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Diagnostic approach of Short stature/ StuntedProf. Dr Jose Batubara
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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