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Flashcards in Eval of Worrisome Growth Deck (27):
1

WHO growth chart vs CDC

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

2

Short stature

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

3

Dwarfism

height below -3SD for age

4

Midget

dwarf with normal body proportions

5

**Growth velocity

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

6

Genetic Potential

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

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

7

Skeletal Maturation

-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

8

body proportions

-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

9

Constitutional growth delay

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)

10

Familial short stature

-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)

11

Failure to thrive

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

12

Nutritional growth retardation

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

13

Children born small for gestational age

-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

14

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

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

15

Hypothesis of pathophysiology for SGA

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

16

GH Tx and SGA children

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)

17

Hormonal Causes of Worrisome Growth

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

18

Hypothyroidism

-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

19

Growth Hormone

Anterior Pituitary hormone

main func to promote linear growth

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

20

Growth hormone deficiency

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

21

Growth hormone deficiency dx/sx

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

22

Eval of GH def

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

23

Syndromic short stature

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

24

Turner syndrome

 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

25

Other abnormalities in Turner syndrome

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

26

Eval of worrisome growth

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

27

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