Poor growth and abnormal puberty Flashcards
When concern about growth, when to reassess
Need two measurements 4-6 months apart
When is length measured
Until 2 years old
How old do you correct for prematurity until
Until child is one year old
Growth chart in celiac
Fall off in weight when weaning to wheat, fall off in length follows
IUGR growth chart
Low birthweight baby, may or may not show catch up.
If restriction occurred early in pregnancy, the HC and length will be affected
Hydrocephalus growth chart
HC crossing the percentiles upwards
Turner’s syndrome growth chart
Poor growth from infancy
Absence of pubertal growth spurt
Growth hormone deficiency growth chart
Fall off in height
GH deficiency is rare
Tanner staging boys
Boys - development of external genitalia
Stage 1: Prepubertal
Stage 2: Enlargement of scrotum and testes; scrotum skin reddens and changes in texture
Stage 3: Enlargement of penis (length at first); further growth of testes
Stage 4: Increased size of penis with growth in breadth and development of glans; testes and scrotum larger,
scrotum skin darker
Stage 5: Adult genitalia
Boys and girls - pubic hair
Stage 1: Prepubertal (can see velus hair similar to abdominal wall)
Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis or along labia
Stage 3: Darker, coarser and more curled hair, spreading sparsely over junction of pubes
Stage 4: Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs
Stage 5: Adult in type and quantity, with horizontal distribution (“feminine”)
Tanner staging girls- breast
Girls - breast development
Stage 1: Prepubertal
Stage 2: Breast bud stage with elevation of breast and papilla; enlargement of areola
Stage 3: Further enlargement of breast and areola; no separation of their contour
Stage 4: Areola and papilla form a secondary mound above level of breast
Stage 5: Mature stage: projection of papilla only, related to recession of areola
First signs of puberty in boys and girls
Testicular enlargement
Breast budding
Precocious puberty age definition
When
When is puberty considered delayed
When >13 in girls and >14 in boys
When does the growth spurt usually occur
Early in puberty for girls, late in puberty for boys
What is considered delayed menarche
When occurs >16 yo
Nutrition requirements of infants->milk and kcal/kg
Infants require 150ml/kg/24 hours
110kcal/kg/day
Bowel motions of breast fed
Non offensive
Porridge consistency
Yellow
Reduced bowel motion frequency without constipation
Ways to encourage successful breast-feeding
- Introduce concept of breastfeeding antenatally
- Baby to breast immediately after delivery
- Feeding on demand
- Avoid offering any formula feeds
- Ensure mother has good nutrition and rest
- Skilled advisors if any issues
- Ensure latching on and good position
Releasing a baby off the breast
Place a clean finger at the side of the baby’s mouth
Should breast and formula be alternating
Formula only if breast contraI or failed
Xtop ups with bottles because reduces milk production
Advantages of breast feeding
- Appropriate nutritional composition
- Little risk of bacterial infection
- Anti-infective properties
- Convenient, no expense, psychologically satisfying
- Reduced risk of atopic
Possible problems with breast feeding->generally rare
- Tiring
- Infection
- Drugs passed through breast milk
Lactation physiology
Sucking->afferent–>posterior pituitary->oxytocin to +let down, also +in milk production.
Weaning
0-6 months->breast or formula only
6 months->pureed/liquedized
7-9 months: finger foods, juice in a cup
9-12 months: 3 mils a day with family + 3 snack times
>1: cows milk, full fat (up to 5 years) in a beaker or cup
Formula feeds process
- Sterilise the feeding bottle
- Add the appropriate volumed of cooled boiled water to the bottle
- Add one level scoop of milk powder to each 30ml water
- Shake bottle well
- Ensure milk is at comfortable temperature before feeding
Most common cause of weight faltering or FTT
non-organic causes
Causes of weight faltering
- Environmental/psychosocial->most common cause
- Cystic fibrosis
- IUGR
- Immunodeficiency->recurrent infections (HIV, SCID)
- Genetic syndrome->LBW common, dysmorphic
- Chronic illness
- GOR->pain, apnea, vomiting/posseting, common in neurodevelopmental
- Celiac disease->weight falls off when weans to wheat
- Endocrine->developmental delay in hypothyroidism, GH deficiency very rare
10 Renal tubular acidosis
History in weight faltering
- Nutritional history->diet, feeding, start at birth, weaning, cause or result
a. Breastfeeding->difficulties, timing, vomiting. Settled after feeds, perception of supply, previous breast feeding
b. Formula feeding->volumes, changes, dilutions, vomiting or diarrhea
c. Timing and introduction of solids, types of solids->interaction, pleasant, stressful
d. In toddlers->mealtime battles, coercive, food refusal - Review of symptoms: diarrhea, colic, vomiting, irritability, fatigue, chronic cough
- Developmental history->neurodevelopmental problems
- Past medical history->LBW and prenatal problems, recurrent/chronic illness
- Family history: history of faltering/genetic syndrome, psychosocial problems, mental health, failure to attend
- Lack suitable housing, supports, maternal mental health, child protection involvement
Examination
- General observation->neglected, ill, malnourished, wasted buttocks, protruberent abdomen, sparse hair
- Growth->percentiles
- Physical examination->signs of chronic disease
- Child-parent interaction
Investigations
For otherwise healthy developing, none needed at firts. Where significant concern, no specific pointers: FBC, ESR UEC, LFT Iron studies CMP Thyroid Glucose Urine MCS Celiac screen Stool MCS Stool for fat globules and fatty acid crystals
Base on clinical findings
Causes of steady growth below percentiles
1. Constitutional/familial Family history, normal P/E, no delay in bone age 2. Maturational delay Delayed puberty FHx of delay Delay in bone age 3. Turner's Features of XO No pubertal No delay in bone age 4. IUGR LBW Evidence of cause 5. Skeletal dysplasias Rare Disproportionate Achondroplasia most common
Causes of fall off in growth percentiles
- Chronic illness
H/E, delayed bone age - Acquired hypothyroidism->delayed bone age, +TSH, low T4, antibodies may be present
- Cushings->most commonly iatrogenic, delayed bone age
- GH deficiency rare
- Psychosocial->evidence of neglect, show catch up growth when removed from the home
History in short stature and poor growth
1. Medical history and review of systems Chronic illness ICP + Malabsorption Hypothryoidism 2. Family Hx Compare with parental heights 3. Birth history 4. Psychosocial history
Examination in short stature and poor growth
- Pattern of growth
- Anthropometric measurements
- General examination
- Head circumference
Investigations in short stature and poor growth
FBC->IBD UEC->Chronic renal failure Celiac antibodies Thyroxine and TSH Karyotype GH tests Xray of wrist for bone age
Red flags for poor growth suggesting neglect/abuse
- Signs of abuse or neglect
2 Poor carer understanding - Signs of family vulnerability->drug/alcohol, DV, social isolation, no family support
- Signs of poor attachent
- Parental mental health issues
- Already previously case managed by child protection services
- Did not attend/previously cancelled appointments
- Signs of dehydration
- Signs of malnutrition or significant illness
Overview of causes of poor growth
- Inadequate calories
Inadequate nutrition, breast feeding difficulties, restricted diet ,structural causes (cleft palate), vomiting, anorexia of chronic disease, formula dilution, early/delayed introduction of solids - Psychosocial
Depression/anxiety, substance, attachment, disability, coercive feeding, difficult at meal times, poverty, behaviour, poor understanding, trauma, neglect, child protection - Inadequate absoprtion
Celiac, chronic liver, pancreatic insufficiency, chronic diarrhea, cow milk protein intolerance - ++Utilisation
Chronic illness, UTI, respiratory, CHD, DM, hyperthyroid - Other medical
Genetic
Metabolic inborn errors
What growth charts are used
For 2 yo use CDC
For those under 2yo use WHO
Management of growth faltering- when to admit
- Significant illness/dehydration
- Abuse, neglect, psychosocial
- Persistent poor growth despite adequate nutritional intervention
- Concern not being adequately cared for->need child protection report
- D/C when professional case conference and case management plan developed.
F/U with growth faltering
- Refer back to GP
- Pediatrician considered
- One clinician to do follow ups.
- If F/U not attended, immediate action taken to determine health of the child
- weight weekly
Average growth->0-3 mo, 3-6 mo and 6-12 mo
- 0-3 mo= 150-200g/week
- 3-6 mo= 100-150g/week
- 6-12 mo= 70-90g/week
How to predict adult height
Boys: [Paternal height in cms + (maternal height in cms +13 cm)] divided by 2= adult height in cms
Girls: [Maternal height in cms + ( paternal height in cms - 13 cms)] divided by 2 = adult height in cms
When history of gastroE and now ongoing diarrhea, what to consider and test to perform
Lactose intolerance
Check stool for low pH and sugar-reducing substances
Loose stools, poor growth
- Lactose intolerance->stool pH and sugar-reducing substances
- Celiac->antibodies and jejunal biopsy
- Cystic fibrosis->sweat chloride
Psychosical issues in growth faltering
- Parental depression
- Substance use
- Attachment difficulties
- Coercive feeding
- Difficult at meal times
- Poverty
- Poor support, trauma
- Neglect
- Involvement with child protection
Management at home for non-organic
1. Meal times Family together No distractions 20-30 minutes Solids before liquids, high calories No force feeding Age appropriate 2. Regular r/v, weight checking 3. Address pscychosocial Poverty, employment Depression Substance use Parenting skills Support systems
Management at home for non-organic
1. Meal times Family together No distractions 20-30 minutes Solids before liquids, high calories No force feeding Age appropriate 2. Regular r/v, weight checking 3. Address pscychosocial Poverty, employment Depression Substance use Parenting skills Support systems
