Child growth and Development Flashcards
Why do we measure growth?
Poor growth in infancy is associated with high childhood morbidity and mortality.
Growth is the best indicator of health – a child who is growing well will be healthy
Demonstration of normality of growth by age and stage of puberty
Measurement allows us to identify disorders of growth
Assess obesity
How is child height measured?
Babies lay on a special measuring plate. Hard board at both ends. Baby is lay flat and their length is measured.
When a child can stand up, measured upright. They need to stand up straight with their heels against a board. High accuracy
How is the accuracy of height measuring equipment ensured?
The equipment should be accurate and maintained properly
Position the child properly to get an accurate height (read the instructions on the growth chart)
Make sure you get rid of things which interfere with measuring- shoes off, hair out of the way, clothes off to weigh.
Calculate the age and plot correctly on the chart.
How are centile charts used?
Centile charts are a way of expressing variation within the population.
Head circumference Weight Height/length Leg length BMI – needs to be plotted on a growth chart Growth velocity – measured in cm/year Specialist charts
What can head circumference and Leg length indicate?
When the baby is born fontanelles present. As the brain grows, the fontanelles in the skull allow expansion of the head. If the head isn’t growing well, possible brain isn’t growing well. (Also see if there is increased fluid in the head.)
Measure leg length to detect any disproportional growth.
What do height velocity charts show?
Height velocity is expressed in cm/year
It gives people an idea of how quickly the child is growing
The baby grows very quickly in utero
When they are born, they are also growing quickly, but are slowing down
In the mid-childhood range, they are growing 5-6 cm/year
When they reach puberty, children grow VERY QUICKLY, and then stop
The pubertal growth spurt can be seen on the chart
What is GF effect on growth?
Growth hormone (GH) makes cells make IGF-1 – this is what mediates growth
The GH-IGF-1 axis is the regulator of human linear growth
GH is a single chain polypeptide – if missing need injections
Somatotroph cells of the anterior pituitary produce GH
It demonstrates pulsatile secretion, which is influenced by nutrition, sleep, exercise and stress
Negative control by somatostatin from hypothalamus
Where does IGF-1 act?
70% of IGF-1 is made in the liver. IGF-1 receptors are located within the growth plates of bones. IGF-1 has an autocrine AND paracrine effect.
The growth plate is cartilage. Within this, are osteoblasts. If IGF-1 interacts with the osteoblasts, they are STIMULATED. They begin to proliferate, and the bone becomes longer.
What are the stages of growth?
Antenatal (Fastest) - Maternal health and the placenta are important factors in control of growth. IGF-2 also controls growth (hormone that is paternally imprinted)
Infancy - Rapid initial growth (23-25cm yr1)
Continuation of foetal growth, (decreased velocity) Growth still nutritionally dependant for a year
After yr1 GH is vital in baby growth (9-12 months influence of GH) In GH deficiency, early severe plataue on growth chart
Childhood
Post infancy to adolescence. Growth rates in boys and girls similar (same growth velocity – 5-6cm/year)
GH/IGF-1 axis drives growth. Nutrition has less impact
Puberty
GH still causes growth however the sex steroids now involved. Sex steroids work with GH to increase growth velocity. Then, sex steroids fuse growth plates. Growth stops after fusion Girls tend to get their growth spurt at the beginning of puberty (slightly earlier than boys). Boys are averagely 13-14cm taller than girls
What are some causes of short height?
Genetic – short parents
Pubertal and growth delay
IUGR/SGA – 10-20% of babies who are small at birth
Dysmorphic syndromes – chromosome abnormalities often result in short stature
Endocrine disorders
Chronic paediatric disease – if you are ill, you won’t grow very well
Psychosocial depravation – stressors can affect the pulsatility of GH
Normal growth pattern
Most short children have a normal growth pattern and do not have any medical problem
They are usually the children of short parents
Not all children with intrauterine growth restriction catch up completely
Growth will be normal in childhood but they have “lost” some height in the antenatal period
What should be investigated to discover if short height is normal for a child?
Look at their birth history and weight to investigate whether there were any illnesses early on in life.
Parental heights.
Medical history of the child
Previous measurements
How is child’s potential height estimated?
MID-PARENTAL CENTILE: we can do a correction on growth charts, in order to estimate the maximum potential height of the child. It shifts the normal distribution down (adjustment) for the parents’ height.
What endocrine problems can cause short stature? What investigations could be done?
Hypothyroidism (also, thyroxine is so important for brain development)
Growth hormone deficiency
Steroid excess
Investigate - Full blood count, Liver and kidney function. Thyroid function. Coeliac screens. IGF-1 levels and bone age.
What are some non-endocrine causes of short stature?
Turner syndrome XO – females who don’t go through puberty, and are short
Down’s syndrome (trisomy 21)
Skeletal dysplasias
Significant illnesses can interfere with growth
(inflammation, poor nutrition and the effects of drugs such as steroids) This blocks the intracellular signalling processes of GH – so IGF-1 deficient
Achondroplasia - normal sitting height, abnormal standing height due to shorter legs
What are some chronic paediatric diseases?
Badly controlled asthma Sickle cell Juvenile chronic arthritis Inflammatory bowel disease (Crohn’s disease) Coeliac disease Cystic fibrosis Renal failure Congenital heart disease
What are the causes of tall stature in children?
Tall parents Early puberty – makes a child tall at first (shorter later) Marfans syndrome Soto syndrome Growth hormone excess
What are the side-effects of obesity in children?
Emotional and behavioural: stigmatization, bullying, low self-esteem
School absence
High cholesterol, high BP, pre-diabetes, bone and joint problems, breathing difficulties
Increased risk of becoming overweight in adulthood
Risk of ill-health and premature mortality in adult life
What are some syndrome associated with obesity?
Cushing’s syndrome
Prader Willi syndrome
Lawrence Moon-Biedl syndrome
What is the genetic component of weight?
Polygenic inheritance – many genes affect how much we will weight (appetite not metabolism)
Weight is a highly heritable trait (40-70%)
There are some monogenic obesity syndromes –rare Leptin deficiency Leptin receptor deficiency POMC deficiency PC-1 deficiency MC4R deficiency
What may be relevant in a child’s history regarding development?
Antenatal – illnesses/infections; medications; drugs; environmental exposures
Birth –Prematurity, Prolonged/complicated labour
Postnatal – illnesses/infections; Trauma
Consanguinity – increases chances of chromosomal or autosomal recessive conditions
Developmental milestones from parent
What examinations can be done to assess developmentt?
Growth parameters – height, weight and head circumference
Dysmorphic features
Neurological examination and skin
Systems examination to identify associations, syndromes
Standardised developmental assessment – SOGSII, Griffith
What can be used to investigate the causes of developmental abnormalities?
Cytogenetic studies; metabolic screen (thyroid, renal, liver and bone profiles); blood ammonia and lactate; urine and blood organic and amino acids; creatine kinase; imaging – CT, MRI; EEG; nerve and muscle biopsy.
What is cerebral palsy?
A disorder of movement and posture arising from a non-progressive lesion of the brain acquired before the age of 2 years.
Incidence 1-2 per 1000 live births
Most causes (~80%) are antenatal
Presentation may evolve and vary with age
Associated problems exist – learning difficulties, epilepsy, visual impairment, hearing loss, feeding difficulties, poor growth, and respiratory problems.
Management
Aim is to minimise spasticity and manage associated problems
What is ASD?
Prevalence is 3-6 per 1000 live births
Boys>girls
Usually presents between 2 – 4 years of age
Features include (1) impaired social interaction; (2) speech and language disorder; and (3) imposition of routines with ritualistic and repetitive behaviour.
Comorbidities include learning and attention difficulties, and epilepsy
Management
Intensive support for child and family
What is ADHD?
Diagnostic criteria – (1 )Inattention; (2) Hyperactivity; (3) Impulsivity; (4) Lasting > 6 months; (5) commencing < 7 years and inconsistent with the child’s developmental level (Present in multiple settings)
Increased risk of: conduct disorder, anxiety disorder & aggression. A significant proportion of children with ADHD will become adults with antisocial personality and there is an increased incidence of criminal behaviour and substance abuse
Management
Psychotherapy – Behavioural therapies
Family therapy
Drugs – If behavioural therapy alone insufficient; stimulants, e.g. methylphenidate (Ritalin), amphetamines (dexamphetamine)
Diet – Some children benefit noticeably from exclusion of certain foods from their diet, e.g. red food colouring
What are the risk factors for development of ADHD?
Risk factors – Boys > girls, ratio 4:1; Learning difficulties and developmental delay
Neurological disorder, e.g. epilepsy, cerebral palsy; first-degree relative with ADHD; family member with depression, learning disability, antisocial personality or substance abuse
What are learning disabilities?
Prevalence of moderate learning difficulty is 30 per 1000 children. Prevalence of severe learning difficulty is 4 per 1000 children
25% severe learning disability cases no found cause
Causes include – (i) chromosome disorders (30%); (ii) other identifiable syndromes (20%); (iii) postnatal cerebral insults (20%); (iv) metabolic or degenerative diseases (1%)
Classified as mild, moderate, severe or profound
May present with reduced intellectual functioning, delay in early milestones, dysmorphic features, ± associated problems (epilepsy, sensory impairment, ADHD)
Management
Involves establishing a diagnosis and input from the multidisciplinary team with long term follow up.
What is development in a child?
Development = global impression of a child (growth, understanding, skill acquisition and sophisticated responses and behaviour.) It serves to endow the child with increasingly complex skills in order to function in society.
Developmental progress depends on the interplay between biological and environmental influences. It follows a constant pattern, although at variable rates, among children.
What are the domains of development?
Four domains or fields –
(1) gross motor and posture;
(2) fine motor and vision;
(3) language and hearing; and
(4) social, emotional and behaviour.
Limit ages are the age by which they should have been achieved = 2 standard deviations from the mean. They indicate cause of major concern.
Developmental progress can be monitored or identified either through developmental screening or by the use of standardised developmental tools.
Describe abnormal development
Refers to the slow acquisition of skills and follows three main patterns: (1) slow but steady; (2) plateau; and (3) regression.
Delay may occur in one or more domain
Biological factors may impact on development – e.g. folate deficiency increases the risk of neural tube defects which, in its most severe form, can result in limb paralysis, neurogenic bladder and bowel; and intellectual impairment.
What behaviours and issues are often present in abnormal development?
Delayed walking Clumsiness Delayed speech and language Odd social interaction- ASD/Aspergers Hyperactivity
Increased
Sleep onset/frequent night waking
Eating
Toileting
What are some causes of motor development delay?
Cerebral palsy Global delay e.g. Down’s syndrome Congenital dislocation hip Social deprivation Muscular dystrophy-Duchenne’s Neural tube defects: spina bifida Hydrocephalus
What are some causes of language delay?
Hearing loss
Learning disability
Autistic spectrum disorder
Lack of stimulation
Impaired comprehension of language – Developmental dysphasia
Impaired speech production – stammer, dysarthria
