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Growth failure in Children.pptx

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Growth failure in Children.pptx

  1. 1. Growth • Growth refers to an increase in physical size of the whole body or any of its parts. • It is simply a quantitative change in the child’s body. • It can be measured in Kg, pounds, meters, inches, ….. etc
  2. 2. Development • Development refers to a progressive increase in skill and capacity of function. • It is a qualitative change in the child’s functioning. • It can be measured through observation.
  3. 3. Introduction • Growth failure is one of the most common presentation to a pediatrician . • Most short children have physiological causes not requiring evaluation . • The aim of evaluation of growth failure is to avoid unnecessary work - up in children with physiological causes while not missing a pathological cause .
  4. 4. • Short child: Any child whose height falls below the 3rd centile for his/her community. • Failure of physical growth • The term ‘Dwarfism’ is no longer used for short stature • Approximately 3% children in any population will be short .
  5. 5. PATHOPHYSIOLOGY • An understanding of growth physiology is of most importance for successful management of growth disorders .
  6. 6. • GROWTH PATTERN: • Growth is characterized by phases of rapid growth ( intrauterine , infancy and puberty ) interspersed with reduced growth ( childhood ) • Maximum linear growth happens in the fetal period with increase of 50 cm . • Fetal growth is regulated by intrauterine environment with limited impact of growth hormone and thyroxine . • Infancy is associated with gain of 25 cm in first year and 12 cm in the second. • Growth during this period is largely driven by nutrition.
  7. 7. • Childhood growth contributes significantly to adult height and occurs at a steady rate of 5-6 cm per year . • Puberty accounts for 20-25 cm of growth . • Pubertal growth spurt starts at breast stage II in girls and testicular volume of 10 ml in boys and lasts for two years . • It peaks at breast stage IV 6 months prior to menarche with a rate of 9 cm / year in girls and a testicular volume of 15 ml with a rate of 11 cm / year in boys .
  8. 8. GROWTH REGULATION • Final height is determined by genetics explaining 60-80 % variation . • Within this framework growth represents an interaction of nutrition and endocrine factors . • Nutrition plays vital role in growth regulation . • Type 1 nutrients ( vitamins , calcium , iodine and magnesium ) play a role in specific processes . There deficiency disrupts a unique facet with normal overall growth . • Type II nutrients are the building blocks of body ( proteins , electrolytes , zinc , phosphorus and sulfate ) . Their deficiency causes global reduction in growth .
  9. 9. ENDOCRINE REGULATION • Growth is regulated by the GHRH - GH - IGF1 axis with inputs from nutritional signals , sex steroids and thyroxine . • Growth hormone - IGF1 axis • Hypothalamic GHRH acts on pituitary to produce growth hormone . • Growth hormone is secreted in pulsatile fashion with maximum release at night . • Growth hormone acts on the liver to produce IGF I , which acts on the type I IGF receptor on the growth plate to induce growth .
  10. 10. • Nutritional influence • Malnutrition is a growth hormone resistant state with high GH and low IGF1 levels. • GHD may therefore be missed in children with malnutrition . • Overnutrition is a growth hormone sensitive state with high IGFI and low growth hormone levels . • This may lead to erroneous diagnosis of growth hormone deficiency in obesity. • Increased insulin in obesity stimulates growth by raising free IGF1 levels and acting on the type I IGF receptor .
  11. 11. CRITERIA • Growth failure evaluation is required for children who are:  very short ( height less than 1st percentile) ,  short and not growing ( height between 1 to 3rd percentile and  not growing at all ( crossing two or more major percentile lines between the age of 2 years and puberty ) . • Growth velocity should be measured over a period of at least 6 months to one year with age specific cutoff for identification of disorder .
  12. 12. ETIOLOGY • Growth is controlled by multiple factors and abnormality in any of these may cause growth failure .
  13. 13. Short child • Six GOLDEN POINTS • 1- Accurate & Serial measures. • 2-Pubertal assessment • 3- Mid Parental Height (MPH). • 4- Height age. • 5- Bone Age. • 6- appropriates Investigations.
  14. 14. Important definitions • Chronological age – Actual age of the child. • Height age – it’s the age at which the height of the child is at 50th centile. • Bone age - is an indicator of skeletal maturation. • Target MPH: F+M/2 +6.5 for boys and -6.5 for girls. • Then plot the result on Growth Chart at Age 20 to form Family chart ±10 to form centile
  15. 15. Assessment of a child with short stature • Accurate height measurement& height velocity • Height plotted on appropriate growth chart.
  16. 16. Normal Measuring • Supine length < 2 y of age • For measurement of supine length it is best to use a firm box with an inflexible board against which the head lies, with a movable footboard on which the feet are placed. • Erect height > 2 y • The head is held in a horizontal plane • Upward pressure is applied to the mastoid processes in order to encourage the child to stand up straight.
  17. 17. Growth charts • The key aspects to look in a growth chart include • absolute status compared to population ( percentile ) , • effect of parental height ( growth chart for the family ) and relative impact on height and weight ( height age and weight age ) . • Greater compromise of weight than height in a short child suggests nutritional cause ( malnutrition , infection , renal tubular acidosis or celiac disease ) while height is more affected in endocrine causes .
  18. 18. Pubertal assessmen
  19. 19. Pubertal assessment • Breast stage II ( elevation of papilla ) suggests that a girl has entered puberty and marks the initiation of growth spurt . • Thelarche should be differentiated from lipomastia by palpating breast tissue between thumb and index finger . • Breast stage IV ( secondary mound ) and vaginal discharge predict menarche within the next six months . • Post menarchal growth is limited to 5-8 cm .
  20. 20. • First sign of puberty in boys is increase in testicular size followed by appearance of pubic hairs and increase in penile length and thickness . • Pubertal onset is marked by a testicular volume of 4 ml with growth spurt starting at 10 ml . • Importantly growth velocity is lowest just before the onset of puberty . • This results in frequent presentation of prepubertal boys with short stature . • Spermarche is a terminal event indicating limited growth potential .
  21. 21. Mid parental height (MPH) • Comparison with child’s own genetic potentia • Mid parental height for boys • MPH = mother's height + father's height /2 + 6.5cm • Mid parental height for girls • MPH = mother's height + father's height /2 – 6.5cm • Then plot the result on Growth Chart at Age 20 to form Family chart ±10 (6)
  22. 22. Family Chart • Example: 3 Y – girl – • Ht=85 cm --Wt=10 Kg • Father Ht= 165 cm • Mother Ht= 155 cm • MPH= 160-6.5= • 153.5 • Plot on age 20 • 153.5 ±10 • 143.5 – 163.5 3rd MPH= 153.5±10
  23. 23. Height age • Height of a person at the 50th percentile for their age.
  24. 24. Height age • Examples: • Girl- Age = 5 y • Ht= 95 cm • Height age= ?
  25. 25. Bone age assessment • X ray of the non - dominant ( conventionally left ) hand and wrist is used for bone age assessment . • The fingers should be widely spread to allow visualization of all bones separately . • Given the difficulties of formal bone age assessment for busy physicians , practical method has been devised to provide quick overview of skeletal maturation . • This involves selection of area of interest , comparison of different areas and overall estimation of bone age . The Greulich and Pyle Method The Tanner–Whitehouse Method Computerized Automatic Systems
  26. 26. • Carpal bones are preferred in infancy ( up to 10 months in girls and 14 months in boys ) followed by phalangeal epiphysis ( till 2 years in girls and 3 years in boys ) . • Comparison of the size of epiphysis to metaphysis is indicated in pre - puberty to early / mid puberty . • Epiphyses are smaller than metaphysis till seven years of age in girls and nine years in boys . • They become equal to metaphysis by 10-12 years , bigger beyond 12 years with capping and fusion by 14 years of age. • Fusion of distal epiphysis is assessed during late puberty ( 13-15 years in girls and 14-16 years in boys with focus on long bones subsequently .
  27. 27. epiphysis to metaphysis
  28. 28. PHYSIOLOGICAL CAUSES • These represent the vast majority of children with growth failure . • Their identification limits unnecessary work - up for causes of growth failure
  29. 29. Familial Short Stature • In contradistinction to CDGP , children with familial short stature have normal bone age and puberty . • The disorder is characterized by early onset growth failure , family history of short stature , normal growth velocity and compromised final height . • Consideration for genetic cause of short stature should be given if either of the parent is very short ( height below -3 SDS ) or has characteristic clinical picture.
  30. 30. Is she short? • Example: 3 Y – girl – • Ht=85 cm --Wt=10 Kg • Father Ht= 165 cm • Mother Ht= 155 cm • MPH= 160-6.5= • 153.5 • Plot on age 20 • 153.5 ±10 • 143.5 – 163.5 • Bone Age = normal 50th 3rd MPH= 153.5±10 Familial short stature
  31. 31. Constitutional Delay Of Growth & Puberty ( CDGP ) • CDGP is one of the commonest cause of growth failure . • It is due to delayed onset of puberty due to genetic factors . • Growth is normal in the initial phase with faltering by seven years of age . • The child remains behind his peers despite a normal growth rate . • Final height is normal as bone age is delayed and growth continues for a longer period than other children . • Family history of delayed puberty ( delayed menarche in mother ; delayed onset of shaving and continued growth in college years in father ) is present . • CDGP is common in boys but also frequently observed in girls.
  32. 32. Is she short? • Example: 5.5 Y – girl • Ht= 98 cm --Wt=13 Kg • Father Ht= 175 cm • Mother Ht= 165 cm • MPH= 170-6.5= • 163.5 ±10 • HT Age=3.5 years • Bone Age=3.5 years 50th 3rd MPH= 163.5 ±10 Constitutional short stature
  33. 33. Is she short? • Example: 5 Y – girl – • Ht= 98 cm --Wt=15 Kg • Father Ht= 175 cm • Mother Ht= 165 cm • MPH= 170-6.5= • 163.5 ±10 • HT Age=3.5 years • Bone Age=1 year 50th 3rd MPH= 163.5 ±10 Pathological short stature
  34. 34. PATHOLOGICAL CAUSES
  35. 35. Endocrine Causes • Endocrine causes of growth failure include hypothyroidism , growth hormone deficiency , pseudohypoparathyroidism and Cushing syndrome . • These children have preserved weight with delayed bone age and puberty . • Hypothyroidism- • Pseudohypoparathyroidism • Cushing syndrome • GH - IGF1 axis disorders
  36. 36. ASSESSMENT • Key aspects of evaluation of a short child is to confirm short stature , exclude physiological causes , differentiate nutritional from endocrine etiology and identification of the cause . • IS IT PHYSIOLOGICAL OR PATHOLOGICAL?
  37. 37. Investigations • Screening tests include • complete blood count, erythrocyte sedimentation rate • Electrolytes, calcium , phosphorus and alkaline phosphatase • blood sugar • creatinine ( chronic kidney disease ) • alanine transferase ( liver disease ) • free T4 , TSH levels ( hypothyroidism ) • celiac disease screening • chest X ray • blood gas ( renal tubular acidosis ) • Karyotype with 50 metaphases should be done in short girls with no apparent abnormality on screening tests to identify Turner syndrome .
  38. 38. Assessment of GH - IGF1 axis • GH - IGF1 axis evaluation should be done only after exclusion of all other causes of growth failure . • Basal GH has no role in diagnosing GHD but can help in screening for GH resistance . • Normal thyroid and cortisol levels are essential to elicit growth hormone response .
  39. 39. • Growth hormone stimulation test is considered the gold standard for identifying GHD . • Sex steroid priming is recommended in girls older than 10 years and boy above 11 years who are pre - pubertal and have predicted adult height in the normal range . • 17 beta estradiol ( Progynova , 2 mg for two days) can be used in both boys and girls .
  40. 40. • Commonly used stimuli include: • clonidine ( 5 mcg / kg to a maximum dose of 200 mcg ) , • glucagon ( 30 mcg / kg with a maximum dose of 1 mg ) and • insulin ( 0.1 unit / kg to induce hypoglycemia ) . • Complete GHD is defined as peak stimulated growth hormone lower than 5 ng / mL and partial GHD as levels between 5-10 ng / ml . • Children with abnormal response to one test should have another dynamic test to establish the diagnosis .
  41. 41. • GH dependent peptides • IGF 1 and IGFBP3 are secreted in response to GH and provide information about GH effect . • These peptides are used for screening for GHD and monitoring response to GH therapy . • IGF 1 is an unreliable marker before two years of age and in those with malnutrition and liver disease . • IGFBP3 is a better marker of growth hormone status in younger children including neonates .
  42. 42. MANAGEMENT • General measures include nutrition ( protein , zinc , iron and calcium supplementation ) and physical activity . • Specific measures include gluten free diet in celiac disease , alkali in RTA , thyroxine in hypothyroidism and supplements and infection control in cystic fibrosis .
  43. 43. MANAGEMENT • Growth hormone therapy is indicated in children with: • GHD ( benefit of 20-25 cm ) , • Turner syndrome ( 10-15 cm ) , • SGA without catchup ( gain 7-10 cm ) , • chronic kidney disease planned for renal transplant and • Prader Willi syndrome with growth failure . • GH therapy is being increasingly used in children with idiopathic short stature with height below 1st percentile .
  44. 44. THANKS FOR YOUR ATTENTION

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