REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)
Short Stature - StatPearls (NCBI Bookshelf NBK556031) - https://www.ncbi.nlm.nih.gov/books/NBK556031/
Most short children are healthy and short, and the work is to prove that rather than assume it. Growth hormone is a specialist decision and the article's doses belong to endocrinology, so no prescribing row is offered. What primary care owns is measuring properly, calculating the mid-parental height, and separating a child who is small but growing normally from one whose growth has slowed.
- THE DEFINITION - a child is short when the height sits more than 2 standard deviations (SDs) under the mean for age, sex and population, which works out at about the 2.3rd percentile - though plenty of texts draw the line at the 3rd percentile instead.
- GROWTH VELOCITY DECIDES, NOT THE SINGLE HEIGHT - a short child who is still growing at a normal rate almost certainly has a physiological cause. The physiological pattern in full: born at a normal length, the child slows during the first 2 to 3 years and drops under 2 SDs; after that the rate of growth is normal again, but the height stays under the 3rd centile line. Two measurements six months apart are worth more than any single number.
- THE PATHOLOGICAL PATTERN LOOKS DIFFERENT - a height sitting lower than 3 SDs from the mean makes something specific likely to be behind it. Such a child may be born a normal length or a short one, but typically slows early, and the gap widens as the years pass. A line that is crossing centiles downwards is the referral, whatever the absolute height.
- MEASURE AGAINST THE PARENTS - in familial short stature the height fits what the parents' heights predict, and there is nothing nutritional, hormonal, acquired or genetically identified behind it. These children go through puberty at the usual age and stay shorter than most people, but they finish at the height their mid-parental height predicted. Measure both parents rather than asking them.
- AND AGAINST THE BONE AGE - in familial short stature the bone age matches the child's actual age, and that supports the diagnosis. In constitutional delay the bone age lags a little, and the height age sits close to the bone age; those two features support that diagnosis instead. A left wrist film is cheap and it separates the two commonest causes.
- THE COMMONEST CAUSES IN A COUNTRY LIKE THIS ARE NOT HORMONAL - a systemic illness of the lungs, the gut, the liver, the kidneys, the heart, the blood or the immune system upsets the body's balance, slows growth and shortens the child. Across much of the developing world it is malnutrition and chronic infection that account for most pathological short stature. Coeliac disease, iron deficiency, chronic parasites and untreated asthma all belong on this list and all have entries here.
- THE SCREENING BLOODS ARE ORDINARY - working out why a child is short takes the lot: a careful history, the family's included; anthropometry done meticulously; blood tests to screen for systemic illness; assessment of the growth hormone and IGF-1 axis; and, in selected children, imaging and molecular genetics. The hormone axis testing is the specialist's part; the screening for systemic illness is not.
- THE BABY WHO WAS BORN SMALL - an infant born small for gestational age - length or weight lower than 2 SDs from the mean - catches up in 85% to 90% of cases, and does so by 2 to 3 years of age; where families are poor, that catch-up may come late or never fully arrive. A child who does not catch up often stays short for life. Three years old with no catch-up is a referral.
- A CAUSE THAT SOCIAL WORK MENDS, NOT MEDICINE - where the shortness is psychosocial, taking the child out of the stressful home and into somewhere supportive and nurturing can produce catch-up growth on its own. It is rare and it is missed by anyone who only looks at bloods.
- TREAT WHAT IS UNDERNEATH IT - for every other cause, the treatment is aimed at whatever is causing it. Replace the hormone where one is deficient. Control the primary disease where a systemic illness is responsible. And where the diet is part of it, dietary advice is essential.
- WHEN THERE IS NOTHING WRONG, SAY SO PROPERLY - where the shortness is physiological, these children are medically well, so what needs managing is the effect on the child and the family. In constitutional delay, reassuring them is usually all that is required. In familial short stature, what matters is expectations that are realistic, and telling the family plainly that no disease underlies it.
- MANAGE THE EXPECTATION ABOUT GROWTH HORMONE - human growth hormone (hGH) is expensive and the results in idiopathic short stature, familial or not, vary. Say clearly how modest the height gained in familial short stature tends to be next to what growth hormone deficiency gains. A family who arrive asking for the injection need this said early, not after they have paid for it.
- NO GROWTH HORMONE DOSE IS PRINTED HERE - the article does give starting doses, and it also shows why they are not a primary-care prescription: the dose is chosen once growth hormone deficiency is confirmed, adjusted on growth response and IGF-1 every 6 to 12 months, and stopped on bone-age criteria. Thyroid function and cortisol are checked 3 months after the treatment starts and yearly thereafter, to catch other pituitary hormones failing. That is an endocrine clinic, not a card.
- THE PSYCHOLOGICAL PART IS PART OF THE TREATMENT - being short carries consequences in the body and in the world, since height counts socially and in the entry standards for certain jobs. Where it is causing real psychological distress, counselling is essential, to build ways of coping and to make life better.