10/19- Growth and Growth Disorders in Children Flashcards

1
Q

What is normal growth in childhood (stats)?

A
  • Standards set with mean heights for age and sex +/- 2 STDs
  • Evaluate those >2 or under -2 SDs
  • May not be a problem if out of norm
  • Check growth rates!
  • Evaluate birth: IUGR, SGA, AGA, LGA
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2
Q

Describe normal growth velocity?

A
  • Growth highest right after birth
  • Peak again in puberty
  • Growth rate is variable
  • Duration of growth spurt is variable
  • Growth rate rapidly declines at end of puberty
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3
Q

What is the average age onset puberty?

A

Girls: 10-11 yr average (range 8-13 yo)

  • Further eval if no development by 13 yo in girls

Boys: 11-12 yr average (range 9-14 yo)

  • Further evaluation if no development by 14 yo in boys
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4
Q

Describe delayed growth:

  • Seen when
  • More common in boys or girls
  • What is delayed
  • What other factors
A
  • Usually seen by 2 yo
  • More common in boys

Delays:

  • Height, weight and bone age lag behind
  • Pubertal development lags behind

Factors:

  • Positive family history
  • Height prediction is normal
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5
Q

Describe Familial Short Stature

  • Family characteristics
  • Growth velocity
  • Development
A
  • Parents usually short
  • Normal growth velocity
  • Normal development
  • Bone age = Chronological age
  • Occasionally parents with genetic cause short stature too
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6
Q

What are some non-endocrine causes of poor growth?

A
  • Malnutrition
  • Psychological
  • Gastrointestinal
  • Celiac disease
  • Inflammatory bowel disease
  • Malabsorption
  • Cystic fibrosis
  • Liver disease
  • Diabetes mellitus (absorbing well, but losing much glucose in urine)
  • Heart disease
  • Respiratory disease
  • Cystic fibrosis (don’t absorb fat well and have huge caloric demands)
  • Asthma
  • Renal disease
  • Chronic renal failure
  • Dysplastic kidneys
  • RTA
  • Hematologic/oncologic diseases
  • Cancer (methotrexate/other treatments play a part)
  • Anemias
  • Bleeding disorders
  • Rheumatologic disorders
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7
Q

What non-endocrine disorders would cause these growth patterns?

A

Top line: inflammatory bowel disease

  • Child typically grows well to a point
  • Cramping, diarrhea, other symptoms may start later

Middle: renal disease

Bottom line: IUGR, Syndromes

  • Start small; have small number of cells to start
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8
Q

What are some endocrine causes of poor growth?

A
  • Hypothyroidism (her most common)
  • Glucocorticoid excess
  • Endogenous (rare)
  • Exogenous (for cystic fibrosis, transplant recipients, bad asthma…)
  • Hypopituitaris
  • Precocious puberty
  • Growth hormone deficiency/insensitivity
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9
Q

Describe congenital hypothyroidism

  • Incidence
  • Major cause of ___ if not treated early
  • Due to what
  • Signs
  • Symptoms
A
  • 1 per every 2500-4000 births
  • Major cause of retardation if not treated early
  • Due to: agenesis, ectopia, dyshormonogenesis

Signs:

  • Big tongue
  • Umbilical hernia
  • Open fontanelle

Symptoms:

  • Poor feeding
  • Increased sleeping
  • Lethargy
  • Poor growth and weight gain
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10
Q

Describe acquired hypothyroidism

  • Epidemiology
  • Mechanism
  • Signs
  • Symptoms
A
  • More in females
  • Lymphocytic infiltration of gland

Signs:

  • Usually enlarged gland
  • Dry skin
  • Constipation
  • Hair abnormalities

Symptoms:

  • Poor growth, weight gain
  • Fatigue
  • Poor concentration/school work
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11
Q

Describe hypercortisolism:

  • Endogenous vs. exogenous
  • Signs/symptoms
A

Endogenous is rare in childhood; exogenous may result from treatment:

  • Asthma
  • CF
  • Cancer
  • Arthritis
  • Renal disease
  • Autoimmune diseases

Signs/symptoms:

  • Central obesity
  • Thin limbs
  • Striae
  • Buffalo hump less common
  • Hirsuitism
  • Fatigue
  • Increased appetite
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12
Q

Describe hypopituitarism

  • Signs of congenital
  • Causes of acquired
  • Evaluate for what else
  • First sign may be
  • Treatment
A

Congenital may involve:

  • Signs of hypothyroidism
  • DI
  • Poor growth
  • Hypocortisolism
  • Microphallus

Acquired may be caused by:

  • Injury
  • Surgery
  • Infiltrative

Need to evaluate first for:

  • Hypothyroidism
  • Hypocortisolism

Hypoglycemia may be 1st sign

Tx: replace all hormones needed

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13
Q

Describe growth hormone deficiency

  • Prevalence
  • How to diagnose
  • Signs/symptoms
  • Relation to GFs
A
  • Prevalence: 1 per 4-8,000
  • Dx of exclusion
  • Pay attention to both sexes

Signs/symptoms:

  • Short, round, usually not thin
  • Under 2-3 STD or poor growth velocity

Monitor GFs:

  • IGF-1: more sign nutrition
  • IGF BP3: best Seen in Hypopituitarism too
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14
Q

What is precocious puberty?

  • Other symptoms
  • Need to delineate what milestones/how to diagnose
  • When to treat
A
  • Child with puberty under 8 (F) or 9 (M)
  • May be overgrown, obese
  • Large early, short later

Diagnosis:

  • Need to delineate thelarche (breast development), adrenarche (pubic/axillary hair), true precocity
  • True precocity = increase in breast size for girl or increase in testicle size in boy

Treat if:

  • Poor ht potential
  • Psychological distress
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15
Q

How to evaluate growth?

A
  • Get accurate measurements
  • Measure more often in infancy
  • Yearly after infancy
  • Plot the data!
  • Equal attention to both sexes
  • Proper equipment
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16
Q

How to get accurate measurements for young kids?

A
  • Measure supine 0-24 months
  • Hold infants and toddlers in place
  • Use stadiometer for older children
  • Position child carefully
  • Time of day can even make difference
17
Q

What are signs of poor growth?

A
  • Height < 3%
  • Height well below height potential
  • Slow growth velocity
  • Crossing percentiles, esp. after 18 months
  • Marked changes in growth pattern
18
Q

What is short stature?

A
  • Height SDs under 2 STD for age/sex
  • 5% of normal children are under 5%
  • Calculate mid-parental height
19
Q

What are equations for mid-parental height?

A

Male:

[M ht(cm) + 13 cm + F ht(cm)]/2

Female:

[M ht(cm) - 13 cm + F ht(cm)]/2 Note: 13 cm ~ 5 in

20
Q

What is included in growth history?

A
  • Pregnancy-maternal health, Etoh, drugs, placental health
  • Birth: IUGR, SGA, AGA, LGA
  • Birth trauma or problems, hypoxia
  • Congenital anomalies, syndromes
  • Neonatal course
  • General health-chronic illness
  • Psychological health
  • Growth: height, weight, growth rate
  • Family history: mid-parental ht, sibs ht
  • Sexual development-early or late?
21
Q

What does the physical exam for growth disorders involve?

A
  • Height, weight, growth velocity
  • Tanner staging
  • Syndromic features-webbed neck, body shape
  • Especially Turner’s (45X): webbed neck, wide-carried arm
  • She likes to evaluate all likely short girls with karyotype to see if mild Turner’s
  • Upper/lower ratio
22
Q

What does the diagnostic evaluation for growth disorders involve?

A
  • T4, TSH
  • Metabolic Panel
  • Urinalysis
  • CBC, sedimentation rate
  • IGF-1, IGFBP-3
  • Chromosomes
  • Bone age
  • MRI w/ attention to pituitary region
  • Growth hormone stimulation testing
  • Exercise
  • Insulin
  • Arginine
  • L-dopa
  • Glucagon
  • Clonidine
23
Q

What is treatment for growth disorder?

A
  • Treat underlying cause first
  • Optimize nutrition
  • Try to lower steroids
  • Hypothyroidism w/ synthetic thyroid
  • Thyroid-8-10 mcg/kg in infants, 3-5 mcg/kg in children, 1-3 mcg/kg in adolescents
  • Hypocortisolism w/HC in childhood
  • HC at 6-8 mcg/m2/d
  • DDAVP at dose to keep Na 135-155
  • Lupron Depo-Ped for precocious puberty
  • Tx GH deficiency early for hypoglycemia
  • GH tx is a long term commitment
  • GH is very expensive-$ 10-20,000/yr