. < 2 yr prevalence of low birth weight

• 5. Psychosocial stress without nutritional

deficiencies.

• 6. Ignorance

Low birth weight

• The contributions of each of these causes to the growth stunting are only partly understood

• 20% - 40% of the stunting in the first two years of life can be attributed to low birth weight.

• inadequate nutrition may still be implicated because some low weight births may be due to maternal nutritional deficiencies during pregnancy

Growth Stunting and Intellectual

Development

• chronic malnutrition in childhood is associated with lower scores on tests of cognitive development.

• First, malnutrition does the majority of its damage to cognitive ability during the first two years of life, when the brain grows to roughly 80% .

• Second, children who were mildly undernourished due to medical conditions did not experience delayed mental development

Causes of Growth Failure in Children

• 1. Familial short stature

• 2. Constitutional growth delay

• 3. Malnutrition

• 4. Diseases and disorders

• 5. Psychosocial dwarfism

• 6. Syndromes

• 7. Endocrine

• 8. Others

Prevention

1. A kind of environment where political

commitment can thrive ("enabling environment")

2. Applying several nutritional modifications or

changes in a population on a large scale which

have a high benefit and a low cost a strong

foundation that can drive change (food security,

3. Empowerment of women and a supportive

health environment through increasing access to

safe water and sanitation

Conclusion

•Growth evaluation important

•Growth pattern

•Anthropometric

•Growth charts analisis

•Diagnostic approached

• In developing countries one of the cause Stunted growth

•Nutrition and chronic illness

TERIMA KASIH