Poor growth and abnormal puberty Flashcards Preview

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Flashcards in Poor growth and abnormal puberty Deck (47):
1

When concern about growth, when to reassess

Need two measurements 4-6 months apart

2

When is length measured

Until 2 years old

3

How old do you correct for prematurity until

Until child is one year old

4

Growth chart in celiac

Fall off in weight when weaning to wheat, fall off in length follows

5

IUGR growth chart

Low birthweight baby, may or may not show catch up.
If restriction occurred early in pregnancy, the HC and length will be affected

6

Hydrocephalus growth chart

HC crossing the percentiles upwards

7

Turner's syndrome growth chart

Poor growth from infancy
Absence of pubertal growth spurt

8

Growth hormone deficiency growth chart

Fall off in height
GH deficiency is rare

9

Tanner staging boys

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

Boys and girls - 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")

10

Tanner staging girls- breast

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

11

First signs of puberty in boys and girls

Testicular enlargement
Breast budding

12

Precocious puberty age definition

When

13

When is puberty considered delayed

When >13 in girls and >14 in boys

14

When does the growth spurt usually occur

Early in puberty for girls, late in puberty for boys

15

What is considered delayed menarche

When occurs >16 yo

16

Nutrition requirements of infants->milk and kcal/kg

Infants require 150ml/kg/24 hours
110kcal/kg/day

17

Bowel motions of breast fed

Non offensive
Porridge consistency
Yellow
Reduced bowel motion frequency without constipation

18

Ways to encourage successful breast-feeding

1. Introduce concept of breastfeeding antenatally
2. Baby to breast immediately after delivery
3. Feeding on demand
4. Avoid offering any formula feeds
5. Ensure mother has good nutrition and rest
6. Skilled advisors if any issues
7. Ensure latching on and good position

19

Releasing a baby off the breast

Place a clean finger at the side of the baby's mouth

20

Should breast and formula be alternating

Formula only if breast contraI or failed
Xtop ups with bottles because reduces milk production

21

Advantages of breast feeding

1. Appropriate nutritional composition
2. Little risk of bacterial infection
3. Anti-infective properties
4. Convenient, no expense, psychologically satisfying
5. Reduced risk of atopic

22

Possible problems with breast feeding->generally rare

1. Tiring
2. Infection
3. Drugs passed through breast milk

23

Lactation physiology

Sucking->afferent-->posterior pituitary->oxytocin to +let down, also +in milk production.

24

Weaning

0-6 months->breast or formula only
6 months->pureed/liquedized
7-9 months: finger foods, juice in a cup
9-12 months: 3 mils a day with family + 3 snack times
>1: cows milk, full fat (up to 5 years) in a beaker or cup

25

Formula feeds process

1. Sterilise the feeding bottle
2. Add the appropriate volumed of cooled boiled water to the bottle
3. Add one level scoop of milk powder to each 30ml water
4. Shake bottle well
5. Ensure milk is at comfortable temperature before feeding

26

Most common cause of weight faltering or FTT

non-organic causes

27

Causes of weight faltering

1. Environmental/psychosocial->most common cause
2. Cystic fibrosis
3. IUGR
4. Immunodeficiency->recurrent infections (HIV, SCID)
5. Genetic syndrome->LBW common, dysmorphic
6. Chronic illness
7. GOR->pain, apnea, vomiting/posseting, common in neurodevelopmental
8. Celiac disease->weight falls off when weans to wheat
9. Endocrine->developmental delay in hypothyroidism, GH deficiency very rare
10 Renal tubular acidosis

28

History in weight faltering

1. Nutritional history->diet, feeding, start at birth, weaning, cause or result
a. Breastfeeding->difficulties, timing, vomiting. Settled after feeds, perception of supply, previous breast feeding
b. Formula feeding->volumes, changes, dilutions, vomiting or diarrhea
c. Timing and introduction of solids, types of solids->interaction, pleasant, stressful
d. In toddlers->mealtime battles, coercive, food refusal
2. Review of symptoms: diarrhea, colic, vomiting, irritability, fatigue, chronic cough
3. Developmental history->neurodevelopmental problems
4. Past medical history->LBW and prenatal problems, recurrent/chronic illness
5. Family history: history of faltering/genetic syndrome, psychosocial problems, mental health, failure to attend
6. Lack suitable housing, supports, maternal mental health, child protection involvement

29

Examination

1. General observation->neglected, ill, malnourished, wasted buttocks, protruberent abdomen, sparse hair
2. Growth->percentiles
3. Physical examination->signs of chronic disease
4. Child-parent interaction

30

Investigations

For otherwise healthy developing, none needed at firts.
Where significant concern, no specific pointers:
FBC, ESR
UEC, LFT
Iron studies
CMP
Thyroid
Glucose
Urine MCS
Celiac screen
Stool MCS
Stool for fat globules and fatty acid crystals

Base on clinical findings

31

Causes of steady growth below percentiles

1. Constitutional/familial
Family history, normal P/E, no delay in bone age
2. Maturational delay
Delayed puberty
FHx of delay
Delay in bone age
3. Turner's
Features of
XO
No pubertal
No delay in bone age
4. IUGR
LBW
Evidence of cause
5. Skeletal dysplasias
Rare
Disproportionate
Achondroplasia most common

32

Causes of fall off in growth percentiles

1. Chronic illness
H/E, delayed bone age
2. Acquired hypothyroidism->delayed bone age, +TSH, low T4, antibodies may be present
3. Cushings->most commonly iatrogenic, delayed bone age
4. GH deficiency rare
5. Psychosocial->evidence of neglect, show catch up growth when removed from the home

33

History in short stature and poor growth

1. Medical history and review of systems
Chronic illness
ICP +
Malabsorption
Hypothryoidism
2. Family Hx
Compare with parental heights
3. Birth history
4. Psychosocial history

34

Examination in short stature and poor growth

1. Pattern of growth
2. Anthropometric measurements
3. General examination
4. Head circumference

35

Investigations in short stature and poor growth

FBC->IBD
UEC->Chronic renal failure
Celiac antibodies
Thyroxine and TSH
Karyotype
GH tests
Xray of wrist for bone age

36

Red flags for poor growth suggesting neglect/abuse

1. Signs of abuse or neglect
2 Poor carer understanding
3. Signs of family vulnerability->drug/alcohol, DV, social isolation, no family support
4. Signs of poor attachent
5. Parental mental health issues
6. Already previously case managed by child protection services
7. Did not attend/previously cancelled appointments
8. Signs of dehydration
9. Signs of malnutrition or significant illness

37

Overview of causes of poor growth

1. Inadequate calories
Inadequate nutrition, breast feeding difficulties, restricted diet ,structural causes (cleft palate), vomiting, anorexia of chronic disease, formula dilution, early/delayed introduction of solids
2. Psychosocial
Depression/anxiety, substance, attachment, disability, coercive feeding, difficult at meal times, poverty, behaviour, poor understanding, trauma, neglect, child protection
3. Inadequate absoprtion
Celiac, chronic liver, pancreatic insufficiency, chronic diarrhea, cow milk protein intolerance
4. ++Utilisation
Chronic illness, UTI, respiratory, CHD, DM, hyperthyroid
5. Other medical
Genetic
Metabolic inborn errors

38

What growth charts are used

For 2 yo use CDC
For those under 2yo use WHO

39

Management of growth faltering- when to admit

1. Significant illness/dehydration
2. Abuse, neglect, psychosocial
3. Persistent poor growth despite adequate nutritional intervention
4. Concern not being adequately cared for->need child protection report
5. D/C when professional case conference and case management plan developed.

40

F/U with growth faltering

1. Refer back to GP
2. Pediatrician considered
3. One clinician to do follow ups.
4. If F/U not attended, immediate action taken to determine health of the child
5. weight weekly

41

Average growth->0-3 mo, 3-6 mo and 6-12 mo

1. 0-3 mo= 150-200g/week
2. 3-6 mo= 100-150g/week
3. 6-12 mo= 70-90g/week

42

How to predict adult height

Boys: [Paternal height in cms + (maternal height in cms +13 cm)] divided by 2= adult height in cms
Girls: [Maternal height in cms + ( paternal height in cms - 13 cms)] divided by 2 = adult height in cms

43

When history of gastroE and now ongoing diarrhea, what to consider and test to perform

Lactose intolerance
Check stool for low pH and sugar-reducing substances

44

Loose stools, poor growth

1. Lactose intolerance->stool pH and sugar-reducing substances
2. Celiac->antibodies and jejunal biopsy
3. Cystic fibrosis->sweat chloride

45

Psychosical issues in growth faltering

1. Parental depression
2. Substance use
3. Attachment difficulties
4. Coercive feeding
5. Difficult at meal times
6. Poverty
7. Poor support, trauma
8. Neglect
9. Involvement with child protection

46

Management at home for non-organic

1. Meal times
Family together
No distractions
20-30 minutes
Solids before liquids, high calories
No force feeding
Age appropriate
2. Regular r/v, weight checking
3. Address pscychosocial
Poverty, employment
Depression
Substance use
Parenting skills
Support systems

47

Management at home for non-organic

1. Meal times
Family together
No distractions
20-30 minutes
Solids before liquids, high calories
No force feeding
Age appropriate
2. Regular r/v, weight checking
3. Address pscychosocial
Poverty, employment
Depression
Substance use
Parenting skills
Support systems

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