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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
Lingkungan

Nutrisi

GROWTH

Well being

Hiperplasia
Hipertrofi
Deposisisi Matrix

Genetik

Hormon

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

Somatostatin -

+ GHRH

Anterior pituitary gland

GH
Liver

IGF-1
Somatomedin

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

GH levels and effects are
most pronounced during
puberty

FIGURE
11.5
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.
13

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
6-12 bl
1 th
2 th
3 th
4 – pubertas

: 18 - 22 cm/th
: 14 – 18 cm/th
: 11 cm/th
: 8 cm/th
: 7 cm/th
: 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

Genetic height in different populations
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)

182.0
179.9
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

Other Parameters for
growth evaluation
• Genetic Height Potential

• Boys
• Girls

= TBA +(TBI+13)
2
= (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
Normal

Abnormal
Normal Variant

Constitutional Delay
Proportional

W/H
Endocrine

Dysproportional

W/H 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 sp
adolescent
• 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