Growth and Development Flashcards
What is important in history and examination when establishing growth and development?
- Birth weight and gestation
- PMH
- Family history/social history/schooling
- Systematic enquiry
- Dysmorphic features
- Systemic examination
How should growth be measured and plotted?
- Accuracy is important
- Value of serial measurements: make every contact count
- Measurements should be taken between 4-6 months
- Different types of centile charts (UK, Boy/girl, condition specific)
- Identify target height and mid parental height (MPH)
- BMI
How should growth be measured in the under 2s?
Weight and length
How should growth be measured in those over 2?
Weight and height
What assessment tools are there for growth and development?
- Height/length/weight
- Growth charts
- MPH an target centiles
- Growth velocity
- Bone age
- Pubertal assessments
What is important when establishing bone age?
- Radiographs must be of high quality
- Evaluation by skilled practitioner
- Pathological conditions can distort bones
- Severe osteopenia confuses interpretations
What is the Tanner method of pubertal staging?
- Breast development (B) 1 to 5
- Genital development (G) 1 to 5
- Pubic hair (PH) 1 to 5
- Axillary hair (AH) to3
- Testicular volume (T_ 2ml to 20ml
How is testicular maturation assessed?
Prader orchidometer
Why is a precise definition of normal growth difficult to establish?
- Wide range within healthy population
- Different ethnic subgroups
- Inequality in basic health and nutrition
- Normality may relate to individuals or populations (genetic influence)
What factors influence height?
- Age
- Sex
- Race
- Nutrition
- Parental heights
- Puberty
- Skeletal maturity (bone age)
- General health
- Chronic disease
- Specific growth disorders
- Socio-economic status
- Emotional well being
What hormones are involved in puberty?
- Growth hormones
- Sex hormones
What are the most important stages in puberty?
•-Breast budding (Tanner stage B2) in a girl
- Testicular enlargement (Tanner stage G2/T3-4ml)
- These are the earliest objective signs of puberty and when present puberty will usually progress onwards
Growth disorders: Give examples of indications for referral
- Extreme short or tall stature (off centiles)
- Height below target height
- Abnormal height velocity (crossing centiles)
- History of chronic disease
- Obvious dysmorphic syndrome
- Early/late puberty
What are common causes of short stature
- Familial
- Constitutional
- SGA/IUGR (Small for gestational age)
What are the pathological causes of short stature?
- Undernutrition
- Chronic illness (JCA, IBD, Coeliac)
- Iatrogenic (steroids)
- Psychological and social
- Hormonal (GHD, hypothyroidism)
- Syndromes (Turner, Prader Will)
What is the most important pubertal stage in a girl?
B2
What is the most important pubertal stage in a boy?
T3-4ml
What is considered early puberty in a boy?
<9 years (rare)
What is considered late puberty in a boy?
> 14 (common, especially CDGP)
What is considered early puberty in a girl?
<8 years
What is considered late puberty in a girl?
> 13 years (rare)
Who does constitutional delay of growth usually affect?
Boys particularly those with a family history (dad and brothers. though may difficult to obtain)
Why does constitutional delay of growth occur?
There is bone age delay
Give examples of causes of delated puberty.
- Gonadal dysgenesis (Turner 45X, Klinefelter 47XXY)
- Chronic disease (Crohn’s, asthma)
- Impaired HPG axis (septo-optic dysplasia, craniopharyngioma, Kallman’s syndrome)
- Peripheral (cryptorchidism, testicular irradiation)
What can cause early breast development?
- Infantile thelarche
- Thelarche variant (premature thelarche)
- True central precocious puberty
What can cause early secondary sexual characteristics?
- Exaggerated adrenarche
- Precocious pseudopuberty
What can cause early PV bleeding?
Premature menarche
What does central precocious puberty present with?
- Breast development in girls
- Testicular enlargement in boys
- Growth spurt
- Advanced bone age
What causes central precocious puberty?
- Usually idiopathic in girls but pituitary imaging should be done
- Underlying cause i.e. brain tumour
How is central precocious puberty treated?
GmRH agonist
What is precocious pseudo puberty?
Gonadotrophin independent (low /prepubertal levels of LH and FSH) process in which there is abnormal sex steroid secretion leading to early virilisation and secondary sexual characteristics
Give examples of endocrine problems that children may present with not related to puberty.
- The new-born with ambiguous genitalia
- Congenital hypothyroidism
- Acquired hypothyroidism
- Thyroid deficiency
- Obesity
How should you manage the new-born with ambiguous genitalia?
- Do not guess the sex of the baby
- Multidisciplinary approach (paediatrics, endocrine, surgery, neonatologist, geneticist, psychologist)
- Exam: gonads?/internal organs
- Karyotype
- Exclude congenital adrenal hyperplasia (Risk of adrenal crisis in first 2 weeks of life’)
How many births are affected by congenital hypothyroidism?
1 in 4000
What causes congenital hypothyroidism?
- Athyreosis/hypoplastic/ectopic
- Dyshormonogenic
When should treatment for congenital hypothyroidism be started?
-New born screening followed by commencement of treatment within the first 2 weeks
What is the most common cause of acquired hypothyroidism?
Hashimoto’s thyroiditis
What issues does acquired hypothyroidism present with in childhood?
- Lack of height gain
- pubertal delay (or precocity)
- Poor school performance (but work steadily)
What is abnormal when it comes to obesity?
To be short and obese is abnormal
How many children are overweight or obese?
Nearly a third (31%) of children aged 2-15 are overweight or obese
Define overweight
- BMI 25-29.9
- BMI>85th centile or SD >1.04
Define obese
- BMI >30
- BMI>97.5th centile or SD >2
How should an individual be assessed for obesity?
- Weight
- Body mass index (BMI) (kg/m^2)
- Height
- Waist circumference
- Skin folds
- History and examination
What is important in gaining in the history when assessing someone’s obesity?
- Diet
- Physical activity levels
- Family history
- Symptoms suggestive of a syndrome, hypothalamic-pituitary pathology, endocrinopathy or diabetes.
What is important when examining someone when assessing their obesity?
- Dark velvet rash indicative of diabetes
- Goitre
- BP
- Imaging of pituitary
Give examples of obesity complications.
- Metabolic syndrome
- Fatty liver disease (non-alcoholic steatohepatitis)
- Gallstones
- Reproductive dysfunction (e.g. PCOS)
- Nutritional deficiencies
- Thromboembolic disease
- Pancreatitis
- Central hypoventilation
- Obstructive sleep apnoea
- Gastroesophageal reflux disease
- Orthopaedic problems (slipped capital femoral epiphysis, tibia vara)
- Stress incontinence
- Injuries
- Psychological
- Left ventricular hypertrophy
- Atherosclerotic cardiovascular disease
- Right sided heart failure
What can obesity be caused by?
- Simple obesity
- Drugs
- Syndromes
- Endocrine disorders
- Hypothalamic damage
What drugs can cause obesity?
- Insulin
- Steroids
- Antithyroid drugs
- Sodium valproate
What syndromes can cause obesity?
- Prader Willi syndrome
- Laurence-Moon Biedl syndrome
- Pseudohypoparathyroidism type I
- Down’s syndrome
What endocrine disorders can cause obesity?
- Hypothyroidism
- Growth hormone deficiency
- Glucocorticoid excess
- Hypothalamic lesion (tumour/trauma/infection)
- Androgen excess
- Insulinoma
- Insulin resistance syndromes
- Leptin deficiency
What is the treatment for obesity?
- Diet
- Exercise
- Psychological input
- Rarely drugs
- Surgery
What is the most common cause of obesity?
Simple obesity
- Increased intake
- Decreased activity
How is an early diagnosis of T1DM made in children?
THINK symptoms
- Thirsty
- Thinner
- Tired
- Toilet more often
What additional symptoms are there in children under 5 with T1DM?
- Heavier than usual nappies
- Blurred vision
- Candidiasis (oral, vulval)
- Constipation
- Recurring skin infections
- Irritability, behaviour change
What is a red flag symptom for T1DM in a child who is toilet trained?
A return to bedwetting or day=wetting in a previously dry child is a red flag symptom for diabetes
What should you do if a child presents with suspected T1DM?
Test immediately
- Finger prick capillary glucose test. If result >11mmol/l then diabetes, if <11mmol/l other cause
- DO NOT request a returned urine sample
- DO NOT arrange a fasting blood glucose test
- DO NOT arrange an oral glucose tolerance test
- DO NOT wait for lab results (urine or blood)
- DK
What should you if a child with suspected T1DM finger prick test is over 11mmol/l?
Telephone urgently
- Contact your local specialist team for a same day review
- DKA can occur very quickly in children
- If in any doubt about a diagnosis of type I diabetes call for advice
- Don’t delay the diagnosis
What are the symptoms of DKA?
- Nausea and vomiting
- Abdominal pain
- Sweet smelling ‘ketotic’ breath
- Drowsiness
- Rapid, deep ‘sighing’ respiration
- Coma
