Poor growth and abnormal puberty

Question 1

When concern about growth, when to reassess

Answer 1

Need two measurements 4-6 months apart

Question 2

When is length measured

Answer 2

Until 2 years old

Question 3

How old do you correct for prematurity until

Answer 3

Until child is one year old

Question 4

Growth chart in celiac

Answer 4

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

Question 5

IUGR growth chart

Answer 5

Low birthweight baby, may or may not show catch up.

If restriction occurred early in pregnancy, the HC and length will be affected

Question 6

Hydrocephalus growth chart

Answer 6

HC crossing the percentiles upwards

Question 7

Turner’s syndrome growth chart

Answer 7

Poor growth from infancy

Absence of pubertal growth spurt

Question 8

Growth hormone deficiency growth chart

Answer 8

Fall off in height

GH deficiency is rare

Question 9

Tanner staging boys

Answer 9

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”)

Question 10

Tanner staging girls- breast

Answer 10

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

Question 11

First signs of puberty in boys and girls

Answer 11

Testicular enlargement

Breast budding

Question 12

Precocious puberty age definition

Answer 12

When

Question 13

When is puberty considered delayed

Answer 13

When >13 in girls and >14 in boys

Question 14

When does the growth spurt usually occur

Answer 14

Early in puberty for girls, late in puberty for boys

Question 15

What is considered delayed menarche

Answer 15

When occurs >16 yo

Question 16

Nutrition requirements of infants->milk and kcal/kg

Answer 16

Infants require 150ml/kg/24 hours

110kcal/kg/day

Question 17

Bowel motions of breast fed

Answer 17

Non offensive
Porridge consistency
Yellow
Reduced bowel motion frequency without constipation

Question 18

Ways to encourage successful breast-feeding

Answer 18

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

Question 19

Releasing a baby off the breast

Answer 19

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

Question 20

Should breast and formula be alternating

Answer 20

Formula only if breast contraI or failed

Xtop ups with bottles because reduces milk production

Question 21

Advantages of breast feeding

Answer 21

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

Question 22

Possible problems with breast feeding->generally rare

Answer 22

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

Question 23

Lactation physiology

Answer 23

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

Question 24

Weaning

Answer 24

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

Question 25

Formula feeds process

Answer 25

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

Question 26

Most common cause of weight faltering or FTT

Answer 26

non-organic causes

Question 27

Causes of weight faltering

Answer 27

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

Question 28

History in weight faltering

Answer 28

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

Question 29

Examination

Answer 29

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

Question 30

Investigations

Answer 30

``` 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

Question 31

Causes of steady growth below percentiles

Answer 31

``` 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 ```

Question 32

Causes of fall off in growth percentiles

Answer 32

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

Question 33

History in short stature and poor growth

Answer 33

``` 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 ```

Question 34

Examination in short stature and poor growth

Answer 34

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

Question 35

Investigations in short stature and poor growth

Answer 35

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

Question 36

Red flags for poor growth suggesting neglect/abuse

Answer 36

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

Question 37

Overview of causes of poor growth

Answer 37

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

Question 38

What growth charts are used

Answer 38

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

Question 39

Management of growth faltering- when to admit

Answer 39

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.

Question 40

F/U with growth faltering

Answer 40

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

Question 41

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

Answer 41

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

Question 42

How to predict adult height

Answer 42

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

Question 43

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

Answer 43

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

Question 44

Loose stools, poor growth

Answer 44

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

Question 45

Psychosical issues in growth faltering

Answer 45

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

Question 46

Management at home for non-organic

Answer 46

``` 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 ```

Question 47

Management at home for non-organic

Answer 47

``` 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 ```