GROWTH DISTURBANCE

STUNTING & SHORT STATURE

GIGANTISM &ACROMEGALY
  The human body needs the right quantity &
quality of nutrients for its growth &
development.
Understanding the Difference
 Multiple factors influence the body’s functioning
between Under weight, process.
Stunting, and Wasting
§ right amount of sleep,
§ eating the right diet,
§ exercising regularly
are some factors that control the body’s
performance ability. 

Understanding the Difference
between Under weight,
Stunting, and Wasting
Diet plays the most important role  ensuring physical,
mental, & emotional health are intact.
But what happens if your body doesn’t get the right
amount of nutrients every day? 3 most common &
important diseases :
§ Underweight
§ stunting
§ wasting
nutrition-deficient diseases that can have severe and
long-term effect on our body.

Understanding the Difference
between Under weight,
Stunting, and Wasting
UNDERWEIGHT
 Condition occurs when the BW is too low to
maintain good health.
 Maintaining the right amount of weight is
necessary for the body.
 Weighing less than the minimum can result
 weakened immune system
 tend to feel tired & lethargic all the time.
 Moving around & walking turns out to be a
challenge because your body doesn’t have
the energy to carry out basic functions.

Understanding the Difference
between Under weight,
Stunting, and Wasting
UNDERWEIGHT
BMI is calculated to check if you are
underweight, overweight, or at a healthy weight.
 BMI: < 18.5, then you qualify as underweight.
 BMI: 18.5 - 24.9, it is considered as a normal or
healthy weight
 Several reasons can contribute to a person
being underweight.
 Family history, too much physical activity, high
metabolism, and chronic diseases are some causes of
Understanding the being underweight.
Difference between Under
weight, Stunting, and  Eating disorders can affect the way you eat and what
Wasting
you eat. Excessive dieting and stress about what food
you are consuming are some symptoms of eating
UNDERWEIGHT disorders.
 Often teenagers are motivated to achieve the perfect
lean body. This leads to mindlessly attaining the
ideal body by starving themselves and avoiding eating
food.
 Condition in which a child has impaired growth & development.
§ Bodiy is unable to attain a decent height.  children have a low
height with respect to their age.
Understanding the § Triggered by poor nutrition or malnutrition.
Difference between Under
weight, Stunting, and § WHO: a child defined as stunted if their height-for-age is > 2SD
Wasting below the WHO Child Growth Standards median.
§ Stunting is a low height for a child’s weight.
STUNTING § A stunted child doesn’t have normal growth as compared to other
children. They have a weak immune system and impaired brain
function. Their organ development is also obstructed.
§ These kids cannot attain a normal life. They cannot go to schools or
play with other kids of their own age.
 Contributing factors:
 Poor nutrition, poor hygiene, infections, lack of clean
water, and lack of healthcare to both the child and the
Understanding the mother are some factors that can contribute to stunting.
Difference between Under
weight, Stunting, and  Most often, poverty-stricken families cannot afford
Wasting
healthcare facilities and food for the mother and the
child.
STUNTING
 These families have a minimum income and they are
unable to provide the right care to the child. If the
mother is malnourished, the child is likely to suffer
from stunted growth.
 occurs when a child has a low weight with respect to his
height.
. has a high morbidity & mortality rate. These children
are at risk of developing severe and chronic diseases at
Understanding the a very young age.
Difference between Under  mostly caused due to malnutrition.
weight, Stunting, and
Wasting  While stunting is a low height for a child’s weight,
WASTING
wasting is a low weight for a child’s height.
 Symptoms: Excessive & rapid loss of muscle mass and
strength. Loss in appetite makes this condition worse.
This is a form of malnourishment that occurs in young
children.
 Wasted children have low fat-stores and a weak immune
system.
 Short Stature

https://emedicine.medscape.com/article/
924411-clinical#showall
 Growth failure (GF) is often confused with short stature
 GF is a pathologic state of abnormally low growth
rate over time, whereas short stature is often a
normal variant
 Regardless of the genetic background, short stature may
be a sign of a wide variety of pathologic conditions
Short Stature or inherited disorders.
 accurate longitudinal growth assessment is a fundamental
aspect of health maintenance in children.
Overview
Practice Essentials  Reviewing the patient's growth chart is critical to evaluating
short stature.
 In addition, analysis of the prior growth pattern helps
distinguish normal growth from pathologic variants of short
stature.
  Compared with a well-nourished, genetically relevant
population, short stature is defined as a standing
height > than 2 SDs below the mean (or below the 2.5
Short Stature percentile) for sex
 Skeletal maturation is typically determined by the
Overview bone age, which is assessed using anteroposterior
Practice Essentials radiography of the left hand and wrist.
 Short Key data to obtain for the evaluation of short stature
Stature  child's weight & length at birth
 prior growth pattern
 final (or current) heights & weights of parents, siblings,
Clinical Presentatyion & grandparents.
History
 Review of symptoms by organ system provides
additional clues to the etiology underlying short
stature.
Short
• GI
Stature • Diarrhea, flatulence, or borborygmi (frequent,
discomforting, or even audible peristalsis)
suggest malabsorption.
• Vomiting can suggest an eating disorder or a
Clinical Presentation
CNS disorder (eg, dysgerminoma).
History • Consider dietary intake and composition. In
particular, ask about intake of carbonated
beverages, juices, and other casual intake.
• Pain or abdominal discomfort
suggests inflammatory bowel diseases.
 Review of symptoms by organ system provides
additional clues to the etiology underlying short
stature.
Short • Cardiac disease: Signs include peripheral edema,
murmurs, and cyanosis.
Stature • Chronic infections: Poor wound healing and
opportunistic infections are signs of potential
immune deficiency.
Clinical Presentation • Pulmonary
History • Sleep apnea can be a cryptic cause of short
stature.
• Other chronic diseases that may result in short
stature include severe asthma associated with
chronic steroid use and cystic
 Review of symptoms by organ system provides
additional clues to the etiology underlying short
stature.
Clinical • Neurologic
Presentation • Visual field deficits often herald pituitary
neoplasms.
• Vomiting, early morning nausea, polyuria, or
polydipsia is often associated with masses of
the CNS.
History
• Renal
• Polyuria and polydipsia are important symptoms
of hypothalamic and pituitary disorders.
• Chronic renal disease is a common cause of
growth failure (GF).
  Measure standing height in triplicate using a
calibrated wall-mounted stadiometer
• in infants, length is determined in triplicate using a
Clinical tabletop recumbent stadiometer.
• The mean value of the triplicate data serves as the
Presentation true measurement
 In children who cannot completely stand or recline
(eg, those with spina bifida, those with
contractures), arm span provides a reliable
Physical alternative for longitudinal assessment of long
bone growth.
• Ascertain arm span by facing the child against a flat
firm surface (usually the wall), fully extending the
arms, and measuring the maximal distance between
the tips of the middle fingers.
 • Documenting growth velocity over time complements
the initial height assessment.
• Calculate growth velocity as the change in standing
Clinical height over at least 6 months (in children) or in length
Presentation over at least 4 months (in infants).
• Poor linear growth is defined as linear growth velocity
more than 2 SDs below the mean for gender, genetic
composition, and chronologic age
Physical • Weigh all patients.
• In infants, determine the fronto-occipital circumference
 • In patients in whom short-limb dwarfism is suspected,
the sitting height can be obtained by measuring the
upper body segment, or crown to pelvis, as the child
sits upright on a platform-mounted stadiometer (or on
Clinical the floor with a wall-mounted stadiometer).
• Alternatively, the lower segment can be
Presentation determined by measuring from the superior
midline brim of the symphysis pubis to the
floor, with the child standing (feet placed
together).
• The upper-to-lower segment ratio (US/LS)
Physical should be close to 1.
• The ratio is more than 1 in children with
shortened limbs, as it is in individuals with
hypochondroplasia or achondroplasia
 • Palpate for thyroid enlargement and firmness, which can
be associated with Hashimoto thyroiditis, the most
common cause of acquired hypothyroidism.
Clinical • Test visual fields for signs of pituitary and hypothalamic
tumors, initially by gross confrontation.
Presentation • Inspect fourth metacarpals, which are shortened in
persons with pseudohypoparathyroidism, Ullrich-
Turner syndrome, and Albright hereditary
Physical osteodystrophy.
• Fifth finger clinodactyly is seen in Silver-Russell
syndrome
 The nonendocrine causes of short can be divided into 3
Clinical major categories, as follows:
• Constitutional delay of growth and sexual development
Presentation • Familial short stature
• Chronic diseases of childhood: Among the chronic
conditions, malnutrition remains the leading cause of
Causes short stature worldwide
 Clinical Genetic causes of short stature are as follows:
Presentation • Down syndrome (trisomy 21)
• Ullrich-Turner syndrome (45,XO)
• Lerí-Weill dyschondrosteosis (SHOX gene)
Causes
 Levels of insulinlike growth factor-I (IGF-I)
 useful tests for growth hormone deficiency (GHD)

Workup • Patients with certain CNS neoplasms may have normal

serum growth factor levels despite having GHD,
particularly during puberty.
• Consider provocative tests of pituitary function in any
patient with normal thyroid function suspected to be
GH deficient.
Laboratory Study • Interpret a low serum IGF-I concentration cautiously
because poor nutrition is associated with low serum
IGF-I concentration.
 Karyotype by G-banding
• The 45,X pattern defines patients with Ullrich-Turner
syndrome
Measurement of serum levels of GH
Workup • Beyond the first months of life, endogenous GH is secreted
in a pulsatile fashion. These intermittent peaks are
greatest after exercise, after meals (as blood glucose
levels decrease), and during deep sleep. Therefore,
measuring a single random serum GH value is of no use
in the evaluation of the short child. Beyond the neonatal
period, values obtained during the daytime are unlikely to
Laboratory Study be detectable.
• Although a random serum GH value of more than 10
mg/dL generally excludes GHD, a random low serum GH
concentration does not confirm the diagnosis of GHD.
 Other useful tests include the following:
• CBC count for hematologic disease
Workup • Wintrobe sedimentation rate for inflammatory bowel
disease
• Antiendomysial immunoglobulin A (IgA) and
immunoglobulin G (IgG), transglutaminase IgG, and
antigliadin IgG titers for sprue (gluten enteropathy)
Laboratory Study • (Antiendomysial IgA titers are more sensitive, and IgG
titers are more specific.)
 Other useful tests include the following:
Workup • Serum total thyroxine (total T4) and thyrotropin (TSH)
levels to test for hypothyroidism
• Determination of serum free T4 concentration is
necessary in patients in whom TSH deficiency, TRH
deficiency, or thyroxine-binding globulin (TBG)
Laboratory Study deficiency is suspected.
 Workup Other useful tests include the following:
• Sweat chloride testing to exclude cystic fibrosis (CF):
Consider this test in patients who are short and have a
history of meconium ileus or pulmonary symptoms.
• Serum transferrin and prealbumin concentrations for
undernutrition
Laboratory Study
 GIGANTSM &
ACROMAGALY

https://Gigantism and Acromegaly: Practice Essentials, Backgro

und, Pathophysiology and Etiology (medscape.com)
  Gigantism : abnormally high linear growth due to
excessive action of insulinlike growth factor I (IGF-I)
while the epiphyseal growth plates are open during
Gigantism & childhood.
Acromagaly  Acromegaly is the same disorder of IGF-I excess but
occurs after the growth plate cartilage fuses in
adulthood.
 Acromegaly:
 a severe disease that is often diagnosed late,
Gigantism &  morbidity & mortality rates are high,
Acromagaly  particularly as a result of associated cardiovascular,
cerebrovascular, and respiratory disorders and
malignancies
 Gigantism
presentation of patients with gigantism is usually dramatic, unlike
Gigantism & the insidious onset of acromegaly in adults

Acromagaly • Tall stature

• Mild to moderate obesity (common)
• Macrocephaly (may precede linear growth)
• Headaches
Signs & Symptoms • Visual changes
• Hypopituitarism
• Soft tissue hypertrophy
• Exaggerated growth of the hands and feet, with thick fingers and
toes
 Gigantism
presentation of patients with gigantism is usually dramatic, unlike the
Gigantism & insidious onset of acromegaly in adults
• Coarse facial features
Acromagaly • Frontal bossing
• Prognathism
• Hyperhidrosis
• Osteoarthritis (a late feature of IGF-I excess)
Signs & Symptoms
• Peripheral neuropathies (eg, carpel tunnel syndrome)
• Cardiovascular disease
• Benign tumors
• Endocrinopathies
 Acromegaly
Gigantism & • Doughy-feeling skin over the face and extremities
Acromagaly • Thick and hard nails
• Deepening of creases on the forehead and nasolabial folds
• Noticeably large pores
• Thick and edematous eyelids
Signs & Symptoms • Enlargement of the lower lip and nose (the nose takes on a
triangular configuration)
• Wide spacing of the teeth and prognathism
• Cutis verticis gyrata (ie, furrows resembling gyri of the scalp)
 Acromegaly
Gigantism & • Hypertrichosis

Acromagaly • Oily skin (acne is not common)

• Hyperpigmentation (40% of patients)
• Acanthosis nigricans (a small percentage of patients)
• Excessive eccrine and apocrine sweating
Signs & Symptoms • Breast tissue becoming atrophic; galactorrhea
• High blood pressure
• Mitral valvular regurgitation
• Mild hirsutism (in women)
 Laboratory studies used in the diagnosis of
growth hormone (GH)/IGF-I excess include the
Gigantism & following
Acromagaly • Oral glucose: To determine the extent to which the
patient can suppress GH concentration after the
consumption of oral glucose
• GH: Clearly elevated GH levels (>10 ng/mL) after oral
glucose, combined with the clinical picture, secure the
Diagnosis diagnosis of acromegaly
Laboratory study
• IGF-I: Elevated IGF-I values in a patient whose
Imaging study
symptoms prompt appropriate clinical suspicion
almost always indicate GH excess
§
 Imaging studies include the following:
Gigantism & • Magnetic resonance imaging (MRI): To image pituitary
adenomas
Acromagaly • Computed tomography (CT) scanning: To evaluate the
patient for pancreatic, adrenal, and ovarian tumors
secreting GH/GHRH;
• use chest CT scans to evaluate for bronchogenic
Diagnosis carcinoma secreting GH/GHRH
Laboratory study • Radiography: To demonstrate skeletal manifestations of
Imaging study GH/IGF-I excess
§
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