We come across a lot of parents complaining “My baby is not growing…….”, “My baby is very small and not gaining height. What can I do Doctor?”
I will be discussing about the some of the important causes of short stature and different ways available to increase height of a child and where to go if you think that your child have short stature.
First of all I will be discussing about the non pharmacological options to stimulate growth. Then I will go into the pharmacologic options to treat short stature.
Before going into the causes and management we need to know what is short stature. Standard definition is taken as height below 2 SD for the same sex and age in a given population. We have to look into the growth chart to know if somebody falls into this category or not. We follow WHO growth chart to look for short stature. WHO has labeled height between -2 to -3SD as moderate stunting and less than -3SD as severe stunting.
So a boy at 2.5 years with a height less than 85cm can be labeled as short stature. I donot recommend taking height one time and labeling as short stature. It should be measured serially in a standard way and then documented. Trend should be followed in the growth chart so that we can comfortably label them as short.
Most common causes of Short stature is familial (genetic), constitutional and idiopathic shortstature, and these are without any organic pathology. Other important cause of shortstature in our part is malnutrition, usually chronic. Children who are not feeding properly or those families with food insecurity are at higher risk of developing shortstature.
We can predict the height of offspring by knowing the height of mother and father and doing some simple mathematics.
For girls: [Father’s Height +Mother’s height – 13]/2 cm
For Boys: [Father’s Height + Mother’s Height +13]/2 cm
Height of Children is largely dependent upon individual genetics, so there are not many things that can be done to increase the height of an individual. Only two areas where we can target upon are Nutrition and Exercise.
We have to monitor the child since birth. We have to take birth length for all babies so that we can find out if the baby is small at birth and also help to follow the growth pattern further. Recommendation is to take height at least once every 6months.
My advice will be to visit your nearest pediatrician if you feel that your child is not growing well and take appropriate advice. Pediatric Endocrinologist deals and manages definite short stature.
What are the Nutritional changes that you can make to enhance growth of your child?
Appropriate Nutrition is the most important for growth. Ensure that all the Macro and micronutrients are available in the diet. Special requirements are Calcium, Phosphorus, Vitamin D, Magnesium and Zinc. It is recommended to supplement all newborn babies with 400IU vitamin D3 per day till one year of age. It is appropriate to ensure all the nutrients through healthy diet but sometimes it might not be possible to feed the feed the child and it is not that easy to make the child eat whatever you want. Most of the parents complain about their child being reluctant to feed. In those circumstances external supplementation is advisable after consulting your pediatrician. If the child is malnourished then we should treat malnutrition timely so that the child doesn’t become stunted. Once the child is stunted it is very difficult to regain their growth and sometimes even not possible to attain target height.
Next important aspect for growth is physical activity. Those children with less physical activity tend to grow more slowly. Exercise stimulates hormones essential for growth. Aerobic exercises like running swimming, jumping are necessary. Physical exercise also ensures adequate blood supply to various organs. Adequate blood supply means adequate nutrition to the growing areas. Sedentary habits and screen viewing should be minimal for growing children.
With Nutrition and exercise body needs adequate rest hence adequate sleep is necessary for mental and physical growth. Ensure good quality sleep for your child and donot disturb his sleep regularly. Growth hormone secretion is highest while sleeping.
Now we come into the Pharmacologic aspect for management for shortstature. This has been a hot topic of debate since longtime. Only pharmacologic agent approved for treatment of shortstature is Recombinant growth Hormone. I will be more focused on non growth hormone deficient shortstature. Biosynthetic growth hormone is available since 1985 and with the introduction of this hormone there has been paradigm shift in management of short stature. There has been a lot of research going on regarding safety and efficacy of Recombinant Human Growth Hormone (rHGH). Our target is to reach average height of the population. This therapy should not be used inorder to exceed the normal growth pattern. There are definite guidelines and recommendation for the use of Growth Hormone, meaning that not everyone fall into the criteria for treatment with growth hormone because it has its own limitations and side effect profile. We also have to know that this is a very long term therapy, one doze of hormone and prompt growth is not what we should expect. It might take years of commitment and sometimes there might be risk of dealing with side effects.
Next important aspect is the cost of the hormone, which is very high till now due to limited production.
One of the standard brand containing 4IU of HGH cost approximately Rs. 2500. This dose is adequate just for a day or two and just think about the cost of treating for years.
Next important question may be “How tall one will be after taking full course of growth hormone?”
This is a very tough question to answer because there is individual variation. Best result is for those having growth hormone deficiency. For non-growth hormone deficient children it is still a part of research but the results are positive.
What is the age for starting Growth Hormone therapy?
It must be started before the epiphyseal fusion of bones. Once there is epiphyseal fusion there can only be lateral growth but no longitudinal growth. Lower limit of starting can be as early as 2 years for small for gestational age babies not attaining adequate height. Appropriate time for start of therapy is decided by the endocrinologist after growth assessment and the establishment of cause of shortstature.
How frequently and for how long do I have to take the hormone?
It is taken through subcutaneous injections using special kind of syringe or pen like insulin on a daily basis as prescribed by the endocrinologist under careful supervision. It needs to be taken until desired height is reached or till the physician recommends you to stop the therapy.
There are options to gain height even after your epiphyseal plates are fused. Now this is only by means of orthopedic surgery. There is special device called Elizarov which are screwed after making a fracture in the leg bones deliberately and then the bones are extended day by day by putting this device and the bone grows by means of periosteal reaction. This is a difficult task and need very skilled personnel and there might be risk of infections, malunion of nonunion.
At the end there are talks about natural growth stimulants and herbal medication that has been used to stimulate growth but they have no proven benefit till date for increasing height.
Lastly, my advice for those parents who are seeking advice for child’s growth will be to visit an experienced pediatrician or a pediatric endocrinologist and discuss about the matter seriously and look into the pros and cons about various treatment options and weight benefit of not treating with that of risks.
Dr. Dhruba Shrestha