Growth PPT-17 Flashcards
Gwen’s father is 6ft. Her mother is only 5’5. Calculate her mid-parental height. (What is the equation?)
Girls height (in inches) = (father’s height -5in)+ mother’s height // 2
Target height = mid parental height +/- 4in
Gilligan’s father is 6ft. His mother is only 5’5. Calculate his mid-parental height. (What is the equation?)
Boys height (in inches) = (mother’s height +5in) + father’s height// 2
Target height = mid parental height +/- 4in
You are given a growth chart. What steps do you take in reading it?
- Plot correctly
- What is the percentile range?
- What is the growth pattern? (Increased or decreased velocity?)
From 0-2 years, which growth charts do you use?
Use WHO
After 2 years, what growth charts should you use?
Use CDC
When do infants start eating solid foods?
cereal at 6 months
Why do you give an infant whole milk?
for brain development
When should you expect the infants weight and height to level out?
6-9 months
When does a child’s weight 2x?
6 months
When does a child’s weight 3x?
12 months
When does the most motor development occur?
1at year of life
What tests would are indicated for microcephaly?
For us, we just want to recognize it.
-refer it
Tests:
1. Genetic (karyotype)
2. Imaging: CT/MRI–MRI more so to see what is developed and what is not
What imaging is preferred for Hydrocephaly?
CT
What is the definition for Failure to Thrive?
Weight below the 3rd to 5th percentile for age on more than one determination
T/F: Height falls first
False
Weight falls first
If the height falls first, are you going to be worried about failure to thrive?
No, you are going to be worried about short stature
T/F: 80% of children with failure to thrive have a medical diagnosis.
False
Most children suffer from non-organic causes
Is palate development organic or non-organic cause?
Organic
What are some developmental disorders that are organic?
Autism –children don’t like certain textures
How do you prepare formula?
2:1 scoops of formula (2oz bottle)
What are examples of inadequate nutritional intake that may lead to failure to thrive?
- Food insecurity
- Poor knowledge
- Poor transition to table food
- Avoidance of high calorie foods
- Formula dilution
- Excessive Juice (causes diarrhea)
- Breastfeeding difficulties
- Neglect `
What are examples of inadequate nutritional intake that may lead to failure to thrive?
- Oromotor dysfunction
- Developmental delay
- Behavioral feeding problems
- Emesis
- GERD
- Malrotation
- Increased intracranial pressure
A mother brings in her infant. On PE, you notice a bulging fontanelle and some macrocephaly. The mother states the child has been vomitting. What is her diagnosis?
Increased intracranial pressure
What medical conditions cause malabsorption?
- CF
- Celiac disease
- Food protein insensitivity or intolerance
- Inflammatory bowel disease
- Pancreatic insufficiency
- Liver disease
What conditions have an increased metabolic demand?
- Prematurity
- Insulin resistance
- Congenital infections
- Chronic infections
- Inborn errors of metabolism
- GH deficiency
- Hyperthyroidism
- Diabetes insipidus
- Congenital heart defects or CHF
- Pulmonary disorders
- Renal tubular acidosis
- Chronic liver disease
- Lead poisoning
- Malignancy
What is the lab workup (if needed)?
- CBC with red cell indices
- UA/culture
- Complete metabolic panel with renal and liver functions
- Consider lead screening (start at 12mo)
*Addl labs ONLY undertaken for suspected diagnosis
When should you consider hospitalization for a Peds patient?
- Majority is outpatient
- Possible if treating underlying medical causes
- If consultants are needed to efficiently evaluate their child’s eating behaviors***
Define Growth Failure
Abnormally slow growth velocity or dropping across two major centile lines on the growth chart
Define Short Stature
Height below -2SD (3% is -1.9) for age and gender or height more than 2 SD below the mid parental target height
What is the normal growth rate during childhood?
Most children establish a pattern of growth by 3 years and do not deviate until puberty
-growth rate is about 2-2.5 inches/year
T/F: Height predictions can be made with bone age
True
T/F: Height predictions can be made with children with growth disorders
False
T/F: Skeletal maturation can does not prediction pubertal tempo
True
What closes the growth plates at the end of puberty?
estrogen and testosterone
What is the standard measurement to measure growth development?
Left hand x ray
When do kids stop taking naps? And why?
- 5-3 years old
- because they don’t grow as much
What drugs cause short stature?
- Glucocorticoids
2. Stimulants*
What Chromosomal defects cause short stature?
- Turner syndrome
- Noonan syndrome
- Pader Willi Syndrome
What skeletal dysplasias cause short stature?
- IUGR/SGA
- Metabolic
- Chronic disease
- Psychosocial deprivation
What are normal causes of short stature?
- Constitutional growth delay
2. Familial short stature
What are pathological–nutritional causes of short stature?
- Zinc
- Iron deficiency
- Anorexia
- IBD
- Celiac disease
- CF
What are pathological–endocrine causes of short stature?
- Hypothyroid
- Growth hormone deficiency
- Cushing
- Precocious Puberty
Characterized by growth deceleration during first 2 years of life followed by normal velocity at lower percentile during puberty years
Constitutional growth delay
Delayed bone age, appropriate for height age Delayed puberty No organic or emotional cause Catch up growth by late puberty More common in males
Constitutional growth delay
What is the treatment for growth delay?
- Growth hormone is very controversial
- Most children can deal with this fine with behavioral interventions/counseling
When is it “ok” to give growth hormones?
If there is an inability to reach normal adult height in a child that has idiopathic short stature
What can you treat boys with testerone if the bone age >11.5 to 12 years to avoid compromising adult height?
Testosterone
Children who have normal growth velocity and height that are within normal limits for parent’s heights
Familial short stature
A child is having a decrease in growth rate between 6 and 18 months; what should you be suspicious of?
Familial short stature
Some families with short stature may also have tubular bone alterations such as : ?
- Brachydactyly syndromes
2. SHOX haploinsufficiencies
Normal growth velocity and bone age
Normal puberty and maturation
Familial short stature
What is the definition of a child that is born small for gestational age?
defined as less than -2SD for brith weight or length
What are some potential causes a child could be small for gestational age?
- Maternal: infection, nutritional deficiencies, uterine abnormalities, smoking, alcohol, drugs
- Placental: previa, abruption, infarcts, structural, multiple gestation
- Fetal: chromosomal abnormalities, metabolic, infections*, malformations
A mother is inquiring when her SGA child will catch up in height? What do you tell her?
by 2 years
When is most of the growth catch up achieved?
within 6 months of birth
What percent of children born SGA stay short as adults?
10-15%
When can the final height for an SGA child be compromised?
puberty
What are some hormonal causes of worrisome growth?
- Hypothyroidism
- Growth Hormone/IGF-1 abnormalities
- Cushing syndrome
- Rickets
Increased TSH
Low T4
Primary Hypothyroidism
Central hypothyroidism
Low T4
normal TSH
T/F: Many clinical features that are seen in hypothyroid adults are lacking in children
True
What image could you order with Hypothyroidism?
MRI
Where does Growth Hormone come from?
Anterior pituitary
What is the function of Growth Hormone?
main function is to promote linear growth
-also effects body composition; increases lean body mass and decreases fat mass
What are some congenital causes of growth hormone deficiency?
Hypothalamic pituitary malformations
What are some acquired causes of growth hormone deficiency?
- CNS infection
- Trauma
- Hypophysitis
- CNS tumors
- Cranial irradiation
How should you evaluate Growth Hormone deficiency?
- Bone age
- IGF-1
- Stimulation testing (this is a 3hr test)
T/F: You should never draw a random GH level
True
Deletion of 15q
Prader-Willi
What are some manifestations of Prader-Willi?
- Hypotonia
- Poor growth, delayed development
- Hyperphagia, obesity
- Narrow forehead, almond shaped eyes, triangular mouth
- Short stature
- Underdeveloped genitals, may be ambiguous at birth
- Delayed, or incomplete, puberty
- Infertility
What is the most common sex chromosome abnormality of females?
Turner syndrome
What is Turner’s syndrome caused by?
complete or partial absence of 1 of the X chromosomes
What would you expect from a “mosaic” Turner’s patient?
For them not to exhibit all the characteristics
What do virtually all girls with Turner’s syndrome exhibit?
short stature
-final height is about 7-8in less than their target height if untreated
50% of Turner’s patients are what?
What are the remaining?
45X
-structural abnormality of X or mosaicism
What other skeletal abnormality besides short stature would you expect to see in a girl with Turner’s syndrome?
increased carrying angle
short neck
micro/retrognathia
What other features are associated with Turner’s–besides short stature? (12)
- low hairline
- webbed neck
- lymphedema
- multiple pigmented nevi
- Epicentral folds
- Hypothyroidism
- Bicuspid valve, coarctation
- horseshoe kidney
- Otitis media
- hearing loss
- ovarian insufficiency
- non-verbal learning disability
What is the evaluation of worrisome growth?
- Bone age (do 1st)
- Screening labs:
-CBC
-UA
-Karyotype in girls
-TSH and T4
IGF-1 - Nutritional growth retardation: also–ESR, TTG, (tissue transglutaminase antibody) and IgA
What should you think with a TTG? (tissue transglutaminase antibody)
Celiac Disease
What is the possible workup for tall stature?
- Bone age
- Karyotype
- T4, TSH
- IGF1
- Special investigations
- LH/FSH/Testosterone
- Glucose suppression test for GH
- Visual tests
- MRI of the pituitary
- Serum cortisol
- Serum prolactin
What is the treatment for tall stature?
- Consider sex steroids
- negative feedback look of HP axis - Somatostatin analogues
- reduce GH hypersecretion
Autosomal dominant (chromosome 15 FBN1 gene)
Marfans syndrome
What is the pathophysiology of Marfans?
connective tissue (fibrillin 1 disorder)
What are Marfans syndrome patients at high risk for?
Aortic dissection
Tall stature
Arm span > height
Marfans presentation
A white 8 year old girl is having puberty signs, is this normal for her age? What is the mean time of puberty for whites?
Not normal–its early
10.4 = mean
A 6.5 year old black girl is having puberty signs, is this normal? What is the mean time of puberty for blacks?
Not normal–it is early
9.5 = mean
A 6.8 year old hispanic girl is having puberty signs, is this normal? What is the mean time of puberty for hispanics?
Not normal–it is early
9.8 = mean
When does the attainment of Tanner 2 breast development occur?
Onset of puberty
–depends on the race
When does monarche typically occur? (Mean)
White: 12.55
Black: 12.06
Hispanic: 12.25
When would you say a girl has had an early menarche?
White: 10.65
Black: 9.7
Hispanic: 10.05
How many more years after breast development does monarche occur?
2 more years after breast development
If a boy has testes that are >3ml (>2.2cm). How old is this boy?
11.8 years
9-14years
What age is a boy that begins to have pubic hair?
12 years
What physical changes would you expect a 13 year old boy to have?
penile enlargement
What age does a boy reach peak height velocity?
14 years
A 13 year old girl comes in and on PE you notice there are no signs of puberty. What is going on?
Delayed puberty
What age is delayed puberty considered for boys?
14 years if no pubertal signs are shown
How do you know if there is a lack of progression in puberty in girls?
If there is no menarche by 4 years after puberty starts
If a girl began puberty at 10 years; is now 14 and has not started her menarche; are you concerned?
A bit; she has lack of progression in puberty
If a boy began puberty at 12 years; is now 17 and still does not have completion of genital growth. Should you be concerned?
A bit; he has lack of progression in puberty
What are some causes for Primary Ovarian Failure?
- Turners syndrome
- XX XY gonadal dysgenesis
- Galactosemia
- Radiation
- Chemotherapy (alkylating agents) (esp. to pelvic area)
- Autoimmune
What are some COMMON characteristics of Turners syndrome?
- 100% display short stature
- Dysmorphic facies
- History otitis
- Ovarian failure
- Cardiovascular (55%)
- Thyroiditis (34%)
What are some causes for primary testicular failure?
- Kleinfelter’s syndrome
- Cryptorchidism
- Vanishing testes
- Radiation
47 XXY genotype (or additional X’s)
Klinefelter’s syndrome
What are some phenotypic characteristics for Kleinfelter’s?
- Microphallus
- Small testes
- Learning disabilities
- Eunuchoid
- Delayed or arrested puberty
- Gynecomastia
- Infertility
There is a patient with delayed puberty, how do you evaluate them?
- Hx
- Height and growth charts
- Bone age
- Labs: gonadotropins, testosterone, estradiol
(MAY consider TSH, T4, prolactin, CBC, ESR, BMP) - Karyotype, if elevated gonadotropins
How do you treat Hypogonadism in boys?
Testosterone injection Q3-4 weeks initially low dose then gradually increase (can also use topical preparation)
How do you treat Hypogonadism in girls?
Estrogen alone followed by cyclic therapy with estrogen and progesterone
Describe Precocious Puberty
- Early onset and progression of physical development
- Accelerated linear growth
- Advancement of skeletal age
- Central (GnRH dependent)
- Peripheral (GnRH independent)
Boys precocious puberty
development before 9 years of age
Girls precocious puberty
development before 8 years of age in Caucasian
7 years in AA and Hispanic girls
What is the MC cause of peripheral precocious puberty in boys?
Adrenal tumor
What are peripheral causes of precocious puberty in girls?
- Ovarian cysts (more common): progression of ovarian follicles to form cysts may occur as part of normal childhood
- Granulosa cell tumor
- Exogenous estrogens
- Lavender products (essential oils)
What are peripheral causes of precocious puberty in boys?
- Leydig cell tumor
- hCH secreting tumor
- McCune-Alright Syndrome
- Congenital adrenal hyperplasia
Describe Familial Testotoxicosis
- Mutation of LH receptor causing it to be constitutively activated
- Autonomous Leydig cell activity
- Testes enlarged but not to the extend expected for degree of virilization
T/F: Severe primary Hypothyroidism is a cause of peripheral precocious puberty
True
- both sexes
- Mechanism may be hormonal overlap (TSH is like FSH)
- Girls: breast development
- Boys: testicular enlargement
- Key: delayed bone age and poor linear growth
How would you evaluate a Precocious Puberty patient?
Strictly clinical:
- Hx
- Growth pattern: normal or accelerated?
- PE: Tanner staging, size and symmetry of testes, cafe-au-lait spots, neurological findings
- Bone age*
- GnRH stimulation test or random gonadotropins
While evaluating a precocious puberty patient, you discover bone age is advanced, what does this signify?
This suggests long-standing sex hormone action
In treating precocious puberty, what might you want to keep in mind?
- To attempt to reclaim loss of final height potential
- Also to halt pubertal progression and alleviate or prevent psychological stress
- Psychosocial development is commensurate with AGE not physical maturity
- May see withdrawal, anxiety, depression
- May be victims of sexual encounters
How to you treat CENTRAL precocious puberty?
GnRH analog (Lupron) down regulates pituitary GnRH receptors thus decreasing gonadotropin secretion
How to you treat PERIPHERAL precocious puberty?
Depends on cause
Ovarian cyst: watchful waiting with follow-up u/s
If a child is developing gynecomastia, what medication and what condition was likely being treated?
He was most likely being treated for precocious puberty with a GnRH analog (Lupron)
Why are you using Lupron to treat precocious puberty?
To engage a negative feedback loop to make the precocious puberty stop
