Clinical Assessment of Growth Failure ✅ Flashcards
What can growth failure arise from?
- Genetic abnormalities
- Nutritional problems
- Endocrine problems
- Defects in almost any organ system
What should be included when taking a history in a child with growth failure?
- Family history
- Antenatal history
- Feeding history
- Development of signs of puberty
- Other symptoms
- Social history
What should be included in the family history for a child with growth failure?
- Parental heights
- Parental timing of puberty
Why is family history important in growth failure?
Genetics has an important influence
What should be included in the antenatal history for a child with growth failure?
- Pregnancy
- Mode of delivery
- Birth weight
Why is antenatal history important in growth failure?
May impact on infant phase of growth
Why is it important to ask about other symptoms in a child with growth failure?
- Look for symptoms suggestive of pituitary dysfunction or intracranial disease
- Look for systemic symptoms that might suggest co-existent medical disorders
What symptoms might suggest pituitary dysfunction or intracranial disease?
- Headache
- Visual disturbance
What is it important to include when taking a social history in a child with growth failure?
Details of how the short stature is affecting the child
What should be specifically enquired about in the history of a child with tall stature?
- Symptoms suggestive of precocious puberty
- Symptoms of thyrotoxicosis, Marfan’s syndrome, or other overgrowth syndromes
What needs to be done when taking serial growth measurements?
- Undertaken at approximately the same time of day
- Preferably by the same measurer
Why should serial growth measurements be taken at the same time of day?
Because of the effect of time of day on height - human height shortens as the day progresses
Why should serial growth measurements ideally be taken by the same person?
To avoid inter-observer variation on measurement
What should be used to measure height in children over 2 years?
A radiometer (preferably wall mounted)
What position should the child be in when measuring using a stadiometer?
- Heels, buttocks, and shoulders against the backplate
- Head in the Frankfurt plane
What is the Frankfurt plane?
Imaginary line connecting lower border of the eye socket with external auditory meatus
How should height be measured under the age of two years?
Supine table measurements or a neonatometer
What is required to ensure accuracy when measuring length in a child under 2?
Two observers
What position should a child be in when using a supine table measurement or neonatometer?
- Frankfurt plate vertical
- Child’s head in firm contact with the headboard
- Foot dorsiflexed against movable baseplate
Why should the sitting height also be measured?
Skeletal dysplasia may impair the growth of different parts of the skeleton differentially
What is the measurement of sitting height a proxy for?
Vertebral body growth
How should sitting height be measured?
Using a table-mounted stadiometer
What does subtracting the sitting height from standing height produce?
Sub-ischial leg length
What is sub-ischial leg length a measure of?
Long bone growth in the leg
When should head circumference be measured as a growth parameter?
In children under 2 years
What should height measurements be compared with?
Weight
How should height measurements be compared with weight?
By plotting measurements on a growth chart
What growth charts are used in the UK?
UK-WHO growth charts
What are the UK-WHO growth charts derived from?
UK90 charts and WHO growth standards
What were the UK90 charts derived from?
Cross-sectional growth data
What do the WHO growth standards describe?
Growth of healthy breastfed children from six countries
Why does weight data need to be adjusted for height?
Because of the association of weight with height (taller children tend to be heavier)
How is weight data adjusted for height?
By calculation of the BMI
How is the BMI calculated?
Weight (kg) / (height (m))^2
How can the growth pattern be interpreted?
Height measurements should be compared with all measurements taken in the past and plotted on a growth chart
What indicates an abnormal height velocity on a growth chart?
Crossing of centiles
How is the appropriateness of a child’s height for their genetic background assessed?
By calculating the target height range
How is the target height range calculated?
Mid-parental centime (mid-point between the parents centimes) +/- 8.5cm
What additional features should be assessed on physical examination of a child with abnormal growth?
- General appearance and nutritional state
- Dysmorphic features
- Pubertal staging
- Detailed systems review
What dysmorphic features in particular should be looked for in the examination of a child with abnormal growth?
Abnormalities of the craniofacial skeleton or suggestive of skeletal disproportion or an underlying syndrome
Why is pubertal staging important in assessing a child with abnormal growth?
It is important in evaluating the chronology of physical development, which has major influences on growth
What should be included in the detailed systems review of a child with abnormal growth?
- Blood pressure
- Visual fields and fundoscopy
What should be done before considering any investigations for abnormal growth?
Integrate the history and examination into a differential diagnosis
What should be done if features on history and examination are suggestive of a defect in a clinical system?
Appropriate further tests of the relevant system to confirm the diagnosis
What investigations should be done in a short or slowly-growing child with no obvious pathology?
- XR left wrist
- Bloods
Why is an XR of the left wrist bone in a short/slowly-growing child with no obvious pathology?
To calculate bone age
Why is it important to calculate bone age in a short/slowly-growing child?
To assess the degree of delay in physical development
What should be checked for in the bloods of a child who is short/slowly growing with no obvious pathology?
- FBC
- Blood film
- ESR or CRP
- U&E
- Calcium and phosphate
- TFTs
- IgA and anti-tTG antibodies
- Karyotype (in girls)
- IGF-1
Why is karyotyping done in a short/slowly growing girl?
To exclude Turner’s syndrome
What is the limitation of measuring IGF-1?
- Limited sensitivity for screening for GH deficiency
- May be affected by nutritional state
What further investigation can be done if initial investigations into a short/slowly-growing child with no obvious pathology are normal?
Formal stimulation tests of GH secretion
What investigations may be done in a tall or rapidly-growing child?
- Bone age
- Karotyping (in boys)
- TFTs
- IGF-1
- Cardiac USS
- FMR1 gene analysis
- DNA for specific genetic syndromes
Why is karyotyping done in boys who are tall/rapidly-growing?
Exclude Klinefelters syndrome
Why are TFTs done in a child who is tall/rapidly growing?
To look for hyperthyroidism
Why is IGF-1 measured in children who are tall/rapidly-growing?
To exclude GH over secretion
When might cardiac ultrasound be done in a child who is tall/rapidly-growing?
If Marfan’s syndrome is suspected
Which children who are tall/rapidliy-growing might FMR1 gene testing be indicated in?
Boys with learning difficulties
What is FMR1 gene analysis looking for?
Fragile X syndrome
Give 3 specific genetic syndromes that may be looked for in a tall/rapidly-growing child?
- Marfans
- Beckwith-Wiedemann
- Sotos syndrome
