Follow-up of children and adolescents with short stature: the importance of the growth rate

",
É
,/  É -ARIA 7ANY ,OUZADA 3TRUFALDI %DINA -ARIKO +OGA DA 3ILVA 2OSANA &IORINI 0UCCINI &OLLOW UP OF CHILDREN AND ADOLESCENTS WITH SHORT STATURE THE IMPORTANCE OF THE GROWTH RATE $EPARTMENT OF 0EDIATRICS 5NIVERSIDADE &EDERAL DE 3áO 0AULO 3áO 0AULO "RAZIL
-/,
/ #/.4%84 !.$ /"*%#4)6% 3HORT STATURE IS DElNED AS A HEIGHT OF MORE THAN TWO STANDARD DEVIATIONS BELOW THE AVERAGE FOR A GIVEN AGE AND SEX IN A REFERENCE POPULATION 4HE OBJECTIVE WAS TO DESCRIBE FOLLOW UP CONDUCTED AMONG SHORT STATURE CHILDREN AND ADOLESCENTS $%3)'. !.$ 3%44).' $ESCRIPTIVE STUDY AT THE 'ROWTH OUTPATIENT CLINIC $EPARTMENT OF 0EDIAT RICS 5NIVERSIDADE &EDERAL DE 3ÎO 0AULO -%4(/$3 4HE STUDY INCLUDED  PATIENTS AGED  TO  YEARS WHO HAD HEIGHT FOR AGE OF LESS THAN 0 ON THE .ATIONAL #ENTER FOR (EALTH 3TATISTICS CURVE 4HE CHILDREN UNDERWENT NUTRI TIONAL EVALUATION AND SEVERAL VARIABLES RELATING TO HEIGHT AND GROWTH RATE WERE CALCULATED TO ESTABLISH ETIOLOGICAL DIAGNOSIS "ONE AGE WAS EVALUATED BY 8 RAY 2%35,43 4HE MAJORITY  WERE MALE )N  THE STATURE OBSERVED WAS WITHIN THE FAMILY PATTERN !MONG THE  PATIENTS FOLLOWED UP FOR MORE THAN  MONTHS  PRESENTED INADEQUATE GROWTH RATES 4HE PREPONDERANT ETIOLOGICAL DIAGNOSIS FOR SHORT STATURE WAS FAMILIALCONSTITUTIONAL IN  OF THE CASES  PATIENTS  WITH ADEQUATE GROWTH RATE PRESENTED BONE AGE ALTERATIONS %VEN WITH INAD EQUATE GROWTH RATES  OF SUCH PATIENTS HAD A NORMAL RESULT FROM GROWTH HORMONE STIMULATION TESTING #LOSE TO  OF PATIENTS WITH A DIAGNOSIS OF SHORT STATURE OF FAMILIALCONSTITUTIONAL ORIGIN AND INTRAUTERINE GROWTH RETARDATION PRESENTED ADEQUATE GROWTH RATE 4HE GENETIC ETIOLOGY WAS SIGNIlCANTLY CHARACTERISTIC OF PATIENTS WITH INADEQUATE GROWTH RATE #/.#,53)/. 'ROWTH RATE ASSESSMENT MUST FORM PART OF THE INVESTIGATION AND FOLLOW UP OF SHORT STATURE CASES (OWEVER ITS UTILIZATION AND VALIDITY SHOULD FORM PART OF AN OVERALL VIEW OF EACH PATIENT +%9 7/2$3 'ROWTH DISORDER "ODY HEIGHT #HILD !DOLESCENT 'ROWTH  /," 1 /" )N FOLLOWING UP GROWTH DURING CHILD HOOD THE HEALTHCARE PROFESSIONAL GENERALLY A PEDIATRICIAN IS ALMOST ALWAYS FACED WITH THE NORMAL VARIATIONS WITHIN THIS PROCESS AND WITH DISEASES THAT COMPROMISE THE CHILDS WEIGHT HEIGHT EVOLUTION $ESPITE THE FAVOR ABLE PROGRESSION IN MOST CASES CHILDREN OF SHORT STATURE CAN BENElT FROM THE ADVANCES IN DIAGNOSIS AND THERAPY IN SOME SPECIlC SITUATIONS )N THIS LIGHT IT IS IMPORTANT FOR THE PEDIATRICIAN TO KEEP UP TO DATE AND FA MILIARIZED WITH THE POTENTIAL BENElTS OF EARLY DIAGNOSIS AND TREATMENT !T THE SAME TIME IN VIEW OF THE COMPLEXITY OF THE DIAGNOSIS AND THE NUMEROUS ETIOLOGICAL POSSIBILITIES IT IS IMPRACTICABLE TO INVESTIGATE ALL THE POSSIBILITIES FOR ALL CHILDREN 3HORT STATURE IS DElNED AS A CONDITION IN WHICH AN INDIVIDUAL HAS A HEIGHT THAT IS MORE THAN TWO STANDARD DEVIATIONS BELOW THE AVER AGE HEIGHT FOR A GIVEN AGE AND SEX IN A REFER ENCE POPULATION 7HETHER A CHILDS STATURE IS hABNORMALv PURELY FROM A STATISTICAL POINT OF VIEW OR WHETHER IT IS INDICATIVE OF INADEQUATE GROWTH IS A QUESTION THAT NEEDS TO BE DElNED BY ADDITIONAL CRITERIA !CCORDING TO A 7ORLD (EALTH /RGANIZA TION BULLETIN PUBLISHED IN  THE PREVALENCE OF CHILDREN WITH HEIGHT DElCIT DElNED AS HEIGHT FOR AGE THAT IS MORE THAN TWO STANDARD DEVIATIONS BELOW THE REFERENCE HAS DIMINISHED OVER THE LAST  YEARS )N DEVELOPING COUN TRIES AROUND  OF CHILDREN PRESENT SUCH DElCIT STUNTING  -ORE SPECIlCALLY IN 3OUTH !MERICA THERE WAS A FALL IN THIS PREVALENCE FROM  TO  OVER THE PERIOD FROM  TO  4HE PRESENT STUDY AROSE FROM THE NEED TO ANALYZE THE ATTENDANCE PROVIDED FOR CHILDREN AND ADOLESCENTS AT AN INTERDISCIPLINARY OUT PATIENT CLINIC DEALING WITH SHORT STATURE )TS AIM WAS BOTH TO CONTRIBUTE TOWARDS OPTIMIZ ING DIAGNOSES AND TO REINFORCE THE ACTUATION OF GENERAL PEDIATRICS IN FOLLOWING UP SUCH CHILDREN 4HUS THE GROWTH OUTPATIENT CLINIC WAS CREATED IN  WITH THE PARTICIPATION OF PROFESSIONALS FROM THE DISCIPLINES OF COM MUNITY PEDIATRICS ENDOCRINOLOGY GENETICS AND NUTRITION AND METABOLISM *
/ /-É
É /" -É !LL THE CHILDREN AND ADOLESCENTS AGED TWO YEARS OR OVER WHO WERE ENROLLED DURING THE PERIOD FROM -ARCH  TO !PRIL  WERE INCLUDED FOR FOLLOW UP AT THIS INTERDISCIPLINARY OUTPATIENT CLINIC IF THEY PRESENTED A HEIGHT OF LESS THAN 0 ON THE .ATIONAL #ENTER FOR (EALTH 3TATISTICS .#(3 CURVE WHICH WAS CHOSEN AS THE REFERENCE 4HE HEIGHT MEASUREMENT WAS ALWAYS PER FORMED WITH THE CHILD OR ADOLESCENT STANDING ERECT WITHOUT SHOES UNDRESSED AND WITH THE HEELS TOGETHER ARMS RESTING AT THE SIDE OF THE BODY AND THE HEAD POSITIONED PARALLEL TO THE mOOR 4HE PATIENTS WERE WEIGHED ON A DIGITAL &ILIZOLA® BALANCE &OR THE NUTRITIONAL EVALUATION OF PA TIENTS AGED LESS THAN  YEARS THE WEIGHT FOR HEIGHT WAS CALCULATED AND THOSE WITH RESULTS OF LESS THAN  WERE CONSIDERED TO BE MALNOURISHED &OR PATIENTS AGED  YEARS OR OVER THE BODY MASS INDEX WAS CALCULATED AND THOSE WHOSE BODY MASS INDEX WAS LESS THAN 0 ON THE .#(3 CURVE WERE CONSID ERED TO BE MALNOURISHED  4HE TARGET HEIGHT WAS CALCULATED FROM THE AVERAGE STATURE OF THE PARENTS PLUS  CM FOR BOYS AND MINUS  CM FOR GIRLS WITH UPWARD AND DOWNWARD VARIATION OF TWO STANDARD DEVIATIONS 4HE Z SCORE FOR THE STATURE OF EACH CHILD WAS CALCULATED BY SUBTRACTING THE CHILDS HEIGHT FROM THE AVERAGE EXPECTED FOR THE AGE AND SEX IN ACCORDANCE WITH THE REFERENCE CURVE AND THEN DIVIDING THE RESULT OF THIS SUBTRACTION BY 3AO 0AULO -ED *    '(/ THE STANDARD DEVIATION CORRESPONDING TO THE AVERAGE EXPECTED 4HE Z SCORE OF THE PARENTS AVERAGE HEIGHT WAS ALSO CALCULATED AND COM PARED WITH THE INITIAL Z SCORE FOR THE PARENTS HEIGHT : SCORES FOR PATIENTS THAT WERE BELOW THE LOWER LIMIT OF THE PARENTS Z SCORE WERE CONSIDERED TO BE ABNORMAL OR OUTSIDE OF THE FAMILYS PATTERN 4HE FOLLOWING PARAMETERS WERE CALCULATED VIA THE 3)3#2%3 3YSTEM FOR !NALYSIS OF $ATA AND 'ROWTH PROGRAM INITIAL Z SCORE FOR STATURE lNAL Z SCORE FOR STATURE RELATING TO THE LAST HEIGHT MEASUREMENT MADE AT THE OUTPATIENT CLINIC BODY MASS INDEX GROWTH RATE CMYEAR TARGET HEIGHT Z SCORE FOR THE PARENTS AVERAGE HEIGHT AND THEIR LIMITS 4HE FOLLOWING CRITERIA WERE UTILIZED IN DElNING THE ETIOLOGICAL DIAGNOSIS y &AMILIAL SHORT STATURE WITHIN THE AVERAGE PREDICTED FROM THE PARENTS STATURE BONE AGE IN ACCORDANCE WITH CHRONOLOGICAL AGE WITHIN n STANDARD DEVIATIONS  GROWTH RATE ADEQUATE FOR THE AGE ABSENCE OF DELAY IN PUBERTY y #ONSTITUTIONAL SHORT STATURE IN PATIENTS WITH STATURE OR GROWTH PATTERN BELOW THE PREDICTION FROM THE PARENTS STATURE DELAY IN PUBERTY ANDOR BONE AGE INADEQUATE GROWTH RATE BEFORE THE PEAK OF THE PUBER TAL STRETCHING POSITIVE FAMILY HISTORY OF DELAYED PUBERTY y )NTRAUTERINE GROWTH RETARDATION SHORT STATURE IN PATIENTS WHOSE BIRTH WEIGHT WAS INADEQUATE FOR THE GESTATIONAL AGE 3INCE FOR MOST PATIENTS THE GESTATIONAL AGE CANNOT BE PRECISELY ASCERTAINED IT (...truncated)