Paediatric Growth and Endocrine Flashcards
What is ‘normal’ growth?
•Precise definition difficult:
- Wide range within healthy population
- Different ethnic subgroups
- Inequality in basic health and nutrition
- Normality may relate to individuals or populations (genetic influence)
how should height be measured?
essential to have good measurements, good technique and equipment
when should you take measurements of a child?
Value of serial measurements: ‘make every contact count’
important to have many measurements, should be measured at every contact
how can you predict a child height?
Target Height and Mid Parental Height (MPH)
short parents make short children
what is bone age?
left has delayed bone age and right has very advanced bone age
A bone age study helps doctors estimate the maturity of a child’s skeletalsystem. It’s usually done by taking a single X-ray of the left wrist, hand, and fingers
assessment of bone maturation, x-ray of the left hand, analyse maturity of 20 bones
if someone is short with a delayed bone age this may mean they still have the potential to grow as they have a young skeleton
Basics are so important!! - what may unaccurate measurements lead to?
may put child through unnecessary investigations
Summary: Assessment Tools
- Height/ length/ weight
- Growth Charts and plotting
- MPH and Target centiles
- Growth velocity
- Bone age
- Pubertal assessment
want to get more information
History and further examination - what would you do?
- Birth weight and gestation
- PMH
- Family history/social history/schooling
- Systematic enquiry
- Dysmorphic features
- Systemic examination including pubertal assessment
Growth disorders: what are indications 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
what are some common causes for short stature?
- Familial - short child from a short family
- Constitutional - Constitutional delay of growth and puberty - variant of normal, will be late developers, will be fine
- SGA/IUGR
Variations of normal
what investigations can be done and what do they look for?
what is used to assess where children are in puberty and how is it done?
Staging of puberty: Tanner method
what are the stages?
stage 2 is beginning of puberty, stage 1 means haven’t started
what hormones are involved in puberty?
these hormones cause breast development in girls and testicular enlargement in boys, also get pubic hair and axillary hair but these are mediated by adrenal hormones and these are produced around when children go into puberty and they produce secondary sexual characteristics in boys and girls (pubic and axillary hair)
Relationship between growth and other changes in puberty: how ar ebyos and girls different?
tempo of puberty different between boys and girls, menarche is a late development, boys start puberty on average a year later and have a later growth spurt that is more marked
what is classed as early and delayed puberty in boys and girls?
•Boys
- early < 9 years (rare)
- delayed >14 (common, especially CDGP)
•Girl
- early <8 years
- delayed >13 (rare)
Constitutional Delay of Growth and Puberty (CDGP) - who does it occur in and why?
- Boys mainly
- Family history in dad or brothers (difficult to obtain!)
- Bone age delay
- Need to exclude organic disease
Puberty essentials:
•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
Short stature: What are Pathological causes?
- Undernutrition
- Chronic illness (JCA, IBD, Coeliac)
- Iatrogenic (steroids)
- Psychological and social
- Hormonal (GHD, hypothyroidism, glucocorticoid excess)
- Syndromes (Turner, P-W, Noonan, PHPT)
- Skeletal dysplasias
picture - hypothyroidism, fallen off centiles, mainly loss of height, short and obese child and you should always be worried about this
what are the features of Turner Syndrome (45X0)?
•Short Stature
•Ovarian dysgenesis (ovaries not fully formed)
- Associated disorders: cardiac, renal, thyroid, ENT problems
- Psychosocial/educational difficulties
- Physical stigmata (wide or web-like neck, wide spaced nipples, shielded chest, wide carrying angle, small nails, short limbs, low set ears)
what happens if you give someone with Turners syndrome GH?
growth chart of turners syndrome, starts to fall off the centiles, treat girls with turners with GH, start to catch up after treatment, not growing really good due to the bones due to skeletal dysplasia
what are the features of Prader-Willi Syndrome?
- Infantile hypotonia/feeding problems
- Hyperphagia/obesity in childhood
- Short stature
- Developmental delay/
- Hypogonadism
- Deletion of 15q11-q13 chromosomal region
can give growth hormone
what are the features of Noonan’s syndrome?
- Typical facial features
- Short stature
- Congenital heart disease (pulmonary valve stenosis)
can benefit from GH
what is Achondroplasia?
lots of skeletal dysplasia but this is the most common one, very short limbs as long bones don’t grow properly, GH doesn’t work on these children
Achondroplasia is a disorder of bone growth that prevents the changing of cartilage (particularly in the long bones of the arms and legs) to bone. It is characterized by dwarfism, limited range of motion at the elbows, large head size (macrocephaly), small fingers, and normal intelligence
how may children who are abused or have bad social circumstances grow?
they may have psychosocial growth disturbance
what may cause Delayed puberty?
- 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)
what is Central Precocious Puberty?
- True pubertal development - Breast development in girls and Testicular enlargement in boys
- Growth spurt
- Advanced bone age
- Need to exclude pituitary lesion—- MRI
Central precocious puberty is a condition that causes early sexual development in girls and boys. While puberty normally starts between ages 8 and 13 in girls and between ages 9 and 14 in boys, girls with central precocious puberty begin exhibiting signs before age 8, and boys with this disorder begin before age 9
Management = Long-acting analogs of GnRH (GnRHas) have been the gold-standard treatment of central precocious puberty (CPP) - dleays further development
what is precocoious pseudopuberty
- Clinical picture: secondary sexual characteristics
- Gonadotrophin independent (low/prepubertal levels of LH and FSH)
- Most common Early Adrenarche
Need to exclude Congenital Adrenal Hyperplasia!
what is involved in assesment of a child when looking for obesity?
•Weight
•Body mass index (BMI) (kg/m2)
•Height
- Waist circumference
- Skin folds
- History and examination
- Complications
Obese + short = ________
abnormal
what information do you want in the history of a child with obesity?
•Diet
•Physical activity
•Family history
•Symptoms suggestive of
- Syndrome
- Hypothalamic- pituitary pathology
- Endocrinopathy
- Diabetes
increased intake and not enough activity
what are the complications with obesity?
·Metabolic syndrome
·Fatty liver disease (nonalcoholic steatohepatitis)
·Gallstones
·Reproductive dysfunction (eg, PCOS)
·Nutritional deficiencies
·Thromboembolic disease
·Pancreatitis
·Central hypoventilation
·Obstructive sleep apnea
·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
what are the causes of obesity?
- SIMPLE OBESITY (obesity related to excessive intake – refer to dietician and give lifestyle advice)
- Drugs
- Syndromes
- Endocrine disorders
- Hypothalamic damage
what is the treatment of obesity?
- Diet
- Exercise
- Psychological input
- Drugs???
Obesity Conclusions:
- _______ obesity is the most common cause
- Investigations are ______ necessary
Simple
rarely
Every Health Board in Scotland has young people present critically unwell with new onset diabetes and tragically several deaths have occurred in recent years
___ is preventable if diabetes is diagnosed early
DKA
what are the symptoms of diabetes?
THINK - 4 Ts:
Thirsty
Tired
Thinner
using the Toliet more
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
Diabetic Ketoacidosis DKA - what are the Symptoms?
Nausea & vomiting
Abdominal pain
Sweet smelling, “ketotic” Breath
Drowsiness
Rapid, deep “sighing” respiration
Coma
how do you test for diabetes?
TEST immediatley
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)
if someone has been ediagnosed with diabetes, what should you do?
TELEPHONE – Same Day Review
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
Diabetes - Making an early diagnosis
what should be done?
