Is short stature a handicap? A comparison of the psychosocial functioning of referred and nonreferred children with normal short stature and children with normal stature

Evaluation of the MC3R gene pertaining to body weight and height regulation and puberty development

Recent studies reported an impact of the melanocortin 3 receptor (MC3R) on the regulation of body weight, linear growth and puberty timing. Previously, allele p.44Ile of a frequent non-synonymous variant (NSV) p.Val44Ile was reported to be associated with decreased lean body mass (LBM) and later puberty in both sexes. We Sanger sequenced the coding region of MC3R in 185 children or adolescents with short normal stature (SNS) or 258 individuals with severe obesity, and 192 healthy-lean individuals. Eleven variants (six NSVs) were identified. In-silico analyses ensued. Three rare loss-of-function (LoF) variants (p.Phe45Ser, p.Arg220Ser and p.Ile298Ser) were only found in severely obese individuals. One novel highly conserved NSV (p.Ala214Val), predicted to increase protein stability, was detected in a single lean female. In the individuals with SNS, we observed deviation from Hardy-Weinberg Equilibrium (HWE) (p = 0.012) for p.Val44Ile (MAF = 11.62%). Homozygous p.44Ile carriers with SNS had an increased BMI, but this effect did not remain significant after Bonferroni correction. In line with previous findings, the detected LoF NSVs may suggest that dysfunction in MC3R is associated with decreased body height, obesity and delayed puberty.

Analysis of risk factors and construction of a prediction model for short stature in children

BACKGROUND

Short stature in children is an important global health issue. This study aimed to analyze the risk factors associated with short stature and to construct a clinical prediction model and risk classification system for short stature.

METHODS

This cross-sectional study included 12,504 children aged 6-14 years of age from 13 primary and secondary schools in Pingshan District, Shenzhen. A physical examination was performed to measure the height and weight of the children. Questionnaires were used to obtain information about children and their parents, including sex, age, family environment, social environment, maternal conditions during pregnancy, birth and feeding, and lifestyle. The age confounding variable was adjusted through a 1 : 1 propensity score matching (PSM) analysis and 1,076 children were selected for risk factor analysis.

RESULTS

The prevalence of short stature in children aged 6-14 years was 4.3% in the Pingshan District, Shenzhen. The multivariate logistic regression model showed that the influencing factors for short stature were father's height, mother's height, annual family income, father's level of education and parents' concern for their children's height in the future (P < 0.05). Based on the short stature multivariate logistic regression model, a short stature nomogram prediction model was constructed. The area under the ROC curve (AUC) was 0.748, indicating a good degree of discrimination of the nomogram. According to the calibration curve, the Hosmer-Lemesio test value was 0.917, and the model was considered to be accurate. Based on a risk classification system derived from the nomogram prediction model, the total score of the nomogram was 127.5, which is considered the cutoff point to divides all children into low-risk and high-risk groups.

CONCLUSION

This study analyzed the risk factors for short stature in children and constructed a nomogram prediction model and a risk classification system based on these risk factors, as well as providing short stature screening and assessment individually.

Prevalence of short stature among children in China: A systematic review

IMPORTANCE

The prevalence and characteristics of short stature (SS) among children in China should be assessed to provide guidance for planning and implementation of nationwide public health policies. Thus far, there have been no accurate estimates of the prevalence of SS in China.

OBJECTIVE

To analyze the prevalence of SS among children in China and to explore the influences of sex, area, age, study year, and study site on prevalence rates.

METHODS

Relevant literature was identified by searching the following databases: PubMed, Embase, The Cochrane Library, Chinese Biomedical Literature, China Knowledge Resource Integrated, WeiPu, and WanFang databases. Meta-analysis was carried out using STATA 11.2.

RESULTS

This meta-analysis included 39 studies with 348 326 Chinese participants; the studies covered 20 provinces, municipalities, and autonomous regions. The pooled prevalence of SS was 3.2% (95% confidence interval [CI], 2.6%-3.7%; I 2 = 99.8%). The prevalence of SS in boys and girls were 3.1% (95% CI, 2.5%-3.7%) and 3.2% (95% CI, 2.6%-3.9%), respectively. The sex difference was not statistically significant (P > 0.05). The prevalence of SS was higher in rural areas than in urban areas (4.7% [95% CI, 3.6%-5.8%] vs. 2.8% [95% CI, 2.2%-3.4%]; P < 0.001). The prevalence of SS was higher in West China (5.2%; 95% CI, 4.4%-6.0%) than in Northeast China (0.6%; 95% CI, 0.3%-0.8%), East China (2.3%; 95% CI, 1.9%-2.8%), or Central China (2.9%; 95% CI, 1.9%-3.9%).

INTERPRETATION

The prevalence of SS among children was higher in western and rural areas of China. Close attention to children's growth and development is needed to prevent the occurrence of SS.

Etiologies, profile patterns and characteristics of children with short stature in Jordan

OBJECTIVES

Childhood growth influences their social and psychological behavior, and abnormal growth may reflect underlying pathological etiologies. It is important to diagnose children with short stature as early as possible to be able to manage treatable causes. We aim to study etiologies and characteristics of short stature in children in Jordan.

METHODS

This is a cross-sectional retrospective review of the medical records of children diagnosed with short stature at a referral university hospital. Clinical characteristics, auxological, laboratory, and radiological investigations were collected and analyzed.

RESULTS

Among a total of 551 children diagnosed with short stature, the number of boys was significantly higher than girls, 304 (55.2%) and 247 (44.8%), respectively with a p-value of 0.015. Average age at presentation for all patients was 10.24 ± 3.23, with no significant difference between boys and girls. Pathological etiology was higher than normal variants 55.7 and 44.3%, respectively with p=0.007. Constitutional delay of growth and puberty (CDGP) was the most frequent cause in the normal variant group, 59.8%. Among the pathological group, the most common etiology was growth hormone deficiency (32.2%) with mean age of presentation of 9.40 years and was not significantly different from the age in other etiological groups, 9.44 years and p=0.931.

CONCLUSIONS

Growth monitoring of children should start at an early age for boys and girls. Referral to the pediatric endocrine clinic should be considered when growth problems are suspected for accurate diagnosis and etiology profiling.

Adolescence and short stature: factors in adjustment to the diagnosis

PURPOSE

Adolescence is a time of change when suffering from a medical condition such as short stature can impact the emotional well-being of adolescents. Our objective was to study the adjustment of adolescents with short stature (SS), analyzing the factors influencing it.

METHOD

In this cross-sectional study, we evaluated 101 adolescents with SS from different hospitals in Valencia, Spain, using instruments validated for the sample: anxious and depressive symptomatology (as a diagnostic adjustment measure), psychopathology, self-esteem, physical self-concept, psychological well-being, and parenting styles. Descriptive analyses, t-tests for independent samples, Pearson correlations, hierarchical regressions, and fuzzy set qualitative comparative analysis models (fsQCA) were performed.

RESULTS

Emotional (β = 0.44; p  = 0.001) and hyperactive (β = 0.20; p = 0.001) symptoms predicted anxiety, emotional symptomatology (β = 0.25; p = 0.022), self-esteem (β = - 0.37; p = 0.001), and promotion of autonomy (β = 0.30; p = 0.001) predicted depression, and hyperactivity (β = 0.45; p = 0.001), self-esteem (β = - 0.43; p = .001), and humor (β = - 0.36; p = 0.001) predicted emotional distress. The fsQCA results show that none of the variables is a necessary condition for anxiety, depression, or emotional distress. However, different combinations of these variables are sufficient conditions to explain 85% of the high levels of anxiety, 81% of the low levels, 62% of the high levels of depression, 64% of the low levels of depression, and 74% of the high levels of emotional distress and 61% of the low levels. The most important variables in the fsQCA models were symptomatology, self-esteem, and parental styles.

CONCLUSION

The patient's family dynamics, self-esteem, and emotional difficulties were the most relevant factors in predicting adjustment.

Cosmetic stature lengthening: systematic review of outcomes and complications

Aims

To systematically review the outcomes and complications of cosmetic stature lengthening.

Methods

PubMed and Embase were searched on 10 November 2019 by three reviewers independently, and all relevant studies in English published up to that date were considered based on predetermined inclusion/exclusion criteria. The search was done using “cosmetic lengthening” and “stature lengthening” as key terms. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.

Results

A total of 11 studies including 795 patients were included. The techniques used in the majority of the patients were classic 3- or 4-ring Ilizarov fixator (267 patients; 33.6%) and lengthening over nail (LON) (253 patients; 31.8%), while implantable lengthening nail (ILN) was used in the smallest number of patients (63 patients; 7.9%). Mean end lengthening achieved was 6.7 cm (SD 0.6; 1.5 to 13.0), and the mean follow-up duration was 4.9 years (SD 2.1; 41 days to 7 years). Overall, the mean number of problems, obstacles, and complications per patient was 0.78 (SD 0.5), 0.94 (SD 1.0), and 0.15 (SD 0.2), respectively. The most common problem and obstacle was ankle equinus deformity, while the most common complications were deformation of the regenerate after end of treatment and subtalar joint stiffness/deformity.

Conclusion

Cosmetic stature lengthening provides favourable height gain, patient satisfaction, and functional outcomes, with low rate of major complications. Clear indications, contraindications, and guidelines for cosmetic stature lengthening are needed.

Cite this article: Bone Joint Res 2020;9(7):341–350.

Excessive Aesthetic Lower Limb Elongation Management

Supplemental Digital Content is available in the text.

With the evolution of surgical techniques and increased availability of cosmetic orthopedic surgery, new complications manifest. Uncontrolled lower limb elongation without limitations can be achieved by disinformation and undergoing surgery in different countries. Patients receive excessive surgical intervention due to misinforming surgeons and clinics of their previous medical history. We present a previously undocumented case of excessive lower limb elongation in an adult male patient and a treatment method for this novel pathology. Lack of personal constraint and severe aesthetic discomfort led the patient to undergo 3 elongation procedures in 3 clinics in different countries. Correction of excessive elongation is a delicate procedure, which must account for previous medical history, the patient’s psychological status, and strict adherence to anatomical standards. In this case, we managed to correct the complications from hyper-elongation by restoring the normal anatomical proportions of the lower limbs. The patient consented to publication of these findings and has undergone psychiatric evaluation in a specialized clinic after corrective surgery. It is important to properly educate patients of surgical risks and to evaluate all aspects of patient psychosomatic well-being before surgical intervention. Advances in aesthetic medicine underline the development of new iatrogenic pathologies. Excessive lower limb elongation can lead to significant musculoskeletal deformation, requiring precise surgical correction with account to normal anatomical proportions.

Dilemmas of growth hormone treatment for GH deficiency and idiopathic short stature: defining, distinguishing, and deciding

Worrisome growth can be a sign of underlying pathology but usually reflects healthy variation. It is often recognized through short stature, which is defined by arbitrarily separating height, a physical trait on a continuum, into "normal" and "abnormal." In some cases of worrisome growth, recombinant human growth hormone (rhGH) treatment is indicated to hasten growth/increase height. This review addresses the two most frequently treated indications for rhGH, growth hormone deficiency (GHD) and idiopathic short stature (ISS). A review of worrisome growth itself, of the history of GH treatment, of the blurry line between partial GHD and ISS, of the GH stakeholders, and of the outside pressures involved in these cases demonstrates the ambiguous platform upon which treatment decisions are made. The rhGH treatment decision process can be examined further by considering the three most impactful factors on parental height-related medical decision-making: treatment characteristics, child health, and psychosocial function. While it is important to note that treatment for classical GHD is uncontroversial and supported, treatment decisions for partial GHD and ISS are more complicated and require careful evaluation of both patient needs and the supporting evidence. As the rhGH community grows, physicians, parents, and patients are encouraged to engage in a shared decision-making process to navigate the many challenges facing the GH field. Although this review addresses GHD and ISS specifically, the issues discussed are often applicable to pediatrics as a whole.

How sociophenomenology of the body problematises the 'problem-oriented approach' to growth hormone treatment

This article examines how people who are shorter than average make sense of their lived experience of embodiment. It offers a sociophenomenological analysis of 10 semistructured interviews conducted in the Netherlands, focusing on if, how, and why height matters to them. It draws theoretically on phenomenological discussions of lived and objective space, intercorporeality and norms about bodies. The analysis shows that height as a lived phenomenon (1) is active engagement in space, (2) coshapes habituated ways of behaving and (3) is shaped by gendered norms and beliefs about height. Based on this analysis, the article challenges what we label as the 'problem-oriented approach' to discussions about growth hormone treatment for children with idiopathic short stature. In this approach, possible psychosocial disadvantages or problems of short stature and quantifiable height become central to the ethical evaluation of growth hormone treatment at the expense of first-hand lived experiences of short stature and height as a lived phenomenon. Based on our sociophenomenological analysis, this paper argues that the rationale for giving growth hormone treatment should combine medical and psychological assessments with investigations of lived experiences of the child. Such an approach would allow considerations not only of possible risks or disadvantages of short stature but also of the actual ways in which the child makes sense of her or his height.

Cosmetic bilateral leg lengthening using intramedullary nail experience of 9 cases

Background

Distraction osteogenesis to correct deformity and limb-length discrepancy was defined by Ilizarov. Traditional distraction osteogenesis was made with circular external fixators or monolateral fixators commonly for deformity, and external fixators was related with pin site infections and pain due to soft-tissue transfixation. Nowadays, bone lengthening method is used with different intramedullary nail systems for cosmetic purposes.

Methods

From 2011 until 2018, a total of 9 patients (6 males and 3 females:16 femoral, 2 tibial), with constitutional short stature, to whom the intramedullary nail lengthening technique for cosmetic purposes had been applied, were retrospectively reviewed. The mean age was 28.3 while the mean height before the lengthening was 151 cm.

Result

The mean lengthening gained in all patients were 8.7 cm. The mean follow-up period was 22 ± 11 months while the healing index with normal bone healing was 46.8 ± 16 months/cm. Complications that we noted were; insufficient bone regeneration (n = 2), quadriceps contracture (n = 1), proximal locking screw runaway (n = 1).

Conclusion

Bone lengthening for aesthetic purposes with different nail systems can be very safe and beneficial to the patients improving their social capabilities and self-confidence. Yet, patients should be well informed about the complications and risks of the lengthening surgery.

Growth hormone therapy and short stature-related distress: A randomized placebo-controlled trial

CONTEXT

Growth hormone (GH) treatment of short healthy children is based on the belief that short stature is associated with psychosocial problems and a diminished quality of life.

OBJECTIVE

To determine the impact of GH therapy on psychosocial well-being and the ability of psychological metrics to define short stature-related distress.

METHODS

Sixty prepubertal boys with idiopathic short stature (age: 10.0 ± 1.4 years, height-SDS: -2.38 ± 0.3) were enrolled in this 4-year intervention study (1-year double-blinded, randomized, placebo-controlled [GH/placebo-2:1] and 3-year open-labelled GH therapy). Explicit (conscious/voluntary) psychological metrics (Pediatric Quality of Life Inventory [PedsQL], Silhouette Apperception Test [SAT], Rosenberg Self-Esteem Scale [RSES], Child Behavior Checklist [CBCL]) and implicit (unconscious/involuntary) psychological metrics (Single-Category Implicit Association Test for height [SC-IAT-H], Height Perception Picture Test [HPPT]). Psychosocial evaluations were performed at study entry, after 1 and 4 years.

RESULTS

At study entry, PedsQL of boys with idiopathic short stature was lower than Israeli norms (P = 0.001). After 1-year blinded intervention, only the GH-treated boys improved their actual and anticipated adult height perception (SAT, P < 0.001 and P = 0.022) with reduced short stature-related distress (SC-IAT-H, P < 0.001). At study end, RSES and SC-IAT-H improved significantly (P < 0.001), with no change in PedsQL and CBCL.

CONCLUSIONS

Our finding of improved psychosocial functioning only in the GH-treated boys after 1-year blinded intervention suggests that it was the GH therapy, rather than being enrolled in a clinical trial, which contributed to the outcome. Long-term open-labelled GH treatment significantly improved height perception and self-esteem. Future studies are needed to fully assess the relevance of complementing the routinely used explicit self-report measures with the implicit measures.

A Retrospective Analysis of Patients with Short Stature in the South of China between 2007 and 2015

OBJECTIVE

To describe the demographic features of children with short stature and poor growth in the south of China and provide better guidance on clinical strategy and decisions.

STUDY DESIGN

This retrospective, chart review study analyzed children with short stature and poor growth admitted to the Department of Endocrinology of Children's Hospital of Nanjing Medical University from Jan 2007 to Dec 2015.

RESULTS

The chart review yielded 4142 patients, including 2546 boys and 1596 girls (P < 0.001); the number of patients gradually increased per year from 2007 to 2015. There was an upward trend in the average levels of height standard deviations (SDs) during the study period (P < 0.001), both in males (P < 0.001) and females (P < 0.001). Mean height SDs were smaller in females (-2.42±1.09) than males (-2.33±1.03; P = 0.01). The percentage of females admitted at normal height (33.83%) was lower than that of males (37.20%; P = 0.028). The peak age range of hospitalization in males was 10-12 years of age, while females were generally admitted earlier-8-10 years.

CONCLUSIONS

There was an increasing tendency to focus on children's height. Parents and pediatricians were recommended to pay more attention to the treatment needs of girls while avoiding excessive treatment of those who merely appear not to be tall enough without a clear medical issue related to growth, especially for boys.

Relevance of polymorphisms in MC4R and BDNF in short normal stature

Background

Variation in genes of the leptinergic-melanocortinergic system influence both body weight and height. Because short normal stature (SNS) is characterized by reduced body height, delayed maturation and leanness, allelic variation of genes in this pathway are hypothesized to affect this common condition.

Methods

We analyzed the coding regions of LEP, MC4R, MRAP2 and BDNF in 185 children with SNS (height < 5th percentile) to search for non-synonymous and frameshift variants. For association studies (two-sided χ²-tests) population-based data sets (ExAC, EVS and KORA) were used. Cyclic AMP accumulation, cell surface expression, central expression and MAP kinase activation were assayed in vitro to determine the functional implications of identified variants.

Results

We detected eleven variants predicted to be protein-altering, four in MC4R, four in BDNF, and three in MRAP2. No variants were found in LEP. In vitro analysis implied reduced function for the MC4R variant p.Met215Ile. Loss-of-function is contrary to expectations based on obesity studies, and thus does not support that this variant is relevant for SNS. The minor SNP alleles at MC4R p.Val103Ile and BDNF p.Val66Met were nominally associated with SNS.

Conclusion

Taken together, although genes of the leptinergic-melanocortinergic system are important for normal growth, our data do not support the involvement of rare mutations in LEP, MC4R, MRAP2 or BDNF in short normal stature.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1245-1) contains supplementary material, which is available to authorized users.

Cosmetic lengthening: what are the limits?

OBJECTIVES

In the last decades, limb lengthening has not been limited to the treatment of patients with dwarfism and deformities resulting from congenital anomalies, trauma, tumor and infections, but, has also been used for aesthetic reasons. Cosmetic lengthening by the Ilizarov method with circular external fixation has been applied to individuals with constitutional short stature who wish to be taller.

MATERIALS AND METHODS

From January 1985 to December 2010, the medical records of 63 patients with constitutional short stature (36 M, 27F; 126 legs) who underwent cosmetic bilateral leg lengthening using a hybrid advanced fixator according to the Ilizarov method, were reviewed, retrospectively. The mean age was 24.8 years, while the mean preoperative height was 152.6 cm. Paley's criteria were used to evaluate problems, obstacles, and complications from the time of surgery until 1 year after frame's removal.

RESULT

The mean lengthening achieved in all patients was 7.2 cm (range: 5-11 cm), with a mean duration of treatment of 9 months and 15 days (range: 7-18 months). The mean follow-up time was 6.14 years (range 1-10).

CONCLUSION

The cosmetic leg lengthening was helpful to all patients, improving their social capabilities and self-confidence. All patients considered their stature as normal and they reported satisfaction and gratification with important changes in their professional and personal life. Cosmetic leg lengthening may raise some ethical objections and for that reason patients should be well informed about all the risks and complications related to this type of surgery.

Association of short stature with life satisfaction and self-rated health in children and adolescents: the CASPIAN-IV study

BACKGROUND

Data on stature in Iranian children and adolescents at national level are limited. The purpose of this study was to investigate the association of short stature with life satisfaction (LS) and self-rated health (SRH) in children and adolescents.

METHODS

Data were obtained from a nationwide survey entitled childhood and adolescence surveillance and prevention of adult non-communicable disease (CASPIAN IV). Participants were 14,880 children and adolescents, aged 6-18 years, who were selected using multistage, cluster sampling method from rural and urban areas of 30 provinces of Iran. LS and SRH were evaluated for every participant by the validated questionnaire prepared based on the global school-based student health survey of the World Health Organization (WHO). Height was measured according to the standard protocol. Short stature was defined as height less than -2 standard deviation (SD) below the mean height for age and sex.

RESULTS

Overall, 13,484 participants with a mean (SD) age of 12.5 (3.36) years (49.24% girls, 50.75% boys) completed the study (response rate 90.6%). The prevalence of short stature, poor SRH and life dissatisfaction was 9%, 20.04% and 20.09%, respectively. Although in the univariate model, participants with short stature had significantly lower odds of LS [odds ratio (OR): 0.83, 95% confidence interval (CI): 0.71-0.97] and good SRH (OR: 0.79, 95% CI: 0.68-0.92), in the multivariate model, only the association of short stature with good SRH remained statistically significant (OR: 0.82, 95% CI: 0.69-0.98).

CONCLUSIONS

Results of the present study show that participants with short stature are at the greater risk of poor SRH and decreased LS in comparison with the subjects with normal height.

Understanding the impact of statural height on health-related quality of life in German adolescents: a population-based analysis

Improving health-related quality of life (HrQoL) is one aim of growth hormone treatment for short-statured patients. Yet, evidence of the relationship between height and HrQoL is inconclusive, especially for young people. This study investigates the association of height and HrQoL in the general German adolescent population. A total of 6646 adolescents and 6388 parents from the German Health Interview and Examination Survey for Children and Adolescents (KIGGS) were included in the analysis. An analysis of covariance was used to evaluate the effect of height deviation on HrQoL as assessed with the KINDL-R in adolescent self-report and parent-report, taking into account sociodemographic and health-related variables. Height was found to be a weak predictor of HrQoL in both adolescent-report and parent-report. Short and tall adolescents did not substantially differ from the normal statured. Sociodemographic and health-related variables failed to significantly interact with height. In contrast, psychosocial variables contributed to the explained HrQoL variance.

CONCLUSION

Height does not appear to be a strong determinant of HrQoL on the population level. These results suggest that the height gain in short stature treatment may not be the most important objective. Contrary to prevalent stereotypes, short adolescents can experience a high HrQoL.

Safe Cosmetic Leg Lengthening for Short Stature: Long-term Outcomes

It is well known that limb lengthening is performed to treat limb-length discrepancies resulting from congenital anomalies and developmental problems. However, few studies discuss lengthening for cosmetic purposes. The current authors conducted a prospective study with long-term follow-up. From July 2002 through June 2007, 133 patients requested that their height be increased. Fifty-two were approved to undergo limb-lengthening surgery. Two were lost to final follow-up, leaving 50 in the study group. For all patients, the Ilizarov ring external fixator was applied with a maximum-stability technique that achieved frame stability and allowed patients to ambulate with a walker from the first week postoperatively. The method requires close follow-up for early detection of problems. Physiotherapy improved ankle function and prevented plantar flexion deformity, which can occur during lengthening. Excellent final outcomes were achieved in all patients except one, who required additional surgery. The Ilizarov device is a safe tool for limb lengthening in individuals of short stature when applied with the authors' maximum stability technique. To the authors' knowledge, this is the first article on this topic to report long-term results (minimum 5-year follow-up for all patients). Many factors influence the outcome of lengthening surgery performed with Ilizarov devices: the material of the rings, the use of a hybrid technique combining pins and wires, the diameter and number of pins over each bone segment, the size of the rings around the limb, the surgical technique for pin insertion, and the use of hydroxyapatite-coated pins or regular stainless pins.

Parents' perception about child's height and psychopathology in community children with relatively short stature

PURPOSE

This study investigated the relationship between height and psychopathology in community children with relatively short stature according to the parents' reports. Also, the matter of parental concern about child's height was explored.

METHODS

The child behavior checklist (CBCL), the Brief Encounter Psychosocial Instrument (BEPSI), and the child-health questionnaire-parent form 50 (CHQ-PF50) were administered to 423 parents (from elementary and middle school children's) in Gangnam, South Korea. Subjects were divided into three groups; (1) relatively short (n=30), (2) average stature (n=131), (3) relatively tall (n=153). CBCL, BEPSI, and CHQ-PF50 scores were compared among three groups.

RESULTS

There were no significant differences in psychosocial burden associated with relatively short stature measured by Korean version of the BEPSI and Korean version of the CBCL scores among three groups. But general health perception score of relatively short was significantly lower than that of nonshort on the CHQ-PF50. Also, they were more used complementary medicines, milk and growth hormone compared to the nonshort. The parents' expected height of their children was 180.6±3.5 cm for boys and 166.7±3.5 cm for girls. This is respectively 90 percentile and 75-90 percentile for the Korean standard adult height.

CONCLUSION

Our study shows that in Korea, Parents tended to regard relatively short children as having health problems. Also, the parental expectation for their child's attainable height is unrealistically tall, mostly due to lack of correct medical information.

Etiologies and characteristics of children with chief complaint of short stature

PURPOSE

Short stature is a very common reason for visits to pediatric endocrine clinics. It could be the first sign of an underlying disease. The purpose of this study is to investigate the etiologies and general characteristics of subjects who visited an outpatient clinic due to short stature.

METHODS

We retrospectively reviewed the medical records of 3,371 patients who visited Severance Children's Hospital with the chief complaint of short stature from 2010 to 2012. Medical history, auxological data, and laboratory tests including bone age were collected and analyzed. Chromosome studies or combined pituitary function tests were performed if needed.

RESULTS

Approximately 89.4% of the subjects with the chief complaint of short stature who visited the outpatient clinic were of normal height, and only 10.6% of subjects were identified as having short stature. Of the subject of short stature, 44.7% were classified as having normal variant short stature; that is, familial short stature (23.0%), constitutional delay in growth (17.7%), and mixed form (3.9%). Pathological short stature was found in 193 subjects (54.2%). Among pathological short stature, most common etiology was growth hormone deficiency (GHD) (38.9%).

CONCLUSION

A majority of children had a normal height. Among children with short stature, pathological short stature and normal variants occupied a similar percentage. GHD was the most common cause of pathological short stature and found in about 20% of the children with short stature. In pathological short stature, the height, height velocity, and IGF-1 level were lower than in normal variants.

Clinical dilemmas in evaluating the short child

Concerns about a child's growth are one of the most common topics parents voice during general pediatric office visits and are a leading cause for referral to a pediatric endocrinologist. There are a variety of conditions that lead to short stature in children; however, in the absence of true pathology, idiopathic short stature and constitutional delay are the most frequent causes. This article reviews the general approach to evaluating the short child and clinical signs that should prompt further evaluation and referral. We also address the unique psychological issues that these children face and approaches to counseling families with a child with idiopathic short stature.

Low incidence of pathology detection and high cost of screening in the evaluation of asymptomatic short children

OBJECTIVE

To determine the incidence of pathology during routine screening of healthy short children, testing adherence to a consensus statement on the diagnosis and treatment of children with idiopathic short stature, and the cost per identified diagnosis resulting from comprehensive screening.

STUDY DESIGN

Retrospective chart review of 1373 consecutive short stature referrals evaluated at the Cincinnati Children's Hospital Medical Center Pediatric Endocrinology Clinic between 2008 and 2011. We identified 235 patients with a height of <3rd percentile, negative history and review of systems, and normal physical examination. Outcome measures were incidence of pathology detection, diagnostic group characteristics, clinicians' adherence to testing guidelines, and screening costs. ANOVA and χ(2) were used to analyze the data.

RESULTS

Nearly 99% of patients were diagnosed as possible variants of normal growth: 23% with familial short stature, 41% with constitutional delay of growth and maturation, and 36% with idiopathic short stature. The incidence of newly diagnosed pathology was 1.3%: 1 patient with biopsy-proved celiac disease, 1 with unconfirmed celiac disease, and 1 with potential insulin-like growth factor I receptor defect. On average, each patient had 64.3% of the recommended tests for age and sex; 2.1% of patients had all of the recommended testing. The total screening tests costs were $315321, yielding $105107 per new diagnosis entertained.

CONCLUSIONS

Healthy short children do not warrant nondirected, comprehensive screening. Future guidelines for evaluating short stature should include patient-specific testing.

Treatment of children and adolescents with idiopathic short stature

Idiopathic short stature (ISS) is defined as shortness in childhood without a specific cause. ISS may be familial or nonfamilial and may be associated with or without delay of pubertal development. Treatment can be considered in an attempt to reduce the psychological burden caused by short stature in childhood and adult life. If counselling alone is not sufficient, medical modifications of the growth process can be attempted. In cases with pubertal delay, sex steroids, such as testosterone and oxandrolone, can favourably influence height velocity and growth tempo, although adult height is not affected. Medications that prolong the process of growth--for example, gonadotropin-releasing hormone agonists or aromatase inhibitors--might increase adult height, but findings to date are still experimental. Growth hormone therapy is approved for the treatment of very short children with reduced adult height expectation, as evidence has accumulated that this therapy can increase height in childhood and in adult life. Sensitivity to growth hormone is impaired in patients with ISS; therefore, doses higher than a replacement dose have to be applied. This treatment still needs to be optimized in terms of efficacy, cost-effectiveness and long-term safety. A debate is ongoing concerning the psychological benefit of height increase, with clinicians warning against the medicalization of a deviation in height.

Debate: idiopathic short stature should be treated with growth hormone

In this paper we outline the case for and against the treatment of idiopathic short stature with growth hormone. Drs Ambler and Fairchild argue that many of those with 'idiopathic' short stature are not 'short, normal children' and will ultimately receive molecular diagnoses. They also argue that there is a subset of children who suffer negative psychosocial consequences of their stature for whom growth hormone therapy is effective. Growth hormone has a very good safety record and is likely to be as cost-effective in idiopathic short-stature as in some other conditions that are currently funded. Dr Wilkinson counters that short stature is not associated with physical or psychological illness, and that there is no evidence that growth hormone improves psychological or physical wellbeing. Moreover, growth hormone for idiopathic short stature represents a form of enhancement rather than treatment, and is not a fair use of resources. Socially mediated disadvantage should be treated by attention to prejudice and not by hormone treatment.

Physical growth and cognitive skills in early-life: evidence from a nationally representative US birth cohort

This paper establishes associations between length/height and cognitive skills in infancy, toddlerhood, and school-entry. The data come from the Early Childhood Longitudinal Study--Birth Cohort (ECLS-B), a representative longitudinal sample of US children born in 2001. A positive association between length/height and cognition is found as early as 9 months and continues through school-entry. These associations are robust to controls for birthweight and economic status. Early growth is also shown to be a stronger predictor of reading and math skills in kindergarten than attained height. Girls exhibit stronger evidence of this latter result than boys. These findings have implications for the interpretation of early life as a critical period for the growth-cognition relationship.

Height and health-related quality of life: a nationwide population study

CONTEXT

Treatment for short stature in childhood has been recommended with the purpose of improving adult health-related quality of life (HRQoL). However, there are only limited data available concerning the consequences of body height for HRQoL in adulthood.

OBJECTIVE

Our objective was to investigate the relationship between body height and HRQoL.

DESIGN, SETTING, AND PARTICIPANTS

This national representative, cross-sectional household survey of the French general noninstitutionalized population included 8857 men and 9248 women, aged 18-50 yr, in 2003.

MAIN OUTCOME MEASURES

Scores on the eight subscales of the Medical Outcomes Study 36-item Short Form (SF-36) were the primary outcomes. Univariate and multivariate linear regression analyses were used to evaluate the effect of height on HRQoL while controlling for age and various socioeconomic variables and pathological conditions.

RESULTS

Height was found to be a very weak predictor of HRQoL both for men and women. Only heights lower than 149.2 and 136.0 cm and higher than 203.6 and 188.7 cm, in men and women, respectively, were associated with a clinically significant reduction in physical functioning. The effects of body height on other (mental and social) dimensions of HRQoL were negligible or undetectable.

CONCLUSIONS

Height appears to have minimal consequences for physical functioning and negligible effects on other dimensions of HRQoL. These results contrast with widely popularized stereotypes and common beliefs and should be carefully considered to avoid further stigmatization and unnecessary medical care of individuals who are at the lower end of the growth distribution.

Emerging options in growth hormone therapy: an update

Growth hormone (GH) was first used to treat a patient in 1958. For the next 25 years it was available only from cadaver sources, which was of concern because of safety considerations and short supply. In 1985, GH produced by recombinant DNA techniques became available, expanding its possible uses. Since that time there have been three indications approved by the US Food and Drug Administration (FDA) for GH-deficiency states and nine indications approved for non-GH-deficiency states. In 2003 the FDA approved GH for use in idiopathic short stature (ISS), which may indirectly cover other diagnoses that have short stature as a feature. However, coverage for GH therapy is usually more reliably obtainable for a specific indication, rather than the ISS indication. Possible future uses for GH therapy could include the treatment of syndromes such as Russell-Silver syndrome or chondrodystrophy. Other non-short-stature indications could include wound healing and burns. Other uses that have been poorly studied include aging and physical performance, in spite of the interest already shown by elite athletes in using GH. The safety profile of GH developed over the past 25 years has shown it to be a very safe hormone with few adverse events associated with it. The challenge for the future is to follow these patients into adulthood to determine whether GH therapy poses any long-term risks.

Psychiatric treatment: A risk factor for obesity?

BACKGROUND

People with psychiatric diagnoses have increased physical health difficulties.

OBJECTIVES

To examine the physical growth parameters documented in children receiving psychiatric treatment.

METHODS

A chart review was performed on consecutive paediatric consultations in 1997 and 1998 on 34 children six to 12 years of age admitted to an intermediate-stay psychiatric inpatient service. Growth parameters of each child were plotted on standard growth curves. The prevalence of obesity (body mass index at or above the 95th percentile), absolute weight at or above the 95th and 50th percentiles, underweight status, tall and short stature, macrocephaly and microcephaly were calculated. The prevalence of atypical findings was compared with the expected prevalence of typical growth parameters in the general population. Risk factors for atypical growth parameters were recorded. An association between weight and specific medication use was explored.

RESULTS

It was found that 11.8% of the children were obese. It was also found that 23.5% of the children had weight at or above the 95th percentile, 79.3% had weight at or above the 50th percentile, 14.7% had macrocephaly and 79.4% had a head circumference above the 50th percentile; these results were statistically significant. The mean number of psychotropic medications prescribed was 6.4, although there was no significant association between higher weight and current medication type.

CONCLUSIONS

Children receiving inpatient psychiatric treatment were more likely to have higher weight than typical children. Monitoring growth parameters is an important component of the paediatric care of children with psychiatric diagnoses. Guidelines are required for obesity prevention and intervention in the context of the risk factors experienced by this high risk population.

Health-related quality of life and cognitive functioning in pediatric short stature: comparison of growth-hormone-naïve, growth-hormone-treated, and healthy samples

The objective of this study was to evaluate the impact of short stature on generic health-related quality of life (HRQOL) and cognitive functioning in pediatric patients. Eighty-nine youth, 48 who were initially seen with short stature (SS group) and 41 with a history of short stature being treated with growth hormone (GHT group) and one of their legal guardians participated in the study. HRQOL and cognitive functioning were assessed using the PedsQL™ 4.0 Generic Core Scales and PedsQL™ Cognitive Functioning Scale. Comparisons were made between the study groups and with a previously obtained matched healthy sample. For the GHT group, height Z score was found to be a positive predictor of overall HRQOL while duration of GHT was found to be a predictor of physical functioning. For the SS group, the difference between midparental height Z score and height Z score was found to be a negative predictor of overall HRQOL and cognitive functioning. Comparison with the healthy sample demonstrated significant negative impact on HRQOL for child self-report and on HRQOL and cognitive functioning for parent proxy-report in both study groups. The GHT group had a significantly higher child self-reported Physical Functioning score than the SS group (effect size (ES) = 0.52, p < 0.05). In conclusion, the GHT group had slightly better HRQOL scores than the SS group, but the difference was not statistically significant. Both groups had significantly lower HRQOL and cognitive functioning scores than healthy sample. Predictors of HRQOL and cognitive functioning found in this study lend support to the use of the PedsQL™ 4.0 Generic Score Scales and PedsQL™ Cognitive Functioning Scale in routine assessment of children with short stature in order to identify children at increased risk for impaired HRQOL and cognitive functioning.

Managing idiopathic short stature: role of somatropin (rDNA origin) for injection

Idiopathic short stature (ISS) is a term that describes short stature in children who do not have growth hormone (GH) deficiency and in whom the etiology of the short stature is not identified. Between 1985 and 2000, more than 40 studies were published regarding GH therapy for ISS. Only 12 of these had data to adult height, of which only 4 were controlled studies. A subsequent placebo-controlled study that followed subjects to adult height indicated that there was a gain of 3.7–7.5 cm in height with GH treatment. In 2003, the US Federal Drug Administration (FDA) approved GH for treatment of short stature. Even before FDA approval, patients with ISS made up about 20% of patients in GH databases, which is largely unchanged since FDA approval. There remains some controversy as to whether GH should be used to treat ISS. This controversy centers on the fact that there has been no definitive demonstration that short stature results in a disadvantage or problems with psychological adjustment, and thus, no demonstration that GH therapy results in improvement in quality of life.

Growth hormone: health considerations beyond height gain

The therapeutic benefit of growth hormone (GH) therapy in improving height in short children is widely recognized; however, GH therapy is associated with other metabolic actions that may be of benefit in these children. Beneficial effects of GH on body composition have been documented in several different patient populations as well as improvements in lipid profile. Marked augmentation of bone mineral density also seems evident in many pediatric populations. Some of these benefits may require continued therapy past the acquisition of adult height. With long-term therapy of any kind, the adverse consequences of treatment should also be considered. Fortunately, long-term GH treatment seems to be safe and well-tolerated. This review describes the long-term metabolic effects of GH treatment in the pediatric population and considers how these may benefit children who are treated with GH.

Short stature in a population-based cohort: social, emotional, and behavioral functioning

OBJECTIVE

The goal was to determine whether there were significant differences between children of normative versus short stature in behavioral functioning and peer relationships, according to teacher and child reports.

METHODS

The study included 712 boys and girls in the sixth grade, from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main outcome measures included Achenbach Teacher's Report Form internalizing, externalizing, and total scores; Children's Depression Inventory scores (child report); Life Orientation Test-Revised scores (child report); Child Behavior with Peers questionnaire asocial with peers, excluded by peers, and peer victimization subscale scores (teacher report); peer social support and victimization scores (child report); and relationships with peers score (teacher report). In bivariate comparisons, these outcomes were compared for children of relatively short (height of <10th percentile) versus nonshort (height of > or =10th percentile) stature, and effect sizes were calculated. Multivariate linear regression models adjusted for maternal education, income/needs ratio, race, and gender.

RESULTS

Effect sizes ranged from 0.00 to 0.35. Short children reported marginally higher levels of self-perceived peer victimization, compared with their nonshort peers. There were no significant differences in the rest of the outcomes for children of short versus nonshort stature, in either unadjusted or adjusted models.

CONCLUSION

Although short children from a population-based sample reported marginally higher levels of self-perceived peer victimization, they did not differ from their nonshort peers in a range of social, emotional, and behavioral outcomes.

The influence of weight and height status on psychological problems of elementary schoolchildren through child behavior checklist analysis

PURPOSE

This study aimed to evaluate weight and height status and their relationship with psychological problems among elementary schoolchildren.

MATERIALS AND METHODS

A total of 405 schoolchildren (211 boys and 194 girls, aged: 10-13 years), living in Seoul, Korea, participated in this study. The participants were divided into 3 groups according to their weight and height standard deviation score. Psychological assessments were performed using the Korean-Child Behavior Checklist (CBCL).

RESULTS

In this study, 34.4% of boys and 32.1% of girls showed dissatisfaction with their weight, whereas 26.2% of boys and 30.2% of girls showed dissatisfaction with their height. The obese group showed higher weight dissatisfaction than the normal or underweight groups (p < 0.001). The short stature group showed higher dissatisfaction in their height than the normal group (p = 0.01). There was no significant difference in total CBCL problems score according to weight or height status. The underweight and obese groups had higher score for social problems than normal weight group (p < 0.05 respectively). There were no significant differences in each CBCL problem score by height status. As a whole, the prevalence rate of a CBCL total problems score in the clinical range was 3 percent (12/405). These children showed no difference in terms of weight or height, compared with normal students. Among the factors related, only school performance was negatively correlated with the total problems score (p < 0.01).

CONCLUSION

Approximately one-third of elementary schoolchildren were dissatisfied with their height or weight. Although their total CBCL psychological problem scores were closely related with school performance, they did not show any significant relation with height or weight status. Contrary to the general view, our study suggests that psychological problems of elementary schoolchildren may be related more with their school performance than their body physique.

Idiopathic short stature: conundrums of definition and treatment

Children with idiopathic short stature (ISS) are statistically defined by height SDS < −2 for their bone age and should be distinguished from children with familial short stature for whom height SDS corresponds to mean parental SDS and from the most common explanation for short stature referred to pediatric endocrinologists, constitutional delay in growth and maturation (CDGM), in which there is normal height for bone age and predicted normal adult stature. Low IGF-I levels reported in ISS may be the result of subtle undernutrition or reference to standards appropriate for chronologic age but not osseous maturation in CDGM inappropriately labeled as ISS. While growth hormone (GH) treatment of ISS may add 4-5 cm to adult height, meta-analysis indicates that there is no documented evidence that such treatment improves health related quality of life or psychological adaptation. Thus, the estimated cost of US$52 000/inch gained is difficult to justify. Absence of data regarding efficacy of the use of IGF-I for treatment of ISS has been noted in a recent consensus statement from the North American and European pediatric endocrinology societies. This report further emphasizes the importance of discouraging the expectation that taller stature from GH treatment will improve quality of life.

Effect of stimulants on height and weight: a review of the literature

OBJECTIVE

Stimulant medications are effective treatments for attention-deficit/hyperactivity disorder, but concerns remain about their effects on growth.

METHOD

We provide a quantitative analysis of longitudinal studies about deficits in expected growth among children with attention-deficit/hyperactivity disorder treated with stimulant medication. Study selection criteria were use of DSM criteria or clear operational definitions for hyperactivity or minimal brain dysfunction; outcome measures including raw, standardized, or percentile measurement of change in height and/or weight; first assessment of effects on growth occurred during childhood; and follow-up for at least 1 year. For issues not suitable for quantitative analyses, we provide a systematic, qualitative review.

RESULTS

The quantitative analyses showed that treatment with stimulant medication led to statistically significant delays in height and weight. This review found statistically significant evidence of attenuation of these deficits over time. The qualitative review suggested that growth deficits may be dose dependent, deficits may not differ between methylphenidate and amphetamine, treatment cessation may lead to normalization of growth, and further research should assess the idea that attention-deficit/hyperactivity disorder itself may be associated with dysregulated growth.

CONCLUSIONS

Treatment with stimulants in childhood modestly reduced expected height and weight. Although these effects attenuate over time and some data suggest that ultimate adult growth parameters are not affected, more work is needed to clarify the effects of continuous treatment from childhood to adulthood. Although physicians should monitor height, deficits in height and weight do not appear to be a clinical concern for most children treated with stimulants.

Idiopathic short stature: management and growth hormone treatment

In the management of ISS auxological, biochemical, psychosocial and ethical elements have to be considered. In boys with constitutional delay of growth and puberty androgens are effective in increasing height and sexual characteristics, but adult height is unchanged. GH therapy is efficacious in increasing height velocity and adult height, but the inter-individual variation is considerable. The effect on psychosocial status is uncertain. Factors affecting final height gain include GH dose, height deficit in comparison to midparental height, age and first year height velocity. In case of a low predicted adult height at the onset of puberty, addition of a GnRH analogue can be considered. Although GH therapy appears safe, long-term monitoring is recommended.

Growth hormone therapy for short children born small for gestational age

Children born small for gestational age may demonstrate continued growth retardation, resulting in persistent short stature. In the majority of the cases, this is linked with abnormal growth hormone secretion and also abnormal insulin-like growth factor levels. This review discusses the treatment of such children with recombinant human growth hormone. It illustrates the importance of starting therapy early, the dose-dependent response, and the advantages of continuous therapy and describes safety considerations.

An evaluation of the relationship between adult height and health-related quality of life in the general UK population

OBJECTIVE

Short stature has previously been shown to influence several social factors during childhood and adult life. However, limited data exist to determine the influence of short stature on health-related quality of life (HRQoL) because of underpowered studies and the fact that children find questionnaires very difficult to complete. The objective of this study was to examine the influence of height on HRQoL for the general adult population in the UK.

DESIGN

The 2003 Health Survey for England (HSE03), commissioned by the Department of Health, provides a random general population sample for the population living in private households in England. Observations for 14 416 adults (aged > 18 years) were included in the analysis.

MEASUREMENTS

The survey involved a questionnaire-based interview and a nurse visit, where measurements and blood samples were taken. HRQoL was measured using the EQ-5D questionnaire. Social class (I-V) was derived according to definitions from UK National Statistics. Height was converted from centimetres to height standard deviation scores (HSDS).

RESULTS

Mean EQ-5D scores were lower in subjects with greater height deficit than in taller subjects. Three significantly different subgroups were identified using an analysis of variance (anova). The first subgroup 'HSDS </= -2.0' had significantly lower EQ-5D scores compared with the second group '-2.0 > HSDS </= 0' and the third group 'HSDS > 0'. Multivariate linear regression analysis showed significant correlations between height and HRQoL, such that an increase in height of 1 HSDS predicts an improvement in EQ-5D score of 6.1% for subjects shorter than -2.0 HSDS. Social class was a significant predictor of HRQoL in taller, but not in shorter, subjects.

CONCLUSION

The results of this study demonstrate that height in adult life is correlated with HRQoL and that short stature in adult life may be associated with a significant reduction in HRQoL.

Health-related quality of life among children and adolescents: associations with obesity

OBJECTIVE

To assess the impact of obesity on health-related quality of life (HRQOL) of children, and to compare HRQOL scores of obese children in a hospital versus community setting.

DESIGN

A cross-sectional study in two clinical samples.

SUBJECTS

A total of 182 children and adolescents recruited from the community pediatric clinics and a hospital-based obesity clinic.

MEASUREMENTS

Obesity was defined as body mass index (BMI) >95th percentile for age and gender. Subjects were divided into quartiles of BMI Z-scores each containing 45 or 46 children. The first two quartiles correspond to normal BMI, 3rd and 4th quartiles represent moderate and severe obesity, respectively. HRQOL was assessed by the Pediatric Quality of Life Inventory (PedsQL) questionnaire submitted by both children and their parents.

RESULTS

Obese children reported significantly lower HRQOL in physical, social and school domains compared with normal weight children (P<0.01). Analyzing results of HRQOL by BMI quartiles showed that the emotional and school domains scores of the moderately obese children were similar to the normal BMI quartiles. Only in the 4th quartile, that of children with severe obesity, were scores significantly lower. In contrast, in both physical and social domains scores decreased progressively with increased BMI Z-scores. In the obese group, parents' scores were lower than the children's in all domains. HRQOL scores of obese children assessed in the hospital clinic were similar to that of obese children assessed in the community.

CONCLUSIONS

Moderately obese children had similar emotional and school HRQOL scores as normal weight children, whereas in the physical domain, a significant difference was documented even in moderate obesity. Parents of obese children perceived their child's HRQOL lower than the children themselves. We believe that intervention programs aimed at improving HRQOL should be directed to both parents and children. Understanding the resilience of moderately obese children in school and emotional domains may assist us in the management of childhood obesity.

Growing up with idiopathic short stature: psychosocial development and hormone treatment; a critical review

To facilitate decisions on interventions in medically referred children with idiopathic short stature, the research on psychosocial functioning of these children, possible risk and protective factors influencing adaptation, and effects of hormone treatment were reviewed. Parents ranked the behaviour of their children on average between normal and below normal. The magnitude of these deviations varied from small to large. Little is known about the children's self-perceived psychosocial functioning. Some risk factors were found: being teased, being juvenilised, being a boy, having a younger but taller sibling, low intelligence, and low socioeconomic status. There have been few studies on the impact of protective factors including temperament, coping strategies, and social support. On average, hormone treatment did not improve psychosocial functioning. The research shows the advantages and disadvantages of hormone treatment that must be considered when choosing a suitable intervention. It is suggested that psychosocial adjustment can be improved by focusing on factors other than height alone.

Neurocognitive Development in Children Experiencing Intrauterine Growth Retardation and Born Small for Gestational Age: Pathological, Constitutional and Therapeutic Pathways

Interest in the neurocognitive and psychosocial outcomes in children who are born small for gestational age (SGA) has increased since the recent approval of growth hormone (GH) therapy in this indication. The objective of GH treatment in SGA children is to provide a symptomatic treatment for growth retardation. From a patient perspective, the ultimate goals of GH therapy are the reduction in the present or future risk of neurocognitive, psychological, social or occupational impairment, not the accompanying improvements in growth velocity and final height per se. Therefore, from a scientific perspective, neurocognitive and psychosocial endpoints become relevant domains of assessment to determine the final treatment benefit experienced by the patient born SGA. This article reviews recent available studies on developmental risks in SGA, and then transforms the empirical findings into an integrated conceptual framework on the sources and mediators of neurocognitive and psychosocial outcomes in intrauterine growth retardation and SGA. This framework depicts two distinct therapeutic pathways by which GH therapy may improve neurocognitive and behavioural outcomes. The first ('traditional') pathway is the prevention of exposure to short-stature-related stressors via an improvement in growth velocity and final height. The second pathway refers to potential metabolic, and thus neurotropic and psychotropic, effects of GH binding at receptors in the central nervous system, thus changing neuronal activity. To date, the existence and potential mechanisms of such physiologically and not psychologically mediated effects of GH on neurocognitive functioning in SGA patients remain hypothetical.

Cosmetic bilateral leg lengthening: experience of 54 cases

The Ilizarov method for leg lengthening was used for cosmetic reasons in 54 patients with constitutional short stature. A mean lengthening of 7 cm with a low rate of complications produced an excellent or good outcome in all the patients, including improvement in psychological disturbances related to short stature. Those who undergo the procedure must be highly motivated, fully informed and understand the technique and possible complications. We suggest that the Ilizarov method for cosmetic limb lengthening is a technique without major complications. However, it requires careful follow-up, and the involvement of orthopaedic surgeons who are familiar with use of the circular frame and are experienced in limb lengthening and correction of deformity for pathological conditions.

The role of somatropin therapy in children with Noonan syndrome

Patients with Noonan syndrome, which is thought to have an incidence of 1 : 1,000 to 1 : 2,500 live births, have variable hypogonadism together with features such as pulmonary valvular stenosis, dysmorphism, deafness, visual problems, cryptorchidism, clotting disorders, and short stature. Noonan syndrome is now known to be associated with mutations in the PTPN11 gene encoding the protein tyrosine phosphatase SHP-2 on chromosome 12 (12q24.1). This discovery will facilitate both knowledge of the true incidence and phenotypic diversity. There are poor genotype-phenotype correlations in Noonan syndrome, and the currently defined gene abnormalities only account for a minority of those identified on a clinical basis. Puberty in patients with Noonan syndrome generally occurs spontaneously but is typically delayed. Mean adult height is 162.5cm (men) and 153cm (women), although standards are based on relatively small samples of largely cross-sectional data and are subject to ascertainment bias. Available evidence suggests that there may be disturbance of the growth hormone/insulin-like growth factor axis in Noonan syndrome and that somatropin (growth hormone therapy) dose-dependently improves vertical growth in the short to medium-term. Final height data from a number of European studies will be available later in 2003. Noonan syndrome patients with echocardiographic features of hypertrophic cardiomyopathy may be at particular risk from somatropin therapy because of its known effects on cardiac muscle mass; these patients have generally been excluded from trials of somatropin. Unbiased evidence for the efficacy and safety of somatropin therapy in Noonan syndrome will come from appropriately controlled studies of sufficiently large numbers of patients defined on such a basis and followed to final height. This is now possible but will require international cooperation. Nevertheless, the clinical relevance of somatropin therapy in Noonan syndrome and other short stature syndromes will be dependent on looking beyond improvement in final height (even if achievable) to psychological and quality of life outcomes.

Motives for choosing growth-enhancing hormone treatment in adolescents with idiopathic short stature: a questionnaire and structured interview study

BACKGROUND

Growth-enhancing hormone treatment is considered a possible intervention in short but otherwise healthy adolescents. Although height gain is an obvious measure for evaluating hormone treatment, this may not be the ultimate goal for the person, but rather a means to reach other goals such as the amelioration of current height-related psychosocial problems or the enhancement of future prospects in life and society. The aim of our study was to clarify the motives of adolescents and their parents when choosing to participate in a growth-enhancing trial combining growth hormone and puberty-delaying hormone treatment.

METHODS

Participants were early pubertal adolescents (25 girls, 13 boys) aged from 11 to 13 years (mean age 11.5 years) with a height standard deviation score (SDS) ranging from -1.03 to -3.43. All had been classified as idiopathic short stature or persistent short stature born small for the gestational age (intrauterine growth retardation) on the basis of a height SDS below -2, or had a height SDS between -1 and -2 and a predicted adult height SDS below -2. The adolescents and their parents completed questionnaires and a structured interview on the presence of height-related stressors, parental worries about their child's behavior and future prospects, problems in psychosocial functioning, and treatment expectations. Questionnaire scores were compared to norms of the general Dutch population.

RESULTS

The adolescents reported normal psychosocial functioning and highly positive expectations of the treatment in terms of height gain, whereas the parents reported that their children encountered some behavioral problems (being anxious/depressed, and social and attention problems) and height-related stressors (being teased and juvenilized). About 40% of the parents were worried about their children's future prospects for finding a spouse or job. The motives of the adolescents and their parents exhibited rather different profiles. The most prevalent parental worries related to the current or future functioning of their children, while a few cases were characterized by no observed motives or by psychosocial problems only reported by the adolescents themselves.

CONCLUSION

The motives for participating in a growth-enhancing hormone trial are more obvious in the parents than in the adolescents themselves. Two out of three parents report worries about the future opportunities or observe modest current psychosocial problems in their children. The adolescents want to gain height, but the motivation underlying this remains unclear. Few of the adolescents experience psychosocial problems. Our analyses revealed differences among individuals in terms of motives, which implies that in an evaluation of hormone treatment, the importance of divergent outcome variables will also differ among individuals. Effectiveness evaluations of hormone treatment to increase height and the consequential fulfillment of other goals must be awaited.

Parental stress and maladjustment in children with short stature

This study examined the psychometric properties of a measure of chronic disease-related parental stress, the Pediatric Inventory for Parents (PIP), in a sample of 22 children with short stature. Additionally, we investigated relations among disease-related parental stress, parental state anxiety, and children's behavioral and psychological maladjustment. Results demonstrated acceptable internal consistency and convergent validity for the PIP. Significant and positive relations of medium to large effect sizes between parenting stress and internalizing and externalizing maladjustment were found. Recommendations for use of the PIP in clinical settings and future research directions are discussed.