Evaluation of Worrisome Growth Flashcards
Why Do We Care?
a. Poor growth may be the first and only sign of an underlying health problem
b. Consequences of delayed or missed diagnoses include potential permanent height deficits
i. limited time to possibly regain loss height (likely to be permenent)
Comparison of WHO and CDC growth charts for girls
a. Comparing the length and weight variables with a specific age
i. *The WHO growth chart is better than the CDC chart
b. AAP 2000 Recommendations:
i. Children’s height and weight should be measured at least at birth, age two to four days,1, 2, 4, 6, 9, 12, 15, 18, and 24 months, and every year thereafter through age 21
ii. Height and weight then plotted on growth charts
Worrisome Growth - Definitions
a. Growth can be worrisome along two variables: height
and growth velocity
b. Height
i. Short stature: height below -2 SD (3% is – 1.9 SD)
for age and gender OR height more than 3.5 inches
below the midparental target height
Midparental Target
For boys:
(Mother’s height + 13 cm (5 in) + (Father’s height) / 2
For girls:
(Father’s height - 13 cm (5 in) + (Mother’s height) / 2
- Notice that 13 cm = 5 inches
- 97% of children will fall within 3.5 inches of target
Worrisome Growth - Definitions
Growth Velocity:
a. Abnormally slow linear growth velocity or dropping
across two major centile lines on the growth chart
b. Rule of 5’s
Abnormal growth Velocity
and Short Stature
*Important slide
a. Abnormal growth velocity shows a slowing of growth on the chart
i. will see “de-accelerating” of the growth
ii. this is clinically WORRISOME= something pathological
b. Short stature–> will have consistent lower growth compared to rest of population
i. short stature is less worrisome
Skeletal Maturation
a. There is a direct correlation between the degree of skeletal maturation and the time of epiphyseal closure
b. The greater the bone age delay, the longer the time
before epiphyseal fusion ceases growth
c. Assessed by most using standards of Greulich-Pyle
(US children living in Cleveland)
Predictions with Skeletal Maturation
a. Height predictions can be made using child’s height and bone age
b. Predictions not accurate in children with growth disorders
c. Predictions may also be inaccurate because cannot predict pubertal tempo
d. May help in differentiating causes of short stature
Causes of Short Stature/Abnormal
Growth
Normal *Familial short stature *Constitutional short stature Pathological Nutritional Zinc, iron deficiency Anorexia IBD, celiac disease, CF Endocrine Hypothyroid Growth hormone deficiency Cushing Rickets
Chromosomal Turner syndrome Down syndrome Prader-Willi syndrome Skeletal Dysplasias Small for gestational age Metabolic Chronic Diseases Psychosocial deprivation Drugs Glucocorticoids Stimulants
Familial Short Stature
a. Children who have normal growth velocity and height that are within normal limits for parents’ heights
b. Initially will have decrease in growth rate between 6 and 18 months of age
c. *Some families with short stature may have an underlying pathologic cause (eg, skeletal dysplasias, Noonan syndrome)
Constitutional Growth Delay
a. Characterized by growth deceleration during first 2 years of life followed by normal growth paralleling lower percentile curve throughout prepubertal years
i. *Will see normal growth velocity after the first 2 years
b. Skeletal maturation is delayed
c. Catch-up growth achieved by late puberty and delayed fusion of growth plates
d. Generally end up along lower end of normal height range for families
e. Appear to be polygenic trait; positive family in about 60-80% if patients
Genetic defects causing CGD unclear
Constitutional Growth Delay
a. Reassurance of normal growth pattern
b. Can treat boys with testosterone if bone age ≥11-1/2 years to avoid compromising final height
c. Can treat girls with estrogen (not as common)
Failure To Thrive
a. Infants or toddlers (< 2 years of age) with:
i. Deceleration of weight gain to a point <3% or
ii. Fall in weight across 2 or more major percentiles
b. Non-organic causes most common – poor nutrition and psychosocial factors
c. May look like constitutional growth delay
Nutritional Growth Retardation
a. Linear growth stunting from poor weight gain in children over 2 years of age
b. May be secondary to systemic illnesses such as celiac disease, inflammatory bowel disease
c. Stimulant medications
d. Sometimes hard to distinguish from constitutional growth delay and constitutional thinness
Hormonal Causes of Worrisome
Growth
Generally, weight is spared —> They will not become underweight
i. will be normal or overweight with hormonal cause
- Hypothyroidism
- Growth hormone/IGF-1 abnormalities
- Cushing syndrome
- Rickets
Hypothyroidism
a. Can result in profound growth failure
b. Many clinical features that are seen in hypothyroid adults are lacking in children
Primary and Central Hypothyroidism
a. Primary hypothyroidism is straightforward - increased TSH, low T4
b. Central hypothyroidism – low T4, normal TSH
Thyroid and TSH levels in example patient
T4 4.9 (5 -12)
FT4 0.5 (0.8 – 1.8)
TSH 3.2 (0.5-5.0)
Based on these values, the patient has central hypothyroidism
(Low T4 and FT4, normal TSH)
Growth Hormone
a. Anterior pituitary hormone
b. Main function is to promote linear growth
c. Also effects body composition – increases lean body mass and decreases fat
Growth Hormone Deficiency –
Congenital
Hypothalamic-pituitary malformations:
1. Holoprosencephaly/Schizencephaly
- Isolated Cleft lip or palate
- Septo-Optic-Dysplasia – 50% have hypopituitarism
i. congenital malformation syndrome featuring underdevelopment of the optic nerve, pituitary gland dysfunction, and absence of the septum pellucidum (a midline part of the brain) - Optic nerve hypoplasia
- Empty sella syndrome
