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 infantile phase of growth?
Rapid period of growth from 0 - 2 years
Continuation of the rapid but decelerating intra-uterine growth phase
Depends on factors such as nutrition and the insulin-like growth factors (IGF1 & IGF2)
Largely independent of growth hormone
In general, birth size reflects intra-uterine environment, e.g. nutrition
Birth size, therefore, has little correlation with final height
From birth to age 2, infant “tracks” on to his/her genetic centile, related to parental heights
By age 2, around half adult height has been attained
describe the childhood phase of growth
Long phase of growth from 2 ~ 12 years (onset of pubertal growth)
Slower, slightly decelerating curve
More dependent on growth hormone & thyroxine
Healthy child will stay on childhood (genetic) centile until puberty
describe the pubertal phase of growth
From around age 12 to final height
Dependent on the sex steroid that cause an increase in growth hormone secretion: testosterone in boys and oestrogen in girls
Resulting growth acceleration is limited by fusion of the epiphyses (due to oestrogen in both sexes)
Variable growth phase in terms of : age of onset, duration and intensity
Correlation between childhood centile & final adult centile is ~60% (i.e. individual may end up on higher or lower centile)
95% of normal individuals will attain final heights within 2 standard deviations of mid-parental height (+/- 8.5 cm)
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)
What are the most important pubertal stages?
Breast budding (Tanner Stage B 2) in a girl
Testicular enlargement (Tanner Stage G2-T 3- 4 ml) in boy
these are the earliest objective signs of puberty and when present puberty will usually progress onwards
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 are the implications of obesity on growth and puberty in girls?
Obese children will be taller
Obese children go into puberty earlier
More or less same height at the end
Obese = taller and early puberty
Obese child that isn’t tall then think about if there is an underlying pathology
Don’t worry about obese tall children
what are some indications for referrals in relation to growth disorders?
- Extreme short or tall stature (off centiles)
- Height below target height
- Abnormal height velocity (crossing centiles)
- History of chronic disease
- Obvious dysmorphic syndrome
- Early/late puberty
Moving onto - Abnormal Growth and Pubertal Development
what are the common causes of short stature?
- Familial
- Constitutional
- SGA/IUGR (Intrauterine growth restriction (IUGR) refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb)
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 are some pathological causes of short stature?
- Undernutrition (malnutrition is most ocmmon)
- Chronic illness (JCA, IBD, Coeliac)
- Iatrogenic (steroids)
- Psychological and social
- Hormonal (GHD, hypothyroidism)
- Syndromes (Turner, P-W)
what is used to treat turnes syndrome?
growth hormone
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 are syndromes that affect growth?
turner syndrome
Prader-Willi syndrome
Noonan’s syndrome
Achondroplasia
what are the features of turners syndrome?
Main features:
Short Stature
Gonadal dysgenesis
Other features:
Cardiac defect (coarctation of aorta)
Renal anomaly
Hypertension
Hearing problems
What are the features of Prader-Willi Syndrome?
Infantile hypotonia(decreased muscle tone)/feeding problems
Hyperphagia(excessive eating)/obesity in childhood
Short stature
Developmental delay
Hypogonadism
Deletion of 15q11-q13 chromosomal region
what is the treatment of syndromes causing short stature?
turner syndrome, Prader-Willi syndrome, Noonan’s syndrome - growth hormone treatment will help them develop
Achondroplasia - no treatment at the moment
now moving onto: pubertal disorders
what are the most important pubertal stages?
- B2 in a girl
- T 3- 4 ml in boy
these are the earliest objective signs of puberty
and when present puberty will usually progress onwards
when does early and delayed puberty occur in boys?
early < 9 years (rare)
delayed >14 (common, especially CDGP)
when does early and delayed puberty occur in girls?
early <8 years
delayed >13 (rare)
(this is referring to the begining of puberty, periods happen at the end of puberty so not worried about them)
Who does Constitutional Delay of Growth and Puberty (CDGP) occur in most likely?
- Boys mainly
- Family history in dad or brothers (difficult to obtain!)
- Bone age delay
- Need to exclude organic disease
what are some other causes of delayed puberty?
Gonadal dysgenesis (Turner 45X (make puberty late), Klinefelter 47XXY(gonads don’t develop properly and don’t progress in puberty))
Chronic disease (Crohn’s, asthma)
Impaired HPG axis (septo-optic dysplasia, craniopharyngioma, Kallman’s syndrome)
Peripheral (cryptorchidism, testicular irradiation)
when does early sexual development occur and what sex is it more common in?
Early sexual development: < 8 yrs ♀, < 9yrs ♂
commoner in females
what happens in early sexual development in relation to breast development?
In girls with premature thelarche, breast tissue develops early—sometimes in the first two years of life, sometimes later, and occasionally even in the neonatal period—and then persists until the true onset of puberty
Premature thelarche is an incomplete form of pubertal development without any other signs of early puberty, such as a pubertal growth spurt or marked acceleration of skeletal age
what happens in early sexual development in relation to development of secondary sexual characteristics?
Exaggerated adrenarche - Adrenarche is an early stage in sexual maturation that happens in some higher primates and in humans typically peaks at around 10 to 14 years of age and is eventually involved in the development of pubic hair, body odor, skin oiliness, and acne
Precocious pseudopuberty - partial pubertal development that results from autonomous (gonadotropin-independent) production of testosterone in a prepubertal boy. Affected boys have premature virilization and rapid growth, but they do not produce sperm
What is premature pubarche/adrenarche?
Premature pubarche/adrenarche is a further normal variant of pubertal development in which pubic and/or axillary hair develop in a girl before age 8 or in a boy before age 9
The serum levels of adrenal androgens are normal, and there is no androgeninduced growth spurt
The skeletal age corresponds to the chronological age or is only mildly accelerated
Premature pubarche is to be distinguished from congenital adrenal hyperplasia, and an androgen-secreting tumor with elevated levels of adrenal androgens
What is Premature menarche?
Premature menarche - defined as isolated or recurrent vaginal bleeding in a prepubertal female in the absence of appropriate secondary sexual characters or a known pathological cause
what is Central Precocious Puberty?
a condition that causes early sexual development in girls and boys. While puberty normally starts between ages 8 and 13 in girls and between ages 9 and 14 in boys, girls with central precocious puberty begin exhibiting signs before age 8, and boys with this disorder begin before age 9
Pubertal development - Breast development in girls and Testicular enlargement in boys
Growth spurt
Advanced bone age
what is important to ask when taking a history from a patient with Central Precocious Puberty?
Acne, greasy skin/hair, body odour
Voice change
Mood swings
Vaginal discharge/bleeding
Growth- acceleration?
Neuro problems: Perinatal history, Headaches, Radiotherapy
Drugs
FHx: Parental pubertal timing
what is important to do when doing an examination on a patient with Central Precocious Puberty?
Fundi/ Neuro
BP
Skin
How do you investigate Central Precocious Puberty in boys and girls?
Girls:
– Usually idiopathic
– Pituitary imaging
Boys:
– Look for underlying cause, i.e. brain tumor?
what is the treatment of Central Precocious Puberty?
GnRH agonist (generally used to down-regulate the secretion of pituitary gonadotropins and to inhibit ovarian steroid secretion)
What is Precocious Pseudopuberty?
Precocious pseudopuberty is partial pubertal development that results from autonomous (gonadotropin-independent) production of testosterone in a prepubertal boy. Affected boys have premature virilization and rapid growth, but they do not produce sperm
Gonadotrophin independent (low/prepubertal levels of LH and FSH)
Abnormal sex steroid hormone secretion
Virilasing or feminasing
Clinical picture: secondary sexual characteristics
usually produces a clinical picture of incomplete puberty in which some of the milestones of puberty do not appear or fail to achieve the usual synchronicity. Development occurs despite low or prepubertal levels of FSH and LH
Treatment depends on the aetiology
• Girls
– usually _____ developers
– watch rapid __________/_______ acceleration
• Boys
– usually ____ developers
• Beware abnormal patterns of _________ ___________
• Girls
– usually early developers
– watch rapid progression/growth acceleration
• Boys
– usually late developers
• Beware abnormal patterns of pubertal development
now moving onto - Other Endocrine Problems
What is the management approach for ambiguous genitalia in a newborn?
- Do not guess the sex of the baby!
- Multidisciplinary approach (paed endo, surg, neonatologist, geneticist, psychologist)
- Exam: gonads?/internal organs
- Karyotype
- Exclude Congenital Adrenal Hyperplasia!- risk of adrenal crisis is first 2 weeks of life
How common is congenital hypothyroidism?
1 in 4000 births
What are the causes of congenital hypothyroidism?
Athyreosis (abnormal condition caused by absence or functional deficiency of the thyroid gland)/hypoplastic (underdevelopment or incomplete development of a tissue or organ)/ectopic (abnormal place)
Dyshormonogenic
What is the management and treatment of congenital hypothyroidism?
- Newborn screening
- Start treatment within first 2 weeks
what is the most common cause of acquired hypothyroidism?
Autoimmune thyroiditis
WHat may be seen in a history of someone with aquired hypothyroidism
- Family history of thyroid/autoimmune disorders
- Childhood issues:
- Lack of height gain
- Pubertal delay (or precocity)
- Poor school performance (but work steadily)
what are the statistics in relation to obesity?
- Nearly a third (31%) of children aged 2–15 are overweight or obese
- The direct cost of obesity to the NHS is estimated to be £4.2bn a year
- At Reception and Year 6, children in the poorest decile are almost twice as likely to be obese compared those in the most affluent decile
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
Is obese + short normal?
no, this is abnormal
what is important information in a histroy of a child with obesity?
Diet
Physical activity
Family history
Symptoms suggestive of
- Syndrome
- Hypothalamic-pituitary pathology
- Endocrinopathy
- Diabetes
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 complications of obesity?
LOADS!
Metabolic syndrome
Fatty liver disease (nonalcoholic steatohepatitis)
Gallstones
Reproductive dysfunction (eg, PCOS)
Nutritional deficiencies
Thromboembolic disease
Pancreatitis
Central hypoventilation
Obstructive sleep apnea
Gastroesophageal reflux disease
Orthopaedic problems (slipped capital femoral epiphysis, tibia vara)
Stress incontinence
Injuries
Psychological
Left ventricular hypertrophy
Atherosclerotic cardiovascular disease
Right-sided heart failure
what are the causes of obesity?
- SIMPLE OBESITY
- Drugs
- Syndromes
- Endocrine disorders
- Hypothalamic damage
what drugs can cause obesity?
- Insulin
- Steroids
- Antithyroid drugs
- Sodium Valproate
what syndromes can cause obesity?
Prader Willi syndrome
Laurence-Moon-Biedl syndrome
Pseudohypoparathyroidism type 1
Down’s syndrome
what endocrine disorders can cause obesity?
Hypothyroidism
Growth hormone deficiency
Glucocorticoid excess
Hypothalamic lesion (tumour/trauma/infection)
Androgen excess
Insulinoma
Insulin resistance syndromes
Leptin deficiency
what is the treatment of obesity?
Diet
Exercise
Psychological input
Drugs??? - not to be used in children
_______ obesity is the most common cause
____________ are rarely necessary
Simple
Investigations
Endocrine causes what
Syndromes cause what
Hypothalamic causes cause what
Endocrine causes = growth failure
Syndromes = learning difficulties
Hypothalamic causes = loss of appetite control
moving onto - diabetes in childhood
What is DKA
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes and, much less commonly, of type 2 diabetes. DKA happens when your blood sugar is very high and acidic substances called ketones build up to dangerous levels in your body. Ketoacidosis shouldn’t be confused with ketosis, which is harmless
1 in 4 children with type 1 diabetes are diagnosed in DKA Rising to 1 in 3 under the age of 5 years
is DKA preventable?
DKA is preventable if diabetes is diagnosed early
how do you make an early diagnosis of diabetes in kids?
THINK – Symptoms
- Thirsty
- Thinner
- Tired
- Using the Toilet more
TEST- Immediately - Finger prick capillary glucose test. If result >11mmol/l
TELEPHONE – Urgently, contact your local specialist team for a same day review
What are the THINK symptoms?
Sometimes referred to as the 4T’s:
Thirsty
Tired
Thinner
Using the Toilet more
What is a red flag symptoms in children for diabetes in relation to peeing?
A return to bedwetting or day-wetting in a previously dry child is a “red flag” symptom for diabetes
what else is also important to think of in children under 5?
heavier than usual nappies
blurred vision
candidiasis (oral, vulval)
constipation
recurring skin infections
irritability, behaviour change
What are Diabetic Ketoacidosis DKA symptoms?
Nausea & vomiting
Abdominal pain
(Vomiting and abdominal pain in diabetics is nearly always DKA unless proven otherwise)
Sweet smelling, “ketotic” Breath
Drowsiness
Rapid, deep “sighing” respiration
Coma
what do you use to test for diabetes in a child and hwat do you not use?
Finger prick capillary blood glucose test
Result >11mmol/l - Diabetes
Result <11mmol/l - Other cause
……………………………………
All these tetss are for when you suspect type 2 in adults:
DO NOT request a returned urine specimen
DO NOT arrange a fasting blood glucose test
DO NOT arrange an Oral Glucose Tolerance Test
DO NOT wait for lab results (urine or blood)
What is involved in passing on a child for review of diabetes?
TELEPHONE – Same Day Review
Call local specialist paediatric diabetes team for a same day review
Diabetic Ketoacidosis (DKA) can occur very quickly in children
If in any doubt about a diagnosis of Type 1 Diabetes call for advice
Don’t delay the diagnosis
