Body dimensions and proportions in the differential diagnosis of child growth retardation

Body dimensions and proportions in the differential

diagnosis of child growth retardation

GrażynaŁysoń-Wojciechowska, TomaszE. Romer,

Waldemar Skawiński

1

Abstract

This study w as aim ed at determ ining the sim ilarities and differences w ith regard to body build traits betw een two groups o f short-statured children: the first one including children w ith grow th retardation related to the grow th hor­ m one deficiency and the second one com prising o f children w ith norm al secretion o f the grow th horm one. S ubse­ quently the traits useful in the differential diagnostics o f grow th retardation w ere selected.

A nthropom etric m easurem ents were taken from 273 short-statured non-treated children aged from 3 to 17 years (73 girls and 200 boys). The children w ere divided into 6 clinical groups on th e basis o f the clinical picture and the results o f stim ulation tests assessing the pituitary reserve for growth horm one secretion. The clinical groups were differentiated using a specifically developed anthropom etric test based on 9 calendar age traits (height, w eight, BM I, length o f upper and lower lim bs, trunk length, shoulders breadth, hips breadth and chest breadth) and 4 developm ental age traits (length and circum ference o f the head, chest circum ference, thigh circum ference) and the calculated value o f arm fat content and the average stature o f the parents.

G rażyna Łysoń-W ojciechow ska, T om asz E. Rom er, W aldem ar Skaw iński, 1997; A nthropological Review, vol. 60, Poznań 1997, pp. 4 7 -5 6 , figs 6, table 1. ISBN 83-86969-18-0, ISSN 0033-2003

Introduction

Short stature may be caused by the growth hormone deficiency (Idiopathic Growth Hormone Deficiency (IGHD)) or other growth disorders [R O M E R et al. 1990, Ro m e r 1993, Ry m k i e w i c z- Kl u- CZYNJSKA 1990a, 1990b ]. The degree o f growth retardation o f the child under study in comparison with healthy chil­ dren o f the same age is one o f the criteria for the analysis o f the clinical picture o f The C linic o f E ndocrinology

Children’s M emorial Health Institute 0 4 -7 3 6 W arszawa-M i^dzylesie 1 “C onsilium ” M edical Centre, Warsaw * Zrealizowano w tem acie K B N 1904/08/91

the disease. So far, the anthropological studies coverin g o n ly a sm all num ber o f features have sh ow n sign ifican t differ­ en ces in the body structure b etw een the

children affected w ith IGHD and the

children w h o se grow th retardation is related to other cau ses [BEVIS et al.

1997, B u u l - O f f e r s a n d B r a n d e 1981,

B u r t a n d K u l i n 1977, K o n f in o ,

P e r t z e l a n a n d L a r o n 1975, L y s o n -

WOJCIECHOWSKA et al. 1984, MARKUS

et al. 1942, S c h a r f a n d L a r o n 1972,

S o r g o et al. 1982, S p i e g e l et al. 1971,

T a n n e r et al. 1971, T r o y e r et al. 1980,

ZACHMANN et al. 1980]. T he attem pts to

use anthropom etric m easurem ents in the screening test? in v o lv in g short-statured

children in order to separate the children affected with IGHD were taken by

SATINDER et al. 1981. His anthropomet­

ric test was based on selected clinical material and a restricted number o f fea­ tures. However, the test failed to differ­ entiate the children with growth hormone deficiency (IGHD) from other ill chil­ dren with a normal level o f growth hor­ mone when applied to a group o f short- statured children formed without pre­ selection. This study was aimed towards determining the similarities and differences with regard to body structure traits between two groups o f short-statured children: the first one including children with growth retardation related to the growth hormone deficiency and the second one including children with normal secretion of the growth hormone. Subsequently the traits useful in the differential diagnostics of growth retardation were selected.

Material

One-time anthropological tests were conducted on 273 children affected with growth retardation (73 girls and 200 boys aged 3 to 17 years) examined in the Children’s Memorial Institute. The short- statured children were divided into clini­ cal groups on the basis o f the results of stimulation tests assessing the pituitary reserve for growth hormone (GH) secre­ tion. Additionally the thyroid hormones viz. T4, T3 and THS were determined as well as the level o f somatomedin (Sm).

D ivision into clin ical groups

Group I (n=49 children) - Idiopathic

Growth Hormone Deficiency (IGHD).

Children whose maximum secretion level o f GH was below 5 mg/ 1 in two stimulation tests.

Group II (n=15 children) - Multihor-

monal Pituitary Deficiency (MPD).

Children whose maximum secretion level o f GH was below 5 mg/ 1 in two stimulation tests (similarly to IGHD) accompanied by below normal level of thyroid hormones. In both groups viz. IGHD and MPD a considerable defi­ ciency o f the growth hormone was noted together with considerable, yet smaller delay in skeletal age in relation to the stature age (the age at which the 50th centile of the standard body height corre­ sponds to the actual growth o f the exam­ ined child.

Group III (n=45 children) - Partial

Growth Hormone Deficiency (PGHD).

Children whose maximum secretion level of GH ranged between 5 m g /1 and 10 m g /1 in two stimulation tests. In this group growth retardation and skeletal age delay are manifested to a lesser extent than in the case o f IGHD.

Group IV (n=62 children) - Familial

Growth Retardation (FGR).

This group consisted of patients who a) had correct birth weight b) whose skeletal age constituted at least 80% of the calendar age, c) whose peak GH con­ centration during stimulation tests ex­ ceeded 10 ng/ml. Children aged from 2 to 9 years were classed into FGR group, if their body height was above the 25th centile on the Ta n n e r’s [1970] grid

taking account o f the parents stature, and below the 3rd centile on the centile grid

[Ku r n ie w ic z-Wi t c z a k o w a et al. 1983],

Children older than 9 years of age were classed into FGR group, if their body height expressed in standard deviations (SD) on average fell within the limits of a single deviation (± LSD) from the aver­ age stature of the parents.

tional Growth Retardation (CGR). Also designated as constitutional de­ lay o f growth and pubescence. Covered the group o f children o f the parents (most often fathers) who had been short-stat- ured for a long time due to late pubes­ cence. Among such children a 2 to 4 years delay o f developmental age was observed with the pubescence corre­ sponding to the skeletal age. Normal birth weight and length. The growth curve was below or equalling the 3rd centile. The growth rate at the lower standard limit for the given age, correct secretion o f GH, late pubertal spurt, the ultimate body height close to the lower limit o f the standard.

Group VI (n=34) - Intrauterine Growth Retardation (IUGR)

Includes children with a variety o f growth disorders, both in the generic program and as a result o f intrauterine foetus injury with normal secretion o f GH. The criterion was met by children with the birth length and weight defi­ ciency (below 2500 g) born following the full-length pregnancy and children with birth length and weight deficiency below the 10th centile born pre-term (starting from the 30th week o f pregnancy).

Method

The studies covered 16 traits, includ­

ing 12 somatic measurements, one

weight-height index (BMI) and 3 head features (length, breadth and circumfer­ ence), used in the BODY program [tY S O ti-W O J C IE C H O W S K A et al. 1992] (Fig 1-6), and additionally the propor­

tion between Mid Arm Fat Area

(MAFA%) and M id Arm Muscle Area (MAMA%) [S A T IN D E R et al. 1981] used in the FAT program [L Y S O N W O J C IE

-CHOWSKA et al. 1992]. T h ese traits being

routine anthropom etric m easurem ents

used in clin ica l d iagn osis after standardi­ sation according to the W arsaw standards

[ K u r n ie w ic z - W it c z a k o w a et al. 1983]

w ere used for statistical p rocessin g o f the clin ica l m aterial em p loyin g the m ethod o f variance analysis.

Results and discussion

Statistically significant differences between growth retarded children in six clinical groups and healthy children o f the same calendar age concerned the somatic traits dimensions, head traits and weight-height index (BMI). A compari­ son with children o f the same stature (the same stature age) showed differences in only certain dimensions. Children af­ fected with growth hormone deficiency (IGHD and M PD) show growth retarda­ tion: -3.6 SD and -4.4 SD respectively. The degree o f growth retardation is smaller in the case o f Children with Familial, Constitutional and Intrauterine growth retardation as well as children affected with PGHD with the average value falling between -2.4 SD and -2.6 SD. Children with PGHD show stronger similarity o f body structure to short- statured children with a normal level o f growth hormone. The comparison o f clinical groups with healthy children from the Polish population (according to the W arsaw norm [K U R N IE W IC Z -W lT - C ZA K O W A et al. 1983]) with regard to anthropological features for a given stat­ ure age, expressed in SD units, is pre­ sented in diagrams (Fig. 1-6).

Body weight, w eight/ height index (BM I), body composition and circum ference values

Weight ₁ Body mass Index ₁

Tru n k length i * * Upper extremity length ■ Low er extremity length ** Biacromial breadth * * Bllliocristale breadth i Chest breadth _■ Sagittal chest diameter i Chest circumference ** Arm circumference w Th ig h circumference i Head circumference US * * Head length _BUS * * Head breadth ₁ S D S -1-50 -1'00 -°.5° 0.00 0,50 1,00 1,50 Stgr>lftc«nc« l«v«l . < O.OS - < 0.01 - < 0.001

Fig. 1. D iagram o f th e standard deviation (SD) o f an­ thropom etric m easurem ents o f children w ith idiopathic grow th horm one deficiency (IG H D ) in relation to norm al

values for children o f the sam e stature

o f the same height, the children with the IGHD and M PD have normal weight and BM I value as well as arm and thigh cir­ cumferences. W hen compared with chil­ dren from other clinical groups the chil­ dren show statistically significant dif­ ferences o f Mid Arm Fat Area, which, ex­ ceeds the normal value (100%) and equals

105.7% and 101.9% respectively. The Mid Arm Muscle Area value is correct.

Children with Familial, Constitutional and Intrauterine Growth Retardation as well as with PGHD show significantly

Weight :

H

Body mass Index

Tru n k length

H

Upper extremity length

4

* Lower extremity length

1

-Biacromial breadth SSI Biillocrietale breadth K Chest breadth _{H i} Sagittal chest diameter 1 Chest circumference _i Arm circumference H H Thigh circumference K Head circumference B Head length _I Head breadth ,_______ ,_______

m

i ,_______ SDS •1'50 -1'00 -0.50 0,00 0,50 1,00 1,50 Significance Wv«l . < 0.08 - < 0.01 - < 0.001

Fig. 2. D iagram o f the standard deviation (SD) o f an­ thropom etric m easurem ents o f children w ith m ultihor- m onal pituitary deficiency (M H PD ) in relation to normal

values for children o f the sam e stature

lower body weight, BMI values and arm and thigh circumferences in comparison with healthy children o f the same stature. These four clinical groups have also smaller values o f Mid Arm Fat Area ranging between 58.3% do 74.3%, with normal Mid Arm M uscle Area value. B ody length

Abnormal proportions o f longitudinal dimensions resulting from significantly increased lower extremity length coincid­ ing with normal or below normal length

Weight Body mats« Index Tru n k length Upper extremity length Lower extremity length Biacromial breadth Biiliocrfstale breadth Chest breadth Sagittal cheat diameter Chest circumference Arm circumference Thigh circumference Head circumference Head length Head breadth SDS -1>50 -1'00 -0.50 0.00 0.50 1,00 1,50 Significance level . < 0.05 - < 0.01 - < 0.001

Fig. 3. Diagram o f the standard deviation (SD) o f an­ thropometric measurements o f children with partial growth hormone deficiency (PGHD) in relation to normal

values for children o f the same stature

o f the trunk were noted in three groups o f children: those with IGHD, those with MPD and those with FGR. A correct length o f lower extremities coinciding with shorter trunk was observed among children with IUGR. Children with PGHD and children with CGR have normal proportions o f longitudinal body dimensions. Shorter upper limbs are characteristic o f children with CGR and IUGR while short-statured children be­ longing to the other groups have normal dimensions o f upper limbs.

H

* * * * i 1 ■ S a M i i * * ■ * * * * ■kirk m m * * u s Weight Body mass Index Tru n k length Upper extremity length Lower extremity length Biacromial breadth BiiliocrUtale breadth Chest breadth Sagittal chest diameter Chest circumference Arm circumference Th ig h circumference Head circumference Head length Head breadth S D S -1-50 -1*00 -0.50 0-00 0,50 1,00 1,50 Significance level . < 0.08 ~ < 0.01 _ < 0.001

Fig. 4. Diagram o f the standard deviation (SD) o f an­ thropometric measurements o f children with familial growth retardation (FGR) in relation to normal values for

children o f the same stature

B ody b re a d th

Children with IGHD and children with Intrauterine and Constitutional Growth Retardation have narrower shoulder span. Children with IGHD and IGR have nor­ mal hip breadth while groups with Intrau­ terine, Constitutional and Familial Growth Retardation as well as children with PGHD have narrower hips than the healthy children o f the same develop­ mental age. The children with IGR, FGR and CGR have also lower values o f the chest breadth, depth and circumference.

H ** *** • * i ■ *** ■ ESE *** ■ * ■ s *** ** ■ ***

CUB

*** HBE *** ***

4

W aigm Body mass Index

T ru n k length Upper extren length Lower extren length Biacron breadth Biitiocrftta breadth Chest breadth Sagittal chea diameter Chest circumference Arm circumfereno Th ig h circumferenc« Head circumfereno Head length Head breadth SDS 1 ■ 1 ** M l *** B H I *** 1 E f *** L _ ■ i *** ■: *** r ~ ** a » *** K ***

zz:

*** — *** — , *** ■ * 50 -1,00 -0,50 0,130 0,j50 1,130 1,5 Weight Body mass Index

Tru n k length Upper extremity length Lower extremity length Biacromial breadth BUIiocristale breadth Chest breadth Sagittal chest diameter Chest circumference Arm circumference Thigh circumference Head circumference Head length Head breadth

**

H

***

*

■Hi

**

i

i

L

**

■HI

**

■n

*

***

*

***

***

***

***

**

S D S -1'50 -1.00 -0.50 0,00 0,50 1,00 1,50

Significance Jevel Significance level . < 0.08 . < 0.05 - < 0.01 - < 0.01 _ < 0.001 - < 0.001

Fig. 5. D iagram o f th e standard deviation (SD) o f an­ thropom etric m easurem ents o f children w ith constitu­ tional delay o f grow th and developm ent (CD G D ) in relation to norm al values for children o f the sam e stature

Similarly lower were the values o f chest depth among children with PGHD. On the other hand children with IGHD have higher value o f the chest circumference in comparison to healthy children o f the same body height. Children with MPD have normal values o f the chest breadth, depth and circumference.

Head dimensions

A statistically significant reduction in the head circumference in relation to the stature was observed among children

Fig. 6. D iagram o f the standard deviation (SD) o f an­ thropom etric m easurem ents o f children w ith intrauterine grow th retardation (IUGR) in relation to norm al values

for children o f the sam e stature

with Idiopathic and Partial Growth Hor­ mone Deficiency as well as in children with Intrauterine, Constitutional and Intrauterine Growth Hormone Deficiency mainly as a result o f the head length re­ duction. Children with MPD have normal length, breadth, and circumference o f the head. A preliminary anthropological analysis showed similar level o f differ­ ences in body structure, proportions and composition between children with GH deficiency belonging to the groups o f IGHD and MPD in comparison with

53 healthy children o f the same stature.

Moreover, differences were found be­ tween the former two groups and the group o f children with PGHD. Despite a partial deficiency o f growth hormone with respect to body dimensions and composition the children belonging to the ju st mentioned clinical group show stronger affinity with children from clinical groups with a normal level o f growth hormone and show similar degree o f differences with healthy children o f the same height.

Statistical processing o f the material Differential diagnostics o f growth re­ tardation in children classed into 6 clini­ cal groups was carried out using the vari­ ance analysis method [O K T A B A 1971]. At subsequent stages o f the study the strongest similarities and differences for the standardised somatic traits (and the head characteristics) o f short-statured children were determined. The results obtained were used for developing an anthropometric test. The greatest differ­ ences and the highest number o f charac­ teristics differentiating the children be­ longing to the clinical groups subject to examination were observed in the case o f the following traits: body height and weight, BMI, upper limbs length, lower limbs length, the trunk length, shoulders breadth, hips breadth, the chest breadth, standardised skeletal age in relation to the calendar age and the difference o f stan­ dardised height o f a child in relation to standardised height o f parents (mother’s and father’s height values were related to the W arsaw standards for 18 years o f age [ Ku r n i e w i c z- Wi t c z a k o w a et al. 1983]).

These traits were included in the anthro­ pometric test. For the developmental age the most substantial differences among

the clinical groups concerned a smaller number o f traits (the head length, head circumference, chest circumference, thigh circumference and Mid Arm Fat Area proportion); also these traits were in­ cluded in the anthropometric test. Simi­ larly to the developmental age also in the case o f skeletal age the num ber o f differ­ entiating traits was small. Therefore, the traits standardised for the calendar age were taken as a differentiating criterion for short-statured children in six clinical groups.

It is problem o f clinical nature how to identify short-statured children who should undergo hormonal tests. The classifica­ tion into clinical groups on the basis o f the anthropometric test was compared with the classification according to the clinical diagnosis. In the case o f children with Idiopathic Growth Hormone Defi­ ciency and M ultihormonal Pituitary D e­ ficiency the conformity between clinical classification and classification with anthropometric test reached 64.0%, when all the clinical groups were taken into account. The conform ity index would increase to 65.6% if children with Partial Growth Hormone Deficiency showing strong similarity with regard to the stud­ ied features to clinical groups o f children with normal level o f the growth hormone were excluded from the test. W ith the anthropometric test some o f these chil­ dren were classified to groups o f a nor­ mal secretion o f the growth hormone. A large spread o f the traits entailed moving o f some children from the Idiopathic Growth Hormone Deficiency to the group o f M ultihormonal Pituitary Defi­ ciency (classification skewness). The an­ thropometric test was used in developing a computer program for the differential diagnosis o f growth retardation (Tab. 1).

T a b le 1. D ifferential diagnosis o f growth retardation

DIFFERENTIAL DIAGNOSIS Of G R O W T H R E T A R D A T I O N

Department of Endocrinology Laboratory of Clinical Anthropology

Merits: Grace Lyson

¡s Statistical analysis: W.Skawiński

Patient's record No: 18971/93 Patients' Name: XXXX

Antropometrie test for diagnosis of growth retardation

PATIENT'S DATA 100 calendar age 10 48 90 bone age 5 50 height [SDS] -3 11 80 body mass [SDS] -2 .75 BMI [SDS] -1 23 70 upper extr.length [SDS] -2 67 trunk length [SDS] -3 90 60 lower extr.length [SDS] -2 84 biacromial bredth [SDS] -2 94 50 chest breadth [SDS] -1 64 biiliocrist.breadth[SDS] -2 19 40 head length* [SDS] -1 45 head circumfer.* [SDS] -2 12 30 chest circumfer.* [SDS] -0 38 thight circumfer. * [SDS] -2 10 20 arm circumfer. [mm] 160 00 triceps skinfold [mm] 6 00 10 mother height [mm] 1529 00 father height [mm] 1721 00 0

* - according to the growth age NOTATION Record No: 18971/93 Patient: XXXX Diagnosis: MHPD Probability- 42.9% CDGD FGR IGHD MHPD IUGR

CDGD - constitutional delay of growth and development FGR - familial growth retardation

IGHD - idiopathic growth hormone deficiency MHPD - multihormonal pituitary defficiency IUGR - intrauterine growth retardation

Conclusions

On the basis o f 9 features of calendar age (height, body weight, BMI, upper limbs length, lower limbs length, trunk length, shoulders breadth, hips breadth, chest breadth) and 4 traits o f the develop­ mental age (the head length and circum­

ference, chest circumference, thigh cir­ cumference) as well as based on the cal­ culated value o f Mid Arm Fat Weight and the parents’ mean stature an anthro­ pometric test was developed with the purpose of differentiating short-statured children. The test differentiates two clini­ cal groups of children with growth hor­

mone deficiency: the first one including children with Idiopathic Growth Hor­ mone Deficiency and the second one including children with M ultihormonal Pituitary Deficiency from the groups o f short-statured children with normal se­ cretion o f the growth hormone. The test fails to distinguish the children with Par­ tial Growth Hormone Deficiency from the children with a normal level o f the growth hormone. The correctness o f diagnosis in the case o f children with growth hormone deficiency (Idiopathic Growth Hormone Deficiency and M ulti­ hormonal Pituitary Deficiency) with the application o f the anthropometric test reaches 65.6%.

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Streszczenie

C elem pracy było ustalenie podobieństw i różnic w cechach budow y ciała u dzieci niskorosłych w dw óch gru­ pach: w w yniku niedoboru horm onu w zrostu i u dzieci z praw idłow ym w ydzielaniem horm onu wzrostu oraz wybór cech przydatnych w diagnostyce różnicow ania niedoboru wzrostu. Pom iary antropologiczne obejm ujące 12 cech budow y ciała, 3 cechy głowy, BM I oraz pom iary m asy tłuszczow ej i beztłuszczow ej ram ienia w ykonano u 273 dzieci nieleczonych z niedoborem w zrostu, w w ieku od 3 do 17 lat (73 dziew czynki i 200 chłopców ), badanych w Instytucie „Pom nik-C entrum Z drow ia D ziecka” . D zieci niskorosłe zostały podzielone n a 6 grup klinicznych w oparciu o obraz kliniczny i testy stym ulacyjne oceniające rezerw ę przysadkow ą w zakresie w ydzielania horm onu wzrostu. Opracow a­ no test antropom etryczny różnicujący w spom niane grupy kliniczne w oparciu o 9 cech dla w ieku kalendarzowego (w ysokość, m asę ciała, BM I, długość kończyn górnych i kończyn dolnych, długość tułow ia, szerokość barków, szero­ kość bioder, szerokość klatki piersiow ej) i 4 cechy dla w ieku wzrostow ego (długość i obw ód głowy, obwód klatki piersiow ej, obw ód uda) oraz o b liczo n ą m asę tłuszczow ą ram ienia i średnią w ysokość ciała rodziców. Praw dopodo­ bieństw o popraw nego oszacow ania rozpoznania testem antropom etrycznym dzieci z niedoborem horm onu wzrostu (SN P i W N P) w ynosi 65,6% .