Growth and Development Flashcards
Define the Following
fetal developement
somatic growth
puberty
development
Fetal Development
- changes that occur as a fertilized ovum progresses through prenatal growth
this continues through chidlhood and adults life with growth
SOmatic Growth = changes in th ebody as a whole or in its indivduals such as
- lenght/height
- weight
- head circumference
Puberty
- hormonal and gondal changes that occur as part of sexual development
Development
- changes int he body function and acuisition of skills in the following domains
- - social, langugae and self-help
- verbal langugae
- gross and finer motor skills
Growth During
- Fetal growth: when does it look like human
- neonatal growth : gestational age and how age is determined if we dont know
Fetal Growth
- the fetus looks like a human by the time of 9 weeks
- after this point: continued somatic growth
Neonatal Growth
Gestational age
- premie: < 34 weeks
- late preterm: 34-36 + 6
- early term: 37 - 38 +6
- later term: 41 - 41 +6
- postterm: > 42 weeks
determination of age
- antepartum: determined via US or FDLMP (first date of last menstrual period)
- postnal” Balalrd score
Growth: Birth weights & size for gestational age
Weights
normal : 3000-4000 grams
low: < 2500
very low: < 1500
extremely low < 1000
size
- small: SGA: < 10th percentile
- approproate (AGA)
- larget (LGA) : > 90th percentile
SGA
if they are symmetrically small, all parameters will be low
- low weight, length and head circumference
Reasons for SGA : if symmetrcailly
- matenal durg use
- chormosomal issues
- intrauterine infections
if they are asymmetrically small (onel 1 or 2 parameters are off)
- placental insufficiency: poor weight gain in pregnancy or multiple gestaitions
- advanced materal age
Larger for GA
- maternal DM
- excessive materal weight gain
- genetic syndromes (rarely)
Measurements to use for kids 0-2 years
anthropometrics
- length (supine laying)
- weight
- weight for length
- head circumference
WHO growth charts used
- these are better descrption of physiologic growth in infants
after the neonatal period: how is Growth measured
Growth Measurements
weight: considered most importnat for out 0-2 year olds
- do it without diaper or clothing
Stature:
- length from 0-2
- height 2+
Wegith
- wegith for length for 0-2 y/o
- BMI for 2+ year olds
head circumference
- measured just above the eyebrows, above the ears at the largest part of the occiput
- occipit-frontal diameter
Growth Charts/ Curves from the WHO and CDC
Charts
- used to track growth over time
- gender specific
- should plot according to actual age
O-2 year olds
- WHO growth charts
- weight for length
- weight
- length
- circumference
2+ year olds
- height
- weight
BMi
Premature and disese specific have their own charts
Weight Patterns of Gain in Infants and Kids
Weight Gain
- infants typically lose weight in theif first few days of life: but back to birth wegiht at 10 days
- by 4-6 monhts: should about 2x their birthwegith
- by 12 months: should be 3x their birthweight
Average weigh gain
-in first 3-4 months: 20-30 grams/day
5 pounds between 1-2 years olde
5 pounds a year from 2-5
Growth Faultering (Failure to Thrive)
etiology
Risk factors
possible reasons for it
Failure to Thirve: Etiology
- initally a weight disorder, but if it gets severe enoug, affects linear growth (head circum. and length)
- can lead to sever lack of max. adult height and cognitive skill if not addessed in teh first 2 years of life
Risk Factors
- low SES
- refugees
- developmental delays
- lowe birthweight bb
- fetal growth restriction
- chronic/recurring infections
- GI disorders
- congenital disorders
Reasons for It
- inaequated caloric intake: negelt, poor patching, reflux, GI issues, etc.
- inadequate absorption of nutreinty: celiac, metabolsim, infection, milk protein allergy
- excessive use of energy: infections, cardiac or lung disease, CF, hyperthyroid, malignancy,
Growth Faulturing
Diagnosis
Diangosis
- anthropometric z scores make the diagnosis
- calculated by weight for length or BMI
- can be diagnosed with a single measurement set
- the z-score range : -3 to 3+ : negative implying lower percentiles
- a decreased in a Z score of 1 or more shoes those who will develop growth faultring
this helps assess response to treatment and how to treat
Growth Faultering
appraoch to treatment
hX. qs
PE
Need a good Hx. in order to properly treat
- figure out the underlying cause
- what are they being fed
- when, how often, symptoms after feeding
- psychosocial facotrs, specific food peferences
PE
- vitals, all measurements
- muslce and fat depostion: mmid-arm circumference can help
- hari thinning, skin changes
- dental and neuro exams, look for dysmorphism
- cardiac murmurs, organomegaly, look for neglect
- **diagnosis studies not needed if there is a normal H&P*8
Growth Faultering
Treatment
initiala and if that fails what labs
calori def. corrections for breast fed v bottle
Treament: Inital
- behavior modification: adjust feeding practices
- increasing calorie consumption
- close monitoring
If inital treatmnet fails
- CBC
- chemc, celiacl
- lead, iron, UA and ESR
Calorie Defict Correction
Breast Fed babies :
- give breast milk (pump and measure) 22cal/oz
- supplement with formula feeds
Formula fed
- give formula 19-21 cal/oz
- swap to calorie dense or concentrated formula
toddlets
- high quality diet
- supplement with high cal. snacks and supplements
Growth Faultering
Monitoring
Monitoring
- monitor Q1weeks to 2 weeks
- until Z score is corrected and the normal growth trajectory consisent and normal weight
Consultation
- nutrition/behavior intervention if conservative measures fails
- hospitalization in severe nutrtion
Overweight & Obesity in Children
- normal growth guidelines
- how is it determined
- obesity and overweigh tby percentile BMI
Normal growth
- at 3 years: child should be approx. 4x their birth wegith
- then grow about 5 pounds a year from age 2 until puberty
Calculate Weight
- usually using BMI: newer push for Z scores
- obersity more likely to be a problem for those over 2 years old
- normal BMI: shold grow, take a little dip during preschol as they run around so much; then remain increasing until levling off in adulthood
BMI for overweight and obestiy
5th-84th percentile = normal
85-95th percentile = overweight
> 95th percentile = obese
> 120% of the 95th percentile = severe obesity
Overweight/Obestiy in Children
Causes
prevention: for..
- newbrons
- toddle
- preschool
- school age
- adolescent
Causes
- calroires in > out
- genetics
- endocrine disorders
- medications (atypicals.)
Prevention
Newborn
- promote breast feeding & teach parents to assess feeding cues
Toddler
- encourgae proper proportions
- but toddler choses how much to eat; dont force feed
- NO sugar beverages (juice)
Preschool
- PARENTS make food choice
- no sugar beverages; limit juice to 4-6 oz day
School age
- watch school lunchchoices
- less junk foor or sugar sweented
- only food in the house that is good choices
Adolescents
- encourage family eating
- ensure they eat breakfast
- limit fast food
Overweight/Obestiy in Children
Ways to prevent overeating in terms of food intake and exercise and screen time
Complications of overweight/obese kids
- no food and eating
- no tv in their room
- 2 or less hours of screen time
1+ hour of activity daily
no sugar sweeted beverages
5+ fruits and veggies
Complications that can arise
- HTN
- OSA, asthma
- T2DM
- insulin resistnace
- hyperlipidemia
- PCOS
- blounts disease (bowing of legs)
- hip issues
- back pain
- NASH
- Gallbladder disease
- depression and poor self esteem
- pseuotumor cerebir (increase ICP)
Overweight/Obestiy in Children
further evalautions to do if you susspect its not a primarily lifestyle choices issue
Further Eval.
- EVERYONE OBESE needs a further evaulation and workup
- everyone with is overweight with other risk factors (ipids, HTn, etc.)
- consider a work up for those increasing thier BMI by 3-4 units a year
Evaulation with
- TSH
- glucose
- lipids
- LFTs
- endcrine referral if unable to control
Overweight/Obestiy in Children
Management in terms of growth goals and charts
mild obestiy
moderate
severe
Mild Obestiy
- the goal should to “maintain” the weight and allow their linear growth (height) to increase to balance it out
- takes 1-2 years
Moderate to Severe Obestiy
- 2-11 year olds = drop 1 pound a month
- those 11+ = can drop up to 2pounds/week or 2 pounds/month
Dietary and Exercise
- general preventivne mananngemetn
- encourage support gropus and management tools
Severe Obesity
- dietician
- comprehensive weight manamgenet
- comorbi management
- specialits (ortho, endo, etc.)
- behavioral management
for adolecents
- semiglutaide has best evidence
- can consider bariatric surgery
what is stature
typicl velocity of growth
average growth men/women at puberty
Typical growth velocity
- this changes over time
- rapid in infant and early childhood
- slows down to 5cm/year
- puberty hits: growth spurt
Puberty
men- average 7-12 cm per year
women - average 6-10.5 cm per year
Abnormal growth
- growth mimics family but nayone with short or tall stature : warrents a workup
after age 2 = start measureing growth on a chart yearly
Predicting height: midparental height
what is stature and its relation to bone age
females = dads height - 13 cm + moms /2
males = dads height + moms + 13/2
Bone Age
- left wrist and hand can be good area to take look at bone age to determine growth
- skeletal maturity is predictable for those > 5
- xray of left hand can indicated the adult height and can be used to evaluate abnormal stature
Short Stature
- define
- some conditions that have it
- evaulation: hx. pearls
Define
- short stature = 2 SD below the mean heigth for the age/gender
COnditions (some)
- consitutional delay: late bloomers
- GH deficient/hypothyroid
- genetic: downs, turners
- chronic medical: celaicl, CKD, IBD
- malignancy, pulmonary and immune diseases
HIstory and Evaluation
- SGA
- hypoglycemia
- poor feeding
- meconium ileus (think CF)
- glucocorticoid use (cushings)
- stimulants (ADHD)
- pituitary issue, HA, vision issue, etc
Short Stature
- evaluation: PE and labs?
PE
- evaluate the growth curve since birth: see the prediction and outcome
- dysmoprhia
- boyd segment distrubution
- pubertal devleopment (sexual matuirty)
Labs
- CBC, CMP,
- TSH
- ESR/CRP
- celiac
- IGF for GH deficiency
- UA
- bone analysis
-
SHort Stature: Idopathic Short Stature
diagnosis of exclusion: need to rule out all other reasons for short stature first
defined as
- short starture with normal size for gestaional age at birth
No
- chronic disease
- endocrine
- chromosomal issues
- nutrtional issues
Bone age: variable
Management
- refer to endocrine for eval of other causes and can consider GH therapy
Short Stature: Familial short stature
Familial
- this is normal
- but the child is still less than 2 SD below the mean of height; however they are on target to meet the midpoint of parental height
Curve
- they will be lower to normal in terms of velocity of growth
- just below, but parallel to the normal curve
Puberty = normal development
normal labs and bone age is consistent with age
can sondier genetic testing & +/- GH therpay
Constitutional Delay: Short Stature
these kids just are small and dont grow as much when young, but when they hit pubertythey catch up with noral curves “late Bloomer”
- often familail
- normal stature at birth
- slower velocity of growth 3-5 years old; then normal growth but theyre behind
- but puberty is delayed : once met they catch up
Bone age = delayed: bone is less than chronologic age
eventually, growth spurt = reach normal hegith
Small for Gestational Age : Short Stature
SGA babies are at risk for short stature
at BIRTH: their length and weight are 2 SD below the mean for their gestaional age
15% of these babies never “catch up” in growth: they may remain small
then reason for grwth failure is unknown; can use GH to help
Acquired Hypothyroidism: Short Stature
- normal growth curve until disase strats
- hashimotos thyroiditis
- most kids = no symptoms, so in ALL kids of short stature, you should screen for this
the Height velocity usually responds well to thyroid replacement meds
Glucocorticoid Excess: Short Stature
diagnosis and treatmetn
chronic expsoure to steroids = big effect on linera growth with concurrent weight gain
most commonly used for IBD, arthritis of kids, etc.
Cushing’s disease presentations ofpt.
Diagnosis
- 24 hour urine cortisol
- midnight salivary cortisol
- low dexatmethasonde sup. test
- need 2+ tests of the above
Treatment
- endo: for treatment
GH deficiency: Short Stature
Diagnsosi and treament
what is it = a below avearge growth rate crossing percentile lines
pt. will have delayed bone age
Causes
- head trauma
- CNS infection/radiation
- unknown
Diagnosis
- IGF-1
- IGF binding protien level
- GH stim test
Treatment = GH supplement
Congential GH Deficiency : SHort Stature
Congenital GH
- typically normal size at birht, but they have signf of other hormone deficienices (micropenis)
midline structural defects
- prolonged jaundice
- hypoglycemia
Diangosis
- low GH with low glucose
FDA aprroved conditions to use GH in kids
- GH deficiency
- growth failure due to CKD
- growth failure for SGA
- turner, nonon, prader willi
- idopathic short stature
- short bowel
- AIDS wasting
a rx. for GH should ONLY COME FROM ENDO: nerv anyone else
Tall Stature
define
causes
Evaluation (hx. and workup) & tests
Tall Stature = 2 SD above the mean for the age/gender
Causes
- common = familial/constitutional or overnutrtion
- hyperthyroid
- percious puberty
- CH excess
- Kleinfelters
- Genetics: marfans, homocysterin, elhers dan.
Evaluation
- detail history = find out timin of growth
- family hx. = include extended!
PE
- dysmoprhias?
- pubert status
- dysproprtional growth? arm span and fingers/toes
Dx. Eval
- TSH
- IGF-1
- bone age assessment
- genetic testing if deemed necessary
Constitutaionl Tall Stature
Constitutional
- begin average length as baby
- accelerated linear growth until they are about 4, then they parallerl normal gorwht patterns, just above
- no disproportional growth:normal PE
- lilkey to have familial influence
- no treatment needed
Overnutrtion: Tall Stature
OVernutrtion
- leads to obesity and accelerated linear growth: eventaully height consistent with predicted
Hormonal influences
- low GH
- normal IGF-1
- abnormal grehelin, leptin an GH secretogogies
- hyperinsulinemia
treament = focuse on wight management: it will eventaully deccelerate
Hyperthyroid: TAll Stature
tests
treatment
Hyperthyroid
- accelerated growth with weight loss
Causes
- graves disease (common)
- hyperthyroid phase of lymphcytic throiditis
- thyroid nodules
Labs - TSH, T3/4
RAI study
Treatment: methimazole (avoid RAI treatment because of gonadal impact)
Percious Puberty: Tall Stature
Percoucious Puberty
- development of secondary sex characteristics before the age of 8 in females, before 9 in males
Estrogen is responsible for pubertal growth purty: in females AND males = increase linear growth
GH Excess: leading to Tall Stature
GH Excess
- rare; but a hormonal secreting pituitary adenoma
- increase linear growth while the growth plates are still open
Feature s
- large jaw
- hands and feet are large
Diagnosis
- IGF-1
- GH suppression test = confiratory
- if suppression test + = get MRI of pituitary
- check prolactin (prolactioma)
Treament = medical or surgical or radiotherapy
Terminology og Puberty
Thelarche
Pubarche
Menarche
Adrenarche
Thelarche
- development of breast tissue = first onset of puberty in females
Pubarche
- pubic hair development with or without breast development in females
menarche
- onset of menstratution
Adrenarche
- adrenal gland “awakens” increased production of androgens (males and females)
- develop pubic hair, oily skin and body odor
Physiology of Puberty: Male
Male : Pre-Puberty
- pituitary and gonadal hormone levels LOW
Onset of Puberty
- inhibition of GnRH is removed: allowing GnRH to trigger in pusatile fashion
- pulsatile LH and FSH release to the testis
- as the adolecent ages, these puslatile waves of release lead to increased frequency and amount of FSH and LH released
- increased levels of FSH and LH = stimulate the testis to produces testosterone
- LH to leydig cells = testosterone
- FSH to sartoil cells = sperm
Male: Sexual Maturity Rating
Prepubetal = Rating 1
- no hair
- no genetial development
Rating 2
- enlarged scrotum and testis but NOT PENIS
- sparse hair at base
Rating 3: peak height
- continued growth
- penil growth
- darker, course hair thicken
- sperm production
Rating 4
- continued growth
- glans penis grwoth
- adult ahir
- facial hair and voice change
RAting 5
- full adult mature sexual matuirty
Femal Puberty: Physiology
prepuberty: pituitary anf gondal hormone levels low
onset of puberty
- inhibition og GnRH is turned off
- leads to pusatile release of LH and FSG to produce estrogen
as age increases: frequency and intestiny of puslatile hromonal release
FSH: stimulates ovary maturation, granulosa cell function & estradiol prodcution
LH : stimultes ovluation, corpus lutem and progesterone production
Estradiol
- initially: ealy on at lower levels inhibits LH and FSh
- then later in puberty: becomes stimulatory and the cyclical nature begins
Female Puberty: Sexual Maturity Scale
Rating 1
- perpubetal
Rating 2
- subareolar buds
- sparce long hair in medial labia
- peak height velocity
Rating 3
- breast begin to develop contour
- darker hair beigns to fill in on mons pubis
Rating 4
- breat enlarge more,
- areola and nipple form second rounded contour on breast
- adult type hair but not to legs
- menarche begins
Rating 5
- mature adult breats; nipple projection
- adult type and quintiy of hair to leds
Abnormal Puberty
delayed and precious
more commony to see balck children develop earlier
Delayed
- femleas = no breasts by 13, no period within 3-5 years after that
- males = no testicualr enlargement by 14, maturiaonal arrest
Precious puberty
- puberty 2 SD before the mean expected onset
- commony early that 8 in females
- commonly earlier than 9 in males
Delayed Puberty: reasons/conditions
Reasons
- constitutional delay
- anatomic abnorm.
- hypogonadism: turners, permature ovarian failure, glactosemia
- central hypogonadims: pitutairy tumonr, congential, cushings, hypothyroid, hyperprolactinomia (prolactin = no period)
FEmales
- if delated menarch only = check preg. test
- FSH/LF not helpful, get karyotying if needed
- cranial MRI for prolactinoma if sus.
Males
- testicular exma: nondisteneded?
- LH/FSH
- inhibin B
mange via refer to endo
Percious Puberty
causes
workup and treatment
Causes
central
- CNS tumor
- hydrocepha.
- CNS radiation or trauma
- mcune albright
- adrenal hyperplasa
- hypothyroif
peripheral
- adrenal/pituitary tumor
- expsoure to OCPs or exogensou hormones
- ovarian cyst
- tumor
- genetic defect
precious puberty = often idopathi
increased rates due to Covid!
