Growth and Development Flashcards
Moving onto - Normal Growth and Pubertal Development
A lot of endocrine problems affect ______ and _______ in children
growth
puberty
What are measurement and assessment tools used for in children?
Growth
Puberty
Normal patterns of growth and development
_______ growth is an index of health. This is monitored by accurately measuring ______ and ______/______ and accurately plotting these on a ______ chart.
Physical growth is an index of health. This is monitored by accurately measuring weight and length/height and accurately plotting these on a growth chart.
Indicators of concern regarding growth include those who are what?
(i) Very tall or short
ii) exhibiting growth failure
iii) out with their parental target range
when does growth accelerate in a child?
Growth accelerates at puberty
What is needed when dealing with precocious or delayed puberty
Assessment of pubertal staging and knowledge of the variations in timing of puberty are needed when dealing with precocious or delayed puberty
Short stature is common and usually reflects constitutional factors
It is important to recognise patterns of growth that suggest what?
And how do you deal with a child a growth or pubertal disorder
It is important to recognise those patterns of growth that suggest a systemic, endocrine or genetic cause
A detailed history and examination will be needed when assessing any child with a growth or pubertal disorder
What usually causes obesity in a child?
Childhood obesity is increasingly common. It usually reflects lifestyle factors of the family and child. There is rarely any underlying endocrine or hormonal cause but hypothyroidism should be excluded
Type 1 diabetes frequently onsets during childhood
What needs to be done for a child with type 1 diabetes?
All new suspected diabetic patients must be referred same day for hospital assessment
Multi-disciplinary input is important for optimal management
All doctors should have a good understanding of how to deal with common diabetic problems
what measuring technique is used for measuring the height of a child?
stadiometer - a piece of medical equipment used for measuring human height
Flat feet, no socks or shoes
Straight back
Head looking forward
Measure to the millimetre
Most of the anthropometric instruments (measuring equipment) used in clinical practice have digital counter displays
Prior to using the equipment it must be calibrated against a rod of standard length or by the baseline readout and checked for cleanliness
How do you select a position for measuirng a childs height?
A child/young person should be measured supine (lying face upward) until two years of age
A child/young person who is unable to stand, or who finds standing difficult, due to illness or physical disabilities should also be measured supine
A child/young person who has one leg shorter than the other should be measured standing on the longest leg
They should always be measured on the same leg
How do you measure length of a child?
The positioning of the child/young person is crucial
Two people are required to measure a child/young person in the supine position
The child/young person may require play and distraction techniques to be utilised whilst obtaining the measurement
Place the measuring board on a firm, flat surface. Lay the child/young person on the board. One person should ensure the head is held in contact with the headboard. They should then place the child/young person’s head with the lower margins of the orbit in the same horizontal plane as the external auditory meati, ie the corner of the eyes horizontal to the middle of the ear. The other person should position the child/young person with their feet together heels touching the back plate of the measuring instrument legs straight and in alignment with the body buttocks against the backboard scapula, wherever possible, against the backboard
They should hold the ankles to ensure this position is maintained
The child/young person must be completely aligned and flat against the boar
Record the measurement to the last complete millimetre
DO NOT round up the measurement
How do you measure sitting height in a child and why is it done?
Special equipment to measure sitting height
Good to see if there is body disproportion
Or problems with the spine
Some conditions cause asymmetry and disproportion to the skeleton eg achondroplasia. It may therefore be necessary diagnostically to undertake sitting height or crown rump (CR) length measurements
The positioning of the child/young person is crucial
It is often easier if two people are involved in the measurement of a child/young person, one of who may be a parent or carer
The measurer must ensure they are eyeball to eyeball with the child/young person to be measured
The child/young person’s body must be positioned on the sitting height table with their: backs of the knees resting on the edge of the table feet supported on adjustable step thighs horizontal back must be straight buttocks against the backboard scapula, wherever possible, against the backboard hands on knees
Once the child/young person has fully exhaled record the measurement to the last complete millimetre, read instrument at eye level
How do you work out body proportions of a child?
In some forms of short stature, body proportions may also be clinically relevant, eg achondroplasia, or after spinal irradiation. The most useful body proportion is the relationship between trunk length and leg length. This is obtained by measuring a sitting height & subtracting this from the total height
Children and young people who need to be measured lying down should have their crown rump length measured, ie head to bottom. This measurement is then subtracted from the child’s total length.
How do you measure head circumference?
Routine in children <2 years
Tape round forehead and occipital prominence (maximal circumference)
Important in young children
OPC – occipital prominence circumference
what is this showing?
this is a graph used to record the childs height against their age
what is important when recording information on these graphs?
Need to plot accurately as may get information mixed up
Need little dots and not crosses or anything else messy
A single measurement does not reflect the rate of growth
To be useful it is essential that a child’s height or length is:
- accurately measured using good equipment
- recorded with the date in the child/young person’s health care records
- plotted accurately on a centile chart
what is the value of serial measurements and what does this graph show?
B growing nicely but child A growth is decreasing
Child A is who you would be worried about as they are falling off the lines
Need to have as many dot sin the chart as possible
Measure them every time they are in general practice etc
Care should be taken in:
- choosing the interval between height measurements
- interpreting growth rates measured over less than a year
How are charts constructed and what variations cna you see in charts?
- Cross sectional charts
- Different ethnic origen
- Different health and nutrition
- Different geographical and environmental setting
- Changes over time
There are different types of centile charts
Are there different growth charts for different conditions?
Yes - Condition-specific Growth Charts
Need to compare the person to other person with the condition
Such as compare a turner girl to other girls with the condition
What is target height and mid parental height (MPH)?
the midparental height is a child’s projected adult height based on the heights of the parents
Need to know height of family e.g. are they form a short family
The potential height of a child is calculated by obtaining the mid-parental height (MPH). This calculation is only valid if both natural parents are of normal stature
Is BMI important in children?
Yes very important
What is Bone age: TW 20?
Not diagnostic, it is an assessment tool
Put in context growth of a child
Use left wrist and hand is standardised
Bone age refers to the maturation of the bone
Scanning 20 bones individually
Why may bone age be delayed?
Constitutional delay of growth
Growth hormone deficiency
Hypothyroidism
Malnutrition/chronic illness
Why may bone age be advanced?
Tall stature
Premature adrenarche
Overweight
Early puberty
Congenital Adrenal Hyperplasia
Overgrowth syndromes
Bone age is necessary for what?
- for confirming the diagnosis of the normal variants of growth, such as familial short stature (FSS) and constitutional growth delay growth (CGD), the former associated with normal skeletal maturation and the latter with delayed bone age
- for interpreting of hormone blood levels in children at the pubertal age
- for diagnosing precocious puberty (differential diagnosis with premature telarche and premature pubarche) or conditions of hyperandrogenism such as congenital adrenal hyperplasia (CAH) characterized by advanced bone age
- for deciding whether to treat or not children with the above mentioned conditions (precocious puberty and CAH)
- for predicting adult height in normal children
bone age is useful for what?
- in evaluating any child with growth retardation and advanced or delayed puberty
- in deciding the right time to start a child with hypogonadism on replacement treatment
- in monitoring children in replacement therapy with growth hormone
When can bone age be misleading?
- in evaluating children with disorders of bone mineralization, such as osteochondrodysplasias
- in predicting adult height in children with precocious puberty or born small for gestational age: adult height prediction should actually be performed in normal children only
- whatever the aim, if different readers, not accurately trained to follow the same procedure, are involved in bone age assessment
In evaluating hand and wrist x-ray we should not miss the opportunity to look for bone shape abnormalities such as what?
- accessory unusual secondary ossification centers may appear in otherwise unusual ends of a bone when growth is overstimulated in rapid catch-up growth
- important changes in the rate of longitudinal bone growth are registered as growth arrest lines
what do these graphs show?
Left image showing the patient has growth delay and they have lots of growth to come
Right is showing an advanced bone age, child is 6 with a bone age of around 11
Bone age refers to puberty timing
Bone age gives a likely time of puberty
staging of puberty is done using what method?
tanner method
Standardised method of assessing puberty
What makes up tanner method?
B - 1 to 5 (breast development)
G - 1 to 5 (genital development)
PH - 1 to 5 (pubic hair)
AH - 1 to 3 (axillary hair)
T (testicular volume in boys) - 2ml to 20 ml
what do the number 1 to 5 in the tanner method represent?
1 – pre pubertal
2 – beginning of puberty
3-4 different stages of puberty
5 – adult
Describe stages 1 to 5 in 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
Describe stages 1 to 5 in girls and boys - 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”)
Describe stages 1 to 5 in 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
B3 PH3 or G2 PH2 6/6
what does this example show?
girl - brest development 3 out of 5 and pubic heair development 3 out of 5 so mid puberty
boy - genital development 2 out of 5 and pubic hair development 2 out of 5 so at the start of puberty
How is Testicular maturation measured?
Prader Orchidometer
How is a Prader Orchidometer used?
It consists of a string of twelve numbered wooden or plastic beads of increasing size from about 1 to 25 ml.
The beads are compared with the testicles of the patient, and the volume is read off the bead which matches most closely in size. Prepubertal sizes are 1–3 ml (black), pubertal sizes are considered 4 ml and up and adult sizes are 12–25 ml
What can testicular size be used to indicate?
Small testes can indicate either primary or secondary hypogonadism
Testicular size can help distinguish between different types of precocious puberty
Since testicular growth is typically the first physical sign of true puberty, one of the most common uses is as confirmation that puberty is beginning in a boy with delay
Large testes (macroorchidism) can be a clue to one of the most common causes of inherited generalised mental disability, fragile X syndrome
What would be done in a history and further examination?
- Birth weight and gestation
- PMH
- Family history/social history/schooling
- Systematic enquiry - find more subtle symptoms like coeliac has more discrete symptoms than children may not go to the doctor for
- Dysmorphic features
- Systemic examination
What are the main assessment tools used in children?
- Height/length/weight
- Growth Charts and plotting
- MPH (mid-parental height) and Target centiles
- Growth velocity
- Bone age
- Pubertal assessment
What is normal growth?
Precise definition difficult:
– Wide range within healthy population
– Different ethnic subgroups
– Inequality in basic health and nutrition
– Normality may relate to individuals or populations (genetic influence)
Normal growth is the progression of changes in height, weight, and head circumference that are compatible with established standards for a given population. The progression of growth is interpreted within the context of the genetic potential for a particular child. Normal growth is a reflection of overall health and nutritional status
Understanding the normal patterns of growth enables the early detection of pathologic deviations (eg, poor weight gain due to a metabolic disorder, short stature due to inflammatory bowel disease) and can prevent the unnecessary evaluation of children with acceptable normal variations in growth
What are factors that influence height?
Age
Sex - boys are slightly taller than girls before puberty
Race - e.g. Scandinavians are tall, Oriental races are short
Nutrition - particularly important prenatally and in infancy. Contributes to height differences between races
Birth weight - little effect on childhood height unless small for gestational age
Parental heights - the underlying genetic component, a particularly strong influence
Puberty - early developers are taller for age than late developers
Skeletal maturity (bone age)
General health
Chronic disease - growth is adversely affected by chronic illness, e.g. Crohn’s disease, chronic renal failure
Specific growth disorders - e.g. growth hormone deficiency, hypothyroidism
Socio-economic status - children from affluent areas, are, on average, taller than children from poor areas
Emotional well-being - can cause profound growth retardation
What is the shape of normal growth?
Infantile
Childhood
Pubertal
Describe the growth of girls in puberty
grow fast at start of puberty
peak height velocity at 12 yr (B2-3)
slow down in later stages of puberty when breast development is mature (B4 to 5)
when menarche occurs (13-13.5 yr) girls are close to final height
Describe the growth of boys in puberty
grow slowly at start of puberty (G2) – still in childhood growth phase
accelerate in mid-puberty (coincides with growth of penis, G3)
peak height velocity at 14 yr (G4)
further growth after pubertal development is complete (G5)
Is the growth pattern of boys and girls the same?
Chart showing different growth patterns in boys (solid line) and girls (dotted line)
Men end up taller than women by around 12.5 cm (5”) because of 3 factors:
- Pubertal growth spurt starts 2 years later than in girls (14 yr cf 12 yr)
- Pubertal growth spurt is more intense in boys
- Boys are slightly bigger than girls during childhood
what is this graph showing?
Familial Short Stature
M = mother
F = father
Ends up short but is normal as parents are short
Bone age not delayed
what is this graph showing and what would the child be like?
When growth and puberty are constitutionally delayed, puberty spontaneously begins at a time that is more than two standard deviations later than the mean time of breast development in girls or increase in testicular volume in boys
Child short, normal but looks younger than chronological age
Parent(s) not short, but may have been so in childhood
Bone age delayed - know they will be a late bloomer
Late puberty and catch-up growth
Final height usually in lower half of target range
what does growth hormone deficiency cause?
Mild GH deficiency might show no features before school age!
Neonatal: hypoglycaemia, prolonged jaundice, micropenis
Other anterior pituitary deficiencies
Excess subcutaneous fat
Mid-face hypoplasia
Features of septo-optic dysplasia (rare congenital malformation syndrome featuring underdevelopment of the optic nerve, pituitary gland dysfunction, and absence of the septum pellucidum)
Delayed skeletal maturation
Treatment very effective - Give them growth hormone
May be otherwise healthy
what are the hormonal causes of impaired growth?
Growth hormone deficiency
Thyroid deficiency
what is the assessment of a child with obesity?
- Weight
- Body mass index (BMI) (kg/m2)
- Height
- Waist circumference
- Skin folds
- History and examination
- Complications
what should you look for on examination of a child with obesity?
Acanthosis Nigricans - Velvet rash – sign of insulin resistance – not everyone who is obese has this
May be short as have a hypothalamic tumour
High blood pressure
Problems with doing exercise
what are the causes of obesity?
- SIMPLE OBESITY
- Drugs
- Syndromes
- Endocrine disorders
- Hypothalamic damage
