Pg 19 Flashcards
What are the determinants of the child growth?
- Fetal: 30%; uterine environment
- Infant: 15%: Nutrition and 3Hs (Health, Happiness, Thyroid Hormones
- Childhood: 40%: Above + genetics
- Pubertal: 15%: Sex and thyroid hormones
tanner stages of puberty?
• 1 => 5 (Pre-puberty => Adult)
Female breast changes (B)
o B2: Bud.
o B3: Juvenile Smooth contour.
o B4: Areola and papilla above breast.
Pubic hair changes: Male and female (PH)
o PH2: Long, straight
o PH3: Curved and curly
o PH4: Fill out
Male genital stages (G)
o G2: Long penis
o G3: Growth (length and diameter)
o G4: Glans penis and dark scrotal skin
How is bone age assessed and what is its significance?
X-Ray of left hand
Predict final height.
How is mid-parental height calculated?
Female: MPH = Mean – 7 => Range: +/- 8.5.
Male: MPH = Mean + 7 => Range: +/- 10.
How does puberty differ between males and females?
- First sign is breast bud in females and scrotum > 4 ml in males.
- Height spurt straight after in females, but 18 months later in males
What is short stature?
• Height is 2 centiles below mean.
Causes?
• Familial • Constitutional delay • Pathological: o SGA (IUGR, PREM) o Syndromes (Down, Turner) o Hormones deficiency (GH, TH deficiency, Steroid excess) o Health issues (Celiac, CF) o Happiness o Nutrients deficiency
extreme short stature?
Below 0.4th centile.
SHOX gene deletion on Chr. X
What is disproportionate short stature?
Confirm by
o Total height – sitting height = Subischial height.
o Short limbs: Achondroplasia. Short back (Scoliosis and
mucopolysacroidosis).
Hx of a child with short stature
o Growth Centiles o Familial: Parental height o Constitutional: FHX delay? o Pathological: Pregnancy (GA, IUGR, drugs/ alcohol/ smoking, PREM, birth weight). Birth, Development (Child and puberty). Nutrition: Early feeding problems, weaning, diet now Health, Hormonal, Happiness Steroids.
Exam of a child with short stature
o Dysmorphic features
o Disproportion
o Disease (Celiac, CF, Crohn’s)
o Development (Tanner).
Investigations of a child with short stature
o Growth charts o Health: § FBC: Anaemia in celiac § U+E+ Creatinine: CKD § Ca, P, ALP: Bone and kidney § ESR, CRP: Crohn’s § TTG, EMA: Celiac o Hormones: § TFT § GH provocation testes and IGF-1. § Dexamethasone suppression test § MRI (Craniopharyngioma) o Karyotype (XO) o X-rays § Bone age § Limited skeletal survey (skeletal dysplasia, scoliosis)
Tx of a child with short stature
SC GH injections (daily)
IGF-1
tall stature causes?
- Familial
- Obesity
- Hormones (Precocious puberty)
- Syndromes (HCU, Marfan’s)
Microcephaly: < 2nd
causes
o Familial: Normal development
o AR condition
o Congenital infection
o Insult (CP)
Macrocephaly: > 98th
causes
o Tall stature
o Familial
o Rapidly enlarging = Raised ICP => US (If AF still open) => MRI/CT
Craniocynostosis is the pre-mature fusion of sutures. (Usually do not fuse until late
childhood), resulting in distortion of head shape.
Generalised causes
Microcephaly and developmental delay.
Syndromes: Alpert (syndactylyl); exophthalmos (Crouzon)
Craniocynostosis localised causes (more common):
Sagittal (most common) => Long flat head
• DDX: Long head of preterm from lying on hard
surface.
Lambdoid:
• Flattening of the skull
• DDX: Plagiocephaly
Coronal:
• Asymmetrical skull
precocious puberty
def
Girls Puberty before 8 Benign and common pre-mature activation of the HPA axis with very sensitive ovaries
Boys
Puberty before 9
pathological in boys
Pituitary or adrenal tumour.
precocious puberty
DX
TX
DX
Hormonal profile (pituitary and adrenal)
Cranial MRI
Adrenal CT
Tx
Aim at the cause (e.g. Ketoconazole for adrenal causes)
Delay skeletal maturation
Behavioural and psychological
definition and causes of delayed puberty?
No puberty by 15 in boys.
Common in boys and usually constitutional: Can give testosterone
injections
No puberty by 14 in girls Pathological ovaries are very sensitive: Treat underlying cause and induce by estradiol for several months. o Chromosomal o Pituitary o Chronic disease o Eating disorder
advantages of breast-feeding?
Nutrition:
o Easily digested protein curd (Whey: Casein. 60:40).
o Rich in oleic acid, LCFA, and Ca, Fe
o Low solute load
Immune: Decreased infections and hospitalisations o IgA o Lysozyme o Bifidus factors o Cellular
bonding
Reduce metabolic disease, atopy and maternal cancer.
Introduce solids and wean-off milk at
Off-bottle by
6 months
12-18 months
What is weight faltering?
What are its causes?
• Sustained drop across 2 centiles or weight below 0.4th.
• Causes: Inadequate food intake
o 90% Non-organic
o 10% organic: (inadequate retention, malabsorption, failure to utilise nutrients, increased requirements)
What are the components of nutritional assessment?
Anthropometry: Height, Weight, MUAC < 115 mm.
Labs: Albumin, minerals
Food intake: Recall or diary
Immunodeficiency: Cellular immunity
indications for PN
functioning gut,
NG
gastrostomy (if > 6 W). Overnight feeds.
indications for TPN?
Bypass gut, PICC or CVC. Monitor for zinc deficiency, blockage, thrombosis and sepsis
definition of severe acute malnutrition
types?
managed?
- Weight -3 Z scores
- MUAC < 115 mm
- Kwashiorkor: Protein, Marasmus: Total
Slow frequent feeding: Formula 75 (Carbohydrates) then Formula (100): Proteins or RUTF
rickets
causes,
clinical manifestations, diagnosis
Causes: Nutritional, Celiac, Liver, kidney disease.
Manifestations: Seizures, hypotonia, Frontal bossing, Ricketic rosary,
Harrison sulcus, open anterior fontanelle, leg bowing.
DX: Celiac serology, LFT, RFT, dietary history (weaning etc.)
Confirmed by low Ca, P, V.D and high OTH and ALP
What is the definition and complications of obesity?
• BMI> 98th
• Complications: SUFE, Sleep apnoea, Diabetes, Hyperlipidaemia,
NAFLD, Psychological
most common causes of vomiting?
Infants:
Older:
Infants: GER, Feeding problems, infection, Food intolerance.
Older: Gastroenteritis, infections, appendicitis, Ulcer
red flags for vomiting?
- Bilious => Intestinal obstruction
- Blood => esophagitis, Intussisiption (Currant jelly stools)
- Big (Abdomen, Liver): Obstruction, Chronic liver disease.
- Persistent
- Projectile => pyloric stenosis
- Peritonitis => Surgical
- Cough => Pertussis
- Dehydration => severe gastroenteritis, DKA, sepsis
- Faltering growth => Celiac, IBD
possible complications of GERD and who is at
risk?
- Faltering growth
- Aspiration (Recurrent)
- Esophagitis
- Sandifer syndrome (GERD+ dystonic neck posturing)
At risk: NM problems and CP
What investigations are performed in GERD?
- 24-Oesophageal PH study
* Endoscopy and biopsy
How is GERD managed?
Food thickeners + Omeprazole
What are the clinical features, Dx and Mgt of pyloric stenosis?
2-8 week old boy: First in a family with history.
Projectile non-bilious vomiting
Dx: Test Feed =. Visible peristalsis with olive-like mass in the RUQ.
Ass. Hypocholremic hypokalaemic metabolic alkalosis.
Confirm by US
TX: IV fluids and electrolyte correction => Pyloromyotomy (Divide up to but excluding the mucosa).
What is infant colic?
Inconsolable crying + drawing up of knees and flatus
• Resolves gradually by 3-12 months
• If severe and persistent => Cow ilk protein allergy? => Two-week trial
of protein hydrolysate formula => trial of reflux Tx.
DDX of acute abdomen?
Surgical: Appendicitis, Obstruction (intussusception and malrotation, inguinal hernia), Peritonitis (Ascites from nephrotic),
Meckle’s diverticulitis, strangulated hernia, ovarian torsion.
Medical: Gastroenteritis, UTI, HSP, IBD, Celiac, constipation, DKA, SCD, pancreatitis
Extra-abdominal: Testicular torsion, Gyne, lower lobe pneumonia
clinical features of appendicitis?
• Progressive Abdominal pain (made worse by movement), anorexia,
N+V
• Guarding and tenderness at McBurney’s point
• +/- Peritonitis (Generalised guarding)
• +/- RIF mass (Abscess, appendicular mass)
• US: Thick non-compressible appendix with increased flow.
clinical features and management of intussusception?
• Paroxysmal colicky abdominal pain and pallor+ currant jelly stool+
Sausage–shaped mass on palpation+ Doughnut sign on US.
• Most commonly from foetal impaction => telescoping of ilium into cecum at iliocecal valve. (3 M-2 yrs.), after this age a leading point
(Merkel’s, polyp) more likely.
Tx
Reduction (Radiological by rectal air insufflation unless peritonitis =>
surgical reduction)
What is mesenteric appendicitis?
Appendicitis mimic, but less severe and often resolve+ URTI
clinical features and management of Volvulus?
• Twisting of the bowel around its mesentery causing obstruction (Ladd
bands) +/- infarction
• Bilious vomiting in the first days of life
• In children the cause is midgut malrotation, resulting in appendix and
caecum staying in the RUQ.
• DX: Is with Enema: Bird peak sign
• TX: surgical (do not re-rotate but broadens the mesentery with Caecum
and duodenum to left and the DJ on right)+ attachment of bowel to
abdominal wall and appendectomy.
recurrent abdominal pain
DEF
DDx
3 or more months+ interrupts daily activities.
90% nonorganic,
manifestation of stress
recurrent abdominal pain
investigations
Urine M+ C&S: Exclude UTI
Abdominal US: Exclude Gallstones and Pelvi-uretric
junction obstruction.
Celiac serology and TFT
recurrent abdominal pain
prognosis
o Half recover quickly
o Quarter take months
o Quarter remain
recurrent abdominal pain
DDx
Abdominal migraine
IBS
Ulcer and non-ulcer dyspepsia
Eosinophilic esophagitis
Abdominal migraine
o Peri-umbilical pain + headache+ vomiting+ facial pallor lasting for 2 days o Long (weeks) symptom-free periods. o Family or personal HX of migraine o TX: anti-migraine Meds
IBS
o Peri-umbilical pain made worse or relieved by defecation
o Bloating
o Alternating bowel habits (Constipation alternating with loose
stool)
o Mucus explosive loose stool
o Feeling go incomplete emptying
Ulcer and non-ulcer dyspepsia
Pain wakes them at night+ radiate to back.
o FHX of peptic ulcers
o DX: urea breath test, stool antigen => Trial of triple therapy (PPI,
Amoxicillin, clarithromycin) => Endoscopy and biopsy => No
(nodular antral gastritis)=> Functional dyspepsia=> Hypo allergic
diet
o non-ulcer dyspepsia: Early satiety, delayed gastric emptying,
post-prandial vomiting, bloating
Eosinophilic esophagitis:
o Bolus dysphagia: “Food stuck in upper chest” + Atopy
o Endoscopy: Macroscopically: Linear fissures and
trachealisation.
Micro: Eosinophilic infiltration
recurrent abdominal pain
Exclude organic causes
Epigastric pain at night +hematemesis (duodenal ulcer)
Dysphagia (esophagitis)
Diahorrea, weight loss, growth failure and bloody stools
(IBD)
Vomiting (pancreatitis)
Jaundice (liver)
Dysuria and secondary enuresis (UTI)
Bilious vomiting and abdominal distension (malrotation)
most common cause of gastroenteritis?
• Viral: esp. rotavirus.
• C.J (bloody stool)
• Shigella and salmonella (Dysentery: mucus, pus and tenesmus); high
fever in Shigella
• Rapidly dehydrating watery diahorrea: E-coli, cholera
Clinical dehydration signs
10% of body weight lost. Deteriorating lethargic
child, sunken eyes, tachypnea, tachycardia and reduced skin turgor
Shock signs
> 10% lost.
Decreased consciousness, sunken Fontanelles,
Increased Capillary refill, weak pulses, hypotension, pale mottled and
cold skin.
principles of fluid replacement in gastroenteritis?
Oral replacement solution NB
o Contains Na and glucose and help drag water away from lumen.
o Used to prevent and treat
• IV fluids if shock.
o Slowly replace deficit over 24 hr. (100 mls/kg)
o 0.9% Nacl +/- 5% glucose
o Give Maintained fluids
o Encourage oral intake of non-carb fluids
o Monitor electrolytes, Creatinine and glucose
types of dehydration?
Isonatremic (Most common)
Hyponatremic (Malnutrition); results in seizure and greater shock
Hypernatremia (High fever and hot); Brain shrinkage =results in seizure, altered consciousness, cerebral haemorrhages.
Difficult to recognise.
clinical presentation and DDX in malabsorption?
Triad: Weight loss + nutrient deficiencies+ abnormal stools
DDX: Celiac, CF, cow’s milk protein allergy, Crohn’s, Short bowel syndrome, Cholestasis liver disease or biliary atresia
Celiac disease
clinical features
DX
Tx
Classical celiac (Rare): early at 8-24 months with Abdominal pain and distension, steatorrhoea, growth flattering, muscle wasting, irritability
Non-classical: later with anaemia, short stature, abdominal pain and
screening (T1DM)
DX:
o Serology: Anti-endomyseal antibodies and IgA ant TTG.
o Endoscopic biopsy: Lymphocytic infiltrate, villous atrophy and
crypt hyperplasia.
TX: gluten-free diet for life => resolution of symptoms and growth catch up
Complications: Osteopenia and small bowel lymphoma
Crohn’s
Presentation:
Classical (25%): Abdominal pain, diahorrea and weight
loss
Growth faltering and delayed puberty (may be the only
feature)
Systemic (Lethargy, fever)
Extra-intestinal (Uveitis, mouth ulcers, perianal skin tags
erythema nodosum and arthralgia).
Crohn’s DX:
Endoscopy (Upper and iliocolonoscopy and biopsy, small bowel imaging= extrainterstinal inflammation). Blood tests
(Anaemia, raised inflammatory markers, low albumin).
Crohn’s TX:
Remission induction: Nutritional therapy: High protein
modular feeds (75% works) if not => Systemic steroids.
Maintenance: Immunosuppression (Azathioprine or MTX),
biological therapy (Infliximab) , supplemental enteral overnight
feeds (NG or gastrostomy tube).
o Surgery (ilial resection) for complications: Abscess, fistula, and strictures
UC Presentation:
Pain, diarrhoea, bleeding (less commonly growth
faltering and delayed puberty
UC DX:
Endoscopy and biopsy
UC TX:
Mesalasine (induction and maintenance)
o Second line: Immunomodulators, low dose steroids and
biological.
o Severe disease: Admit, IV fluids and steroids => Cyclosporine
o Surgery: Colectomy with ileostomy or iliorectal pouch if
fulminating disease or toxic megacolon.
o Colonoscopy screening for adenocarcinoma (10 years after diagnosis).
red flags of constipation?
- Failure to pass meconium in 24 hrs: Hirschsprung.
- Gross abdominal distension: Hirschsprung.
- Growth faltering: Celiac, hypothyroidism.
- Spine lesion: Spina bifida.
- Lower limb neurology or deformity: Lumbosacral pathology
- Anal anatomical abnormality
- Anal bruising: abuse
- Anal fistula, abscesses: crohn’s
management steps of constipation?
• Dis-impaction regimen: high dose polyethylene glycol+ electrolytes
• Maintenance: Low dose PEG+ electrolytes +/- Stimulant laxative
(sinna)
• Maintain for 6 months+ encourage fluid intake, dietary changes,
physical activity and good toileting habits
Hirschsprung disease diagnosed and managed?
• Neonate: Failure to pass meconium + gross abdominal distension.
• Childhood: severe constipation, abdominal distension and growth
failure
• DX: rectal suction biopsy
