When “cute” is be a problem

We often look at children who are small in size and comment on how cute they are. However, as Joanna Lee finds out, this cuteness might be related to growth disorders which need to be quickly dealt with

Growth disorders are problems that prevent a child from achieving a normal height, weight, or sexual maturity in some conditions, making them appear smaller in height than their peers of the same age. In Malaysia, the awareness of growth disorders remains low.

At a roundtable meeting with journalists as part of the first ever SEA Growth Summit, two paediatric endocrinologists, Martin Savage, Professor of Paediatric Endocrinology (emeritus) at the University of London and Consultant in Paediatric Endocrinology at The London Clinic Centre for Endocrinology and Professor Dr. Wu Loo Ling, Paediatric Endocrinologist and Diabetologist at the Department of Paediatrics, Universiti Kebangsaan Malaysia (UKM) Medical Centre shared their concerns and experience treating children with growth disorders.

Reasons for late detection

Growth disorders in children are seldom detected early enough for intervention even though they’re prevalent around the world, often with detrimental effects on the physical and mental health of children. For Professor Savage, short stature is not perceived as a problem by the general public or a problem that could be successfully treated as it isn’t a life and death situation.

In the Malaysian context, Professor Wu cited common reasons for not further investigating a child’s short stature: “the child looks well otherwise”, “he/she is just petite or cute”; “we are naturally short people”, “there are still many years ahead for him/her to catch up”, “the child is a picky eater” and the most often heard –“the child will shoot up at puberty!” Parents may sometimes hear this from doctors as well.

How do kids grow?

Children grow because in their long bones (arms, legs and spine), there is a layer of cartilage where there is active growth – the growth plate made up of cells called chondrocytes and a smaller section at the end of the main bone called the epiphysis. The cartilage cells grow to become bones.

The endocrinal glands sends messages to the growth plates to grow through the pituitary glands which produces the growth hormones. The pituitary glands also stimulates the liver to release a second hormone called insulin-like growth factor (IGF-1). Together, the growth hormone and IGF-1 act on bones, muscles and other organs and tissues, which grow by adding more cells.

Factors that may stop kids from normal growth

Not all growth issues are related to hormones. Professor Savage said that paediatricians should think broadly and have a list of differential diagnosis of short statures. Some are due to fever, appendicitis, genetics and idiopathic short stature (where both parents are short). Diabetes and kidney issues may also play a role.

One hormonally-related condition is Growth Hormone Deficiency (GHD). This is where the pituitary gland does not produce enough growth hormones. It could be present from birth or if there’s been an injury to the pituitary glands due to cancer or a traumatic injury.

Another growth disorder is Small for Gestational Age (SGA). An SGA baby is born smaller in height or weight. Growing up, these children have an increased risk of perinatal morbidity, neuro-developmental disorders, persistent short stature and metabolic alterations later in life.

The third common growth disorder discussed by the two professors was Turner Syndrome, a common genetic disorder among females that is caused by the loss of all, or a critical part of one X chromosome. Dr. Wu said these girls have certain characteristic physical features, but more often than not, the condition remains undiagnosed and untreated.

Early diagnosis and intervention

The good news is that growth disorders are treatable. However, there is only a short window of time to treat growth disorders before the bones stop growing. Females stop growing between the ages of 14-16 while it’s 16-18 for males in general. Thus, early intervention is vital to helping children with growth disorders reach their maximum potential heights. Treatment should ideally start before the age of six.

Diagnosis can be made after a) blood tests to rule out hormonal, chromosomal, or other chronic disorders associated with growth failure; b) X-ray of the hand to determine maturity and growth potential of bones; c) additional tests to test the pituitary gland’s function to see if the gland is in an optimal state; d) observance of the child’s health and growth over several months if necessary.

For Turner Syndrome patients, Dr. Wu reiterated that they should begin treatment as soon as a fall in their height percentile is detected. Usually these girls grow to be 20-25cm shorter than their peers. Early diagnosis and treatment gives them a better fighting chance of growth.

Treatment and challenges

Both Professor Savage and Dr. Wu spoke about treatment using synthetic human growth hormones which are safe with no major side effects. Patients have to inject themselves daily with the growth hormones. Commitment to the treatment (which includes daily injections) is key as it is a long term treatment which takes years.

Dr. Wu shared her experience of treating a 6-year-old boy who didn’t seem to respond to the treatment at all. She later surmised that the patient has been refusing to have himself injected and had lied about it. His family continued doctor-shopping until he was referred to her again. By the time the treatment had resumed and run its course, the child’s height had only reached just slightly below his height percentile. However, there were other children whom she has treated that have achieved their height potential while improving their physical performance and mental health.

A big deterrent to growth disorder treatments is the cost. It could go up to about US$260 per month for a child. For the 6-year-old boy, however, his treatment was enabled by a public fund available through Universiti Kebangsaan Malaysia’s Medical Centre. Only hospitals with endocrinologists can help patients apply for funds for treatment.

How can parents ensure a child’s healthy growth?

Parents must have their children’s height and weight measured consistently and keep records of this data. If it gets plotted on a growth chart, the doctor can tell as early as possible if there’s a potential growth issue and can refer the child to a specialist. Thus, it is important to have regular health checks and monitor each child’s growth.

Doctors should play their part to detect any growth disorders. They can refer their patients to paediatric endocrinologists for diagnosis.

The stigma of being short has an untold impact on children. Children with growth disorders suffer from physical and psychological disadvantages, not to mention a poorer quality of life.  Studies have also shown that taller people generally have better levels of income and tend to be in leadership positions. Many Asian parents force their children to drink exotic broths, eat supplements and subject their children to novel stretching sessions. However, parents also need to look out for hormonal issues that could affect their child’s growth.

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