Stunted growth with more or less normal appearance

Birthweight distribution in southern Chinese infants with symptomatic congenital heart disease

OBJECTIVE

Western infants with congenital heart disease have frequently been reported to have a low birthweight for gestational age. Studies in Asian infants seem to be lacking in this area. This is the first extensive study presenting the birthweight distribution of Chinese newborns with symptomatic congenital heart disease.

METHODS

The birth data of 454, mainly southern-Chinese infants with symptomatic cardiovascular defects, born between 1990 and 1995 and admitted to Grantham Hospital, Hong Kong in 1994 and 1995, were analysed retrospectively. Infants with (non)-genetic syndromes or other major extracardiac malformations were excluded.

RESULTS

Fifteen per cent of all newborns had a birthweight below the reference mean of - 2 Z-score. After correction for length of gestation, no significant difference could be detected in birthweight between the cyanotic and acyanotic groups, nor between the different haemodynamic disturbances. Infants with atrial or ventricular septal defects, tetralogy of Fallot, pulmonary atresia with ventricular septal defect, heart with univentricular atrio-ventricular connection or double outlet right ventricle showed significant birthweight deficits. Transposition of the great arteries was not related to being small for gestational age.

CONCLUSIONS

Similar to Western infants, prenatal growth impairment was a common feature in Chinese infants with symptomatic congenital heart disease. The birthweight distribution in Chinese might be comparable to that in Western populations. Exceptions are possibly the high frequency of low birthweight in Chinese newborns with atrial septal defect or a single-ventricle abnormality. Further studies on fetal anthropometry and haemodynamics are necessary to provide insight into the relation between cardiovascular malformations and being small for gestational age.

Postnatal growth in southern Chinese children with symptomatic congenital heart disease

Many Western children with congenital heart disease (CHD) show significant growth retardation. In this study postnatal growth was examined in Chinese children with symptomatic CHD in Hong Kong, in relation to their diagnosis and the time of surgery. 363 children of four years old or younger, who were admitted at Grantham Hospital, Hong Kong, in 1994 and 1995, were subdivided into six diagnostic categories and categorised into cyanotic and acyanotic groups. While a reduced birth weight SDS was present in 18% of patients, at the time of operation approximately 40% of them had subnormal weight and height values. Girls were more impaired in weight and weight-for-height than boys (-1.90 SDS vs -1.52 SDS, and -0.90 SDS vs -0.46 SDS, respectively). Children with acyanotic lesions were more affected in growth than those with cyanotic lesions, but they were also operated on at an older age than children in the latter group. Left to right shunt and common intracardiac mixing were particularly associated with wasting; transposition of the great arteries and pulmonary outflow tract obstruction with stunting; while children with left ventricular outflow obstruction revealed a proportional growth retardation in weight and height. Age at operation did not seem to have an independent effect on postnatal growth in children with CHD. As with Western children, growth retardation is a common feature in Chinese children with symptomatic cardiac defects. Haemodynamics, age at operation and nutritional influences are discussed as potential aetiologic factors.

[Definitive body height in constitutional retardation of growth and puberty]

BACKGROUND

Constitutional delay of growth and puberty (CDGP) is a frequent cause of short stature in childhood. Controversial results have been reported on the full achievement of these patients of their target height.

PATIENTS AND METHODS

The final adult height of 20 patients with CDGP (11 male and 9 female), who did not received hormonal treatment, was compared with their target height and with the predicted adult height, by the Bayley-Pinneau method obtained before the onset of puberty.

RESULTS

A spontaneous improvement of the stature from pre-puberty to adulthood was observed in all patients (from -2.9 +/- 0.7 SDS to -1.3 +/- 0.6 SDS in male and from -2.6 +/- 0.6 SDS to -0.9 +/- 0.3 SDS in female; P < 0.001). Adult height in male (166.4 +/- 4.1 cm) at the mean age of 21 years was very close to the target height (165.7 +/- 3.9 cm) and to the predicted adult height (167.3 +/- 3.1 cm). Also in female, final height (156.6 +/- 2.0 cm) did not differ from target height (153.3 +/- 4.2 cm) and from predicted adult height (155.6 +/- 2.3 cm).

CONCLUSIONS

In our experience, patients with CDGP reach their predicted adult height and achieve their genetic potential without medical treatment.

Chromosomal and genetic forms of growth failure

This chapter does not deal with single diseases, but gives a general account of chromosomal and genetically caused disturbances of growth; even a complete list and description of the various disorders would, in view of the large number of syndromes involving short stature, exceed its scope. Many chromosomal aberrations are non-viable disturbances of growth that lead to intrauterine amniotic death. Following a brief account of the normal development of the germ cell (gametogenesis, embryogenesis, phenogenesis) to the newborn, the incidence of the various chromosomal disturbances in the different stages of development and the effects on growth are discussed. In the case of chromosomal aberrations, particular attention is paid to the significance of mosaic formation. In addition, the new phenomena of genomic imprinting and uniparental disomy, exemplified by the Prader-Willi syndrome, are dealt with. Uniparental disomy, which was first demonstrated with the aid of molecular genetics, may provide an explanation for the sporadic appearance of many syndromes involving short stature. Many genes and environmental influences are involved in the individual shaping of body size so that a systematic classification of the various syndromes involving short stature is not possible. Finally, attention is drawn to the increased rate of formation of malignant tumours in certain syndromes involving disturbances of growth.

Clonidine treatment for short stature

34 pubertal children with constitutional growth delay (CGD) were treated with clonidine orally twice a day. In 25 of the children the height velocity rose on clonidine treatment, and in 21 of them by more than 2 cm/yr during the first 6 months of treatment (mean [SD] growth increment 4.4 [0.5] cm/yr). Of the 22 who were treated for 12 months the increment in height velocity was maintained in 13 (3.4[0.4] cm/yr). Withdrawal of clonidine for 6 months did not stop the stimulatory effect of the drug on linear growth in 6 children, but in the other 8 children height velocities fell to pretreatment levels or below. In a few children reinstitution of clonidine for 2-4 months resulted in a new increment in height velocity. A high height standard deviation score and low growth velocity before treatment were predictive of a good growth response to clonidine. Clonidine did not induce noticeable side-effects. It may be a useful form of therapy for children with CGD.

Introduction to the study of pre- and postnatal growth in humans: a review

This review is divided in several items. A brief introduction on the characterization of the growth processes is made; the ways of assessing fetal development and well-being, the factors acting on fetal growth and birth weight, the causes and post-natal consequences of prematurity and intrauterine growth retardation are discussed in the first part. The following items deal mainly with: the normal pattern of growth from birth to puberty according to sex, race, and nutritional status, with special mention to pubertal changes; methods for predicting adult height from skeletal age; the effect of hormones during pre- and post-natal life; and the genetics of adult stature. The remainder of this review deals with genetic causes of growth abnormalities. Constitutional delay of growth, familial short stature, hypothalamic-pituitary dwarfism, skeletal dysplasias and many genetic syndromes presenting intrauterine growth retardation are listed. Aneuploidy effects on human growth are extensively reviewed, and usual growth patterns in Down and Ullrich-Turner syndrome patients as well as other sex aneuploid individuals and mosaics are fully described. The influences of X and Y chromosomes on growth and maturation are also discussed. Finally, some remarks are made about overgrowth syndromes.