Paediatric Growth And Development Flashcards
Phases of growth
Foetal/prenatal: most rapid phase of growth dependant on placental supply if nutrients and oxygen, determinants if birth size are maternal nutrition and intrauterine environment (not genetics)
Infantile (0-2y): rapid but decelerating. Double birth weight by 4 months, triple birth weight by 12m, grow 25cm in first year,, HC increases 12cm first year, 90% SGA infants will catch up by 1-2y
Childhood: constant growth, half adult height by 24-30m, GH dependant growth, 5-6cm/y from 4-puberty, 2kg/y from 2-pub
Puberty all growth spurt: driven by gonadal/adrenal steroids and GH, accounts for 20% final height, preceded by a reduction in growth velocity, girls 23-28cm, boys 26-28cm
Target height aka mid-parental height
Girls: (paternal height-13cm +maternal height)/2
Boys: (maternal height + 13cm + paternal height)/2
Body proportions
Arm span within 6cm of height Upper:lower segment ratios: - birth 1.7 - 3y 1.33 - 5y 1.19 - 10y 1.0
Gonadarche
Breast development in girls (telarche) and ovarian volume >4mls
Testicular volume > 4mls
Results from activation of hpg axis
Adrenarche
Androgen secretion from adrenal glands causing pubic hair and apocrine secretion
Puberty in girls (onset, order, total height gain)
Onset between 8-13y
Menarche 2-3y post onset of puberty
Avg total height gain 20cm (8cm post menarche)
Breast development, then pubic hair growth then menarche
Boys puberty (onset, height gain, order)
Onset 9-14y
Avg total height gain 28cm (peak in tanner4, 2 years later than girls)
Testicular enlargement followed by penile enlargement and pubic hair growth
Differentials for short stature
Familial/genetic short stature Constitutional delay Skeletal dysplasias(achondroplasia, hypochondroplasia) Rickets Turners syndrome Noonan's syndrome Russell silver syndrome (dwarfism) GH deficiency Cushing syndrome Hypothyroidism Precocious puberty (early accelerated growth, short adults) Chronic disease (renal, nutritional. GI) IUGR Emotional deprivation/psychosocial Idiopathic (most coon esp in girls)
Tall stature differentials
Dysmorphic: - Marfan syndrome - homocystinuria - Klinefelter syndrome - 47XYY, 47XXX Non-dysmorphic - precocious puberty - hyperthyroidism - pituitary gigantism - familial tall stature - hypogonadism - obesity - e2 deficiency or insensitivity -
Familial short stature v constitutional delay
Both are normal variants, not pathological
Familial: normal growth velocity (following pattern of chars) but consistently shorter than peers (usually on 3rd percentile), height is appropriate for mid-parental height, bone age = chronological age, pubertal spurt at appropriate time
Constitutional delay:
Short during childhood but adult height consistent with target height, pubertal spurt later than peers (difficult to diagnose until after growth spurt), bone age
GH eligibility
GH deficiency
Turner syndrome
Height
Differentials for precocious puberty
Raised gonadotropin levels (true/central)
- idiopathic (>90% females, 25% males
- intracranial pathology (hypothalamic/pituitary tumours, irradiation)
- familial
- treated congenital adrenal hyperplasia
Gonadotropin independent precocious puberty
- ingestion of sex steroids
- adrenal (CAH, tumour)
- ovarian (mccune Albright, tumours, follicular cysts)
- testicular ( testicular or germ cell tumours, mccune Albright syndrome)
- tumours secreting non pituitary gonadotropin e.g. hCG
Definition of precocious puberty
Pubertal development in ALL domains before 8 In girls or 9 in boys
I.e accelerated growth, breast development and pubic hair development in girls
Accelerated growth, genital and testicular growth and pubic hair development in boys
Premature Adrenarche
Isolated pubic hair development (+body odour, oily hair, pimples)
Adrenal androgens slightly elevated
LH, FSH, and gonadal steroids all prepubertal levels
Premature thelarche
Isolated unilateral or bilateral breast development
Commonly seen between 6m-4y
Manage with observation and follow-up
Height velocity
Based on sequential height measurements no less than 3 months apart more sensitive index than a single measurement
Components of CHARGE syndrome
Coloboma Heart defects Atresias Retarded growth/development Genital hypoplasia (undescended testes) Ear abnormalities
RDI of energy in children
Approx. 100 cal/kg/day +/- 5 or so according to age
Stages of feeding in babies and children
Stage 1: 6-7 months, first tastes, smooth foods
Stage 2: 7-8 months, learning to chew, soft lumps
Stage 3: 9-12 months, self-feeding, finger foods + firmer lumps
Stage 4: 12 months on, family diet with some changes
Common definitions of failure to thrive
Weight below the 2.5th percentile for gestation-corrected age on more than 1 occasion
OR
A rate of weight change that causes a decrease of 2 or more percentile lines over time
OR
A rate of daily weight gain less than that for expected age
Expected daily weight gain for age
0-3 months: 26-31 g/d 3-6 months: 17-18 g/d 6-9 months: 12-13 g/d 9-12 months: 9-13 g/d 1-3 years: 7-9 g/d
Category of causes of FTT
- Inadequate dietary intake
- Inadequate appetite or inability to eat large amounts
- Inadequate absorption
- Defective utilisation
- Increased urinary or intestinal losses
- Increased metabolic requirements
Common causes for FTT onset prenatally
IUGR, prematurity, prenatal infection, congenital syndromes, teratogenic exposures
Common causes for onset of FTT before 1 month (8)
Poor quality of suck Incorrect formula preparation Breastfeeding problems Inadequate number of feedings Poor feeding interactions Neglect Parental mental illness Metabolic, chromosomal or anatomic abnormalities
Common causes for onset of FTT 3-6 months (8)
Underfeeding +/- poverty Improper formula preparation Milk protein intolerance Oral motor dysfunction Cystic fibrosis Congenital heart disease GORD Recurrent infections
Common causes for onset of FTT 7-12 months (6)
Feeding problems - autonomy struggles - oral motor dysfunction (interfering with adaptation to textured foods) - delayed introduction of solids Intestinal parasites Coeliac disease Recurrent infections
Common causes for onset of FTT after 12 months (7)
Coercive feeding Distractible child Distracting environment Acquired illness New psychosocial stressor (divorce, new sibling, job loss etc.) Sensory-based feeding disorders in children with developmental disorder (E.g. Autism) Swallowing dysfunction Inappropriate mealtime
Investigations in failure to thrive
\+/- food diary CBE Urine MCS Sweat test Iron studies
\+/- the following: Electrolytes LFT Coeliac screen Stool MCS
If severe malnutrition: Albumin ALP Calcium (check for Rickets if very low) Phosphorus
Karyotype of Klinefelter’s
47, XXY
Inheritance pattern of achondroplasia
Autosomal dominant
Causes of bulging fontanelles
Raised ICP
i.e. meningitis, intracranial haemorrhage, intracranial effusion, hydrocephalus etc
Effect of rickets on the skull
Thickening of skull (frontal bossing)
Delayed closure of fontanelles
Effect of congenital hypothyroidism on the fontanelles
Enlarged POSTERIOR fontanelle
Measuring height accurately in a child
Under 2: Prone mat on firm surface Over 2y: wall mounted stadiometer - childs eyes at level of ear canal - Squat to level of child's head to read measurement - Feet flat on ground, knees straight
How to measure head circumference
Tape just above top of ear
Classic triad of Mccune Albright Syndrome
Polyostotic fibrous dysplasia
Cafe au lait spots
Precocious puberty
Causes of delayed puberty (%s)
Constitutional delay (50%) Functional hypogonadotropic hypogonadism (20%) Permanent hypogonodotropic hypogonadism (10%) Permanent hypergonadotropic hypogonadism (10%)
Prepubertal v postpubertal pelvic ultrasound findings in girls
Ovarian volume: Prepubertal less than 1.5mLs, pubertal over 3-4 mLs
Follicle size: prepubertal less than 6mm, many, pubertal more than 6mm, dominant
Uterus:cervix ratio:
Less than 1 = prepubertal, over 1 = pubertal
Good predictors for normal progression of a child with delayed puberty
Testes 4mL or B2 tanner stage, 95% will progress normally, despite apparent delayed puberty
