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Flashcards in Paediatric Growth And Development Deck (39):
1

Phases of growth

Foetal/prenatal: most rapid phase of growth dependant on placental supply if nutrients and oxygen, determinants if birth size are maternal nutrition and intrauterine environment (not genetics)
Infantile (0-2y): rapid but decelerating. Double birth weight by 4 months, triple birth weight by 12m, grow 25cm in first year,, HC increases 12cm first year, 90% SGA infants will catch up by 1-2y
Childhood: constant growth, half adult height by 24-30m, GH dependant growth, 5-6cm/y from 4-puberty, 2kg/y from 2-pub
Puberty all growth spurt: driven by gonadal/adrenal steroids and GH, accounts for 20% final height, preceded by a reduction in growth velocity, girls 23-28cm, boys 26-28cm

2

Target height aka mid-parental height

Girls: (paternal height-13cm +maternal height)/2
Boys: (maternal height + 13cm + paternal height)/2

3

Body proportions

Arm span within 6cm of height
Upper:lower segment ratios:
- birth 1.7
- 3y 1.33
- 5y 1.19
- 10y 1.0

4

Gonadarche

Breast development in girls (telarche) and ovarian volume >4mls
Testicular volume > 4mls
Results from activation of hpg axis

5

Adrenarche

Androgen secretion from adrenal glands causing pubic hair and apocrine secretion

6

Puberty in girls (onset, order, total height gain)

Onset between 8-13y
Menarche 2-3y post onset of puberty
Avg total height gain 20cm (8cm post menarche)
Breast development, then pubic hair growth then menarche

7

Boys puberty (onset, height gain, order)

Onset 9-14y
Avg total height gain 28cm (peak in tanner4, 2 years later than girls)
Testicular enlargement followed by penile enlargement and pubic hair growth

8

Differentials for short stature

Familial/genetic short stature
Constitutional delay
Skeletal dysplasias(achondroplasia, hypochondroplasia)
Rickets
Turners syndrome
Noonan's syndrome
Russell silver syndrome (dwarfism)
GH deficiency
Cushing syndrome
Hypothyroidism
Precocious puberty (early accelerated growth, short adults)
Chronic disease (renal, nutritional. GI)
IUGR
Emotional deprivation/psychosocial
Idiopathic (most coon esp in girls)

9

Tall stature differentials

Dysmorphic:
- Marfan syndrome
- homocystinuria
- Klinefelter syndrome
- 47XYY, 47XXX
Non-dysmorphic
- precocious puberty
- hyperthyroidism
- pituitary gigantism
- familial tall stature
- hypogonadism
- obesity
- e2 deficiency or insensitivity
-

10

Familial short stature v constitutional delay

Both are normal variants, not pathological
Familial: normal growth velocity (following pattern of chars) but consistently shorter than peers (usually on 3rd percentile), height is appropriate for mid-parental height, bone age = chronological age, pubertal spurt at appropriate time
Constitutional delay:
Short during childhood but adult height consistent with target height, pubertal spurt later than peers (difficult to diagnose until after growth spurt), bone age

11

GH eligibility

GH deficiency
Turner syndrome
Height

12

Differentials for precocious puberty

Raised gonadotropin levels (true/central)
- idiopathic (>90% females, 25% males
- intracranial pathology (hypothalamic/pituitary tumours, irradiation)
- familial
- treated congenital adrenal hyperplasia
Gonadotropin independent precocious puberty
- ingestion of sex steroids
- adrenal (CAH, tumour)
- ovarian (mccune Albright, tumours, follicular cysts)
- testicular ( testicular or germ cell tumours, mccune Albright syndrome)
- tumours secreting non pituitary gonadotropin e.g. hCG

13

Definition of precocious puberty

Pubertal development in ALL domains before 8 In girls or 9 in boys
I.e accelerated growth, breast development and pubic hair development in girls
Accelerated growth, genital and testicular growth and pubic hair development in boys

14

Premature Adrenarche

Isolated pubic hair development (+body odour, oily hair, pimples)
Adrenal androgens slightly elevated
LH, FSH, and gonadal steroids all prepubertal levels

15

Premature thelarche

Isolated unilateral or bilateral breast development
Commonly seen between 6m-4y
Manage with observation and follow-up

16

Height velocity

Based on sequential height measurements no less than 3 months apart more sensitive index than a single measurement

17

Components of CHARGE syndrome

Coloboma
Heart defects
Atresias
Retarded growth/development
Genital hypoplasia (undescended testes)
Ear abnormalities

18

RDI of energy in children

Approx. 100 cal/kg/day +/- 5 or so according to age

19

Stages of feeding in babies and children

Stage 1: 6-7 months, first tastes, smooth foods
Stage 2: 7-8 months, learning to chew, soft lumps
Stage 3: 9-12 months, self-feeding, finger foods + firmer lumps
Stage 4: 12 months on, family diet with some changes

20

Common definitions of failure to thrive

Weight below the 2.5th percentile for gestation-corrected age on more than 1 occasion
OR
A rate of weight change that causes a decrease of 2 or more percentile lines over time
OR
A rate of daily weight gain less than that for expected age

21

Expected daily weight gain for age

0-3 months: 26-31 g/d
3-6 months: 17-18 g/d
6-9 months: 12-13 g/d
9-12 months: 9-13 g/d
1-3 years: 7-9 g/d

22

Category of causes of FTT

- Inadequate dietary intake
- Inadequate appetite or inability to eat large amounts
- Inadequate absorption
- Defective utilisation
- Increased urinary or intestinal losses
- Increased metabolic requirements

23

Common causes for FTT onset prenatally

IUGR, prematurity, prenatal infection, congenital syndromes, teratogenic exposures

24

Common causes for onset of FTT before 1 month (8)

Poor quality of suck
Incorrect formula preparation
Breastfeeding problems
Inadequate number of feedings
Poor feeding interactions
Neglect
Parental mental illness
Metabolic, chromosomal or anatomic abnormalities

25

Common causes for onset of FTT 3-6 months (8)

Underfeeding +/- poverty
Improper formula preparation
Milk protein intolerance
Oral motor dysfunction
Cystic fibrosis
Congenital heart disease
GORD
Recurrent infections

26

Common causes for onset of FTT 7-12 months (6)

Feeding problems
- autonomy struggles
- oral motor dysfunction (interfering with adaptation to textured foods)
- delayed introduction of solids
Intestinal parasites
Coeliac disease
Recurrent infections

27

Common causes for onset of FTT after 12 months (7)

Coercive feeding
Distractible child
Distracting environment
Acquired illness
New psychosocial stressor (divorce, new sibling, job loss etc.)
Sensory-based feeding disorders in children with developmental disorder (E.g. Autism)
Swallowing dysfunction
Inappropriate mealtime

28

Investigations in failure to thrive

+/- food diary
CBE
Urine MCS
Sweat test
Iron studies

+/- the following:
Electrolytes
LFT
Coeliac screen
Stool MCS

If severe malnutrition:
Albumin
ALP
Calcium (check for Rickets if very low)
Phosphorus

29

Karyotype of Klinefelter's

47, XXY

30

Inheritance pattern of achondroplasia

Autosomal dominant

31

Causes of bulging fontanelles

Raised ICP
i.e. meningitis, intracranial haemorrhage, intracranial effusion, hydrocephalus etc

32

Effect of rickets on the skull

Thickening of skull (frontal bossing)
Delayed closure of fontanelles

33

Effect of congenital hypothyroidism on the fontanelles

Enlarged POSTERIOR fontanelle

34

Measuring height accurately in a child

Under 2: Prone mat on firm surface
Over 2y: wall mounted stadiometer
- childs eyes at level of ear canal
- Squat to level of child's head to read measurement
- Feet flat on ground, knees straight

35

How to measure head circumference

Tape just above top of ear

36

Classic triad of Mccune Albright Syndrome

Polyostotic fibrous dysplasia
Cafe au lait spots
Precocious puberty

37

Causes of delayed puberty (%s)

Constitutional delay (50%)
Functional hypogonadotropic hypogonadism (20%)
Permanent hypogonodotropic hypogonadism (10%)
Permanent hypergonadotropic hypogonadism (10%)

38

Prepubertal v postpubertal pelvic ultrasound findings in girls

Ovarian volume: Prepubertal less than 1.5mLs, pubertal over 3-4 mLs
Follicle size: prepubertal less than 6mm, many, pubertal more than 6mm, dominant
Uterus:cervix ratio:
Less than 1 = prepubertal, over 1 = pubertal

39

Good predictors for normal progression of a child with delayed puberty

Testes 4mL or B2 tanner stage, 95% will progress normally, despite apparent delayed puberty