Growth Flashcards
Respiratory Rate and Heart Rate (2)
- Should be counted for a full minute with child calm and at rest
- Each degree of Farenheit increases the HR 8-10 beats/minute (apical HR and degree of fever should correlate)
Blood Pressure (2)
- Have patient raise their arm if it’s too quiet to hear the BP with their arm down
- There is increased BP in taller children, males, and older children
Head ultrasound
Non-invasive way to evaluate head changes in first year of life when fontanel is still present
*Tells you whether or not child’s ventricles are normal or if there is external hydrocephalus, which will cause increased growth
Weight-for-age (4)
- Reflects body weight relative to age
- Influenced by recent changes in health or nutritional status
- NOT used to classify as under or overweight
- Used in early infancy for monitoring weight and helping explain changes in weight-for-length and BMI-for-age in older children (BMI is done at 2 years and older)
Stature/length-for-age (2)
- Linear growth relative to age
- Used to define shortness or tallness
* Be sensitive to cultural differences, may be at lower percentiles in certain cultures but doesn’t mean there is a problem
BMI-for-age (3)
- Antrhopometric index of weight and height combined with age
- Used to classify children and adolescents as underweight, overweight, or obese
Weight-for-length/stature
Reflects body weight relative to length and requires no knowledge of age; indicator to classify infants and young children as overweight and underweight
*For birth-3 years old
Head circumference-for-age
Critical during infancy and can be charted up to 36 months (3 years old)
*measurements reflect brain size
Primary microcephaly vs. Secondary microcephaly
Primary: occurs before birth, in utero (ex: Zika)
Secondary: occurs after birth; could be due to injury
BMI-for-age percentiles: obese, overweight, underweight
Obese: Above 95th percentile
Overweight: Between 85th and 95th percentile
Underweight: Under 5th percentile
Weight for length/Stature percentiles: obese
Above 95th percentile
Stature/Length-for-age: short stature
Under 5th percentile (usually familial)
Head circumference-for-age: developmental problems
Less than 5th percentile or above 95th percentile
*Being micro or macrocephalic puts you at risk for developmental delays
BMI (4)
- Body fatness changes as children grow
- BMI declines and reaches a minimum around 4-6 years of age before beginning a gradual increase through adolescence and most of adulthood
* Increase in body fat that occurs earlier on puts child at risk for obesity - BMI is NOT a direct measure of body fatness, but it parallels changes obtained by direct measures of body fat such as underwater weighing and DXA
- BMI can be considered a proxy for measures of body fat
Small for gestational age (SGA)
A birth weight and/or length greater than 2 standard deviations below the mean
*Below the 10th percentile in weight, length, or head circumference
Large for gestational age (LGA)
Greater than 2 standard deviations in weight and/or length
*Birth weight, length, or head circumference lies above the 90th percentile for gestational age
Mid-parental Height Calculation in girls
*Determining heights of girls by the heights of biological parents
(Father’s height + Mother’s height - 5 inches) / 2
*If doing it in centimeters:
(father’s height - 13cm) + mother’s height / 2
Mid-parental Height Calculation in boys
(Father’s height + Mother’s height + 5 inches) / 2
*If doing it in centimeters:
(father’s height + 13cm) + mother’s height / 2
Statural growth
A process that is determined by the interaction of genetics, nutrition, and socioeconomic factors
History taking for growth: maternal pregnancy
Emphasize medications used, infections, and nutrition during pregnancy
History taking for growth: perinatal history
Emphasize duration of gestation, perinatal information, growth (weight and length)
- Need to know if child was SGA, AGA, LGA
- Perinatal history may point in specific pathologies, such as hypopituitarism or hypothyroidism
- Birth measurements reflect intrauterine conditions
- Duration of gestation determines pre or post maturity
History taking for growth: growth pattern in first 3 years
Establish a pattern of growth! Many children have catch-up or catch-down growth between 18-24 months of age. Growth rate percentile shifts linearly (up or down, depending on parents heights) until the child reaches his or her genetically determined growth channel or height percentile
*Patterns of growth are established in first 3 years of life, which are all about nutrition
History taking for growth: growth patterns after 3 y/o (3)
- Emphasis: prepubertal and pubertal growth velocity
- Most children with normal growth usually do not cross percentiles after two years of age
- Peak height velocities typically occur at Tanner stage III in girls and IV in boys
History taking for growth: family history
Know father’s height and age during pubertal growth spurt, mother’s height and age at menarche, heights of siblings, grandparents, etc., and medical conditions of family members
*Heights of parents determines heights of children and follow parent’ pubertal tempos
History taking for growth: ROS
Energy level, sleep pattern, headaches, visual changes, diarrhea, etc. to evaluate functional capacity of various body systems
*Also want to know social history; growth can be affected by stress (ex: psychosocial dwarfism)
Dysmorphology/Dysmorphic features
Looks at face, hands, and feet
Confounding factors: Obesity (4)
- Obese children are taller
- With endocrinopathies, height is impaired (they will be shorter)
- If the child’s height is at or greater than mid-parental height, an endocrine cause of the obesity is likely
- Obese children go into puberty earlier and as a result end up being shorter
Genetic Channeling
- Upward to downward movement towards mid-parental range
2. Usually accomplished by 12-15 months
Constitutional Growth Delay Risk Factors (6)
- Family history
- The child is healthy, growing below but parallel to the 3rd percentile line
- Between 6-24 months, the linear growth and weight track downward to the 3rd percentile
* Linear growth slows and they wind up with growth spurts that are lower than normal - Slow growth rate between 12-30 months
- Delayed onset of puberty and growth spurt and usually end up with heights in lower half of the normal range
- Bone age that is delayed by 2 or more years
Confounding Factors in Late Childhood Growth (4)
- Infrequent measurement opportunities
- Normal prepubertal growth deceleration
- Effects of medications for common disorders (ADHD, asthma, depression)
- Normal variation in onset of puberty
Key Information Required to Decipher a Child’s Growth Curve (6)
- Birth length and weight (SGA vs. prematurity)
- Mid parental height
- Family growth and pubertal history
- Growth rate-normal for age?
- Bone age (Left wrist)-contributions of delayed vs
genetic/intrinsic growth disturbance - Health history – effects of disease on growth
Bone Age
Bone age is a measure of skeletal maturity.
A conventional X-ray of the left hand and wrist to evaluate bone age may be obtained at the initial visit to assess skeletal maturation, and may be repeated over time if needed
Skeletal Maturation
- Occurs under the influence of estrogen, thyroid hormone, androgen and growth hormones
- Bone age is generally more than 2 years in advance of chronologic age in longstanding precocious puberty because of the action of sex hormones
Sexual Maturity Rating: Males and Females
Males: size of the testes and length of the penis
Females: breast development and pubic hair development
Body Fat (3)
- Continually increases in girls during most of
the second decade, while boys tend to decrease fat
after age 14. - In the lower ranges, BMI-for-age tends to increase
more slowly in both adolescent boys and girls. - At the 5th percentile, BMI-for-age increases at the
rate of about 0.5 unit/year during most of the second
decade.
Thelarche
The appearance of breasts in girls; the earliest signs of pubertal development in 85%
Pubarche
Pubic hair growth in females; the initial pubertal sign in 15% of girls
Puberty in Females (5)
- Menarche occurs an average of 2 years after thelarche
* Range 1-5 years - Peak height velocity is reached at l2 years in girls immediately prior to menarche
- Usually if you start to see feet growing, breast budding is coming
- Tanner II stage girls develop body fat and need cholesterol for estrogen to cause breast buds to occur; should be a little rounder/chubby
- Between the age of 12 and 13, girls at the 5th percentile gain less than 8 lbs. while those at the 95th percentile gain more than 13 lbs.
Early Puberty in Females (2)
- Slow their accumulation of total body fat, but during their peak height velocity they accelerate their accumulation of fat and lean body tissue, leading to an increase in weight that peaks just prior to menarche.
- After that time, the rate at which weight is added
slows, with an inflection point around 13 years of age.
Sexual Maturity Rating: Tanner Stages for Breasts (I-V)
Tanner I: non
Tanner II: Breast bud diameter = areola width
Tanner III: Breast diameter > areolar with; beyond breast budding
Tanner IV: Mounding of areola above plane of breast
Tanner V: adult
Sexual Maturity Rating: Tanner Stages for Female Pubic Hair (1-5)
Tanner 1: None
Tanner 2: Slightly pigmented over mons or labia
Tanner 3: Dark, course on mons
Tanner 4: Adult in character, confined to mons
Tanner 5: Adult spread to medial thigh
Male Puberty (5)
- In boys, testicular size should be measured by a “Prader orchidometer”
- A testicular volume of >/=4mL in boys indicates puberty is starting
- Prepubescent boys testicle equals 2.5cm in length
- The increase in stature in males is due to androgen produced by the testes, so the growth spurt in stature is preceded by an increase in the size of the testes
- Androgens also cause the penis to lengthen and widen
Sexual Maturity Rating: Genitalia Male (Tanner 1-5)
Tanner 1: Pre-pubertal testes (3cm, volume =6-8mL
Tanner 4: Further development of glans and penis, DARKENING OF SCROTAL SAC, further increase ins ize
*Testes >4cm, volume=10-15mL
Tanner 5: Adult; testes >5cm, volume >15mL
Sexual Maturational Rating (Tanner): Genital development
Tanner 1: Preadolescent: Testes, scrotum, and penis about same size and proportion as in early childhood
Tanner 2: Enlargement of scrotum and testes, skin of scrotum reddens and changes in texture; little or no enlargement of penis
Tanner 3: Enlargement of penis first mainly in length; further growth of testes and scrotum (11.5-14)
Tanner 4: Increased size of penis with growth in breadth and development of glans further enlargement of testes and scrotum and increased darkening of scrotal skin
Tanner 5: Genitalia adult in size and shape
Adolescent with Alkaline phosphatase (2)
- With rapid bone growth, alkaline phosphatase levels increase
- Peaks at about the peak height velocity in males and females so occurs earlier in females.
* Alkaline phosphatase is elevated in growing children
Delayed Puberty
Absence or incomplete development of 2nd sexual characteristics by an age at which 95% of children of that sex and culture have initiated sexual maturation.
The upper 95th % in the U.S. for age is:
Boys 14 years of age
Girls 12 years of age
Precocious Puberty (5)
- Any sign of puberty in girl less than 8
- Boys less than 9
- With increases to tanner 3 within a 6-12 month period in a 6-8 year old
- Menarche before age 10 years
- Pubic Hair
White: Before age 7 years
Black: Before age 6 years
Pubertal changes: adrenarche (5)
Increased adrenal androgen secretion
- Occurs between ages 6 to 8 years
- Transient growth spurt
- Some children develop axillary and pubic
- No sexual development occurs
Pubertal changes: Gonadarche (boys vs girls)
Release of GnRH
In Boys: LH stimulates Testosterone production, FSH stimulates sperm maturation
In Girls: FSH stimulates Estrogen and follicle formation, LH stimulates corpus luteum after ovulation
Mean Ages of Menarche (african american, caucasian)
A.A.: 12.2 y/o
C: 12.9 y/o
Precocious Puberty (males and females)
Any sign of secondary sexual maturation before 8
years in girls and 9 years in boys.
Red flags for pathologic pubertal development in females (6)
- Virilization (development of male physical characteristics) - clitoris enlargement, acne. voice deepening, increase in muscle mass
- Extensive pubic hair growth (would be a peripheral cause)
- Menarche without breast bud development
- Rapid enlargement in breast development through tanner III in an 8 year old or less
- Documented growth acceleration in a child over 6-12 months in a girl less than 8
Red flags for pathologic pubertal development in males (5)
- Feminization in boys - gynecomastia
- Penis enlarges without scrotal development (peripheral cause); enlargement of penis without enlargement of testicles
- Precocious puberty in boys is 50% pathological
- Documented growth acceleration in a child over 6-12 months in a boy less than 9
- Any virilization signs such as clitoris enlargement, voice deepening or increase in muscle mass.
Pseudo-precocious puberty
Some of the changes of puberty are present, but appearance is isolated or out of normal sequence
Isosexual puberty
When changes of puberty are consistent with gender
when they are discordant with gender, it is heterosexual puberty
True precocious puberty (3)
- Early pubertal changes
- Normal progression in order of breasts, pubic hair development, growth spurt
- For females, menstruation
Premature Thelarche
Development of breast buds, usually 1-4 years of age.
*Usually benign if not associated with the onset of other pubertal events
Precocious puberty should be suspected if (with premature thelarche) (3)
- Breast, nipple and areolar development reach tanner 3
- Linear growth accelerates
- Androgenization with pubic and/or axillary hair
Premature Thelarche features (8)
- Incidence: 6 months-2 years
- Breasts: usually Tanner 2 or early 3
- No pubic hair
- No axillary hair
- No apocrine odor
- No menses
- No accelerated growth
- No advanced bone age
Outcome: considered benign!
Precocious puberty features (6)
- Incidence: 5-8 years old
- Breasts: Tanner 2-5
- Pubic hair or axillary hair + breasts
- Apocrine odor and axillary hair present
- Menses occurs
- Accelerated growth and advanced bone age
Outcome: early puberty, short stature
Premature Adrenarche Features (7)
The growth of axillary hair stimulated by androgen
- Look for androgen exposure
- Family history (partial forms of adrenal hyperplasia)
- Look at breasts for female
- Testicular enlargement for male
- Axillary hair is only finding, check in 3-4 months
- Acne
- Enlargement of the clitoris
History taking for precocious puberty includes (7)
- Pubertal signs
- Age of onset
- Rate of progression
- Growth patterns
- PMH: CNS insults? environmental sex hormones? illnesses? symptoms?
- Family history of sexual precocious
- siblings with ambiguous genitalia?
Family may consider precocious puberty normal…
Clinical Evaluation of Precocious Puberty (7)
- Plot height, weight and head circumference (if less than 3); will be rapid if CPP or pseudoisosexual precocious puberty
* Height will rise to higher growth percentile than occupied previously - Check BP: HTN may suggest congenital adrenal hyperplasia due to deficiency of 11-beta hydroxylase
- Check sexual maturity (breast buds? regression from birth?)
- Check for signs of systemic disease
- Look for evidence of CNS mass (optic fundus and visual fields)
- Look for evidence of androgenic influence
- Look for evidence of any other mass! (asymmetrical testicular enlargement, hepatomegaly, abdominal mass)
Evidence of andorgenic influence of precocious puberty (7)
- Acne
- Facial and axillary hair
- Increased muscle bulk
- Extent of pubic hair
- Penile elongation
- Scrotal rugation increased with thinning
- Clitoris enlargement
Further Clinical Evaluations of Precocious Puberty (5)
- Café au lait spots
- Myxedematous face
- Thyroid enlargement
- Abnormal visual field
- Abnormal neurologic findings
Evidence of estrogenic influence in precocious puberty (5)
- Size of breast tissue
- Must distinguish breast from soft smooth consistency of increased fat
- Reddish, less moist vaginal mucosa in prepubertal girl
- Pale moist appearance of pubertal vaginal mucosa, elongated clitoris
- Labia minor more visible as puberty progress
Evidence of gonadotropic stimulation in precocious puberty (3)
- Measure phallic and testicular dimension: testicles must be equal
- Without testicular enlargement, penis enlargement, adrenal pathology
- Testicular volume is greater than phallic size in normal puberty, CPP, and Primary hypothyroidism
Evidence of pseudosexual precocious puberty
Penile dimensions are disproportionately greater than testicular size
Lab testing for precocious puberty (7)
- Check nutrition
- CBC
- Erythrocyte sedimentation rate
- Liver function tets
- Thyroid tests (TSH, free T4)
- If growth abnormality is found, do a bone age of left wrist!
- Hormonal evaluation of LH and FSH, estradiol (females, testosterone (males)
Precocious puberty: stature
Because of very early epiphyseal closure; paradoxically the tall child will be a short adult
*Linear growth is accelerated during childhood, often with markedly advanced bone maturation
Type 1 Pattern of precocious puberty
- Normal head circumference, normal height and decreased weight initially and eventually decelerating height and head as well (infants and children
Type 2 Pattern of Precocious puberty
- Normal head circumference, disproportionate height and almost normal weight in infants and children under 3
* Near proportional retardation of weight and height with normal head circumference - Can lead to: constitutional growth delay, genetic short stature, endocrinopathies, structural dwarfs
Type 3 Pattern of Precocious Puberty
- Small head circumference and decreased weight and height
* Concomitant retardation of weight height and head circumference - Suggests
- SGA: In utero and perinatal insult
- Chromosomal aberrations
- CNS abnormalities
- Rarely familial
Normal upper segment: to lower segment ratio (6)
- Upper segment head to symphysis pubis to lower
segment (type 2) - US to LS in infants is 1.7 to 1.8 to 1
- As child approaches adolescent .9 to l.0:1
- Upper: lower segment ratio is low in Marfan syndrome
- Abnormal in bony dysplasia
- After spinal irradiation
Deceleration of linear growth in a well-nourished child can suggest… (3)
- Growth hormone deficiency
- Hypothyroidism
- Glucocorticoid excess (causes Cushing’s)
Initial decline in weight followed by decreased height velocity suggests… (2)
- Malnutrition
2. Systemic illness
Dysmorphic features suggests…
Chromosomal abnormality (Trisomy 21 or Turner’s) or other specific syndrome
Disproportionate features or skeletal abnormalities suggests…(2)
Skeletal dysplasia or metabolic bone disease
Evaluations of attenuated growth (6)
- Careful physical examination
- Free T4, TSH
- ESR
- Electrolytes, BUN creatinine, UA, LFT
- Bone age of left hand and wrist
- Markedly delayed bone age suggestive of endocrinopathy
* * Refer to endocrine
Differential Diagnoses for Attenuated Growth (5)
*Over-nutrition is most common cause
- Precocious puberty (adrenal or gonadal)
- Hyperthyroidism
- Genetic (familial) or syndrome (Klinefelter or Marfan’s)
- GH excess
- Development of pubic hair
Short Stature Causes (5)
- Normal patterns of growth –> familial or constitutional growth delay
- Primary growth disturbance –> itrauterine growth restriction
- Systemic illness
- Genetic disorders (Turner, Down, Noonan, Prader Willi, russel Silver)
- Disproportionate short stature –> skeletal dysplasia or spinal irradiation
When to worry about short stature? (4)
- Abnormally slow growth rate
- Downward crossing of percentile channels on the growth chart after the age of 18 months
- Height below the 3rd percentile
- Height significantly below genetic potential by 2 standard deviations
Evaluating Short Stature (6)
- Do a careful prenatal history with birth weight; IUGR is birth weight less than 10th percentile for gestational age
- Look at growth points
- Look at growth velocity
- Determine parental height, do midparental height
- For constitutional growth delay, do bone age
- Look at weight to height ratio
Turner’s Syndrome Features (9)
- Multiple nevi
- Low posterior hairline
- Webbed neck
- Broad chest with wide spaced nipples
- Short fourth metacarpals
- Coarctation of the aorta with bicuspid aortic valve
- Increased carrying angle of arms or CUBITUS VALGUS (can’t fully extend arms; hallmark)
- No menses
- Lymphadema at birth
Systemic Illnesses Associated with Short Stature (4)
- Hypocaloric (malnutrition, GI, poorly controlled DM)
- Metabolic (renal, hepatic, cardiac, hematologic, respiratory (CF, severe asthma) chronic infection)
- Endocrine (hypothyroidism, Cushing’s)
- Growth hormone deficiency
Abnormally Rapid Growth Velocity
In general, a child whose height differs by more than 2 standard deviations (SD) from the population mean is considered too tall
*Few families will seek medical attention for it
Assessments for abnormally rapid growth velocity (4)
- Child’s pattern of growth
- Medical history
- Physical exam
- When dysmorphic features are found, special effort should be made to rule out syndromes that are associated with excessive growth
Causes of overgrowth in infancy (3)
- Maternal diabetes (most common cause of LGA)
- Cerebral gigantism
- Beckwith-Wiedemann Syndrome
Soto’s syndrome
Cerebral Gigantism
Infants with cerebral gigantism tend to be large at birth and continue to grow rapidly during the early years of childhood.
Cerebral Gigantism Features (8)
- high forehead
- frontal bossing
- hypertelorism
- prominent jaw
- high arched palate
- mental retardation
- poor coordination
- adult height is normal in many of these children
Beckwith-Wiedemann Syndrome Features (6)
- Macrosomia
- Visceromegaly
- Macroglossia
- Omphalocele
- Prominent occiput
- Hypoglycemia with hyperinsulinism
Tall Stature
Height is 2 standard deviations above corresponding mean for age and gender
Familial (Constitutional) Tall Stature (2)
- Genetic factors play the most important roles in the pathogenesis of familial tall stature.
- Growth hormone secretion and serum IGF-1 and IGF binding protein-3 concentrations often are in the upper range of normal.
Exogenous Obesity (3)
- These children usually have diminished overall growth hormone production but high normal serum concentrations of growth hormone-binding proteins and IGF-1
* due to leptin increase, may have upper limit TSH and T4 - They are taller initially, but get very big, hit early puberty, and end up being short
- Bone age may be advanced and puberty starts early causing premature epiphyseal fusion
Gigantism (growth hormone excess)
Excessive linear growth that occurs with growth hormone (GH) excess when epiphyseal growth plates are open during childhood
Tall Stature Summary (4)
- Growth velocity is the best way to assess a child whose
height > 2 SD. - Dysmorphic features and developmental delay may suggest a non-endocrine cause of tall stature.
- Although rare, growth hormone excess should be considered if the growth velocity is accelerated + a family history of multiple endocrine neoplasia
- Transsphenoidal removal of the pituitary adenoma, when present, offers definitive treatment of growth hormone excess.
