Full Length ArticleNormal and Abnormal Growth in the Pediatric Patient
Introduction
Normal growth is the series of changes in height/length, weight, and head circumference in reference to established norms for a given population. Appropriate growth is a sign of the overall health of the child within the context of one's genetic potential. In general, a normal pattern of growth suggests satisfactory health, while growth that is abnormal increases the possibility of an underlying sub-acute or chronic illness. This can include an endocrinologic cause of poor growth. By recognizing normal versus abnormal patterns of growth, one can detect when a further evaluation is needed to rule out pathology. The World Health Organization (WHO) Global Database on Child Growth and Malnutrition uses a range within two standard deviations (SD) above and below the mean height as the standard measure for identifying children with normal growth.1 A cutoff point of greater than 2 SD below the mean, for persons of the same chronologic age and sex in a given population, is used to identify children with short stature. Not all children that meet criteria for “short” need an assessment. Normal, non-pathologic variants of short stature are familial short stature and constitutional delay. The aim of the diagnostic evaluation of a child with short stature is to determine the subset with a pathologic cause.
Section snippets
Factors of Normal Growth
Size at birth is primarily determined by intrauterine and placental factors. This includes factors such as maternal nutrition, uterine size, eclampsia, alcohol/drug/tobacco exposure, and infections.2 Genetic factors, including family members' heights and genetic syndromes (i.e. Turner, Noonan, Prader-Willi, Trisomy 21, skeletal dysplasia, SHOX, pseudohypoparathyroidism), have a later affect and do not directly impact birth length. Because of this, the correlation coefficient between birth
Growth Hormone Axis
Growth hormone releasing hormone (GHRH) is secreted from the hypothalamus. Pulsatile GH release from somatotrophs of the anterior pituitary gland is an interplay of decreased somatostatin superimposed on increased GHRH. GH stimulates the liver to produce IGF-1.2 IGF-1 acts synergistically with GH to promote epiphyseal growth via stimulating cell proliferation and differentiation. IGF-1 acts antagonistically against GH by increasing insulin sensitivity in opposition to GH. IGF-1 levels reflect
Measurement of Growth
In order to recognize if there is pathology, one first needs to know normal growth patterns with accurate measurements. The Center for Disease Control (CDC) developed growth charts in 2000 based on a descriptive study, observationally describing how children in the population grow. It included cross-sectional data of 4697 observations on 4697 distinct children, with no single child studied longitudinally.6 It used data from the National Health and Nutrition Examination Surveys (NHANES) I, II,
Evaluation
Further testing is warranted for children with concerns of growth failure or short stature. Signs of abnormal linear growth include crossing of two percentiles beyond the first two years of life, IUGR/SGA with lack of catch up growth, or HV inappropriate for age. Further evaluation for short stature should be carried out when height is less than 2 SD below the mean for sex and age or for height significantly below the genetic potential according to projected adult height greater than 2 SD
Growth Hormone Treatment
GH therapy was first made available for severely GH-deficient children in the 1950s.11 GH was first extracted from the human pituitary gland in 1956. The first trial to show the benefits of GH on growth occurred in 1958, and this was used for the next 30 years. In 1985, the FDA received reports of four young adults in the U.S. with Creutzfeldt-Jakob disease (CJD) who had been treated with GH in the 1960s. On April 19, 1985, the distribution of human pituitary GH was suspended and the use of
Conclusion
Short stature in infants and children may be due to variations in normal growth or pathological causes. Accurate measurements of length/height and weight using standardized methods is an essential part of pediatric medical visits. In children with concerns about linear growth, additional evaluation is helpful with laboratory and radiological testing. Careful growth monitoring in the pediatric office may allow for detection of children with familial short stature or CDGP, which are normal
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The author has no significant financial interest or other relationship with commercial interests to disclose