Failure to gain weight or height Flashcards
Normal growth - 3 key phases
- Infancy - age 2: very rapid, dependent on birthweight, feeding and health
- Age 2 - puberty: grow 5cm/yr, dependent on growth hormone and health
- Puberty: grow 12.5cm/yr, dependent on timing of puberty and health
Height measurement tips
- Without shoes
- Heels and back touching wall
- Look straight ahead
- Gentle but firm pressure upwards applied to mastoids from underneath
- US/ LS ratio
- Total arm span
What is upper segment: lower segment ratio?
Upper to lower segment ratio (U/L) reflects trunk vs legs ratio, where lower segment is the distance from the middle of pubic symphysis to the floor level and upper segment is height minus lower segment
At birth, U/L is about 1.7:1 or trunk longer than legs - decreases to 1:1 from age 10
How is age most accurately measured in infancy?
- Most accurate plot in infancy is to calculate the number of weeks of age by total number of days of age then divide by 7 (rather than estimating the number of weeks from age in months)
Definition of short stature
= height 2 standard deviations below average height
A perceived or real impairment of linear growth
What is target height?
TH is a term used for the expected height of a child given the heights of the parent
Boys: (Father’s height (cm) + Mother’s height + 13cm) / 2
Girls: (Father’s height (cm) + Mother’s height - 13cm) / 2
Endocrine causes of short stature
- Isolated growth hormone deficiency
- Hypothyroidism
- Hypopituitarism
- Adrenal excess e.g. CAH
- Post cranial irradiation hypopituitarism
Causes of failure to thrive
Aspects of the consultation if child has FTT
FTT Hx
- Dietary: keep a food diary, formula feeds, check volume and preparation, mealtimes (when, where, with who?)
- Pregnancy/ birth: maternal health during pregnancy, foetal growth, neonatal problems
- PMHx: illnesses, hospital admissions, symptoms of reflux, vomiting, stools
- Family and social hx: who lives at home, family difficulties, medical conditions and growth in parents, siblings
FTT: examination
- Plot height, weight and head circumference
- Dysmorphic features
- General and systems exam
- Poor suck or motor skills
- Watch parent/ carer feed child
FTT: investigations
1st line:
- Bloods: FBC, ESR, CRP, U&E, glucose, TFTs, coeliac serology
- Congenital infection screen
- Sweat test
2nd line:
- Metabolic disease: serum amino acids, carnitine ammonia, blood gas, urine organic acids
- Lead level
- Genetic karyotype
- CXR
- ECG/ echo
FTT: diagnosis
- Hx and examination usually more important than tests
- Many cases are non-organic
- Detailed hx of feeding pattern usually helpful
- Understand the complex physical and emotional issues in successful infant feeding
FTT: management
- Assessment for pathological cause
- Feeding plan
- Education and support to parents/ carers
- Inpatient observation of feeding and weight gain
- Work with safeguarding teams in health and social care
What is a neonate?
Birth - 28 days
What is an infant?
28 days - 1yr
What is a toddler?
1-3yrs
What is a young child?
4-6yrs
What is an older child?
7-10yrs
What is an adolescent?
11-17yrs
What is Gaussian distrubution?
AKA normal distrubution
At which age can BMI be used to assess growth?
2yrs
What is mid parental height?
Mean of mother and father’s height and therefore the expected height of the child in adulthood
AKA target height
In girls, the father’s height minus 13 cm (5 in) is averaged with the mother’s height; in boys, the mother’s height plus 13 cm is averaged with the father’s height
Weight gain of children aged 1-5
Children gain around 2kg/yr
What factors does intrauterine growth depend on?
Depends on three factors: maternal, uteroplacental and foetal
- Maternal: good nutrition, conditions such as DM can restrict growth usually due to affect on placenta, maternal smoking reduces placental blood flow and thus foetal growth
- Uteroplacental: if growth falters, placental blood flow is assessed via doppler USS to measure blood flow in umbilical arteries - absent or reversed flow usually triggers urgent delivery
- Foetal factors: intrauterine infection can cause growth restriction, chromosomal anomalies
What is the major determinant of growth during infancy and childhood?
- Nutrition is the major determinant of growth at this stage but thyroid function also plays a part
Hormones affecting growth
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Growth hormone and thyroid hormones are the key determinants of growth during middle childhood
-
Growth hormone is secreted by the anterior pituitary in response to growth hormone releasing hormone which is released from the hypothalamus
- GH is released in pulses triggered by multiple stimuli including exercise, secretion peaks after the onset of deep sleep
- Growth hormone acts by stimulating cell division and maturation of chondrocytes in the growth plates which leads to widening of the growth plate and lengthening of bone
- Growth hormone also acts by stimulating the liver to release insulin like growth factor one which stimulates growth of money tissues in the body including muscle, cartilage, bone, liver and nerves
- Growth hormone deficiency becomes apparent around the age of two years, children are shorter and stockier than their peers
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Thyroid hormones are necessary for normal growth throughout childhood and are needed for the development of the CNS in the foetus and infant
- Thyroid hormones to promote protein synthesis and promote bone growth
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Growth hormone is secreted by the anterior pituitary in response to growth hormone releasing hormone which is released from the hypothalamus
Actions of LH
Women: oestrogen and progesterone production, mid-cycle surge triggers ovulation
Men: testosterone production
Actions of FSH
Women: follicular growth
Men: testicular growth, spermatozoa maturation
How does oestrogen affect growth?
- Oestrogen promotes bone growth by increasing secretion of growth hormone, growth hormone increases production of insulin like growth factor one which stimulates the growth of various body tissues
- Oestrogen is also responsible for the maturation of chondrocytes and osteoblasts which ultimately leads to fusion of the growth plates thus preventing further growth
What are the side-effects of puberty?
- Acne due to increased see them production in the skin
- Moodiness due to increased sex hormone production
- Body odour due to bacterial breakdown of sweat produced by apocrine glands
- Gynaecomastia due to oestrogen and testosterone imbalance
Which staging system is used to assess the process of puberty?
Tanner staging system
Changes in girls during puberty
- Breast bud development
- Small growth of breast tissue under each nipple, the breasts continue to grow and develop stimulated by oestrogen secreted from the ovaries
- This is followed by the appearance of pubic and axillary hair which occurs due to adrenal androgens
- Menarche
- The term for the first period which usually occurs around the age of 13 years and 2–3 years after the onset of puberty
- Once Monarch has occurred there is little subsequent growth in height – only around 5cm
Changes in boys during puberty
- First physical sign is increasing testicular size known as gonadarche, because on average at 12 years of age
- The increase in testicular size is mainly secondary to the secretion of follicle stimulating hormone but the effects of LH also contribute. The testes begin to secrete testosterone and this combined with adrenal androgens is responsible for the growth of the genitalia and development of male secondary sexual characteristics
- 1–2 years after going at Ark there is an increase in penile length and development of the glands
- Pubertal growth spurt occurs around two years later than in girls
