The period when linear growth is highest is the first 2 years and the puberty period. First year babies are 25 cm; In the 2nd year, it grows 10-12 cm. The growth rate between the age of 2 and puberty is approximately 6 cm per year. During this period, a growth rate below 5 cm per year is considered abnormal. Just before puberty, the growth rate slows down. It may decrease to 4.2 cm in boys and 3.8 cm in girls. Growth accelerates again when we enter puberty. In girls, the pubertal growth spurt begins simultaneously with breast growth and peaks before menarche (first menstrual period). During this period, girls gain 8-9 cm in height per year. After menarche, the growth rate decreases and they grow approximately 7 cm more. The pubertal growth spurt in boys begins with an increase in testicular volume, and they reach their peak growth rate at approximately 13-14 years of age. Boys gain an average of 10 cm in height per year during the pubertal period. Since the age at which puberty begins in children varies individually, the growth rates of children of the same age and gender may also differ. At the end of the pubertal period, growth rate decreases and height growth ends with the closure of the epiphyses.
Height is measured lying down in the first 2 years, and standing after the age of 2. Height measured lying down is 1 cm higher than height measured standing up. It is measured once a month for the first year, and every 3-6 months after the age of 1, as height growth occurs in leaps. Measurements are evaluated according to the percentile chart prepared according to age and gender. Values below the 3rd percentile according to age and gender define short stature.
FACTORS AFFECTING HEIGHT GROWTH
Familial and Genetic Factors
Both parental height and parental growth rate are the most important factors affecting the child's height.
Birth Size
The causes of intrauterine growth retardation are fetal It reduces the number of cells, causing birth length to be short.
Nutrition
Adequate and balanced food intake is required for normal growth. Inadequate food intake first affects the weight, and if it continues for a long time, the height is also affected.
Chronic Diseases
Chronic diseases such as inflammatory bowel diseases, Celiac disease, kidney diseases. These may cause secondary short stature.
Psychological Factors
Under normal circumstances, psychological and psychological factors do not have a serious effect on growth.
However, in some cases, psychological stress can prevent growth.
Hormones
The hormone that has the primary effect on height increase is the growth hormone. It is secreted from the pituitary and controlled by growth hormone-releasing factor (GHRF) and somatostatin from the hypothalamus. Growth hormone is secreted intermittently during the day and its peak release occurs during sleep.
It achieves its growth stimulating effect by stimulating the production of insulin-like growth factor 1 (IGF-1) or by directly stimulating the bones. Lack of growth hormone in children causes height and growth retardation.
Thyroid hormone is also essential for growth. In its deficiency, both physical and mental retardation is observed.
In case of excess cortisol secreted from the adrenal gland, growth stops.
Sex steroids (estrogen in girls, testosterone in boys) affect pubertal growth. In early puberty, the jump in height occurs early and the final height remains short because the epiphyses close early.
SHORT HEIGHT
Familial Short Stature
The height of the child is proportional to its genetic height. These children are completely healthy. One or both parents are short. The percentiles of these children are low, but their growth course is parallel to the percentile. His bone age is the same as his peers, which indicates that his adult height will be shorter than average. These children are below the 3rd percentile, but their annual growth rate is normal.
Constitutional Short Stature
This condition is a variant of normal. It is observed more frequently in men. These children are short in the prepubertal period, but are otherwise completely healthy. The parents are of normal height, but one or both parents have a history of delayed puberty. All tests are normal, only bone age is delayed. This situation shows us that the child has a greater growth capacity than his peers and can reach his genetic potential in the percentile curve.
PATHOLOGICAL SHORT HEIGHT.
Some Syndromes Associated with Short Stature
Turner Syndrome (45X0)
It develops due to the absence of one of the X chromosomes. It has been reported with a frequency of 1/2500 in girls. The average adult height is 142 cm. In Turner syndrome, in addition to short stature, delayed puberty, aortic coarctation, and kidney anomalies are observed. In the newborn period, there is low birth weight, mane neck, low nape hairline, edema on the hands and feet, and shortness of the fourth toe. Chromosome analysis should be performed to exclude Turner syndrome in every girl with short stature of unknown cause. In order to increase the final height of these children, growth hormone treatment should be given before the epiphyses close and sex steroid treatment should be given during adolescence.
Prader-Willi Syndrome
A part of the 15th Chromosome inherited from the father. It occurs due to the absence of the segment. These children have short stature, hypogonadism, mental retardation, and malnutrition.
Down Syndrome
21. There are 3 copies of the chromosome. These children have typical facial appearance. Hypothyroidism is very common in children with Down syndrome, but short stature is independent of this.
Bone Dysplasias
It is a group of disorders in which congenital bone or cartilage growth is inadequate. Disproportionate short stature, that is, a decrease in the limb/trunk ratio, is typical for this condition. In achondroplasia, the limbs are short and the relatively large head is noticeable even in newborns. On plain radiography, it is typical for the first and second lumbar vertebrae to beak forward. The average adult height is 125 cm for girls and 130 cm for boys. There is no effective treatment for short stature. Hypochondrolasia is the milder form of achondroplasia. Short stature becomes evident around the age of 3. On plain radiography, the metaphyses are enlarged and irregular, and the illium (part of the hip bone) is underdeveloped.
Malnutrition
Malnutrition is inadequate nutrition due to hunger, inadequate food intake or chronic diseases. and occurs due to digestive problems. Weight loss is more important than short height. Vitamin D deficiency also negatively affects height growth.
Chronic Diseases
Chronic diseases such as inflammatory bowel disease, kidney disease, and Celiac disease can lead to short stature. In chronic diseases, there may be loss of appetite, inadequate food intake and digestion, chronic acidosis, and growth and development retardation caused by side effects of medication use. In some cases, short stature may be the first sign of a chronic disease
Spiritual Deprivation
Very severe psychological traumas, although rare, may cause short stature
Growth Hormone Deficiency
Growth hormone is essential for growth, and its deficiency causes serious shortness of stature. Growth hormone deficiency can be congenital or secondary. Congenital growth hormone deficiency may be accompanied by midline defects (cleft palate, holoprosencephaly, single central incisor). Secondary growth hormone deficiency may be due to reasons such as birth trauma, head trauma, cranial radiotherapy, and midline tumors. Growth hormone deficiency may be isolated or may be associated with other pituitary hormone deficiency. In congenital growth hormone deficiency, newborn size is normal, but hypoglycemia (low blood sugar), prolonged jaundice, and small phalluses in male babies may be observed or may not cause any symptoms. Short stature begins around the age of 3. Bone ages are delayed. Checking randomly taken growth hormone levels has no diagnostic value. For screening, IGF-1 and IGF binding protein-3 levels should be checked. The actual diagnosis is made with a growth hormone stimulation test. When a diagnosis of GH is made, MRI should be performed to exclude a possible tumor or structural brain abnormality. Additionally, screening should be performed for other accompanying pituitary hormone deficiencies. Growth hormone replacement is used in the treatment.
Hypothyroidism
The deficiency of thyroid hormones may be congenital or acquired. Hypothyroidism negatively affects linear growth. With the implementation of a newborn thyroid screening program, it is now possible to detect congenital hypothyroidism cases immediately and start their treatment without delay. Therefore, short stature due to congenital hypothyroidism is now rarely encountered. Acquired hypothyroidism in children is often due to autoimmune thyroiditis. develops as. In some cases, children with diseases such as Turner syndrome, Down syndrome, and diabetes mellitus type 1 are at risk of autoimmune thyroiditis. Thyroid hormone tests should be screened periodically for hypothyroidism in these patients. Constipation, dry skin and hair, decrease in school performance, slowdown in growth rate, slowdown in teething, weight gain and goiter may be observed in hypothyroidism. Bone age is delayed in these patients. In diagnosis, free T4, TSH, thyroid antibodies and thyroid gland ultrasound are performed. Thyroid hormone replacement is used in the treatment.
Cushing's Syndrome
It occurs due to excess glucocorticoid (cortisol). It may be due to corticosteroid drugs given endogenously or exogenously. As the growth rate slows down, weight gain occurs. It can be confused with exogenous obesity; in exogenous obesity, the growth rate increases with weight gain. Long-term oral or topical corticosteroid drug use should be questioned in the history. Fat accumulation in these children shows a typical distribution, with fat concentrated on the trunk, moon face, and buffalo hump. Stretch marks, striae, increased hair growth and hypertension develop due to rapid weight gain and thinning of the skin. If Cushing's syndrome is due to excessive ACTH increase, hyperpigmentation develops. ACTH increase may be caused by a pituitary tumor or ectopic ACTH increase. MRI and adrenal imaging, dexamethasone suppression test are performed for the diagnosis of pituitary tumor. Treatment is performed according to the cause.
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