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
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