Paediatric Growth and Endocrine Flashcards
discuss normal child growth
A precise definition of what is normal growth is difficult. There is a wide range within a health population and further range in ethnic subgroups. There is inequality in basic health and nutrition. Normality may relate to individuals or populations (genetic influence).
list the factors influencing 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
child measurement techniques
• Length • Height • Sitting height • Head circumference o Routine in children < 2 years o Tape round forehead and occipital prominence (maximal circumference)
describe bone age TW20
standardised left hand
• Radiographs must be of high quality
• Evaluation by skilled practitioner
• Pathological conditions can distort bones
• Severe osteopenia confuses interpretation
growth disorders: indicators 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
common causes of short stature
familial
constitutional
IUGR
pathological causes of short stature
- Undernutrition
- Chronic illness (JCA, IBD, coeliac)
- Iatrogenic (steroids)
- Psychological and social
- Hormonal (GHD, hypothyroidism)
- Syndromes (Turner, P-W)
investigation of short stature: FBC and ferritin
general health
coeliac
Crohn’s
JIA
investigation of short stature: U+E, LFT, Ca, CRP
general health
renal and liver disease
disorders of Ca metabolism
investigation of short stature: coeliac serology and IgA
coeliac
investigation of short stature: IGF-1, TFT, Prolactin, cortisol (gonadotrophins and sex hormones)
hormonal disordres
investigation of short stature: karyotype
Turner’s syndrome
if IGF-1 is low what would you proceed to do?
• Proceeded to GH stimulation test: o Arginine test o Insu • Isolated growth hormone deficiency • MRI pituitary: o Ectopic posterior pituitary gland o Small anterior pituitary
give an overview od the Tanner Staging of puberty
Breast development (B) o 1-5 • Genital development (G) o 1-5 • Pubic hair (PH) Figure 2 Investigations of Small Stature o 1-5 • Axillary hair (AH) o 1-3 • Testicular volume o 2ml to 20ml
relationship between growth and other changes in puberty: boys
see notes
relationship between growth and other changes in puberty: girls
see notes
early and delayed puberty: boys
< 9
> 14
early and delayed puberty: girl
< 8
> 13
constitutional delay of growth and puberty
This affects boys mainly. There is commonly a family history in dad or brothers, however, this may be difficult to obtain. Bone age delay. Need to exclude organic disease.
causes of delayed puberty
CDGP
• 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)
early sexual development
• Breast development (hypothalamic activation)
o Infantile thelarche
o Thelarche variant (premature thelarche)
o Central precocious puberty)
• Secondary sexual characteristics (sex steroid hormone secretion)
o Exaggerated adrenarche
o Precocious pseudopuberty (i.e. congenital adrenal hyperplasia)
• PV bleeding
o Premature menarche
central precocious puberty
• Pubertal development o Breast development in girls o Testicular enlargement in boys • Growth spurt • Advanced bone age • Need to exclude pituitary lesion – MRI
precocious pseudopuberty
- Abnormal sex steroid hormone secretion
- Gonadotrophin independent (low/prepubertal levels of LH and FSH)
- Clinical picture: secondary sexual characteristics
- Need to exclude congenital adrenal hyperplasia
ambiguous genitalia: management approach
- Do not guess the sex of the baby!
- MDT – paed endo, surgical, neonatologist, geneticist, psychologist
- Exam: gonads?/internal organs
- Karyotype
- Exclude congenital adrenal hyperplasia – risk of adrenal crisis is 1st 2 weeks of life
congenital hypothyroidism: causes
athyreosis
hypoplastic
ectopic
dyshormonogenic
congenital hypothyroidism: when to start treatment?
within first 2 weeks
congenital hypothyroidism: how is it identified?
newborn blood screening
acquired hypothyroidisim
• Most common cause: autoimmune (Hashimoto’s) thyroiditis
• Family history of thyroid/autoimmune disorders
• Childhood issues:
o Lack of height gain
o Pubertal delay (or precocity)
o Poor school performance (but work steadily)
assessment of obese children
- Weight
- BMI
- Height
- Waist circumference
- Skin folds
- History and examination
- Complications
complications of childhood obesity
- 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
causes of childhood obesity
- Simple obesity
- Drugs
- Syndromes
- Endocrine disorders
- Hypothalamic damage
treatment of childhood obesity
• Diet • Exercise • Psychological input • Drugs?? Simple obesity is the most common cause. Investigations are rarely necessary
making an early diagnosis of diabetes
- THINK symptoms
a. Thirsty
b. Thinner
c. Tired
d. Using the toilet more - TEST immediately
a. Finger prick capillary glucose test
b. If result > 11 mmol/l - TELEPHONE urgently
a. Contact your local specialist team for a same day review
when to consider diabetes in children
A return to bedwetting or day wetting in a previously dry child is a red flag symptom for diabetes. In children under five also think: • Heavier than usual nappies • Blurred vision • Candidiasis (oral, vulval) • Constipation • Recurring skin infections • Irritability, behaviour change
DKA symptoms
- N+V
- Abdo pain
- Sweet smelling “ketotic” breath
- Drowsiness
- Rapid, deep “sighing” respiration
- Coma
testing for diabetes in children
• Finger prick capillary blood glucose test
o Result > 11 – diabetes
o Result < 11 – other cause
