Poor growth and abnormal puberty Flashcards Preview

Pediatrics > Poor growth and abnormal puberty > Flashcards

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

When concern about growth, when to reassess

Need two measurements 4-6 months apart


When is length measured

Until 2 years old


How old do you correct for prematurity until

Until child is one year old


Growth chart in celiac

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


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


Hydrocephalus growth chart

HC crossing the percentiles upwards


Turner's syndrome growth chart

Poor growth from infancy
Absence of pubertal growth spurt


Growth hormone deficiency growth chart

Fall off in height
GH deficiency is rare


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")


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


First signs of puberty in boys and girls

Testicular enlargement
Breast budding


Precocious puberty age definition



When is puberty considered delayed

When >13 in girls and >14 in boys


When does the growth spurt usually occur

Early in puberty for girls, late in puberty for boys


What is considered delayed menarche

When occurs >16 yo


Nutrition requirements of infants->milk and kcal/kg

Infants require 150ml/kg/24 hours


Bowel motions of breast fed

Non offensive
Porridge consistency
Reduced bowel motion frequency without constipation


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


Releasing a baby off the breast

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


Should breast and formula be alternating

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


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


Possible problems with breast feeding->generally rare

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


Lactation physiology

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



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


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


Most common cause of weight faltering or FTT

non-organic causes


Causes of weight faltering

1. Environmental/psychosocial->most common cause
2. Cystic fibrosis
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


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



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



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

Base on clinical findings


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
No pubertal
No delay in bone age
Evidence of cause
5. Skeletal dysplasias
Achondroplasia most common


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


History in short stature and poor growth

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


Examination in short stature and poor growth

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


Investigations in short stature and poor growth

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


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


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
Metabolic inborn errors


What growth charts are used

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


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.


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


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


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


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


Loose stools, poor growth

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


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


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
Substance use
Parenting skills
Support systems


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
Substance use
Parenting skills
Support systems

Decks in Pediatrics Class (58):