[Parenteral nutrition in treatment of short stature in adolescents with Crohn disease]

Growth retardation and delayed puberty occur in 20-35% of children and adolescents with Crohn's disease. Alternate day corticosteroid treatment, use of azathioprine, enteral or parenteral hyperalimentation and surgery have been advocated to reverse growth failure. Because of nonacceptance of elemental diet 7 patients with Crohn's disease and growth retardation received parenteral nutrition for 2-3 months (maximal for more than 30 months in one patient). All of them exhibited a mean weight gain of 10 kg and a mean increase of their height velocity from 2.4 to 7.1 cm/year. Main problems were bacterial infections and dislocations of the central lines. Surgery was performed in 3 adolescents immediately after parenteral nutrition. One patient showed a catch-up growth during a 30-months nocturnal home parenteral nutrition at a biological age of 21 years. Parenteral nutrition is an effective regimen to manage growth failure in children with Crohn's disease, but has to be performed for larger periods in individual cases.

[Growth disorders]

Growth assessment forms the basis of the management of endocrine disorders in childhood. However, it is important to emphasize that there is no clear demarcation between normal and abnormal stature and that an understanding of the various components of growth and its endocrine correlate is a basis of the logical investigations and the eventual diagnosis of growth disorders. In this context it is obvious that the definition of a tall or a short child is arbitrary. In fact, normal growth embodies many normal variants, not only terms of growing within or outside the percentiles, but also in terms of skeletal maturation and duration of puberty. It is worth reinterating that percentiles mean nothing more than the proportion of children who had reached given heights at given ages when they, the standardizing population, were measured. Therefore, percentile position in itself is of no consequence in the diagnosis or management of an individual child. To estimate the rate at which a child is growing, it is necessary to measure height on more than one occasion over a not too short period of time and to divide the increment in height by the time elapsed. As the growth of a normal child tends to follow a particular percentile an endocrine investigation becomes only necessary if a child is growing extremely quickly or slowly and if a significant deviation from the percentile lines becomes apparent.

[Shwachman syndrome. Exocrine pancreatic insufficiency, growth retardation, peripheral dysostoses and neutropenia]

Since the second year of her life a now 32-year-old woman had growth retardation and recurrent diarrhoea, caused by exocrine pancreatic insufficiency. During intermittent treatment with pancreatic enzymes the diarrhoea ceased and she gained weight. In the course of the illness she had to undergo several orthopaedic operations. Radiological examinations had revealed metaphyseal dysostoses. At the age of 14 years the marked growth retardation stimulated further clinical investigation. The growth retardation, compensated exocrine pancreatic insufficiency and peripheral dysostoses established the diagnosis of Shwachman syndrome, although there was no neutropenia. The severe exocrine pancreatic insufficiency, confirmed by pancreatic function tests, was probably compensated by extrapancreatic lipases, and pancreatic enzyme substitution therefore was unnecessary.

[Tooth and jaw development in the Silver-Russel syndrome]

The symptoms of Silver-Russel syndrome are described using two cases. Special attention was paid to the development of the teeth and the jaws. The typical microretrognathism is accompanied by a frontal crowding especially in the lower jaw. It is possible to adjust it to a regular occlusion using functional orthopedic appliances. Noticeable is the high degree of caries in the first dentition. Paramorphiae are not ascertainable. Etiologically, the submucosal cleft palate, which was diagnosed for the first time, would suggest an intrauterine disturbance in the eighth to the tenth week of pregnancy.

[Lucilia sericata infestation of the skin openings for the bone traction device in lengthening of the tibia: apropos of a case]

Fly larvae are responsible for animal disease well known by veterinarians. However, their finding in humans in nontropical countries is a rarity. Recently, we have found several larvae of Lucilia sericata in an achondroplastic child during the phase of lengthening of both tibiae with osteotax. We think that the myasis diagnosed in our patient is the first such case reported in the literature. For the time being, it should be considered a fortuitous finding and not as a complication of surgery.

Effect of human chorionic gonadotropin on growth velocity and biological growth parameters in adolescents with thalassaemia major

The effect of long-term human chorionic gonadotropin (HCG) therapy on the linear growth and biological growth parameters was studied in six thalassaemic boys aged 14.5-15.5 years old with hypogonadotropic hypogonadism. A significant (P less than 0.001) increase in growth velocity (from 3.3 +/- 0.3 to 7.6 +/- 0.6 cm/year) was found after 6-12 months of therapy, without acceleration of bone age. A striking improvement in pubertal development was observed. The treatment significantly increased growth hormone (GH) response to L-dopa administration (P less than 0.025) as well as sleep GH secretion (P less than 0.025). Serum growth factors, evaluated as thymidine activity during deep sleep, increased (P less than 0.001), but somatomedin C (Sm-C) levels did not. Prior to treatment, baseline and peak values of plasma growth hormone releasing hormone (GH-RH) following L-dopa were low. After HCG therapy, GH-RH response to L-dopa increased significantly (from 9.2 +/- 5.6 to 20.2 +/- 6.2 pg/ml; P less than 0.05), but remained (P less than 0.001) lower than in normal prepubertal children. This study suggests that in thalassaemia major an impaired GH-RH release can be observed, in addition to the described alteration in Sm-C generation.

Effect of pituitary hollow fiber units and thyroid supplementation on growth in the little mouse

Hollow fiber units containing allogeneic pituitary cells were implanted intracranially into heterozygous (lit/+) and homozygous, mutant (lit/lit) C57BL/6J "little" weanling mice. Over the 48 days of the experiment, heterozygous mice with pituitary cell implants had a lower percentage weight gain than control mice. Homozygous, mutant mice with cell implants, however, made significant weight gains over mutant controls. Long bone lengths were lower, and organ and carcass weights were higher, in heterozygous mice receiving pituitary cell implants than in control mice, but corresponding measurements in mutant mice with and without implants were not significantly different. Supplementation of the diet with thyroid powder increased the percentage weight gain during the latter half of the 48-day period in both genotypes with and without implanted cells. Thyroid-supplemented mutant mice with pituitary cell implants had significantly higher organ and carcass weights than other mutant groups. The little mouse may serve as a model for pituitary studies and for the treatment of isolated growth hormone deficiency type 1 in man.

[Case report on the positive development and caught-up growth in a child with psychosocial dwarfism]

The somatic, psychological and psychosocial findings in a boy with psychosocial dwarfism are presented in a 7-year follow-up report. The positive development achieved by the change of environment is described, particularly a catch-up growth from far below the 3rd percentile up to the 25th percentile.

[A case of anorectic dwarfism, its methods of care and their theories]

The management of a young female anorectic dwarf followed over ten years is studied. The author attempts to recognize specific earmarks in the patient's relationships during periods of resumed growth. Certain psychoanalytic [2, 5, 6, 9, 26, 36, 38, 52] and systemic [3, 12, 18, 32, 50], concepts are referred to as they provide material for understanding the relationships between self and self [45, 53], environment [11, 42], body [5, 6, 9, 36, 38, 56] and family [3, 13, 33, 49, 51, 57]. The author believes the periods of resumed weight gain, followed by statural gain, to be concomitant with decreases in the cleavages induced by the patient, and with a framing of her conflictual relationships. Further study is needed to confirm this hypothesis.

[Mother-child relationship and psychosocial dwarfism]

Results of a study of 11 children presenting what is known as psychosocial dwarfism are discussed. Clinical observations and projective tests (Rorschach) show the crux of the problem within the mother-child relationship to originate in reciprocal feeling of hate between mother and child. This hatred constantly manifests itself in daily life through acts and behaviour rather than through verbal expression. These results are in agreement with our findings in the psychotherapies of one child and one mother. Characterizing the mother-child relationship as ont of aggressiveness and hatred fits with other author's findings who describe the mother's neglect and rejection. However we think it is more adequate as it applies to both ends of the relation: mother on one hand, child on the other.

Psychosocial dwarfism: identification, intervention and planning

Psychosocial Dwarfism, a syndrome caused by deprivation, emotional stress and/or neglect, occurs in both infants and children. The identification of children who are delayed because of such stress can be difficult. This article reviews historical and observational diagnostic clues including typical family interactional patterns and attitudes. Diagnosis of PSD is made by a demonstration of change, generally one that occurs upon removal of the child from the family environment. This removal is frequently the beginning of the intervention process, the goal of which is the reversal of physical and psychological delays, the elimination of bizarre behaviors, and the completion of catch-up growth and stabilization of normal growth. Too little is known about successful treatment methods in cases of PSD. The success of interventions is validated by change and can only be determined over long-term follow-up. There is a great need for research and it is important that all health care workers become aware of this challenging disorder.

Extreme hypernatremia as a presenting sign of child abuse and psychosocial dwarfism

A 21-month-old girl presented with seizures and a serum sodium concentration of 206 meq/l. She had many of the features of psychosocial dwarfism, including short stature, bizarre eating and drinking habits, absent growth hormone response to arginine and insulin infusion and a rapid weight gain during her hospitalization. During the initial rehydration, the patient's weight gain was only 2 percent of her body weight. This finding probably indicates that her hypernatremia was chronic, did not represent acute dehydration and may well have derived from willful denial of water, although a chronic salt load could not be ruled out. This report further emphasizes that extreme hypernatremia may be the presenting feature of child abuse.

Growth failure with normal serum RIA-GH and low somatomedin activity: somatomedin restoration and growth acceleration after exogenous GH

Two three-year-old boys with dwarfism (height ages 1-4/2 and 1-11/12 years) and delayed bone ages (1-4/12 and 1-9/12 years) had normal growth hormone (GH) responses after stimulation and low levels of somatomedin. Unlike patients with Laron syndrome, the two patients generated normal levels of somatomedin after administration of exogenous hGH. Treatment with hGH (2 IU every other day) brought about a significant increase in the growth rate of both patients. The growth rate of the first patient increased from 2 cm/year before treatment to 12 cm/year on therapy. The growth rate of the second patient was 4.5 cm/year before treatment, and 8.3 cm/year while on treatment. The two cases represent a new syndrome of dwarfism which may be caused by secretion of a biologically inactive but immunoreactive GH.

[Proceedings: The clinical effects of human growth hormone. Report on an international symposium of the German Kabi Corp. on February 15, 1975 in Munich]

Report of an International Symposion (Febr. 15, 1975, Munich). Human growth hormone (HGH) acts on proliferation of cartilage, the basal process of growth, by the way of somatomedine and changes in protein metabolism. Growth can be enhanced in hypopituitary dwardism and with higher dosage in other forms of failure to thrive. HGH also seems to have a beneficial effect in patients with muscular dystrophy as shown in a preliminary report but not in thrombocytopenia. First observations on patients with osteogenesis imperfecta and on patients with non healing fractures of the long bones (pseudarthroses) have shown significant improvement. Of importance are the reports on stopping severe gastric hemorrhage in patients with stress ulcera.

Zinc deficiency occurring in females. Report of two cases

The syndrome of dwarfism, hypogonadism, iron-deficiency anemia and geophagia, first reported in 1960 from Iran, was thought to be limited to males. In 1971-1972 two females with the same clinical features were observed over a 14-month period. The anemia responded rapidly to iron. Growth and sexual development occurred promptly when 120 mg of zinc sulfate was administered daily in conjunction with a well-balanced diet and iron supplement. This diet prior to the addition of zinc sulfate, resulted in gradual but much slower growth and sexual development. Observations in these two patients provide confirmation of the occurrence of human zinc deficiency in females, which responds to large doses of zinc salt.