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Short Stature in Childhood — Challenges and Choices

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Short Stature in Childhood — Challenges and Choices T h e new england journal o f medicine clinical practice Short Stature in Childhood — Challenges and Choices David B. Allen, M.D., and Leona Cuttler, M.D. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations. From the Division of Pediatric Endocri- A family seeks evaluation and treatment of short stature in their 11.5-year-old son. He nology and Diabetes, American Family previously was in the 3rd percentile for height, but his growth rate has slowed during Children’s Hospital, University of Wis- consin School of Medicine and Public the past 2 years, and his height is now just below the 1st percentile (Fig. 1). His moth- Health, Madison (D.B.A.); and the Center er is 5 ft 0 in. (152 cm), and his father is 5 ft 6 in. (167 cm). The child’s size at birth was for Child Health and Policy and the Divi- normal. His medical history and a review of systems are unremarkable. His physical sion of Endocrinology and Diabetes, Rainbow Babies and Children’s Hospital, examination is normal and shows prepubertal development. The complete blood count, Case Western Reserve School of Medi- erythrocyte sedimentation rate, thyrotropin, tissue transglutaminase antibody, and cine, Cleveland (L.C.). Address reprint insulin-like growth factor I (IGF-I) levels and growth hormone levels after provoca- requests to Dr. Allen at the University of Wisconsin School of Medicine and Public tive testing are normal. His skeletal maturation (bone age) is approximately 9 years, Health, H4/448 CSC, Dept. of Pediatrics, and his predicted adult height is 5 ft 5 in. (165 cm) plus or minus 1.3 in. (3.3 cm).1 600 Highland Ave., Madison, WI 53792- How should his condition be managed? 4108, or at [email protected]. N Engl J Med 2013;368:1220-8. DOI: 10.1056/NEJMcp1213178 The Clinical Problem Copyright © 2013 Massachusetts Medical Society. Short stature in childhood is a very common reason for referral to pediatric endo- crinologists. Although evaluation for growth-inhibiting disorders is often indicat- ed, most children with short stature are essentially healthy. Testing for growth hormone secretion often does not clearly distinguish isolated growth hormone defi- ciency from idiopathic short stature. Treatment with recombinant human growth hormone can increase the adult height of children with idiopathic short stature by An audio version 1.2 to 2.8 in. (3.0 to 7.1 cm), with wide variation in the incremental gain.2-5 In 2003, of this article is the Food and Drug Administration (FDA) approved human growth hormone treat- available at NEJM.org ment for children with idiopathic short stature and height below the 1st percentile (−2.25 SD). Accordingly, at least 500,000 children in the United States (i.e., approxi- mately 1% of children 4 to 13 years of age)6 were considered to have a condition for which there is available, effective, and expensive treatment (approximately $10,000 to $60,000 per patient per year).3 The FDA approval gave rise to controversies, uncertain- ties, and inconsistencies regarding therapeutic options that often overshadow the problem of short stature itself. Strategies and Evidence Evaluation Clinicians who evaluate children with short stature must consider many potential causes (Fig. 2).7 Although evaluation is needed to rule out disorders such as true growth hormone deficiency and hypothyroidism, the Turner syndrome, and chronic diseases, the majority of children with short stature ultimately receive a diagnosis of 1220 n engl j med 368;13 nejm.org march 28, 2013 The New England Journal of Medicine Downloaded from nejm.org at SUNY STONY BROOK on April 4, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. clinical practice key Clinical points short stature in childhood • Thorough evaluation of short stature in childhood is warranted when the child’s height deficit is severe (<1st percentile for age), the growth rate is abnormally slow (<10th percentile for bone age), the predicted height differs significantly from midparental height, or the body proportions are abnormal. • Human growth hormone treatment increases the growth rate, modestly increases adult height, and has been shown to be safe thus far, but it is expensive and the long-term risk:benefit ratio for essen- tially healthy children remains uncertain. • Observation and reassurance are reasonable for most children with short stature, given the lack of good evidence linking short stature with psychological harm or showing a long-term psychosocial benefit with growth-enhancing therapy. • Low-dose oral oxandrolone is an effective and relatively inexpensive option for growth acceleration, but it has not been shown to increase adult height. idiopathic short stature due to physiological vari- is disproportionate to height gain) may suggest a ants such as familial short stature, constitutional nutritional disturbance or chronic disease. Al- delay of growth and puberty (CDGP), or both. In though children with true growth hormone de- general, a growth rate that is abnormally slow for ficiency may have classic physical findings such chronologic and bone age should prompt a thor- as increased subcutaneous fat, most present ough examination and possible laboratory evalu- primarily with attenuated growth from infancy ation. Growth patterns in a child that differ mark- (congenital growth hormone deficiency) or later edly from the midparental height (estimated by (acquired growth hormone deficiency). averaging the two parents’ sex-specific height per- Familial short stature, CDGP, or both are the centiles) are also of concern, although these esti- most common causes of short stature. However, mates are less accurate when parental-height per- when the height for age is less than the 1st per- centiles are more disparate and are based on the centile, the growth rate is less than the 10th assumption that parental height was not itself percentile for bone age, the predicted adult diminished by a growth-restricting condition. A height1 differs significantly from the midparen- family history of late onset of puberty and the age tal height, or the body proportions are abnormal, at attainment of adult height may suggest a laboratory evaluation is warranted (Fig. 2). Screen- slowed “tempo” of growth and development (as ing laboratory studies target potential hormonal in CDGP). A history of intrauterine growth re- disorders (e.g., with measurement of thyroid hor- striction should also be assessed, since about mone levels), renal disorders (with measurement 15% of children with this condition continue to of electrolyte and creatinine levels), inflamma- have short stature throughout life.7 tory and immune disorders (with measurement of Physical examination should assess for the fol- the erythrocyte sedimentation rate and tests for lowing: abnormal body proportions (e.g., an in- tissue transglutaminase antibodies), and hema- creased ratio of the upper to lower body segment, tologic disorders (with a complete blood count). calculated by comparing the height in a sitting Genetic testing for specific syndromes may be position with the height in a standing position, indicated by physical findings or simply by a which suggests bone dysplasia or the Turner syn- growth pattern and height projection that differ drome); characteristics that suggest genetic con- significantly from those in other members of ditions (e.g., lymphedema or a low posterior the family. Assessment of the growth hormone– hairline, both of which occur in the Turner syn- IGF-I axis begins with measurement of the se- drome, or a murmur related to pulmonic-valve rum IGF-I level, but since levels increase rapidly stenosis, which occurs in the Noonan syndrome); with the onset of puberty, results must be inter- or findings (e.g., goiter) that suggest hypothy- preted relative to bone age rather than to chron- roidism. Poor weight gain (i.e., weight gain that ologic age. A normal IGF-I level for bone age n engl j med 368;13 nejm.org march 28, 2013 1221 The New England Journal of Medicine Downloaded from nejm.org at SUNY STONY BROOK on April 4, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. T h e new england journal o f medicine be helpful in such children, since abnormal find- cm in. in. ings such as diminished pituitary size or ectopic 200 78 78 195 Stature-for-Age Percentiles: or absent posterior pituitary enhancement further 76 76 11 190 Boys, 2–20 Yr 97th support this diagnosis. In the large majority of 74 95th 74 185 90th 72 72 short children, however, the history and examina- 180 75th 70 70 tion are unrevealing, and tests yield equivocal or 175 50th 68 68 170 25th normal results. These children are generally con- 66 10th 66 165 5th sidered to have short stature that is not related to 64 3rd 64 160 62 62 growth hormone deficiency — idiopathic short 155 60 60 stature due to physiological variants (i.e., famil- 150 58 58 145 ial short stature, CDGP, or both). Familial short 56 56 140 stature and CDGP are commonly included under 54 54 135 the umbrella of idiopathic short stature.12 Height 52 52 130 50 125 50 Management 120 48 48 115 46 46 Children with short stature that is not related to 110 44 44 growth hormone deficiency may receive mark- 105 42 42 40 40 edly different recommendations for management 100 11.5-yr-old boy 38 38 options that vary in complexity and costs and for 95 Height, 0.9th percentile 90 36 Bone age, approximately 9 yr 36 which the relative benefits and risks are uncer- 85 34 Predicted adult height, 5 ft 5 in.
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