Eval of Worrisome Growth

Question 1

WHO growth chart vs CDC

Answer 1

WHO: based on breast fed, international

• steep weight gain initially, then less so after breast feeding.
• Use for 0-3 y

CDC:
US only
-use from 3-20 y

Question 2

Short stature

Answer 2

height below -2 SD (on growth chart, -1.9 SD is 3%) for age and gender or height more than 2SD below midparental target high

Question 3

Dwarfism

Answer 3

height below -3SD for age

Question 4

Midget

Answer 4

dwarf with normal body proportions

Question 5

**Growth velocity

Answer 5

abnormally slow linear growth or dropping across two major centile lines on the growth chart

Question 6

Genetic Potential

Answer 6

For boys:
(Mother’s height + 13 cm (5in) + father’s height)/2

For girls:
(Father’s height- 13cm + mother’s height)/2

Question 7

Skeletal Maturation

Answer 7

• correlation b/t the degree of skeletal maturation and the time of epiphyseal closure
• greater the bone age delay, longer time before epiphyseal fusion ceases growth
• asses by standards of Greulich-Pyle
• height predictions can be made using child’s height and bone age
• not accurate in growth disorders
• predictions may also be inaccurate because cannot predict pubertal tempo
• may help in differentiating causes of short stature

Question 8

body proportions

Answer 8

-upper to lower body ratio starts at 1.7 at birth and falls to 1.0 by 10yrs of age

Avg adult male has arm span 5.2 cm greater than height and F 1.2 cm greater than height

Question 9

Constitutional growth delay

Answer 9

Characterized by growth deceleration during first 2 years
of life followed by normal growth paralleling lower
percentile curve throughout prepubertal years
 Skeletal maturation is delayed
 Catch-up growth achieved by late puberty and delayed
fusion of growth plates
 Generally end up along lower end of normal height range
for families
 Appear to be polygenic trait; positive family in about 60-
80% if patients
 Genetic defects causing CGD unclear

• Reassurance of normal growth pattern
• Can treat boys with testosterone if bone age greater than 11.5 yrs to avoid compromising final height
• cant treat girls with estrogen (not as common)

Question 10

Familial short stature

Answer 10

• children who have normal growth velocity and height that are within normal limits for parent’s heights
• initially have decrease in growth rate b/t 6 and 18 mo of age
• some families with short stature may have tubular bone alterations (brachydactyly synd; SHOX haploinsufficiencies)

Question 11

Failure to thrive

Answer 11

infants and young children with:
Deceleration of weight gain to a point less than 3%
Fall in wt across 2 or more major percentiles

Non-organic: poor nutrition and psychosocial factors

May look like constitutional growth delay

Question 12

Nutritional growth retardation

Answer 12

Linear growth stunting from poor weight gain in children
over 2 years of age
 May be secondary to systemic illnesses such as celiac
disease, inflammatory bowel disease
 Stimulant medications
 Sometimes hard to distinguish from constitutional growth
delay and constitutional thinness

Question 13

Children born small for gestational age

Answer 13

-defined as less than 2SD for birth weight or length

Etiologies
Maternal – infection, nutritional deficiencies, uterine
abnormalities, smoking, alcohol, drugs,
 Placental – Previa, abruption, infarcts, structural, multiple
gestation
 Fetal – Chromosomal abnormalities, metabolic, infections,
malformations

Question 14

Catch-up growth in children and final height (w/ SGA)

Answer 14

Most healthy infants born SGA achieve catch-up in height
by age 2 years
 Most catch-up growth is achieved within 6 months of birth
 ~10-15% of children born SGA remain short as adults
 Final height may also be compromised by early puberty

Question 15

Hypothesis of pathophysiology for SGA

Answer 15

Fetal response to prolonged nutritional deficiencies late in
gestation may be to prematurely reset to a slow growth
rate with a degree of resistance to GH, IGF-1, and insulin

Question 16

GH Tx and SGA children

Answer 16

If failed to have catch-up growth by 2
years
 GH should not be given without appropriate nutritional
intake
 May increase final height by an average of 3 inches (-2.3
SDS vs -1.1 SDS or -0.9 SDS)

Question 17

Hormonal Causes of Worrisome Growth

Answer 17

 Generally, weight is spared
 Hypothyroidism
 Growth hormone/IGF-1 abnormalities
 Cushing syndrome
 Rickets

Question 18

Hypothyroidism

Answer 18

• can result in profound growth failure
• many clinical features that are seen in hypothyroid adults are lacking in children

Primary:
increased TSH, low T4

Central: low T4, normal TSH

Question 19

Growth Hormone

Answer 19

Anterior Pituitary hormone

main func to promote linear growth

also effects body composition; increases lean body mass and decreases fat

Question 20

Growth hormone deficiency

Answer 20

Hypothalamic pit malformations:
Holoprosencephaly/Schizencephaly
Isolated Cleft lip or palate
Septo-Optic-Dysplasia – 50% have hypopituitarism
Optic nerve hypoplasia
Empty sella syndrome

Can be GH def alone or with other pit hormone def

Acquired:
trauma
CNS infection
hypophysitis
CNS tumors (craniopharyngioma, germinoma)
cranial irradiation

Question 21

Growth hormone deficiency dx/sx

Answer 21

abnormal growth velocity with exclusion of other causes

Decreased muscle build
 Increased subcutaneous fat, especially around trunk
 Face immature for age
 Prominent forehead, depressed midface
 In males, small phallus
 Other midline facial defects
 May have history of prolonged jaundice and/or
hypoglycemia in newborn period

Question 22

Eval of GH def

Answer 22

bone age
IGF-1 (low in underweight children, though, regardless of GH status)
-stimulation testing (never draw random GH level): clonidine, arginine, glucagon, L-dopa

Question 23

Syndromic short stature

Answer 23

 Skeletal Dysplasias and other genetic syndromes
 Turner syndrome – Haploinsufficiency of SHOX genes
 Prader-Willi syndrome – GH deficient
 Noonan syndrome – abnormal GH post-receptor signaling

Question 24

Turner syndrome

Answer 24

 Most common sex chromosome abnormality of female
 Affects ~3% of female concepti
 Caused by complete or partial absence of 1 of X
chromosomes
 Occurs in approximately 1/2,000 live-born females

• short stature
• 20cm less than target height if untreated
• haploinsuff of SHOX genes
• generally not growth hormone deficient
• but GH given to improve final adult height
• starting tx early is important

Question 25

Other abnormalities in Turner syndrome

Answer 25

Cardiac abnormalities- bicuspid aortic valve,
coarctation
 Renal – horseshoe kidney
 Ovarian insufficiency
 Hypothyroidism/celiac disease
 Otitis media
 Hearing loss
 Non-verbal learning disability

Question 26

Eval of worrisome growth

Answer 26

bone age (left hand and wrist)
Screening labs: metabolic panel, CBC,UA, karyotype in girls, TSH and T4, IGF-1
Nutritional growth retardation: also ESR, TTG, and IgA

Question 27

Look at last few slides

Answer 27

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