So how do you tell if it’s constitutional growth delay? Those are the children remember who have a delayed growth spurt. Let’s look at an example really carefully. Here is a child who is growing relatively normally along their growth curve, right about the 50th percentile. Here is a child who has a constitutional growth delay. You can see they were growing along with 50th percentile, failed to grow for a period of time and then suddenly grew a lot. I’m sure you know someone who did this in high school, somebody who grew a lot a little bit later in life. So this is a child who ended up at their appropriate height, started at their appropriate height, just did their growing a bit later. The curve was different. But what if this child didn’t come in here, but came to see you here? You can see now this is the same child. They’re going to end up at the correct height, but the mom is coming here to see you because now this child, at the age of about 13, is coming to see you because look, her child is falling off her growth curve. Whereas previously compared to other kids she was about on target, now she seems to be a shorter than a lot of the other children and the mom’s worried, why is my daughter not growing well? Well, there is a way we can delve into this and it has to do with the hand. The human hand develops with puberty, not with age. So, when we’re ready to have our growth spurt, our hand starts developing. If her hand x-ray has a normal age for a younger girl, she just hasn’t grown yet. She may have delayed puberty and a delayed growth spurt. So, let’s look at this carefully. This girl was here in her growth curve. We’re zooming in on that growth curve. That height she had achieved was really more appropriate for a 12-year-old. You can see she was delayed back. That she was not growing the way we would have expected her to. So we’re gonna go and get a hand x-ray on this girl and we’re going to look at it. And the radiologist is gonna tell us, yes, her hand looks like the appropriate age for a 12-year-old. So the radiologist is gonna look at this x-ray and say, this is a typical appearance of a child with a hand x-ray and this hand x-ray looks like it’s for about a 12-year-old. Now in this girl who’s 14, you see that her hand x-ray is 12 and you can say this is probably constitutional growth delay. If the hand x-ray were lagging three or more years, you would probably suspect growth hormone deficiency. If the hand x-ray were less than one year different, you would expect that this child actually has short stature and some other reason may be contributing for why this child is not gaining height. So, if you suspect that this child is not gaining height and that there was no delay in the bone maturity, then we would start to look into other causes for what might be going on. You might get a CBC to check for anemia, or look for evidence of chronic illness. You might get a sed rate to look for inflammatory bowel disease or other sort of inflammatory process. Thyroid studies would probably be indicated. For thyroid studies, we typically just get a TSH and if it’s high we will reflexively get a free T4 to see exactly what the thyroid level is. We might check a Chem 7 looking for specifically renal diseases and in particular some of the subtle ones such as renal tubular acidosis, for that we might get a urine as well. It will be very appropriate to check for celiac disease. We can get a TTG and a total IgA level to look and see if they have celiac disease. And if we suspect growth hormone deficiency and a child with a desperate growth of the hand, we can get IGF1 and IGFBP3 as heralding markers for growth hormone deficiency. So, if we suspect a patient has growth hormone deficiency we can usually treat this. We usually choose to treat people whose ultimate eventual growth is likely to be under 5 feet and who are growth hormone deficiency. If they are growth hormone deficient and are likely to be less than 5 feet, we should really consider growth hormone replacement. Why should we not do growth hormone replacement in everyone? Because it’s exceptionally expensive and also because it’s unclear that that’s the morally right thing to do. So, this is standard of care in diseases like Turner’s, whether it’s an associated decrease in height, these people can have difficulties with simple, daily function like driving cars or getting around the streets, and dealing with normal obstacles in life, and we should give them the hormone they need to be able to achieve a maximal height. These growth hormone shots are everyday. They are extremely expensive and they are controversial also because the expense is only buying maybe just a few centimeters especially people who do not have growth hormone deficiency. It’s very, there’s very little benefit in those patients without growth hormone deficiency and so we really wanna know whether they have growth hormone deficiency before their insurance company will be willing to pay the tens of thousands of dollars a year it could cost to provide this therapy. So that’s my overview for short stature and how we track height and weight in children. Thanks for your attention.