Abnormal Growth Flashcards
Describe normal growth from foetus to adolescent
Foetal: fastest periods, dependent on size of mum and placental nutritional supply
Infantile: until 18 months, dependent on adequate nutrition, good health and normal thyroid, rapid deceleration growth rate
Childhood: slow, stead, prolonged growth, driven by IGF-1 production the liver + GH spikes at night
Pubertal growth spurt: testosterone and oestradiol cause lengthening of the back and GH secretion + fusion of epiphyseal growth plates and growth cessation
What is classed as abnormal growth
Measurements outside 0.4th or 99.6th centiles if the mid-parental height is not short or tall
The height centile is more than 3 centile spaces below the mid-parental centile (see below).
A drop in the height centile position of more than 2 centile spaces.
Any other concerns about the child’s growth.
Define faltering growth
lower weight or rate of weight gain than expected for age and sex in childhood
First few days: weight loss >10% or <10% without returning within 3 weeks
Birthweight:
- <2nd centile
- <9th centile and falls ≥ 1 centile spaces
- 9-91st centile and falls ≥ 2 centile spaces
- >91st centile and falls ≥ 3 centile spaces
BMI: <2nd/0.4th centile
Length/heigh 2 centile spaces below the mid parental centile
What are the causes of faltering growth
Inadequate nutrient intake (85-90% non-organic)
- Lack of healthy food available or knowledge on what is appropriate healthy food
- Child maltreatment
- Feeding difficulties e.g. breastfeeding or formula prep, cleft lip/palate, poor appetite
- Developmental delay
- Eating disorder
Inadequate absorption:
Persistent vomiting e.g. gastro-oesophageal reflux, obstruction, adverse drug effects, food sensitivities, underlying metabolic disease, infection, CNS enteropathy
Excessive energy expenditure
Cardiac: Congenital heart disease
Resp: CF, laryngomalacia
Met/endo: hyperthyroidism, DM, inborn errors of metabolism
Renal: renal tubular acidosis
Immunodeficiency
Down’s syndrome
What investigations should be done for faltering growth
Growth chart plotting + mid-parental height
Avoid investigations
Bedside: urinalysis, BM
Bloods: FBC, U&Es, LFTs
What is the management for faltering growth birth-1month
MDT: Paediatric dietician | Clinical psychologist | SALT with expertise in feeding and eating difficulties |Occupational therapist | School nurse | Social services
Liaise with midwife and health visitor
<10%: reassure it is common, come back in 3 weeks if it still hasn’t returned, offer feeding support
>10% or no return by 3 weeks: paediatrician referral, feeding support
+ follow up
+ resources: NHS pregnancy and Baby guide, UK breastfeeding network
What is the management for faltering growth >1 month
Paediatrician referral
MDT: Paediatric dietician | Clinical psychologist | SALT with expertise in feeding and eating difficulties |Occupational therapist | School nurse | Social services
Conservative advice:
- Feeding support
- Relaxed and enjoyable mealtime
- 20-30mins duration
- Allow children to be messy with their food
Recovery in weight gain usually begins within four to eight weeks of a successful intervention and may take several months
+ follow up
How often should follow up be for faltering growth
<1 month old Daily
1-6 months Weekly
6-12 months Fortnightly
>1 years old Monthly
What is the prognosis for faltering growth
Recovery in weight gain usually begins within four to eight weeks of a successful intervention and may take several months
If there is underlying condition, prognosis is dependent on that condition and its treatment
Early identification and treatment of all cases may improve prognosis and prevent long-term complications
Impairments in cognition, attention, and behaviour may persist
Define short stature
height < 2nd centile or 0.4th centile
What are the causes of short stature
Familial: short parents (child falls in the target range)
IUGR and extreme prematurity (1/3)
Constitutional delay of growth and puberty
Endocrine: hypothyroidism, GH deficiency, IGF-1 deficiency, steroid excess, overweight, Cushing’s syndrome
Nutritional: insufficient intake, restricted diet, raised metabolic rate
Chronic illnesses: coeliac’s, Crohn’s, chronic renal failure, SCD, CF, Congenital heart disease, juvenile arthritis, asthma
Psychosocial deprivation (Can catch up growth)
Chromosomal disorders: Down’s, turner’s, noonan’s, achondroplasia
What are the causes of extreme short stature
Laron syndrome (resistance to GH)
Primordial dwarfism
Abnormalities in gene SHOX (short stature homeobox) on X chromosome
Klinefelter’s syndrome
How is disproportionate short stature assessed and what condition is associated with it
Sitting height
Subischial leg length
Limited radiographic skeletal survey
Achondroplasia
What investigations should be done for short stature
Bloods: FBC, CRP/ESR, TFTs, IGF-1, coeliac screen, karyotype
Other
- X-ray of non-dominant hand for bone age (check for fusion and presence of growth plate)
- GH stimulation testing
- MRI
- Echocardiogram
What is the treatment for growth failure and what are the indications for it
Somatotropin
- Severe hormone deficiency
- Turner syndrome, Prader-Willi syndrome
- Chronic renal insufficiency
- Born SGA and subsequent growth failure at ≥ 4 years old
- SHOX deficiency
Laron syndrome, IGF-1 deficiency → recombinant IGF-1
