Professional Documents
Culture Documents
*
Professor of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
†
Assistant Professor of Pediatrics, New York Presbyterian Hospital/Weill College of Cornell University, New York, NY.
‡
Professor of Pediatrics, University of Oklahoma Health Science Center, Oklahoma City, Okla.
mid-parental height or target height (the average of the tissue and oral ectoderm. Several of these genes have
parents’ height percentiles). For example, a boy at the 5th been identified and their functions defined, including
percentile for height might be the shortest in his class, Hesx-1, Lhx-3/Lhx-4, Prop-1, Pit-1, SF-1, Dax-1, and
although this would not be unexpected if his mother and GATA-2. Although much is known about genes in-
father were 4 feet 11 inches and 5 feet 4 inches tall, respec- volved in normal pituitary development and function,
tively. only approximately 12% of hypopituitary children have a
Finally, short stature should not be confused with definable gene defect; approximately 6% of those have a
failure to thrive. Failure to thrive is associated with PROP-1 defect.
greater impairment in weight gain than linear growth
(resulting in a reduced weight-for-height ratio). Al-
GH Secretion and Action
though failure to thrive may be associated with short
GH, a polypeptide (191 amino acids), is secreted by the
stature or slow growth velocity, it primarily represents an
anterior pituitary in pulsatile fashion. GH pulses occur
inability to gain weight appropriately and only second-
during sleep, exercise, and physiologic stress. These
arily an impairment in linear growth.
pulses represent the net interaction between two oppos-
ing hypothalamic peptides that regulate the synthesis and
Pathogenesis
secretion of GH from the somatotrope: GH-releasing
Physiology of Growth
hormone (GHRH) and somatostatin (somatotropin re-
Normal somatic growth results from a complex interac-
lease inhibiting hormone) (SRIH). GH secretion also is
tion among genetic, nutritional, and hormonal factors in
regulated by other neurotransmitters that act directly or
a cellular environment conducive for growth. In exam-
indirectly through GHRH or SRIH and by negative
ining the causes of poor growth and short stature, it is
feedback systems involving GH and IGF-I. Ghrelin (en-
important to understand the important basic ingredients
dogenous GH secretagogue) is secreted from the stom-
of normal growth, including nutrition (calories, protein,
ach in increasing concentrations as time extends after the
calcium, minerals, vitamins), oxygen, hormones, the ab-
prior meal, leading to hunger and a significant rise in GH
sence of toxins, and the more general components of a
secretion through the stimulation of GH secretagogue
healthy environment for children, including adequate
receptors located in the hypothalamus and pituitary. GH
sleep, exercise, and psychosocial factors (positive atti-
circulates in either free form or bound to a binding
tude, self-esteem, sense of security, sense of being loved).
protein (GHBP) that is structurally similar to the extra-
Hormonal factors, in particular, are required in the right
cellular portion of the GH receptor. GH exerts most of
amounts and at the right times for optimal growth.
its biologic effects through binding to the GH receptor
Growth hormone (GH) and insulin-like growth factor-I
and stimulating secretion of IGF-I from the liver and
(IGF-I) play key roles in this process. Other hormones
other tissues.
(eg, thyroid hormone, insulin, sex steroids, and glu-
cocorticoids) also affect growth, in part through their
interactions with the hypothalamic-pituitary-GH-IGF IGFs and IGF Binding Proteins
axis. Many of the growth-promoting actions of GH are me-
diated by IGF-I, which exerts its actions through both
Hypothalamic-Pituitary Development endocrine and local effects. IGFs influence fetal growth
The pituitary gland develops in two parts. The anterior independently of GH. The IGFs circulate and exert
pituitary develops as an invagination of the primitive biologic effects, in large part, through interaction with
foregut ectoderm to form the Rathke pouch. This pouch binding proteins (IGFBPs). GH stimulates both IGF-I
is “pinched off” from the foregut by about 8 weeks’ and IGFBP3 production by the liver. Circulating con-
gestation and assumes an anatomic position directly ad- centrations of IGF-I are low during the first 5 years after
jacent to the posterior pituitary. The anterior pituitary birth; they slowly increase to peak concentrations during
communicates with the hypothalamus through a capil- adolescence. IGFBP3 values (highly GH-dependent) are
lary plexus. The posterior pituitary arises as a downward not as low as those of IGF-I in the young child, but also
extension from the brain and retains direct neuronal increase during childhood and adolescence. GH also acts
connections with the hypothalamus. directly on the growth plate and stimulates local IGF-I
The pituitary gland develops as a result of a sequential production in all tissues. IGF-I blood concentrations also
cascade of programmed gene expression of transcrip- are influenced by malnutrition, chronic renal and liver
tional factors triggered by contact between the fetal brain disease, and hypothyroidism.
Changes With Development and requires careful evaluation and investigation. During
The role of hormonal factors on growth depends on age puberty, children again may cross growth channels (ei-
and developmental stage. Although GH and thyroid ther up or down), depending on when the particular
hormone are of major importance in the process of child begins his or her pubertal growth spurt relative to
normal growth in childhood, their roles in the control of that of the normal reference population.
fetal growth are relatively minor. This is illustrated clin-
ically by most infants who have congenital GH deficiency Analysis of the Growth Curve
and hypothyroidism being of normal weight and length An appropriate analysis of the growth curve is the most
at birth. The most important factors involved in the important step in evaluating a child who has a growth
control of fetal growth are uterine function and size, problem. Four specific aspects of the growth curve
maternal nutrition, insulin, and the IGFs and IGFBPs. should be examined closely.
Postnatal growth is characterized by rapid linear
growth velocity that declines progressively after birth Reliability of Measurements
(approximately 25, 12, and 8 cm/y during the first 3 Obtaining and plotting height and weight measurements
postnatal years). Thereafter, until the onset of puberty, do not require expensive or sophisticated equipment, but
linear growth occurs at a relatively constant rate of 4 to they do require some training and attention to details.
7 cm and weight gain occurs at approximately 2.5 kg The importance of this step cannot be overemphasized;
annually in both sexes. A small linear growth deceleration two of the most common reasons for misdiagnosis of
often is seen before the onset of puberty. Throughout growth disorders and inappropriate referral to a specialist
childhood, GH and thyroid hormone exert major influ- are measurement errors and inaccurate plotting of mea-
ences on the process of normal growth, with nutrition surements on the growth chart.
and insulin also playing important roles.
At puberty, sex steroids (testosterone, estrogen) act in Absolute Height
concert with GH, thyroid hormone, and nutrition, re- The absolute height of a child bears some relationship to
sulting in an accelerated rate of growth known as the the likelihood of a pathologic condition (ie, a child
pubertal growth spurt. In addition, spontaneous GH whose height is three standard deviations [SD] below the
levels increase during puberty, most likely in response to mean is more likely to have a pathologic condition than is
estrogen and androgen. The first sign of puberty in a child whose height is only 1 SD below the mean).
females (typically, breast enlargement) precedes the on- However, most children whose heights are below the
set of puberty in males (typically, testicular enlargement) lowest percentile (either 3rd or 5th percentile on the
by only about 6 months. However, the pubertal growth height curve) do not have pathologic conditions.
spurt is a relatively early event in girls and a relatively late
event in boys. Thus, the pubertal growth spurt in girls Growth Velocity
occurs approximately 2 years earlier than in boys, usually The most important aspect of a growth evaluation is the
at pubertal stage 3 for breast development in girls and repeated measurement of a child’s height over time to
pubertal stage 4 in boys. Peak height velocity is slower in assess growth velocity. Most children’s linear growth
girls (8.3 cm/y) than in boys (9.5 cm/y). This factor, does not occur steadily and continuously; rather, it oc-
combined with a 2-year longer duration of growth in curs in small increments. For this reason, as well as
boys, results in an average 13-cm difference in adult inherent inaccuracies in measurements of linear growth
height between the two sexes. Growth ultimately ceases when using conventional equipment, accurate determi-
following puberty, a result of estrogen-induced epiphy- nation of growth velocity requires at least 3 and prefera-
seal maturation and closure in both sexes. bly 6 months of observation.
Documenting normal growth velocity is the most
valuable tool to exclude a significant growth disorder. Weight-for-Height Ratio
However, large infants born to small parents tend to have Determination of the weight-for-height ratio has some
late deceleration, often during the second year after diagnostic value in identifying the cause of growth retar-
birth. Small (but otherwise healthy) infants born to large dation in a short child. Endocrine disorders (including
parents tend to experience early growth acceleration, GH or thyroid hormone deficiency or glucocorticoid
typically during the first 6 postnatal months. An abnor- excess) usually are associated with relatively preserved
mal growth velocity documented after age 3 years, re- weight gain or frank obesity in a short child. In contrast,
gardless of absolute height, almost always is abnormal most “systemic” disorders resulting in poor linear
GHD. GHD can be congenital or acquired and may measured GH values. With the recent advent of GHRH
occur in association with other pituitary hormone de- as a diagnostic agent, a GH response of less than
fects. Congenital GHD occurs in two well-described 18 ng/mL (18 mg/L) to a combined arginine-GHRH
patterns. The first is related to perinatal asphyxia because stimulation test also has been proposed as a biochemical
often affected infants have a history of perinatal distress, criterion for the diagnosis.
breech delivery, cesarean section, and low Apgar scores. For a child who has GHD, the rest of the pituitary
The second pattern of GHD presenting in infancy is function must be evaluated to identify potential com-
associated with early prenatal embryologic malforma- bined anterior pituitary hormone deficiencies (TSH,
tions, including central nervous system (CNS) malfor- ACTH, prolactin, or gonadotropin deficiencies or diabe-
mations (eg, septo-optic dysplasia), midface abnormali- tes insipidus). Children who have severe head injury and
ties (eg, coloboma of the eye, midface hypoplasia, cleft children who are long-term survivors of cancer merit
palate and lip, median cleft face, and single central inci- longitudinal monitoring of their growth and pubertal
sors), and in males, micropenis. Many of these infants development because GHD, primary or central hypothy-
have a characteristic neuroradiologic picture on magnetic roidism, ACTH deficiency, and hypogonadism may de-
resonance imaging (MRI), with interruption of the pitu- velop over time.
itary stalk and displacement of the posterior pituitary Recent research has focused on the effects of GHD in
bright spot (ectopic posterior pituitary). Otherwise, find- adults, who are no longer capable of linear growth.
ings on MRI of the brain in GHD may be normal or, Metabolic effects of GHD include increases in body fat
alternatively, may show abnormal anatomy such as a and cholesterol and reductions in lean body mass, bone
small pituitary gland, pituitary stalk agenesis, empty sella, mineral density, cardiac function, stamina, and quality of
or sellar or suprasellar mass. A small minority (approxi- life. Thus, GHD has clinical importance not only in
mately 12%) of children who have congenital hypopitu- growing children but in adults. GH currently is approved
itarism can be shown to have gene mutations involving by the United States Food and Drug Administration for
either the organization and development of the pituitary use in GH-deficient children and adults, those who have
gland or one or more of the pituitary cell types. Turner syndrome or renal insufficiency, adults who have
The postnatal clinical course is similar in all types of acquired immunodeficiency syndrome wasting or
GHD, with prolonged jaundice and hypoglycemia often Prader-Willi syndrome, children born small for gesta-
present. Failure to thrive, with relatively normal growth tional age (SGA) who have not reached the 5th percen-
velocity, may be present initially. Subsequent linear tile by age 2 years, and children who have idiopathic
growth deceleration and normal weight gain typically short stature and are not expected to reach an adult
develop after the first postnatal year (Fig. 2). height in the normal adult range.
Acquired GHD occurs most commonly as an idio-
pathic diagnosis, but may result from tumors (cranio- GH INSENSITIVITY. GH insensitivity syndrome is an
pharyngioma, glioma, germinoma), traumatic head in- autosomal recessive syndrome caused by defects of the
jury, CNS infection or irradiation, or surgical damage to GH receptor. The phenotype of affected patients is sim-
the pituitary and hypothalamus. The physiology usually ilar in many respects to that of patients who have GHD.
is that of hypothalamic deficiency of GHRH, rather than Biochemically, such children have elevated serum con-
pituitary deficiency of GH. Deficiencies of thyroid- centrations of GH and low serum concentrations of
stimulating hormone (TSH), adrenocorticotropic hor- IGF-I, IGFBP3, and GHBP.
mone (ACTH), or pubertal hormones or diabetes insip-
idus also may be present. Although specific clinical HYPOTHYROIDISM. Congenital hypothyroidism is
features vary according to the cause, slow growth rate is identified most often through newborn screening. How-
prominent and an overriding feature in most cases. ever, many cases of primary hypothyroidism are acquired
Clinically, a child who has untreated GHD has short after the newborn period. Acquired hypothyroidism in
stature, slow growth velocity, a facial phenotype resem- childhood usually is an autoimmune condition (lympho-
bling a younger child, delayed BA, and low IGF-I and cytic or Hashimoto thyroiditis) but occasionally is related
IGFBP3 values. The biochemical definition of GHD to an inborn error of thyroid hormone metabolism or
classically has been a peak stimulated GH concentration late failure of an ectopic or hypoplastic thyroid gland,
of less than 10 ng/mL (10 mg/L) in response to two undiagnosed at the time of newborn screening.
GH stimulation tests (arginine, insulin, clonidine, gluca- In untreated hypothyroidism, congenital or acquired,
gon). Variations in GH assay methodology influence the the growth velocity is slow and BA is delayed relative to
CA. Normal intelligence typically can be expected in cholesterol, or anorexia nervosa. With restoration of
acquired hypothyroidism developing after 2 years of age adequate nutrition, growth usually accelerates (catch-up
and in children who have congenital hypothyroidism growth), although adult height may be compromised if
detected within the first 2 or 3 months after birth, the malnutrition is profound, especially in the first few
although the risks of mental retardation and learning years after birth.
deficits are related directly to the length of delay in Malabsorption and inflammatory bowel disease (IBD)
diagnosis. Children who have a gradual onset of even should be emphasized as causes of growth disorders be-
severe hypothyroidism may be remarkably asymptomatic cause both can be missed during a cursory history. IBD may
(with only mild symptoms such as constipation, dry skin, result in growth retardation or failure to thrive even prior to
decreased stamina, with or without a goiter) or may be the development of overt gastrointestinal symptoms.
profoundly symptomatic. Whether a child who has severe The cause of growth retardation in socially neglected
primary hypothyroidism attains a normal adult stature children usually is nutritional and related directly to
depends primarily on the duration of untreated hypothy- inadequate caloric intake. Affected children typically
roidism, the adequacy of replacement therapy after diag- present with failure to thrive that involves a more severe
nosis, and the confounding effects of the onset of compromise of weight than height. However, an occa-
puberty. sional neglected child develops a clinical picture charac-
teristic of GHD, known as psychosocial dwarfism. Psy-
GLUCOCORTICOID EXCESS. Glucocorticoid excess usu- chosocial dwarfism results from a disturbed parent-child
ally is iatrogenic, caused by pharmacologic treatment of a relationship and has a characteristic behavior pattern.
concurrent disease such as renal or connective tissue disease Infants and children may demonstrate bizarre behavior
or cancer. Rarely, it may be caused by endogenous steroid (eg, encopresis, personality disorders, aggressive food-
production because of an adrenal adenoma or ACTH- and water-seeking habits). They also may have abnormal
secreting pituitary adenoma. In states of glucocorticoid pituitary hormone responses to provocative testing.
excess, growth velocity is slow, BA is delayed relative to the Growth velocity is slow, and BA is delayed relative to CA.
CA, and weight gain and elevated blood pressure typically Typically, such children resume normal growth when
are present. In contrast, weight gain in endogenous obesity removed from the adverse home environment.
usually increases the growth velocity slightly. Whether the Virtually any chronic systemic disease can attenuate
child exposed to high doses of glucocorticoids attains a growth to a degree dependent on the severity and ade-
normal adult stature depends on the steroid dose, the quacy of management of the underlying disease. The
duration of exposure, and the confounding skeletal matur- systemic diseases most likely to be “silent” or subtle
ing effects of sex steroids, either from the intervening onset include gastrointestinal disorders (IBD, celiac disease),
of puberty or sex steroids cosecreted (in the case of endog- which can impair growth years prior to gastrointestinal
enous Cushing syndrome) with glucocorticoids. symptoms, and some kidney diseases. Renal tubular aci-
dosis or nephrogenic diabetes insipidus may be present
Proportionate Short Stature with Decreased from birth and typically present with a clinical picture of
Weight-for-Height Ratio failure to thrive. In contrast to many cases of subtle renal
This group includes most children who have growth and gastrointestinal disease, most growth failure associ-
disorders due to a variety of systemic diseases, most ated with other chronic diseases (heart, pulmonary, im-
notably undernutrition or malnutrition. Children who munologic, connective tissue, neurologic) is evident clin-
have nutritional deficiency (eg, starvation, anorexia ner- ically and obviously related to the status of the
vosa, malabsorption, or poorly controlled type 1 diabetes underlying disease. For example, a small heart murmur
mellitus) typically show weight loss or a decline in the not associated with exercise intolerance or cyanosis is
rate of weight gain that is more pronounced than the unlikely to be the cause of growth failure in contrast to
decline in linear growth (Fig. 2). These children also the growth impairment seen with recurrent episodes of
typically exhibit delayed sexual development and delayed congestive heart failure.
skeletal maturation proportionate to the severity of the
underlying malnutrition or systemic disease activity. Disproportionate Shortening and Dysmorphic
Malnutrition (protein, calorie) is the most common Features: Genetic or Syndromic Causes of
cause of short stature internationally. Short stature may Short Stature
be associated with single-nutrient malnutrition (calcium, Skeletal dysplasias and clinical syndromes are diagnosed
vitamin), disinterest in eating, fear of obesity or fear of most commonly because of abnormalities evident on a
(eg, Kallmann and Klinefelter syndromes) typically are uals. A subnormal growth velocity at any other time
not short in the prepubertal years, but may cross percen- indicates disease until proven otherwise. Indeed, the
tiles on the linear growth curves at ages 12 to 15 years, as process of linear growth is a sensitive and powerful
age-matched peers experience a pubertal growth spurt. reflection of the general health of a child. The physician
The physical examination confirms delayed sexual matu- who understands a few simple concepts distinguishing
ration, and a low U/L ratio may help identify the truly normal from abnormal growth patterns can reassure
hypogonadal patient, especially during and after the teen the anxious parent of a healthy short child and is well
years. Because hypothalamic and skeletal maturation prepared to embark on a focused and efficient screen
usually go hand in hand, the BA is delayed in nearly all for pathologic causes and to make appropriate referrals
children who have delayed puberty. Elevated serum go- to a pediatric endocrinologist.
nadotropin levels indicate primary gonadal failure; nor-
mal or low levels are consistent with either CDGA or
gonadotropin deficiency.
Suggested Reading
Normal Growth Velocity in a Short Child Argyle J. Approaches to detecting growth faltering in infancy and
This clinical scenario is most common in children who childhood. Ann Hum Biol. 2003;30:499 –519
Baloch Z, Carayon P, Conte-Devolx B, et al. Laboratory medicine
have CDGA and FSS. The child is proportionately short practice guidelines. Laboratory support for the diagnosis and
and otherwise healthy, and his or her linear growth is monitoring of thyroid disease. Thyroid. 2003;13:3–126
below but parallel to the lower percentiles of the growth Frias JL, Davenport ML, the Committee on Genetics, and the
curve. A delayed BA, a target height in the normal adult Section on Endocrinology. American Academy of Pediatrics
range, and a family history of delayed puberty all point to Clinical Report. Health supervision for children with Turner
syndrome. Pediatrics. 2003;111:692–702
CDGA. BA consistent with CA and a low target height
Kant SG, Wit JM, Breuning MH. Genetic analysis of short stature.
(mid-parental height) suggest FSS. Horm Res. 2003;60:157–165
Lee PA, Chernausek SD, Hokken-Koelega AC, Czernichow P.
Conclusion International Small for Gestational Age Advisory Board consen-
Although a number of simple diagnostic measurements sus development conference statement: management of short
(including analysis of weight relative to height and cal- children born small for gestational age, April 24-October 1,
2001. Pediatrics. 2003;111:1253–1261
culation of U/L ratio) and associated clinical findings
Participants in the Growth Hormone Research Society on Child
(including dysmorphic features and SGA) are helpful, the and Adolescent Growth Hormone Deficiency. Consensus
most useful test in distinguishing the short normal child guidelines for the diagnosis and treatment of growth hormone
from one who has a pathologic condition is the collection deficiency in childhood and adolescence: summary statement of
of accurate height measurements over time and calcula- the Growth Hormone Research Society on child and adolescent
growth hormone deficiency. J Clin Endocrinol Metab. 2000;85:
tion of growth velocity. Most apparently healthy children
3990 –3993
who have short stature but are growing at a normal Pitukcheewanont P, Rose SR. Nocturnal TSH surge: a sensitive
growth velocity are normal and healthy. On the other diagnostic test for central hypothyroidism in children. The En-
hand, any child whose growth velocity is declining, re- docrinologist. 1997;7:226 –232
gardless of absolute height, merits careful evaluation. Rose SR. Endocrinopathies after childhood cancer. The Endocrinol-
ogist. 2003;13:488 – 495
During the first 3 years after birth, most channel changes
Varma S. Growth hormone effects on adult height in idiopathic
on the linear growth curve are normal. Examples include short stature. AAP Grand Rounds. 2005;13(1):2–3. Commen-
the large infant born to small parents or the small infant tary on Lesche K, Rose SR, Yanovski JA, et al. Effect of growth
born to tall parents growing into a more “genetically hormone treatment on adult height in peri-pubertal children with
appropriate” growth channel or the child who has idiopathic short stature: a randomized, double-blind, placebo-
controlled trial. J Clin Endocrinol Metab. 2004;89: 3140 –3148
CDGA or FSS adjusting to his or her own channel at the
Wilson T, Rose SR, Cohen P, Rogol AD, and the Drug and
lower percentiles. Height channel changes during the Therapeutics Committee of the Lawson Wilkins Pediatric En-
teen years may be normal and indicative of variations in docrine Society. Update of guidelines for the use of growth
the onset and tempo of puberty among normal individ- hormone in children. J Pediatr. 2003;143: 415– 421
PIR Quiz
Quiz also available online at www.pedsinreview.org.
9. In which of the following conditions is the bone age consistent with chronologic age (ie, not delayed)?
A. Acquired hypothyroidism.
B. Constitutional delay of growth and adolescence.
C. Familial short stature.
D. Glucocorticoid excess.
E. Psychosocial dwarfism.
10. Which of the following statements regarding growth in children is true?
A. Crossing height percentiles in the first 3 years after birth can be normal.
B. The best indicator of the appropriateness of a child’s growth is the comparison of the child’s actual
height with the target height.
C. The pubertal growth spurt occurs later in puberty in girls than it does in boys.
D. The upper-to-lower body segment ratio is at its highest during puberty.
E. The weight-for-height ratio has little importance in the evaluation of a child who has short stature.
11. You are evaluating a 6-year-old girl for short stature. Her growth chart reveals a birth length at the 60th
percentile and a current height at the 5th percentile. Her growth velocity over the last 2 years has been
3 cm/y. Her weight is at the 50th percentile. Findings on her physical examination otherwise are within
normal limits, and her intelligence appears normal. There are no midline defects or dysmorphic features.
Her bone age is 4 years. Of the following, the most likely diagnosis is:
A. Congenital hypothyroidism.
B. Crohn disease.
C. Growth hormone deficiency.
D. Spondylodysplasia.
E. Turner syndrome.
12. A 15-year-old boy is brought to your clinic by his mother. He tells you that he is concerned that he is the
shortest boy in his class at school. His mother’s height is 155 cm (61 inches), and his father’s height is
178 cm (69 inches). His height is 158 cm (62 inches), which is between the 5th and 10th percentiles.
You think that he likely has either constitutional delay of growth and adolescence or familial short
stature. In addition to an evaluation of his pubertal development, the assessment that is most likely to
give you the information you need to distinguish between these two conditions is:
A. Bone age.
B. Calculation of his target height.
C. Calculation of his upper-to-lower body segment ratio.
D. Growth hormone assay.
E. Growth velocity measurement.
13. You are evaluating a 2-year-old girl who is new to your clinic. Her mother is worried that she seems
small. She has had no recurrent infections, and her mother says that her daughter’s appetite is good. Her
mother appears petite and says that her height is 5 feet 1 inch. The child’s weight is 9 kg (below the 3rd
percentile), and her height is 78 cm (3rd percentile). She is appropriately interactive with her mother and
shows no obvious behavior abnormalities. Findings of her physical examination are normal except for very
little subcutaneous fat. Her bone age is 12 months. Of the following, the most likely explanation for her
growth failure is:
A. Celiac disease.
B. Familial short stature.
C. Growth hormone deficiency.
D. Psychosocial dwarfism.
E. Turner syndrome.
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