Are short normal children at a disadvantage? The Wessex growth study.

OBJECTIVE: To examine whether short stature through childhood represents a disadvantage at around 12 years. DESIGN: Longitudinal non-intervention study of the physical and psychological development of children recruited from the community in 1986-7 after entry into primary school at age 5-6 years; this is the second psychometric assessment made in 1994-5 after entry into secondary school at age 11-13 years. SETTING: Southampton and Winchester health districts. SUBJECTS: 106 short normal children (< 3rd centile for height when recruited) and 119 controls of average stature (10th-90th centile). MAIN OUTCOME MEASURES: Psychometric measures of cognitive development, self concept development, behaviour, and locus of control. RESULTS: The short children did not differ significantly from the control children on measures of self esteem (19.4 v 20.2), self perception (104.2 v 102.4), parents'' perception (46.9 v 47.0), or behaviour (6.8 v 5.3). The short children achieved significantly lower scores on measures of intelligence quotient (IQ) (102.6 v 108.6; P < 0.005), reading attainment (44.3 v 47.9; P < 0.002), and basic number skills (40.2 v 43.5; P < 0.003) and displayed less internalisation of control (16.6 v 14.3; P < 0.001) and less satisfaction with their height (P < 0.0001). More short than control children, however, came from working class homes (P < 0.05). Social class was a better predictor than height of all measures except that of body satisfaction. Attainment scores were predicted by class and IQ together rather than by height. Height accounted for some of the variance in IQ and locus of control scores. CONCLUSIONS: These results provide only limited support for the hypothesis that short children are disadvantaged, at least up until 11-13 years old. Social class seems to have more influence than height on children''s psychological development.     

Pubertal growth of the short normal girl

OBJECTIVES: To determine the timing, magnitude and duration of the pubertal spurt for short normal and average height girls, to compare these with Tanner's standard and to investigate predictors of pubertal growth. METHODS: The growth of 46 short normal and 55 control girls, identified at school entry, was monitored throughout puberty. Height and weight were measured at 6-month intervals from which body mass index (BMI) was derived. Annual velocities were calculated and used to estimate the age and magnitude of peak height velocity (PHV). Age of menarche was recorded to the nearest month. Parents provided information on the child's medical and social history. RESULTS: The mean age at PHV, the magnitude of PHV and age at menarche were similar for both groups and close to Tanner's 50th centile values. Pre-pubertal BMI predicted age at menarche for short and control girls, accounting for 17% of the variance. There was a tendency for early maturing girls of average stature to have greater PHV. However, this relationship was not observed in short girls, nor did any other variable, genetic or environmental, predict the timing or magnitude of their pubertal spurt. CONCLUSIONS: Delayed puberty in short normal girls is unlikely and their growth during puberty is comparable to girls of average height. The pubertal variables measured remain close to Tanner's original standards for both groups, suggesting the lack of a secular trend towards earlier puberty in girls. The onset of menstruation is influenced by pre-pubertal BMI. However, the clinician should be aware that short normal girls have normal pubertal growth and that no genetic or environmental variable can predict the timing or magnitude of their growth spurt.     

Effect of chronic clonidine treatment on urinary growth hormone excretion and linear growth in children with short stature

Eleven prepubertal children with short stature were treated with clonidine (0.15 mg/m2 daily) for a period of 1 year. The effect of this drug was evaluated on both clinical (growth velocity, height standard deviation scores for chronological age and bone age) and hormonal (urinary growth hormone excretion and insulin-like growth factor I) parameters. Our study shows that long-term clonidine administration in children with short stature did not result in significant differences in growth velocity, height standard deviation scores for chronological age and bone age, insulin-like growth factor I or in urinary growth hormone excretion.     

Child growth and adult physique in Brazillan Xingu Indians

Data on stature, sitting height, biacromial width, and some other body measurements on 267 children and 363 adults of the Xingu Indians of Brazil have been analyzed. Adult height shows no significant decrease with age over an age range of 20–50 years, thus indicating the absence of secular changes. The average Xingu child seems to be around the twenty-fifth to fiftieth centile for height of British children (if our age estimates are correct) until about ten years in girls and 14 years in boys, but ends at below the third British centile as an adult. In sitting height, however, the Indians show substantially lower values, with children being at about the fifteenth centile until ten years in girls and 14 years in boys, while the adults are considerably below the British third centile. Other comparisons show that the Xingu are taller than Surinam Indians although of similar shoulder width. The lack of anthropometric data concerning South American Indian adults, and more especially children has been stressed. Investigations of these populations facing rapid acculturation and possible assimilation will form a baseline for the future work in public health as contacts with non-Indians increase.     

Psychosocial adaptation to short stature - an indication for growth hormone therapy?

Although growth hormone does not clearly improve final height in non-growth-hormone-deficient children with short stature, it leads to a temporary acceleration of growth velocity. It is an ongoing discussion whether this effect supports psychosocial adaptation to short stature and therefore could be an indication for growth hormone treatment in children with short stature without growth hormone deficiency. We have reviewed recent literature concerning psychosocial consequences of short stature. Together with own data we can demonstrate that short people regularly adapt well to their height and have a good self-esteem. On the other hand, we focus on the problem that most studies on this subject suffer from methodical problems. A growth-related questionnaire that evaluates subjective and objective perceptions of being short in patients and peers is not at hand. As a consequence, psychosocial problems due to short stature have not been exactly classified yet and therefore do not represent an indication for growth hormone therapy.     

Effect of growth hormone on short normal children.

The growth of 26 short normal prepubertal children (mean age 8.4, height velocity standard deviation score for chronological age between +0.4 and -0.8) was studied for two years. Sixteen children were treated with somatrem (methionyl growth hormone) during the second year, and the remaining 10 children served as controls. During one year of treatment the height velocity standard deviation score for chronological age increased from the pretreatment mean of -0.44 (SD 0.33) to +2.20 (1.03). These values represented a change in height velocity from a pretreatment mean of 5.3 cm/year (range 4.6-6.9) to 7.4 cm/year (range 5.7-9.9). In the control group the height velocity standard deviation score was unchanged. Bone age advanced by 0.75 (0.33) years in the treated group compared with 0.70 (0.18) years in the control group. There was a significant increase in the height standard deviation score for bone age (0.63 (0.55] in the treated group. Multiple regression analysis of predictive factors contributing to the change in height velocity standard deviation score over the first year of treatment showed that the dose of growth hormone and pretreatment height velocity standard deviation score were important, together yielding a regression correlation coefficient of 0.80. The only metabolic side effect of treatment was an increase in fasting insulin concentration, which may be an important mediator of the anabolic effects of growth hormone. Treatment had no effect on thyroid function, blood pressure, or glucose tolerance. At the end of the treatment year seven of the 16 treated children had developed antibodies to growth hormone, but they were present in low titre with low binding capacity and in no child was growth attenuated. Biosynthetic growth hormone improved the height velocity of children growing along or parallel to the third height centile, but the effects on height prognosis need to be assessed over a longer period.     

Chromosomal region 13q21q31 and heterochrony of development

If the theory of evolution is now largely accepted, there are still many debates on the mechanisms of evolution, including human evolution. One of these mechanisms is heterochrony of development including progenesis and neoteny. We report on a patient who could be an example of human progenesis. This boy was born prematurely, after a cesarian section for preeclampsia. Family history was unremarkable. He walked unaided when he was 2.5 years old. At 5 years of age height was 95 cm (< 3rd centile), weight 18.6 kg (40th centile) and OFC 54 cm (98th centile is 53 cm). He had a macropenis. He attended elementary school. However, at 9 years of age he had to have special education. Puberty occurred when he was 8 years old. At 14 years of age height was 141 cm (3rd centile is 144 cm), weight 32.5 kg (3rd centile) and OFC 55.5 cm (75th centile). At physical examination he had hypertelorism, narrow forehead, short philtrum, retromicrognathia, large and low set ears, hyperlaxity, overcrowed teeth, dorsal kyphosis, and macropenis. Karyotype showed a deletion 13q21q31. The deletion was de novo and pure. In conclusion this case with sexual precocity and small final stature could be an example of progenesis, rising the question of the presence of a critical region for human evolution within chromosomal region 13q21q31.     

Final height after growth hormone therapy in peripubertal boys with a subnormal integrated concentration of growth hormone.

The aim of this study was to test the effect of growth hormone (GH) therapy on final height in peripubertal boys with idiopathic short stature in whom a subnormal integrated concentration of GH (< 3.2 micrograms/l) was found. Twenty-eight peripubertal children were studied. Height was below 2 SD for age, growth velocity was < 4.5 cm/year, bone age was more than 2 SD below mean for age and GH response to provocative tests was more than 10 micrograms/l. Eleven subjects (group B) were treated with recombinant GH 0.75 unit/kg/week, divided into 3 weekly doses for 2 years, and then the same weekly dose divided into daily injections was administered until final height was attained. Seventeen untreated children (group A) who were followed until cessation of growth served as controls. The GH-treated patients reached their target heights (-2.1 +/- 0.5, mean +/- SD in SDS) and predicted heights (-1.8 +/- 0.8) determined by the Bayley and Pinneau method, while the final heights of the untreated patients were significantly lower than their target heights and their predicted final heights (-2.7 +/- 0.7, -1.8 +/- 1.0 and -2.7 +/- 0.7, respectively). The main effect of GH was observed during the 1st year of treatment when height velocity was significantly higher in the GH-treated group than in the untreated one (9.3 +/- 2.1 vs. 5.3 +/- 1.1, respectively, p < 0.001). The high cost of the treatment in this specific age group should be weighed against the results.     

Abnormal growth in noonan syndrome: genetic and endocrine features and optimal treatment

Noonan syndrome (NS) is a phenotypically heterogeneous syndrome which is frequently associated with short stature. Recent genetic investigations have identified mutations in five genes, namely PTPN11, KRAS, SOS1, NF1 and RAF1 in patients with the NS phenotype. PTPN11 is the commonest, being present in approximately 50% of cases. The degree of short stature in children does not associate closely with the presence of mutations, however some PTPN11-positive patients have decreased GH-dependent growth factors consistent with mild GH insensitivity. GH therapy, using doses similar to those approved for Turner syndrome (TS), induced short-term increases in height velocity over 1-3 years, and may improve final adult height with longer-term treatment.     

An approach to solving problems of growth retardation in the child and teenager.

The physician who looks after children and teenagers is often confronted with the problem of short stature or growth failure. Common causes of growth failure include genetic background, intrauterine disease, malnutrition, chronic illness and hormonal disorders; some cases are attributed to mental retardation or primary central nervous system disease. A major concern in the evaluation of these patients is when, and how extensively, to investigate the problem. From a practical standpoint assessment can be related to height percentiles. The aims of treatment are a) to identify and treat appropriately the patients in whom there is an organic cause and b) to provide psychologic counselling and support.     

Physiological growth hormone secretion in children with short stature and intra-uterine growth retardation

31 prepubertal children with short stature [mean height standard deviation score (SDS) -2.84] and low birth weight (mean -2.82 SDS) were studied. Mean age was 6.0 years and mean height velocity SDS was -0.76. Patients were classified as having either the clinical characteristics of Russell-Silver syndrome (RSS) (4 F, 13 M) or not (4 F, 10 M). All children had an overnight profile of spontaneous growth hormone (GH) secretion. 4 children achieved a maximum GH concentration of less than 20 mU/l. 9 children with RSS secreted only one large GH peak during the night. Most of the non-RSS group had normal GH pulse frequency but 3 boys had a fast-frequency pattern. Abnormal GH secretion may contribute towards growth failure in children with low birth weight/RSS.     

Knemometry in the assessment of short-term linear growth in a population of healthy school children.

Short-term lower leg length increments were monitored with weekly knemometry measurements during 3 months in 27 healthy school children aged 8-12 years. One year after the first visit the children were measured once again. The mean short term velocity of lower leg growth was 0.40 mm/week (SD 0.12 mm/week). The mean short-term and annual ratios between height velocity and lower leg growth velocity were identical (2.8). The relative variation between two observers was 0.08%. Knemometry is a suitable method for monitoring short-term linear growth in populations of children. Two trained observers may substitute for each other in group studies.     

Diet and retarded growth.

The diets of 36 children below the third centile for height but with no organic disease were compared with the diets of a control group. In most cases retarded growth was associated with a long-continued deficiency in calorie intake. When the diets were reassessed about a year later the shortfall in calorie intake was significantly reduced. This improvement, which tended to be followed by an increase in the rate of growth in height, might have been due to alteration in the child''s circumstances or improvement in the family attitudes and feeding habits or both. Advice given at the clinic is thought to have played a part in bringing these changes about.     

Clinical standards for growth velocity in height of Belgian boys and girls,aged 2 to 18 years

The present paper presents the first clinical standards for growth velocity in height of Belgian boys and girls, based on purely longitudinal data. Growth charts are provided with centiles of height for age, along with the growth velocity curves of the typical early, average and late maturing child in the population. These new growth velocity standards provide centile lines which allow to judge whether a child's growth velocity over a one-year interval lies within the limits of normal variation for his age, irrespective of his stage of maturation. They also provide information about variability in the individual patterns of growth velocity in the population and can, as such, also be used to evaluate the normality of a child's pattern in growth velocity over a longer period of time. Age at peak velocity occured in 95% of the children within an age range of about 4 years. The average age at peak height velocity at puberty was 14.0 years (S.D.=1.0) in boys and 11.6 years (S.D.=0.9) in girls. Peak height velocity was in the average 9.1 cm/year (S.D.=1.4) in boys and 7.5 cm/year (S.D.=1.1) in girls. The representativity of these new standards with respect to the actual Belgian population was tested by comparison with recent cross-sectional data, collected on a large number of subjects. These new charts will find useful applications in longitudinal health screening surveys, and in clinical follow-up studies, where interest lies in the examination of a child's growth retardation in relation to some disease, or catch-up growth, as a response to subsequent medical treatment.     

US experience in evaluation and diagnosis of GH therapy of intrauterine growth retardation/small-for-gestational-age children

The potential role of exogenous GH in treating short children born small for gestational age (SGA) has been discussed since the early 1960s. Pivotal studies in Europe during the last 10 years have shown that GH treatment of short children born SGA during childhood and early puberty (1) normalizes stature, (2) increases final height above predicted height and (3) allows children to reach their target height. A study now under way in the USA will provide additional much needed data about efficacy and safety of GH treatment in intrauterine growth retardation/SGA.     

Adult outcome of normal children who are short or underweight at age 7 years.

OBJECTIVES--To evaluate the adult growth outcome (at age 23) of children who are short or underweight at age 7 years in whom no identifiable pathological cause exists for their poor growth. DESIGN--Longitudinal follow up of a birth cohort. SETTING--The national child development study (1958 birth cohort) of Great Britain. SUBJECTS--523 children with a height or a weight below the fifth centile at age 7. Of these, 70 (13.4%) were excluded because they had a longstanding illness that could account for their poor growth. The remaining 453 subjects, who were followed to age 23, provided the base group from which those with additional data, such as parental height, were obtained. RESULTS--55/174 (31.6%) boys who were short at age 7 became short men; 60/211 (28.4%) girls who were short at age 7 became short women. Among boys who were underweight at age 7, 46/160 (28.7%) were still underweight at age 23, while 61/200 (30.5%) girls underweight at age 7 became underweight women. Having short parents did not increase the probability of being small as an adult. Children with delayed puberty were as likely to remain small as those in whom puberty was not delayed. CONCLUSIONS--One in three normal children who was short or underweight at age 7 became a short or underweight adult. This informs the management of short children and may be valuable when prolonged growth hormone treatment for short stature is being considered.     

Serum zinc and somatic growth in children with growth retardation

A possible role for zinc deficiency in some cases of growth retardation in southern France was investigated. Control values for zinc for 160 children (age=12.5±2.4 yr) are 0.85±0.22 mg/L (mean ±2 SD). Twenty-five children with low serum zinc values (<0.63 mg/L) and 25 matched short children with normal serum zinc values (>0.63 mg/L) were studied. Children in the two groups did not differ significantly in age, pubertal development, stature, and weight. For the 25 children whose serum values were low, we found significantly lower values for bone age delay, growth velocity in mm/month, as well as the ratio between calculated growth velocity and theoretical growth velocity for the bone age (so that zincemia was correlated to these parameters in the whole sample of 50 subjects). Nevertheless, no significant difference could be found between the two groups for serum somatomedin C, serum osteocalcin values, and GH responses to the GH stimulatory tests (exercise test, overnight sampling, insulin-induced hypoglycemia, arginine test). Therefore, low serum zinc is associated with a retardation in both somatic growth and pubertal maturation.     

Growth profile of rural Meitei children of Manipur state of India

Patterns of growth in 10 anthropometric measurements among the rural Manipuri children (N=425), aged 5 to 14 years, with poor socio-economic backgrounds are reported. The anthropometric dimensions include weight, stature, sitting-height, head, chest and midupper-arm circumferences, biepicondylar widths of humerus and femur, and triceps and biceps skinfolds. Except skinfolds, the boys measured more than the girls in all measurements at all ages, except from 10 to 12 years in weight, stature, sitting-height, and chest and mid-upper-arm circumferences. Across all ages, the girls had thicker fat folds. Up to 12 years, the children lie approximately on the 10th centile of NCHS in stature and weight. The arm circumferences was below the 3rd centile of the Dutch children, until 11 years. The triceps fat fold fluctuated between 10th and 25th centiles of US whites. The rural Meiteis were taller and heavier than rural Burmese and urban Meiteis. The overall growth performance of the rural Meitei children was poor as compared to US, Urban Chinese, and well-nourished Indian children.     

Regional differences in short stature in England between 2006 and 2019: A cross-sectional analysis from the National Child Measurement Programme

BackgroundShort stature, defined as height for age more than 2 standard deviations (SDs) below the population median, is an important indicator of child health. Short stature (often termed stunting) has been widely researched in low- and middle-income countries (LMICs), but less is known about the extent and burden in high-income settings. We aimed to map the prevalence of short stature in children aged 4–5 years in England between 2006 and 2019.Methods and findingsWe used data from the National Child Measurement Programme (NCMP) for the school years 2006–2007 to 2018–2019. All children attending state-maintained primary schools in England are invited to participate in the NCMP, and heights from a total of 7,062,071 children aged 4–5 years were analysed. We assessed short stature, defined as a height-for-age standard deviation score (SDS) below −2 using the United Kingdom WHO references, by sex, index of multiple deprivation (IMD), ethnicity, and region. Geographic clustering of short stature was analysed using spatial analysis in SaTScan. The prevalence of short stature in England was 1.93% (95% confidence interval (CI) 1.92–1.94). Ethnicity adjusted spatial analyses showed geographic heterogeneity of short stature, with high prevalence clusters more likely in the North and Midlands, leading to 4-fold variation between local authorities (LAs) with highest and lowest prevalence of short stature. Short stature was linearly associated with IMD, with almost 2-fold higher prevalence in the most compared with least deprived decile (2.56% (2.53–2.59) vs. 1.38% (1.35–1.41)). There was ethnic heterogeneity: Short stature prevalence was lowest in Black children (0.64% (0.61–0.67)) and highest in Indian children (2.52% (2.45–2.60)) and children in other ethnic categories (2.57% (2.51–2.64)). Girls were more likely to have short stature than boys (2.09% (2.07–2.10) vs. 1.77% (1.76–1.78), respectively). Short stature prevalence declined over time, from 2.03% (2.01–2.05) in 2006–2010 to 1.82% (1.80–1.84) in 2016–2019. Short stature declined at all levels of area deprivation, with faster declines in more deprived areas, but disparities by IMD quintile were persistent. This study was conducted cross-sectionally at an area level, and, therefore, we cannot make any inferences about the individual causes of short stature.ConclusionsIn this study, we observed a clear social gradient and striking regional variation in short stature across England, including a North–South divide. These findings provide impetus for further investigation into potential socioeconomic influences on height and the factors underlying regional variation.

Joanna Orr and coauthors investigate regional differences in short stature among children in England, between 2006-2019, using a cross-sectional analysis of the National Child Measurement Program data.