Paediatric Growth and Endocrine

Question 1

discuss normal child growth

Answer 1

A precise definition of what is normal growth is difficult. There is a wide range within a health population and further range in ethnic subgroups. There is inequality in basic health and nutrition. Normality may relate to individuals or populations (genetic influence).

Question 2

list the factors influencing height

Answer 2

• Age
• Sex
• Race
• Nutrition
• Parental heights
• Puberty
• Skeletal maturity (bone age)
• General health
• Chronic disease
• Specific growth disorders
• Socio-economic status
• Emotional well-being

Question 3

child measurement techniques

Answer 3

• Length
• Height
• Sitting height
• Head circumference
o Routine in children < 2 years
o Tape round forehead and occipital prominence (maximal circumference)

Question 4

describe bone age TW20

Answer 4

standardised left hand
• Radiographs must be of high quality
• Evaluation by skilled practitioner
• Pathological conditions can distort bones
• Severe osteopenia confuses interpretation

Question 5

growth disorders: indicators for referral

Answer 5

• 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

Question 6

common causes of short stature

Answer 6

familial
constitutional
IUGR

Question 7

pathological causes of short stature

Answer 7

• Undernutrition
• Chronic illness (JCA, IBD, coeliac)
• Iatrogenic (steroids)
• Psychological and social
• Hormonal (GHD, hypothyroidism)
• Syndromes (Turner, P-W)

Question 8

investigation of short stature: FBC and ferritin

Answer 8

general health
coeliac
Crohn’s
JIA

Question 9

investigation of short stature: U+E, LFT, Ca, CRP

Answer 9

general health
renal and liver disease
disorders of Ca metabolism

Question 10

investigation of short stature: coeliac serology and IgA

Answer 10

coeliac

Question 11

investigation of short stature: IGF-1, TFT, Prolactin, cortisol (gonadotrophins and sex hormones)

Answer 11

hormonal disordres

Question 12

investigation of short stature: karyotype

Answer 12

Turner’s syndrome

Question 13

if IGF-1 is low what would you proceed to do?

Answer 13

• Proceeded to GH stimulation test:
o Arginine test
o Insu
• Isolated growth hormone deficiency
• MRI pituitary:
o Ectopic posterior pituitary gland
o Small anterior pituitary

Question 14

give an overview od the Tanner Staging of puberty

Answer 14

Breast development (B)
o 1-5
• Genital development (G)
o 1-5
• Pubic hair (PH)
Figure 2 Investigations of Small Stature
o 1-5
• Axillary hair (AH)
o 1-3
• Testicular volume
o 2ml to 20ml

Question 15

relationship between growth and other changes in puberty: boys

Answer 15

see notes

Question 16

relationship between growth and other changes in puberty: girls

Answer 16

see notes

Question 17

early and delayed puberty: boys

Answer 17

< 9

> 14

Question 18

early and delayed puberty: girl

Answer 18

< 8

> 13

Question 19

constitutional delay of growth and puberty

Answer 19

This affects boys mainly. There is commonly a family history in dad or brothers, however, this may be difficult to obtain. Bone age delay. Need to exclude organic disease.

Question 20

causes of delayed puberty

Answer 20

CDGP
• Gonadal dysgenesis (Turner 45X, Klinefelter 47XXY)
• Chronic disease (Crohn’s, asthma)
• Impaired HPG axis (septo-optic dysplasia, craniopharyngioma, Kallman’s syndrome)
• Peripheral (cryptorchidism, testicular irradiation)

Question 21

early sexual development

Answer 21

• Breast development (hypothalamic activation)
o Infantile thelarche
o Thelarche variant (premature thelarche)
o Central precocious puberty)
• Secondary sexual characteristics (sex steroid hormone secretion)
o Exaggerated adrenarche
o Precocious pseudopuberty (i.e. congenital adrenal hyperplasia)
• PV bleeding
o Premature menarche

Question 22

central precocious puberty

Answer 22

• Pubertal development
o Breast development in girls
o Testicular enlargement in boys
• Growth spurt
• Advanced bone age
• Need to exclude pituitary lesion – MRI

Question 23

precocious pseudopuberty

Answer 23

• Abnormal sex steroid hormone secretion
• Gonadotrophin independent (low/prepubertal levels of LH and FSH)
• Clinical picture: secondary sexual characteristics
• Need to exclude congenital adrenal hyperplasia

Question 24

ambiguous genitalia: management approach

Answer 24

• Do not guess the sex of the baby!
• MDT – paed endo, surgical, neonatologist, geneticist, psychologist
• Exam: gonads?/internal organs
• Karyotype
• Exclude congenital adrenal hyperplasia – risk of adrenal crisis is 1st 2 weeks of life

Question 25

congenital hypothyroidism: causes

Answer 25

athyreosis hypoplastic ectopic dyshormonogenic

Question 26

congenital hypothyroidism: when to start treatment?

Answer 26

within first 2 weeks

Question 27

congenital hypothyroidism: how is it identified?

Answer 27

newborn blood screening

Question 28

acquired hypothyroidisim

Answer 28

• Most common cause: autoimmune (Hashimoto’s) thyroiditis • Family history of thyroid/autoimmune disorders • Childhood issues: o Lack of height gain o Pubertal delay (or precocity) o Poor school performance (but work steadily)

Question 29

assessment of obese children

Answer 29

* Weight * BMI * Height * Waist circumference * Skin folds * History and examination * Complications

Question 30

complications of childhood obesity

Answer 30

* Metabolic syndrome * Fatty liver disease (non-alcoholic steatohepatitis * Gallstones * Reproductive dysfunction (e.g. PCOS) * Nutritional deficiencies * Thromboembolic disease * Pancreatitis * Central hypoventilation * Obstructive sleep apnoea * 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

Question 31

causes of childhood obesity

Answer 31

* Simple obesity * Drugs * Syndromes * Endocrine disorders * Hypothalamic damage

Question 32

treatment of childhood obesity

Answer 32

``` • Diet • Exercise • Psychological input • Drugs?? Simple obesity is the most common cause. Investigations are rarely necessary ```

Question 33

making an early diagnosis of diabetes

Answer 33

1. THINK symptoms a. Thirsty b. Thinner c. Tired d. Using the toilet more 2. TEST immediately a. Finger prick capillary glucose test b. If result > 11 mmol/l 3. TELEPHONE urgently a. Contact your local specialist team for a same day review

Question 34

when to consider diabetes in children

Answer 34

``` A return to bedwetting or day wetting in a previously dry child is a red flag symptom for diabetes. In children under five also think: • Heavier than usual nappies • Blurred vision • Candidiasis (oral, vulval) • Constipation • Recurring skin infections • Irritability, behaviour change ```

Question 35

DKA symptoms

Answer 35

* N+V * Abdo pain * Sweet smelling “ketotic” breath * Drowsiness * Rapid, deep “sighing” respiration * Coma

Question 36

testing for diabetes in children

Answer 36

• Finger prick capillary blood glucose test o Result > 11 – diabetes o Result < 11 – other cause