III. Exam: Findings suggestive of Collagen bone disease

  1. Examples
    1. Osteochondrodysplasia
    2. Metaphyseal dysostosis
  2. Extremely Short
    1. Disproportionate shortness ("Dwarf")
      1. Arms and legs short compared with trunk
    2. Proportionate shortness
      1. "China Doll" Shortness
  3. Abnormal measurements
    1. Linear Growth Velocity
    2. Tanner Staging (See Tanner Staging)
    3. Arm Span
    4. Upper to Lower Segment Ratio

IV. Exam: Term Newborn

  1. Micropenis (size <2.8 cm stretched)
    1. Assess for Luteinizing Hormone deficiency
    2. Associated with Panhypopituitarism
  2. Congenital Nystagmus
    1. Assess for septo-optic dysplasia
    2. Associated with Growth Hormone Deficiency
  3. Small for Gestational Age
    1. Catch-up growth results in normalization of growth curve by 2 years old in 90% of cases
    2. Pathologic Delayed Growth may be considered if no catch up growth is evident in the first 6 months of life
    3. SGA Infants may have delayed catch-up growth in 10% of cases
    4. SGA Preterm Infants may not attain normal height for age until age 4 years

V. Diagnostics

  1. Bone Age Films
  2. Formal dental exam for dental age

VII. Differential Diagnosis (with specific related evaluation)

  1. Normal tests, evaluation and Bone Age Films
    1. Familial Short Stature
    2. Idiopathic Short Stature
  2. Normal tests and evaluation with a minimally delayed Bone Age Film
    1. Constitutional Short Stature
  3. Medication causes
    1. Chronic Corticosteroids
    2. Stimulant Medications for Attention Deficit Disorder
    3. Anticonvulsants
  4. Abnormal tests or evaluation with a normal Bone Age Film (requires further evaluation)
    1. Iron Deficiency Anemia
    2. Inflammatory conditions
  5. Dysmorphic features present - Refer to geneticist and endocrinologist
    1. Down Syndrome
    2. Noonan Syndrome
    3. Prader-Willi Syndrome
    4. Russell-Silver Syndrome
    5. Skeletal Dysplasia
    6. Turner Syndrome
    7. Fetal Alcohol Syndrome
    8. Achondroplasia
  6. Abnormal labs or evaluation with delayed Bone Age imaging
    1. Gluten-sensitive Enteropathy (Celiac Disease)
      1. Tissue transglutaminase antibodies
      2. Antiendomysial Antibody titers
    2. Inflammatory Bowel Disease
      1. Erythrocyte Sedimentation Rate (ESR)
      2. C-Reactive Protein (CRP)
      3. Endoscopy with biopsy
    3. Chronic Renal Insufficiency
      1. Urinalysis
      2. Serum Creatine and GFR estimate
    4. Cystic Fibrosis (typically age <2 at diagnosis)
      1. Sweat Chloride testing
    5. Cushing Disease
      1. 24 hour Urine Cortisol
    6. Growth Hormone Deficiency (acquired or congenital)
      1. IGF-1
      2. IGF-binding Protein #3
    7. Hypothyroidism
      1. Thyroid Stimulating Hormone (TSH)
      2. Free T4
    8. Vitamin D Deficiency (Rickets)
      1. 25-hydroxyvitamin D
      2. 1,25-dihydroxyvitamin D
      3. Parathyroid Hormone

VIII. Evaluation

  1. Indications for evaluation
    1. Height >2 SD below mean for age (or <3rd percentile)
    2. Growth Velocity <5 cm (2 in) per year
    3. Projected height <2 SD (10 cm) below Midparental Height
  2. Approach
    1. Determine if growth is truly delayed (see indications above)
      1. See Calculation of Growth Delay
    2. Determine when Growth Delay began (in-utero, perinatal or childhood)
      1. See Growth Delay Onset Determination
    3. Determine cause if possible
      1. Only 5% of Short Stature referrals have an identifiable pathologic cause
      2. Most common identifiable causes
        1. Growth Hormone Deficiency
        2. Hypothyroidism
        3. Celiac Sprue
        4. Turner Syndrome (girls)
  3. Gastrointestinal symptoms
    1. Consider Celiac Sprue or Inflammatory Bowel Disease
    2. Pediatric Gastroenterology Referral
  4. Endocrinology symptoms
    1. Consider Cortisol excess or Hypothyroidism
    2. Pediatric Endocrinology Referral
  5. Dysmorphic proportional
    1. Consider Genetic Syndromes (e.g. Down Syndrome, Turner Syndrome)
  6. Dysmorphic non-proportional
    1. Consider chondrodystrophy
  7. Normal Growth Velocity (>5 cm/year) and delayed Bone Age
    1. Constitutional Growth Delay (or Delayed Puberty)
  8. Normal Growth Velocity (>5 cm/year) and normal Bone Age, with projected height consistent with Midparental Height
    1. Familial Short Stature
  9. Decreased Growth Velocity (<5 cm/year) and delayed Bone Age (with normal or increased weight)
    1. Consider endocrine conditions

IX. Management: Pediatric Endocrinology Referral Indications

  1. Children with IUGR
    1. Failure to catch up to their growth curve percentile by 2 years old
  2. Failure to follow expected growth
    1. Height >3 SD below mean height for age
    2. Growth Velocity <5 cm (2 in) per year
    3. Projected height >2 SD (10 cm or 4 inches) below Midparental Height
    4. Bone Age >2 SD below Chronological age
  3. Delayed onset of Puberty
    1. Girls >13 years old
    2. Boys >14 years old
  4. Conditions indicating treatment with recombinant Growth Hormone
    1. Growth Hormone Deficiency
    2. Turner Syndrome
    3. Chronic Renal Failure
    4. Prader-Willi Syndrome
    5. Small for Gestational Age
    6. Noonan Syndrome
    7. Short Stature homeobox-containing gene deficiency
    8. Idiopathic Short Stature

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Related Studies

Ontology: Short stature (C0349588)

Concepts Finding (T033)
ICD9 783.43
ICD10 R62.52
SnomedCT 206930002, 277266007, 158283003, 237836003
English Short stature, [D]Short stature (context-dependent category), Stature Short, [D]Short stature, short stature, short stature (physical finding), short stature was noted, Stature short, Short stature NOS, Short;stature, stature short, small stature, [D]Short stature (situation), Short stature (finding), Small stature, SS - Short stature, short; stature, stature; short, Short;growth
Dutch korte gestalte, kleine gestalte, gestalte; klein, klein; gestalte
French Petite taille, Insuffisance staturale, Petite stature
German untersetzte Statur, kleine Statur
Italian Bassa statura, Statura bassa
Portuguese Estatura baixa, Estatura pequena
Spanish Corta estatura, Pequeña estatura, Estatura disminuida, [D]baja estatura (categoría dependiente del contexto), talla baja, baja estatura, [D]baja estatura, baja estatura (hallazgo), [D]baja estatura (situación), estatura pequeña, trastorno con baja estatura (trastorno), trastorno con baja estatura, trastorno con talla baja
Japanese 低身長, テイシンチョウ
Czech Malý vzrůst, Malá postava
Hungarian Alacsony termet, Termet alacsony, Kis termet

Ontology: Growth delay (C0456070)

Concepts Pathologic Function (T046)
SnomedCT 276617005
English Delayed growth, growth delay, Delayed;growth, delays growth, delay growth, delayed disorder growth, Delayed Growth, Growth delay (disorder), Growth delay, delayed growth
Dutch Vertraagde groei
Spanish retraso del crecimiento (trastorno), retraso del crecimiento

Ontology: Short stature for age (C2732728)

Concepts Finding (T033)
SnomedCT 71781005, 444000005
English Body height decreased, Decreased body height, Decreased height, Short for age, Short stature for age, Short stature for age (finding), decreased height, Decreased;height
Italian Altezza corporea diminuita
Japanese 身長減少, シンチョウゲンショウ
Czech Tělesná výška snížená
Spanish estatura baja para la edad, baja estatura para la edad (hallazgo), estatura baja para la edad (hallazgo), bajo para la edad, altura corporal disminuida, baja estatura para la edad, Estatura corporal disminuida
Hungarian Testmagasság csökkent
Portuguese Peso do corpo diminuído
Dutch lichaamslengte verlaagd
French Taille corporelle diminuée
German Koerpergroesse erniedrigt