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It's my pleasure to be here today to speak with you about growth hormone deficiency. I will focus on diagnosis and management and also discuss the evolving therapies. And here's my disclosure. And as as you have seen that this um session learning objectives are on uh growth hormone deficiency. And the outline of my talk um includes clinical evaluation of growth disorders and we'll use two cases uh to discuss how we work through um the diagnosis and we will also discuss treatment of growth hormone deficiency um daily versus once weekly options. So, um so here, the definition of short stature is defined as a height below the third percentile or more than two standard deviations below the mean and a significant drop in height percentile can also be concerning even if the child remains above the third percentile. Uh So looking at this growth chart, we see a patient whose height initially followed the 50th percentile but gradually declined to the 25th percentile. So the downward shift suggests a potential growth problem that warrants further evaluation. And if we look at the height velocity chart in this same patient, we notice that it falls below the fifth percentile and that indicates impaired growth which could be due to an underlying medical problems that we need to address. So, monitoring growth velocity is crucial as it provides an early indicator of abnormal growth before a significant change in height percentile uh becomes apparent. So sometime you know, we have to look at uh growth records to know that there's a problem. So key informations in assessment of short stature, uh growth is one of the most sensitive indicators of a child's overall health deviations from the normal range, both in height and in the rate of growth may uh signal an underlying medical condition that requires further evaluation. Uh There are several factors influence growth including genetics, nutrition, psychosocial environment and systemic diseases. So, one of the first steps in assessment, uh assessing short stature is to determine the child's genetic height potential. And that's done by using mid parental height. And you know, we have to ask father's height, mother's height. If a child is a boy, then we need to convert mom's height to male height by adding five inches or 13 centimeter to mom's height. And then add to dad's height and divide by two to get the average uh mid parental height for girls. We have to uh adjust dad's height to female's height by subtracting 13 centimeter or five inches, an average with m mother's height divide by two. So, and then we need to um ask about family history, you know, growth and pubertal history because, you know, timing of puberty plays an important role in growth. And we need to look at the child's pubertal status as well because sometimes, you know, when we see um an adolescent with no growth in the past couple of years and then turns out, you know, the child developed early puberty and has finished growth. So that's something we need to, you know, do thorough uh examination and you know, look at the pupil status and getting growth records is also important as mentioned earlier that we have to look at um you know, the trend of growth, you know, coming from higher percentile and drop to lower percentile that can be concerning as well. Um And uh we also need to make sure that uh we get accurate height and weight measurements because um you know, this can, can cause um interpretation errors if we don't have accurate height measurements. So in young Children, less than two, we do supine length. Um and older than three, we always do standing height using stadiometers. So the the gray zone is the 2 to 3 years. Some, you know, the child might not want to stand up or some, you know, we we, we get super length and so we have to pay attention to this because I found that, you know, it's a common um uh pitfall in getting uh correct height measurement. So, um you know, so we, we can see here, there are two types of growth chart, birth to 36 months, you know, which is uh for super high lens and the growth chart 2 to 20 years um is for standing height. So if we have uh a child who is um um about like two year old and we get standing height. But if we plot on the um zero birth to 36 months growth chart, we need to uh convert um standing height to Supine length by adding 0.7 centimeter, you know, to get the l Supine length because Supine length is slightly longer than standing height. So this will provide um you know, uh accurate spotting, you know, on the correct grow chart. So, and he is also um to show you the correct technique that we need to um make sure for infants that we need to have heels against footboard. Um and make sure that the shoulders touching baseboard, the crown of head, touching headboard and make sure that, you know, the head position in the Frankfurt plane, which I will explain later. And for um correct technique to measure height for older child, you know, it's best to have a second person to help um make sure that, you know, the child standing against the, the the wall or the board at the back and you know, the shoulder, um uh you know, knees and ankles, everything touching the board. Um And then we need to make sure that, you know, the head is positioned in the correct plane, you know, and we have this imaginary imaginary line that runs from the bottom of the eye socket to the top of the ear canal. Um So this line need to be parallel to the floor in order to have the right um position of the head, you know, because if head is tilted up or down, you know, that can affect the height measurement. So we need to pay attention to this. So in terms of growth rate, um growth velocity, you know, the highest growth rate is in utero, you know, 50 centimeter in nine months. So that equals to 68 centimeter per year. Uh That's very rapid growth that we see in fetus and after birth, um we also have rapid growth as well about 25 centimeter per year. And then uh growth rate will um slow down to about 12.5 centimeter per year in the second year and drop to eight centimeter per year in the third year. So from um throughout childhood, from fourth birthday to preadolescent years, um you know, the growth rate is about five centimeter per year or we say two inches a year. Um So any growth, you know, if we see a child with growth rate less than four centimeter per year, you know, that's indicates the need for further evaluation. And once kids get into puberty, you know, they will have a growth spurt and typically girls start having uh growth spurt before boys and that occurs before menarche. And for boys, uh the growth spurt occurs um in mid to late puberty about 10 or 3 to 4. And um you know, if we do examination um during the peak growth spurt, boys um have the testicular size about 15 ml. So, you know, the peak, you can see, you know, um that it's about two years later than girls. So we have different phases of childhood growth. Um, you know, the first two years of life is influenced by nutrition and you know, growth hormone starts coming into play, you know, from age two years. And then during adolescent years, we have the combination of growth hormone and puberty hormones or six steroid that help, you know, increase growth. So if we evaluate short stature, uh we, we should