Growth problems

Question 1

What are important points to obtain on history of child presenting with slow growth or short stature?

Answer 1

Growth History & Familial Patterns of growth

Intake history

• Breast feeding - frequency/duration, issues, exclusive vs partial, timing of solids
• Formula - type, amount, dilution method
• solids - when, what, range of foods
• Behavioural issues with feeding
• Milk consumption

Output history - bladder, bowels, vomiting

ROS - general and signs of puberty

FHx - digestive, hormonal, autoimmune issues, short stature

social hx - any child protection issues?

Question 2

What are important points to obtain on examination of child presenting with slow growth or short stature?

Answer 2

Growth charts

• Slow growth (‘failure to thrive’) if child is <3rd percentile for weight or drops >= 2 percentiles height and head circumference are initially well preserved
• Further investigation required if child below the 25th percentile on growth velocity chart

Expected height

• Determine mid-parental height and plot on growth chart to compare expected growth
• Child’s height should be within one SD of the MPH (+/- 7.5-8cm)

Nutritional status

Signs of child abuse

Behaviour/parental interaction

Systems to exclude organic i.e. abdo, endocrine

Question 3

What are red flags for children presenting with slow growth or short stature?

Answer 3

• Signs of abuse or neglect
• Poor carer understanding e.g. non-English speaking, intellectual disability
• Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support
• Signs of poor attachment
• Parental mental health issues
• Already/previously case managed by child protection services
• Did not attend or cancelled previous appointment/s
• Signs of dehydration
  Signs of malnutrition or significant illness

Question 4

What are DDx for slow growth/FTT?

Answer 4

Malabsorbtive diseases
Dentition/oral structural issues
Breast feeding/formula issues 
Psychosocial factors, restrictive diet
Genetic and metabolic conditions

Question 5

What are DDx for short stature?

Answer 5

Physiological

a. Constitutional delay of growth & puberty
b. Familial short stature

Intrauterine

a. Placental insufficiency
b. Russell-Silver syndrome

Skeletal

a. Bony dysplasia
b. Spinal irradiation

Nutritional

a. Malabsorption
b. Rickets
c. Malnutrition

Chronic illness

Iatrogenic - Corticosteroids

Chromosomal/genetic

a. Turner syndrome
b. Down syndrome
c. Prader-Willi
d. Others

Endocrine

a. Hypothyroid
b. GH deficiency
c. Cushing syndrome
d. Pubertal delay/arrest

Question 6

Features of constitutional delay of growth & puberty?

Answer 6

• Common normal variant
• Usually FHx of delayed puberty
• Growth slows around 2 years old fall in height percentile
• Growth is thereafter parallel to 3rd centile
• Prepubertal decline in growth exaggerated and onset of pubertal growth spurt is later than average
• Bone age is delayed height for bone age usually within normal mid-parental range
  Final likely in keeping with family members

Question 7

Features of familial short stature?

Answer 7

• Several adult family members are short
• Skeletal proportions & growth velocity normal
• Bone age equivalent to chronological age
  May have constitutional delay in maturation