Growth and Endocrine

Question 1

What is normal growth?

Answer 1

Wide range within healthy population
Different ethnic subgroups
Inequality in basic health and nutrition
Normality may relate to individuals or populations (genetic influence)

Question 2

How might you use parents to assess whether child’s growth normal?

Answer 2

Mid Parental Height (MPH) and Target Centile Range (TCR)

Question 3

What is a way of assessing bone age?

Answer 3

Tanner-Whitehouse TW 20

Uses hand bones

Question 4

What assessment tools can be used to assess growth?

Answer 4

Height/ length/ weight
Growth Charts and plotting
MPH and Target centiles
Growth velocity
Bone age
Pubertal assessment

Question 5

What might you look for in history and further examination?

Answer 5

Birth weight and gestation
PMH
Family history/social history/schooling

Systematic enquiry
Dysmorphic features
Systemic examination including pubertal assessment

Question 6

What are indications for referral for growth disorder?

Answer 6

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

Question 7

What are common causes of short stature?

Answer 7

Familial
Constitutional
SGA/IUGR
(small for gestational age and intrauterine growth restriction)

Question 8

When testing FBC and ferritin in growth disorder, what are you looking for?

Answer 8

General health
Coeliac
Chron’s
JCA

Question 9

When testing coeliac serology and IgA in growth disorder, what are you looking for?

Answer 9

Coeliac disease

Question 10

When testing U&E, LFT, Ca and CRP in growth disorder, what are you looking for?

Answer 10

General health
Renal and liver disease
Disorders of Ca metabolism

Question 11

When testing IGF-1, TFT, Prolactin and Cortisol (gonadotrophins and sex hormones) in growth disorder, what are you looking for?

Answer 11

Hormonal disorders

Question 12

When testing karyotype/microarray in growth disorder, what are you looking for?

Answer 12

Turner’s syndrome Chromosomal abnormalities

Question 13

If IGF1 id low, what might you do next?

Answer 13

Growth hormone stimulation test

-

Question 14

In isolated growth hormone deficiency, what might a pituitary MRI look like?

Answer 14

Ectopic posterior pituitary gland

Small anterior pituitary gland

Question 15

What is a method of staging puberty?

Answer 15

Tanner method

Question 16

Describe the Tanner method

Answer 16

B - 1 to 5 (breast development) 
G - 1 to 5 (genital development)
PH - 1 to 5 (pubic hair)
AH - 1 to 3 (axillary hair) 
T - 2ml to 20ml

SO eg statement as B3 PH3 or G2 PH2 6/6

Question 17

What defines early and delayed puberty in boys and girls?

Answer 17

Boys

• early <9years (rare)
• delayed >14 (common, especially CDGP)

Girl

• early <8 years
• delayed >13 (rare)

Question 18

What is CDGP?

Answer 18

Constitutional Delay of Growth and Puberty (CDGP)
Boys mainly
Family history in dad or brothers (difficult to obtain!)
Bone age delay
Need to exclude organic disease

Question 19

What are the essential in assessing puberty?

Answer 19

Pubertal staging:

• Breast budding (Tanner Stage B 2) in a girl
• Testicular enlargement (Tanner Stage G2 -T 4 ml) in boy

Pubertal tempo

Normal pubertal age

Question 20

What are some pathological causes of short stature?

Answer 20

Undernutrition
Chronic illness (JCA, IBD, Coeliac)
Iatrogenic (steroids)
Psychological and social
Hormonal (GHD, hypothyroidism, glucocorticoid excess)
Syndromes (Turner, P-W, Noonan, PHPT)
Skeletal dysplasias

Question 21

What are the features of Turner syndrome?

Answer 21

45X
Short Stature
Ovarian dysgenesis

Associated disorders: cardiac, renal, thyroid, ENT problems
Psychosocial/educational difficulties
Physical stigmata

Question 22

What are the features or Prader-Willi syndrome?

Answer 22

Infantile hypotonia/feeding problems
Hyperphagia/obesity in childhood
Short stature 
Developmental delay
Hypogonadism 
Deletion of 15q11-q13 chromosomal region

Question 23

What are the features of Noonan’s sydrome?

Answer 23

Typical facial features
Short stature
Congenital heart disease
(pulmonary valve stenosis)

Question 24

What is achondroplasia?

Answer 24

Disorder of bone growth that prevents the changing of cartilage (particularly in the long bones of the arms and legs) to bone
It is characterised by dwarfism, limited range of motion at the elbows, large head size (macrocephaly), small fingers, and normal intelligence

Question 25

What are the causes of delayed puberty?

Answer 25

Chronic disease (Crohn’s, asthma) and constitutional

Primary gonadal disorders

• Gonadal dysgenesis (Turner’s, Klinefelter’s, DSD)
• Testicular irradiation

Impaired HPG axis (septo-optic dysplasia, craniopharyngioma, Kallman’s syndrome)

Question 26

breast

Answer 26

z

Question 27

secondary

Answer 27

z

Question 28

pv bleeding

Answer 28

z

Question 29

What is central precocious puberty?

Answer 29

True pubertal development
– Breast development in girls
– Testicular enlargement in boys

Growth spurt
Advanced bone age
Need to exclude pituitary lesion - MRI

Question 30

What is precocious pseudopuberty?

Answer 30

Clinical picture: secondary sexual characteristics

Gonadotrophin independent (low/prepubertal levels of LH and FSH)

Most common Early Adrenarche

Need to exclude Congenital Adrenal Hyperplasia!

Question 31

How is obesity assessed?

Answer 31

Weight
Body mass index (BMI) (kg/m2) • Height
Waist circumference
Skin folds
History and examination
Complications

Question 32

Is it normal for a child to be obese and short?

Answer 32

No

Question 33

What are causes of obesity?

Answer 33

• SIMPLE OBESITY (intake>output)
• Drugs
• Syndromes
• Endocrine disorders
• Hypothalamic damage

Question 34

What are non-simple types of obesity and how do you recognise them?

Answer 34

Endocrine causes - growth failure

Syndromes - learning difficulties

Hypothalamic causes - loss of appetite control

Genetic causes - starts before age 5

Question 35

How might diabetes present?

THINK

Answer 35

Sometimes referred to as the 4Ts

Thirsty
Tired
Thinner
Using the Toilet more

Question 36

What is a red flag sign for diabetes?

Answer 36

A return to bedwetting or day-wetting in a previously dry child

Question 37

How may diabetes present in children under 5?

Answer 37

Heavier than usual nappies 
Blurred vision
Candidiasis (oral, vulval) 
Constipation
Recurring skin infections 
Irritability
Behaviour change

Question 38

What are the signs of DKA?

Answer 38

Nausea & vomiting
Abdominal pain 
Sweet smelling, "ketotic" breath
Drowsiness 
Rapid, deep “sighing” respiration 
Coma

Question 39

If you suspect DKA or type 1 diabetes, what must you do immediately?

TEST

Answer 39

Finger prick capillary blood glucose test
Result >11mmol/l - Diabetes
Result <11mmol/l - Other cause

DO NOT request a returned urine specimen.
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).

Question 40

After testing blood glucose, what must you do?

TELEPHONE

Answer 40

Call local specialist paediatric diabetes team for a same day review
Diabetic Ketoacidosis (DKA) can occur very quickly in children
If in any doubt about a diagnosis of Type 1 Diabetes call for advice 
Don’t delay the diagnosis

Question 41

Summarise diagnosing diabetes

Answer 41

THINK – Symptoms

• Thirsty
• Thinner
• Tired
• Using the Toilet more

TEST- Immediately

• Finger prick capillary glucose test
• If result >11mmol/l

TELEPHONE – Urgently
-Contact your local specialist team for a same day review

Question 42

What is the blood glucose result that indicates diabetes?

Answer 42

> 11mmol/l