29 terms

Pediatric Growth Disorders

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Abnormal Growth
Often the first sign of a wide variety of disease processes that may involve any organ system; important to observe accurate growth data/ growth curves
Growth Charts
Weight; height;head circumference; growth velocity; BMI; specialized charts (Prematurity, Down's syndrome, Marfan)
Growth Velocity
Normal growth tracks along curve; crossing percentiles after 2 yo suggests slow or accelerated growth; catch up or catch down growth before 2 yo may be normal
Birth Weight Classification
AGA (appropriate for gestational age)

LHA (large for gestational age): expect catch down growth

SGA (small for gestational age): expect catch up growth, but 10% stay small
Head Size
Measure & plot head growth through 2 yo; measure parents head size if child's result is outside the range of normal
1˚ Microcephaly
-Causes?
Genetic causes; Familial (recessive), Down's syndrome, Edwards syndrome, Cri-du-chat syndrome
2˚ Microcephaly
-Causes?
Radiation; congenital infections (CMV, rubella, toxoplasmosis); drugs (fetal EtOH, hydantoin), meningitis/encephalitis; malnutrition; metabolic; fetal hyperthermia
Macrocephaly
-Causes?
Familial; hydrocephalus (barin malformation w/ obstruction, neoplasms, AVM); pseudomotor cerebri;intracranial hemorrhage; megalencephaly (metabolic disorders, severe anemia, Cerebral gigantism, Beckwith-Wiedemann syndrome, Histiocytosis X, fetal EtOH); benign subdural effusions
Weight
-Failure To Thrive (FTT)?
Failure to grow or gain weight adequately > SD below mean or persistent deviation below own establish curve; may or may not be severe enough to affect height and head circumference; classified as non-organic (most common → environmental/psychosocial causes), organic (<20%), or mixed
Anthropometric categories of FTT
Type 1: ↓ weight, ↔ height, ↔ head circumference, due to malnutrition

Type 2: ↓ weight, ↓ height, ↔ head circumference, due to constitutional growth delay, endocrinopathy

Type 3: ↓ weight, ↓ height, ↓ head circumference, due to chromosomal, metabolic, or CNS abnormalities
Non-organic FTT
-Work up?
H&P; growth monitoring; nutritional assessment; evaluation of social, cultural, & environmental conditions; observation of caretaker interaction

Imaging, labs → costly & may be harmful; must be guided by concerns raised in the H&P; patients with normal PEs →screening CBC, electrolytes, BUN/Creatinine, protein/albumin, ESR, UA, screening test for celiac disease
Organic FTT
-Causes?
GI → GERD, celiac, pyloric stenosis, cleft lip/palate, lactose intolerance, IBD, hepatitis, Hirschsprung disease

Renal → UTI, renal tubular acidosis, chronic insufficiency

CV/pulm → cardio disease that lead to CHF, asthma, CF

Endo → hypothyroidism, DM, GH deficiency

Neuro → mental retardation, cerebral hemorrhages

Infectious → TB, HIV, GI parasites/bacteria

Congenital → fetal EtOH

Other → Pb poisoning, malignancy
Childhood obesity
-Definitions?
Measured using weight-stature curve;
Obesity: >95% for age & sex
Super-obesity: >99% for age & sex
Concerning: 85-95%
If short & overweight → greater chance of genetic cause
Prader-Willi Syndrome
-Features?
Functional abnormality of chromosome 15;
Obesity (starts by age 1-3); hypogonadism; short stature; hypotonia; mental retardation; fish-like mouth
Cushing's Syndrome
-Features?
Glucocorticoid excess; moon facies; central obesity; buffalo hump; muscle wasting & weakness; HTN
Pseudohypoparathyroidism (A.K.A Albright Hereditary Osteodystrophy)
-Features?
Obesity; mental retardation; subcutaneous calcifications; short 3rd to 5th metacarpals/metatarsals
Height
-Significant short stature?
Height ≤1 percentile (3 SD) for age OR incremental height inappropriate for age OR height inappropriate for family;
3-5 yrs = < 7cm/yr
6-12 yrs = < 5cm/yr
3-14 yrs = < 2 in/yr
Short Stature
-DDx?
Familial
Constitutional delay
Growth Hormone deficiency
Chromosomal
Skeletal dysplasias/chondrodystrophies
Systemic disorders
Calculating Predicted Midparental Height
-Girls?
= (Father's Ht + Mother's Ht - 5 in)/2
Calculating Predicted Midparental Height
-Boys?
= (Father's Ht + Mother's Ht + 5 in)/2
Normal Variant (Familial) Short Stature
-Criteria for Dx?
Birth wt > 2.5 kg; Ht < 3rd percentile for age; predicted adult height < 3rd percentile (5' 4" boys, 4' 11" girls); no organic or emotional cause for growth failure
Short Stature
-Evaluation?
CBC; ESR; SMA 6 & 12 = chem 6 & 12; T4, IGF-I, IGF-BP-3; Left wrist/hand XR for bone age; brain MRI if indicated; Chromosomal analysis (females); if height < 1 percentile (3 SD) w/ abnormal growth rate → stimulatory tests for GH
Normal Variant Constitutional Delay
-Criteria for Dx?
No Hx of systemic illness; Normal nutrition, PE including body proportions, T4, GH, CBC, ESR, electrolytes, BUN; Ht ≤ 3rd percentile, but annual growth rate of ≥ 3.5 cm/yr; Delayed puberty, bone age; Normal predicted adult height; Normal chromosomes in females
Systemic Disorders
-Associated w/ Short Stature/Delayed Puberty?
Malabsorption; Chronic bowel, heart, lung, renal disease; Rickets; DM; Nephrogenic diabetes insipidus; Chronic infection; Collagen disease; Neoplasia; Hemoglobinopathies
Growth Hormone Deficiency
-Features?
destruction of malformation of pituitary; 1:4000; Short statue; Chubby face & truncal obesity; Poor growth velocity; Delayed skeletal maturation; High-pitched voice; single central incisor; septa-optic dysplasia
Turner's Syndrome
-Features?
45XO; 1:2500; Mean adult height 4'8''; No 2˚ sexual development; Webbed neck, low hairline
Broad nasal bridge, epicanthal folds; Low set ears; Widely spaced nipples/broad chest; Neonatal lymphedema
GH for Short Stature
-FDA Approved uses?
GH deficiency
Turner syndrome
Prader-Willi syndrome
Idiopathic Short Stature
Chronic renal insufficiency
Klinefelter's Syndrome
-Features?
1:500 males; Seminiferous tubular dysgenesis ; Small, firm testes; Eunuchoid body proportions; Gynecomastia; ↓ facial and body hair; Infertility
Cerebral Gigantism
-Features?
Ht > 2 SD above mean; Bone age > 2 SD above normal; Big hands and feet; Mental retardation; Dolichocephalic (long head) skull; Characteristic facial appearance