How Come I’m Still Shorter Than the Other Guys?

Patient Presentation
A 15-year-old male came to clinic for a sports physical. He and his father had no concerns but the patient wanted to know when he was going to grow taller.
The past medical history showed that he had always been smaller than his peers.
The family history revealed that his father was a ‘late-bloomer” and the patient’s brother had his growth spurt around 15-16 years of age too. Mother’s puberty history was unavailable.
The review of systems was negative.
The pertinent physical exam revealed a healthy male. Weight is 42.3 kilograms (<3% and equal to 12.5 years ) His height is 151.5 cm (<3% and equal to 12.5 years ). His growth in the past year was 2.3 cm which is below the usual 4-5 cm/year before adolescence. Tanner 3 male. The rest of his examination was normal.
The chart review showed that the estimated mid-parental height should be ~180 cm and the patient’s height was not within 5 cm of this prediction (see Figure 25).
As the adolescent had a family history of late puberty and had a growth pattern consistent with constitutional growth delay, the physician felt that this was the most common diagnosis. However, the adolescent was already Tanner stage 3 and appeared to have a decrease in his growth
velocity in the past year. Therefore a radiologic evaluation of the hand and wrist for a bone age was completed and showed a bone age of 13 years with a standard deviation of 8.9 months.
The diagnosis of constitutional growth delay was confirmed and the patient will be monitored.

10-10-05Figure25GrowthChart.jpg:
Figure 25 -Growth chart for the patient showing short stature.


Figure 26 – AP radiograph of the left hand showing that the patient’s bone age is greater than two standard deviations below his chronological age, according to the method of Gruelich and Pyle.

Discussion
Normal growth patterns in children and adolescents are good signs for both parents and health care providers to see, as they often are reassuring evidence that the child is healthy. When abnormal growth rates or patterns are seen, this is a cause for concern.
Generally if there is a problem, the growth parameters will be affected in the following order: weight before height before head circumference. The differential diagnosis is dramatically different based upon if one, two or all three growth parameters are affected.

Primary evaluation for linear growth problems includes a growth and pubertal history of the parents and siblings, the patient’s prenatal and perinatal history and developmental milestones, and a careful evaluation of previous growth measurements.
Sometimes previous growth measurements are not available and some indications can be obtained from group photographs or changes in clothing and shoe size.

Normal growth rate is 5 cm/year for ages 2 – puberty onset. The peak linear growth is Tanner 2-3 for girls (9 cm/year) and Tanner 3-4 for boys (10 cm/year). The potential for achieving additional growth after Tanner 4-5 (full maturity) is small as this correlates with epiphyeseal closure.
A bone age radiograph is very helpful in determining how skeletally mature the adolescent is compared to their chronological age.

Learning Point
The most common causes of short stature in adolescence are consititutional growth delay, familial/genetic short stature and chronic illness (in this order). Short stature in adolescence includes:

  • Constitutional growth delay (chronological age > bone age) – These patients are small in the first few years then have an average growth rate. Puberty is late and the growth spurt occurs later. These adolescents catch up with their peers and have a normal range of stature in adulthood.
    If no signs of puberty emerge by 15 for females and 16 for males, an endocrine consultation is recommended.

  • Familial or genetic short stature (chronological age = bone age) – These patients are small at birth and remain so throughout childhood. They enter puberty at an average age and remain short relative to their peers and are short in adulthood.
  • Chronic illness
  • Endocrine abnormalities
    • Cortisol excess

    • Growth hormone deficiency – These patients have marked dwarfism (i.e. usually 3-4 standard deviations below the mean). Growth is normal for the first 1-2 years of life and then a decrease in height velocity is seen. Physical signs include infantile features and body proportions, weight age > height age, and delayed puberty.
    • Hypothalamic disorders
    • Hypothyroidism
  • Genetic syndromes (i.e. Turner’s Syndrome, Russell-Silver syndrome, Albright’s hereditary osteodystrophy, Down’s syndrome, Prader-Willi syndrome, etc.)
  • Nutritional abnormalities – (i.e. Anorexia nervosa, Inflammatory bowel disease, etc.)
  • Psychosocial dwarfism
  • Skeletal dysplasia

FDA approved indications for growth hormone treatment in children includes:

  • Growth hormone deficiency

  • Turner syndrome
  • Chronic renal insufficiency
  • Small for gestational age or intrauterine growth retardation
  • Prader-Willi Syndrome
  • Continued height deficit in puberty

Questions for Further Discussion
1. What is included in the differential diagnosis of a child with short stature and decreased weight?
2. What is included in the differential diagnosis of a child with short stature and macrocephaly?
3. What psychosocial evaluation should be done for an adolescent with short stature?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

To view current news articles on this topic check Google News.

Hofmann AD, Greydanus DE. Adolescent Medicine. 1983. 243-246.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1-6.

American Association of Clinical Endrocrinologists Medical Guidelines for Clinical Practice. Growth Hormone Use for Adults and Children.
Endocrine Practice. 2003:9;64-76. Available from the Internet at http://www.aace.com/clin/guidelines/ (cited 8/23/05).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 10, 2005