Jonah Patel
Constitutional growth delay (CGD) is a common cause of short stature in children, resulting in a height that is significantly below the mean for their sex, age, and ethnic group. It is characterised by a delay in the onset of puberty and a slower rate of linear growth and weight gain, typically within the first three years of life. Children with CGD tend to be smaller than their peers but grow at a normal rate, eventually catching up and reaching a normal adult height. Diagnosis involves evaluating growth patterns, bone age, family history, and ruling out other conditions. Treatment options include growth hormones, testosterone injections, and sex steroids to accelerate puberty, but these may not change the final height.
| Characteristics | Values |
|---|---|
| Definition | Children with constitutional growth delay (CGD) typically have retarded linear growth within the first 3 years of life. |
| Growth Rate | Children with CGD grow at a normal rate but tend to be smaller than other children their age. |
| Short Stature | Short stature is defined as two standard deviations or more below the mean for children of the same sex, chronologic age, and ideally, race. |
| Growth Percentiles | Children with CGD show downward crossing of growth percentiles, often until age 2-3 years, after which growth resumes at a normal rate. |
| Puberty | CGD is associated with delayed puberty and a delayed pubertal growth spurt. |
| Bone Age | Bone age is typically delayed in CGD, with an average lag of 2-4 years during adolescence. |
| Family History | CGD often has a positive family history of delayed but normal puberty and growth. |
| Treatment | Treatment may include "jumpstarting" puberty with testosterone injections or a short course of low-dose sex steroids. |
| Adult Height | Children with CGD typically attain a normal adult height within the range expected for their genetic potential. |
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What You'll Learn
A radiographic study of the left hand and wrist
During a radiographic study of the left hand and wrist, an X-ray of the patient's left hand and wrist is compared to a reference atlas of X-ray images. These reference images depict the skeletal structure of the left hands of children deemed representative of the average appearance of bones for a given age and sex. The most well-known atlas is the Greulich and Pyle atlas, which contains images of left hands and wrists of children aged 3 months to 19 years for males and 3 months to 18 years for females. The chronological age of the patient in the atlas that most closely matches the patient's X-ray is assigned as the patient's bone age.
The bone age is a critical factor in diagnosing constitutional growth delay. Typically, in children with constitutional growth delay, the bone age begins to lag behind the chronological age during early childhood, and this delay persists into adolescence, with an average gap of 2-4 years. This delay in bone maturation is a variant of normal development, indicating that the child's growth and development are appropriate for their biologic age (skeletal age) rather than their chronological age.
By comparing the child's bone age to their chronological age, healthcare professionals can determine if the child's growth is following the expected trajectory. If the bone age is significantly behind, it may indicate a growth disorder or an underlying medical condition that requires treatment.
In addition to radiographic studies, the evaluation of constitutional growth delay may include laboratory studies to assess hormone levels, such as thyroxine (T4), thyroid-stimulating hormone (TSH), growth hormone (GH), and insulin-like growth factor-1 (IGF-1). These evaluations help rule out potential underlying causes of growth impairment, such as hormonal deficiencies or systemic illnesses.
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Bone age and growth rate
Bone age is a critical factor in diagnosing constitutional growth delay. Typically, the bone age of a child with constitutional growth delay begins to lag behind their chronological age during early childhood and is delayed in adolescence by an average of 2-4 years. The bone age of a child can be determined through a radiographic study of the left hand and wrist, which is considered the gold standard procedure. This is because bone maturation is generally delayed by longer than 1 year and often by 2 years or more.
Hand and wrist X-rays reflect the maturity of different bones, which is an important factor in the biological maturation process. During growth, biological maturity is defined by several parameters, including skeletal maturity, sexual maturity, dental elements eruption, menarche, spermarche, deepening of the voice, growth spurt, and the achievement of 95% of adult height. Many of these parameters, particularly growth spurt and menarche, correlate better with bone age than chronological age.
In children aged 7 years and older, a hand radiograph for bone age can help predict how tall the child will be as an adult. In most cases, the bone age will be within a year of the child's age, and the adult height prediction will be within 2 to 3 inches of the estimated height.
In some cases, a delayed bone age may be caused by malnutrition, chronic diseases, or chronic inflammatory states. Untreated growth hormone (GH) deficiency can also cause a delay in bone maturation.
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Familial short stature
In most cases, children with familial short stature are healthy, with normal screening laboratory tests. A hand radiograph for bone age can be useful in predicting the child's adult height, and whether they will experience delayed puberty. This is because children with familial short stature will often start puberty later than their peers, and continue to grow when others have finished. This can result in a normal adult height, but one that is shorter than predicted.
In some cases, growth hormone treatment may be used to treat severe cases of familial short stature. However, this treatment is not always covered by insurance. Boys with this diagnosis may benefit from a brief course of testosterone if they have not started puberty by the age of 14.
It is important to distinguish familial short stature from constitutional growth delay, a similar condition in which the child is growing at a normal rate, but slightly below the curve, and neither parent is short.
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Treatment options
Constitutional growth delay (CGD) is a benign condition that does not usually require medical treatment. However, in some cases, treatment may be initiated to address psychosocial distress or other psychological complications associated with the condition. Here are some treatment options:
Monitoring and Reassurance
For most children with constitutional growth delay, the recommended course of action is careful monitoring and reassurance. Medical care involves obtaining frequent growth measurements, often every six months, to calculate linear height velocities and establish a trajectory on the growth curve. This helps ensure that children with CGD are growing and developing within an expected range, even if at a slower pace than their peers.
Hormone Treatment
In rare cases, growth hormone treatment may be considered, especially if the child has not started puberty by a certain age. For example, some boys with CGD who have not entered puberty by age 14 may benefit from a brief course of testosterone. However, insurance may not always cover the costs of growth hormone treatment.
Addressing Psychological Complications
While CGD itself does not usually require treatment, it is important to address any psychological or social issues that may arise due to the child's delayed growth or delayed puberty. This may include providing support and guidance to help the child cope with feelings of self-consciousness or differences in physical development compared to their peers.
Nutritional Support
Although constitutional growth delay is primarily a developmental condition, ensuring adequate nutrition can support overall health and well-being. A balanced diet with sufficient calories, protein, and essential nutrients can help optimize the child's growth potential within the context of their individual growth pattern.
Referral to Specialists
In some cases, referral to a pediatric endocrinologist or another specialist may be beneficial for further evaluation and management. This is particularly relevant if there are concerns about significant growth delays or if there is a family history of growth-related issues. An interprofessional team, including nurses and primary care providers, can provide appropriate screening and follow-up protocols.
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Diagnosis and distinguishing from other conditions
The diagnosis of constitutional growth delay (CGD) is made when a child is growing at a normal rate but is smaller than other children their age. Doctors usually define short stature based on standard growth charts, rather than how a child is growing relative to other children. A child is typically diagnosed with short stature when their height falls below the 2.3 percentile, and with extreme short stature when below the 1st percentile.
CGD is the most common cause of short stature and pubertal delay, affecting around 10-15% of the general population. It is characterised by retarded linear growth within the first three years of life, with a slowdown in linear growth velocity and weight gain beginning as early as 3-6 months of age. This results in a downward crossing of growth percentiles, which often continues until the age of 2-3 years. At that point, growth resumes at a normal rate, and these children grow either along the lower growth percentiles or beneath the curve but parallel to it for the remainder of the prepubertal years.
CGD is a benign condition and is not a medical disorder. Children with CGD don't show any signs or symptoms of growth disorders or diseases that would cause a growth delay. They typically have a family history of 'late bloomers' and are otherwise healthy, with normal screening laboratory test results. However, it is important to distinguish CGD from other conditions that can cause short stature and growth delay, such as endocrine problems, growth hormone deficiency, or chronic medical conditions.
A radiographic study of the left hand and wrist to assess skeletal maturation is critical in diagnosing CGD. This is because bone maturation is typically delayed in children with CGD, with bone age lagging behind chronological age during early childhood and adolescence. In most cases, bone age will be within a year of the child's age, and the adult height prediction will be within 2 to 3 inches of that estimated by the formula: (mother's height + father's height + 5"/2 for boys; (mother's height + father's height – 5"/2 for girls.
Another distinguishing factor is that children with CGD will typically catch up with their peers in adulthood and reach an adult height within the normal range for their genetic potential. However, it is important to note that some studies have found that males with CGD may not attain their predicted adult height, falling short by a few inches on average.
CGD is also similar to familial short stature (FSS) in that the child is usually healthy and growing normally but slightly below the curve. However, FSS is typically diagnosed when one or both parents are short, whereas in CGD, neither parent is usually short, and one parent was a late maturer.
In terms of treatment, CGD does not usually require medical intervention. However, in adolescents experiencing psychosocial distress due to their short stature, a brief course of low-dose sex steroids or testosterone injections may be used to accelerate the onset of puberty. It is important to carefully monitor patients undergoing testosterone treatment to ensure they enter "true" puberty and avoid compromising their final height.
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Frequently asked questions
Constitutional growth delay (CGD) is a common cause of short stature and pubertal delay, affecting 10-15% of the general population. Children with CGD typically experience retarded linear growth within the first 3 years of life, followed by growth at a normal rate, either along the lower growth percentiles or beneath the curve.
CGD is diagnosed by assessing skeletal maturation through a radiographic study of the left hand and wrist. This helps determine bone age, which is typically delayed in children with CGD. Bone age can also be predicted using the formula: (mother's height + father's height + 5")/2 for boys, and (mother's height + father's height - 5")/2 for girls.
Children with CGD grow at a normal rate but tend to be smaller than their peers. They may have an immature appearance for their age, with more infantile body proportions. During puberty, their height may drift further from the growth curve due to a delayed onset of the pubertal growth spurt.
CGD is often familial, with a history of late bloomers in the family. It is similar to familial short stature but differs in that neither parent may be short, and at least one parent was a late maturer.
Treatment for CGD depends on the individual child and their specific needs. In most cases, reassurance about their growth pattern is sufficient. If there is a desire to hasten pubertal development due to psychosocial considerations, a short course of low-dose sex steroids or testosterone injections may be considered.
