Week 121 Growth Faltering Flashcards
Called to see 48 hour old baby girl. They are grunting and cyanotic. All pulses are palpable and there is no murmur on auscultation of chest. 02 sats are 55% on room air. Which of the following congenital cardiac lesions is most likely?
Aorta comes off right ventricle Pulmonary artery off left ventricle So how does the baby survive before birth? Ductus arteriosus But what happens at birth?
Transposition of great arteries
Ductus arteriosus
Ductus arteriosus allows blood to bypass lungs during fetal life
Closes at birth as lungs are now functioning
A newborn baby presents with shock, poor perfusion of distal limbs and absent femoral pulses. What is the most likely congenital cardiac lesion?
Coarctation of the aorta
Problem with descending aorta
What would a machine like murmur indicate?
Patent ductus arteriosus
Cyanotic murmurs
Tetralogy of Fallot
Transposition of great arteries
CT - cyanotic murmurs begin with T
Cardiac murmur summary
Cyanosed with murmur - Tetralogy of Fallot
Cyanosed without murmur - TGA
No femoral pulses other pulses normal - Coarctation
Continuous machine like murmur which radiates to back - PDA
A 6 month old girl born in Bangladesh is referred by GP as she is not growing normally along centiles. Born on 50th centile now below 2nd centile despite good intake. Two previous chest infections but was not admitted, looks thin but not pale. Abdomen not distended and soft on palpation. Which investigation is most likely to give you diagnosis?
Cystic fibrosis
Diagnosed with sweat test
Excess chloride ions in sweat
Respiratory symptoms
No GI symptoms
Coeliac usually presents at 6 months
A midwife asks you to review a baby on postnatal ward as she is worried it is hypotonic. Baby is hypotonic and has unusual looking face. He has a flat nasal bridge, almond-shaped eyes and prominent epicanthic folds and low set ears. His genitalia are normal. What is the most likely cause of these signs?
Down syndrome
3 copies of chromosome 21
Amniocentesis or CVS definite diagnosis
Common signs= decreased muscle tone at birth
- excess skin at nape of neck
- flattened nose
- upward slanting ears
- small ears and mouth
- Wide, short hands with short fingers
- Separated joints between the bones of the skull
- single palmar crease
- White spots on colours of eyes
Foetal alcohol syndrome features
Low nasal bridge Epicanthal folds Short palpebral fissures Flat midface and short node Thin upper lip Micrognathia Indistinct philtrum Minor ear abnormalities
4 y/o girl is referred with growth faltering. Weighed 3.5 kg at birth and grew along 50th centile for weight, length and head circumference. Since 1st birthday her growth has tailed off and height is now well below 4th centile with weight on 9th centile. Admitted to neonatal unit when she was a neonate due to hypoglycaemia and jaundice. What investigation is most likely to reveal her underlying problem?
Growth hormone test
Short stature
Delayed bone age
Normal rate of growth til 6-12 months then falls off
A 2 y/o girl is referred to GP with 6 week history of foul-smelling diarrhoea associated with weight loss. O/E her abdomen looks full and slightly distended. Which of the following is the most appropriate first line investigation that would identify the cause?
TTG IgA
Coeliac disease
Autoimmune associated with gluten
Often presents at 6 months old - age of weaning (Giveaway)
Questions to ask in failure to thrive
Was their birth weight and height normal?
What is their growth velocity?
Did it happen at 6 months? Coeliac
What are the parental heights?
Bone age? Delayed - growth hormone deficiency
Gut instinct - does this sound pathological?
End target of growth hormone acting through IGF1 is
Chondrocytes
What has least influence on a Childs growth in the first year of life
Hormones
What are the 2 types of small children /malnutrition?
Acute- wasted
Chronic- Stunted
What is marasmus?
thin, flaccid skin (“little old man”appearance)
•reduced fat and muscle
•Alert, irritable
Kwashiorkor
oedema (pitting, bilateral; limb, periorbital) •flaky-paint dermatitis •dry, thin, depigmented hair •hepatomegaly •apathy, misery, lethargy
How quickly should infants grow?
0-3 months: 200g/week
4-6 months: 150g/week
How much is abnormal growth ?
Age 3 years to Puberty: <1.75 inches (4.5 cm)
–Age 5 years to Puberty: <2 inches (5 cm)
Minimum time interval between assessments of abnormal growth
Age <3 years: minimum 4 month interval
–Age >3 years: minimum 6 month interval
How much milk for infants?
Infants > 2.5kg150-200mls/kg/24hrs
•4-6 months140mls/kg/24rs
•1 year 600mls milk/ plus water
How many calories?
Normal infants100-120 kcals/kg/d
•Underweight infants* 130-140 kcals/kg/d*or feed at 110-120% for actual weigh
What is the composition of breast milk?
COLOSTRUM •Days 0-3 (up to 10) •High protein (x9 mature breast milk): Whey 80%/Casein 20% •Very little fat •Anti-infective agents •Growth factors
MATURE MILK
•Casein 40% / Whey 60%
•More fat –especially in hind milk
•Lactose main CHO
Iron content of milks
Breast milk 76-150mg/100ml**lactoferrin in breast milk has excellent absorption/bioavailability (as well as anti-infective properties)
•Infant formula 500-700mg/100ml
•Follow On700-1200mg/100ml
•Cow’s Milk62mg/100ml
Age 8 months
•Several months: irritable, crying and drawing-up knees, sleeping poorly –seems to wake in pain
•Feeding seems to make tummy pain worse
•Loose stools x5-8/day occasionally with blood
•Frequent possetting
•Weight gain slow
Cow’s milk protein intolerance
Partially hydrolysed formula started; increase volume to give 120% calorie requirement for catch-up growth
•Symptoms improve
•Advice re regular milk challenges (e.g. every 3 months): active induction of tolerance
•But loose stools persist –often “frothy”and cause perineal soreness
Secondary lactose intolerance problems;
Fe deficiency
•Oral iron supplement (and check B12, folate)
•Pallor and lethargy improves
•But infant remains generally unhappy; not gaining weight as well as expected and developmental milestones may be delayed
•HV reports house untidy and curtains often closed
COULD BE POOR MOTHER-INFANT BOND
Role of Growth Hormone
At the growth plate Growth hormone via IGF1 stimulates the chondrocytes to undergo mitosis
Role of PTH
Osteoblast activity is influenced by PTH at physiological levels but at increased levels of PTH then osteoclast activity is also stimulated
What hormones drive normal growth?
TH GH SxH Insulin (drive IGF1)
What are the 4 phases of growth and what do they depend on?
Foetal 30% (nutrition, placenta)
Infantile 15% (nutrition, health and happiness)
Childhood 40% (GH, TH, happiness and health)
Pubertal 15% (GH, Test/E3)
How does growth end?
- Growth ends mainly due to fusion at the epiphyseal plate ie skeletal maturation mainly as a result of Oestrogen
- Boys grow for 2yrs more than girls before entering puberty and so girls will not be as tall as boys in general
- In boys some testosterone is also converted in tissues to oestrogen and this will then cause fusion at the epiphseal growth plate and so growth eventually ceases.
Eg Oxandrolone given to boys (to induce puberty and so growth), has no compromising effect in final height because oxandrolone is a non-aromatizable anabolic steroid and so is not converted in tissues to oestrogen and so cannot promote excessive skeletal maturation
Phases 1 and 2 of growth most dependent on:
Nutrition
Genes
Environment (e.g. alcohol thalidomide)
Least on hormones
What can you be charged with if you don’t consent a patient?
Trespass -This therefore means that any treatment, investigation or deliberate touching without consent may be a trespass to the person (a civil wrong –Tort)which may result in actions in the Civil courts and result in compensation, and/or a battery (a criminal act) which may result in an action in a criminal court and result in punishment for the perpetrator.
•2.Negligence. This can also include inadequate information provided (i.e. did not fully consent to the action undertaken)
Pathophysiology of PDA
Patend ductus arteriosus
PDA exists to divert blood away from the foetal lungs (as they do not need much blood) to the aorta
- At birth, PDA is meant to close but in some infants it remains open
- During first few weeks after birth, pulmonary arteries dilate & resistance to flow of blood into lungs decreases
- Pulmonary artery pressure then becomes less than aortic pressure & blood flows through PDA from aorta into pulmonary artery (“left to right”), causing 2 problems:
- Excess pulmonary blood flow
- Reduced systemic blood flow
