Introduction
Growth is a fundamental biological process valid for biological systems. It is expressed as increase of dimensions and size of the body of man. It is a well-known characteristic of the childhood and adolescence stages of life, which begins during the gestational phase. A given stature is normal when its value is included between −2 and 2 standard deviations (SD) compared with the average range of studied age and gender of the child.[1
Accordingly, it is considered to be a delay of growth in any child with stature lower than mean (−2 SD). The systematic follow-up of the stature–weight growth is a key component of the supervision of children. This allows detecting any delay in growth that might be a consequence of known chronic affection, which could be improved by appropriate care. Thus, allowing to minimize stature delay impact.[1 weight delay that might be due to congenital or acquired origins. Indeed, the early diagnosis allows detecting critical diseases and initiates appropriate treatments.[1
The purpose of this work is to study various clinical aspects of patients presenting a stature–weight growth delay (SWGD). The study reports the main exploration methods used and presents main etiological findings.
Patients and Methods
This retrospective study included 103 patients admitted in Endocrinology Diabetology and Metabolic Diseases Department of the University Hospital of Fez for exploration of SWGD. The study was carried out over a period of 6 years extending from January 2009 to October 2015.
The study included patients presenting a stature growth delay with a height size that was lower or equal to 2 SD for the corresponding age while considering the reference curve of Sempe and Pedron.[2
An investigating form allowed collecting data of demographics; patient's history, including the pregnancy evolution, neonatal pathologies, every chronic pathology, and family pathologies; the clinical examination data including weight (SD), stature (SD), targeted size (SD), and dysmorphic syndrome; paraclinical data, including basic biological assessment, hormones assessment, blood dynamic tests, and imaging assessment; and revealed etiologies, and indicated treatment.
Results
The study included 103 patients. The average age of our patients was 14.44 years, ranging from 5 to 21 years. Male predominance was significant with 68.93% of cases. The consanguinity and chronic pathologies were well demonstrated by patient's histories, with 19.4 and 17.65% of cases, respectively [Table 1 ].
Table 1: Pathological histories of studied patients
The clinical examination data showed an average weight of −2.37 SD and ranging from −4 SD to −0.5 SD [Figure 1 ]. The stature demonstrated values ranging between −4.5 SD and −2 SD for corresponding age with an average of −3.12 SD. A severe stature delay of −3 SD was noticed in 39.6% of assessed cases. The average SDs of the stature of patients at their adulthood compared to their genetic size was −2.44 SD and was ranging from −4 SD to −1.5 SD.
Figure 1: Presentation of the collected clinical data of patients
The revealed dysmorphic signs were deficient morphotype of growth hormone (GH) in 51.4% of cases, a micropenis in 31% of cases, and a syndrome morphotype of Turner in 11.6% of cases. Delayed puberty was noticed in 27.4% of cases, 23.3% demonstrated puberty onset, whereas 5.8% of the patients were pubescent [Table 2 ].
Table 2: Presentation of the signs dysmorphic symptoms revealed during clinical examinations
The biological assessment of our patients demonstrated hypochromic microcytic anemia in 9.7% of studied cases; serological positive celiac disease in 5.8% of cases; biopsy jejune positive celiac disease in 14.5% of cases; normal renal function and phosphocalcic assessments in all patients; a peripheral hypothyroidism with high thyroid stimulating hormone and low LT4 in 4.8% of cases; and insulin-like growth factor-1 (IGF1) was inferior than its lower limit for each age in 40.7% of cases. Results of biological assessments are summarized in Table 3 .
Table 3: Biological assessments achieved for each studied patients
GH stimulation tests
Hypoglycemia insulin test was achieved in 64 patients, Glucagon–propranolol test was done in 26 patients, and Clonidine test was done in 20 patients; global deficit of GH was shown in 41.7% of our patients and partial deficit in 30% of cases [Figure 2 ].
Figure 2: Results of growth hormones achieved in our patients
Karyotyping was indicated for 40 patients, and was realized in 13 patients, whereas result was positive in six patients with diagnosis of Turner syndrome. X-ray measurements of the left hand and wrist were realized in all patients; image data were interpreted according to GREULICH and PYLE method. The average osseous age was 11.3 years, and the average difference between chronological age and osseous age (CA-OA) was 3.32 years. Magnetic resonance imaging was done in 60 patients, and demonstrated pathological diagnosis in 14 patients. The disorder findings were syndrome of interruption of pituitary tract in seven patients, atrophic pituitary gland in three patients, a craniopharyngioma in two patients, and pituitary microadenoma and prolactin in one patient.
Various etiologies were implicated as origin of the stature delay in child with predominance of GH deficits [Figure 3 ]. The difference between CA-OA is determined by involved etiology. CA-AO is very important in the hypothyroidism and Turner syndrome, with an average age of 9 and 5 years, respectively.
Figure 3: Presentation of RSP etiologies of our patients
Celiac disease and GH deficit demonstrated difference superior to 2 years with an average of 4 and 3.1 years, respectively. Finally, CA-AO is lower in the puberty delay and the chronic diseases with an average of 2.67 and 2.17 years, respectively [Figure 4 ].
Figure 4: Difference between CA-AO according to RSP etiologies of our patients
The treatment using GH was suggested in 16 children since presenting a deficit in GH, and two girls presenting a Turner syndrome. Unfortunately, other cases of GH deficit were indigent without strong medical care security, hence they were lost. Inappropriate etiologic treatment was initiated in other cases.
Discussion
Primary care medicine (PCM) is a major tool for early diagnosis and further treatment orientation of stature and weight growth. Indeed, most stature–weight delays are revealed during primary care of third benign diseases and disorders. The delay of growth is a frequent indication of PCM consultation. Various etiologies are involved and are mostly endocrine.[3 4 5 6 7 et al . and Moayeri et al . reported a series where the average age at the first consultation was ranging between 2 and 15 years, with an average of 8.6 years.[2 8
The growth delay is defined by a stature lower or equal to third percentile or to −2 SD below the average value of given age, gender, and population geo-ethnicity.[1 et al . at the first consultation revealed that 63% cases demonstrated −2 SD and 37% showed a stature delay[2 2
The endocrine pathology is involved in <10% of SWGD. The endocrine etiology diagnosis is crucial because to find out appropriate treatment that improves the stature prognosis.[9 10 et al . and Moayeri et al . studies, including 50 and 34% of all etiologies, respectively.[7 8
Chronic diseases will slow the growth because of originating an increased basic metabolism and often in diseases such as anorexia, celiac disease, inflammatory diseases, renal disease, chronic lung disease, chronic encephalopathy, and heart disorders. According to some studies, the prevalence is varying from 5.9% reported by Rais et al . to 20.48%.[6 11
The genetic and malformative diseases are not frequent causes of stature delay; they are essentially dominated by Turner syndrome, which has to be evoked in context of any isolated apparent stature delay of females, thus Turner Syndrome represents 1/2500 at birth of females.[12
Conclusion
PCM is a major tool for early diagnosis and for further treatment orientation of stature and weight growth. Thus PCM is mostly finding endocrine etiologies that are insignificant causes of abnormal human small body size. It is required to discard any clause before initiating appropriate treatment. Stature and weight growth follow-up is essential and have to be systematic for every child. The dynamic and evolving aspect of stature and weight growth is very important; hence PCM must achieve measurements referenced within growth standards in the follow-up booklet and health file of children. This PCM assessment allows practitioner to detect without delay any abnormal growth, and therefore, helps in early detection of any critical diseases.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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