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Growth charts - OSCE

Dec 04, 20245 min read

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Causes of FTT

  1. Nonorganic, referred to as psychosocial (70%)
  • Psychosocial Dwarfism
  • Familial dysfunction
  • Maternal depression
  • Poverty (Major risk factor)
  • Child Abuse?
  1. Organic (30%) (A) Causes of excessive calorie loss
  • Gastrointestinal Disorders
    • Intestinal malabsorption
    • Pancreatic disease
    • Short gut syndrome
    • Celiac disease
    • Milk protein intolerance
  • Endocrine Disorders
    • Diabetes Mellitus
  • Renal Disorders
    • Nephrogenic DI
    • Chronic renal failure

(B) Causes of increased caloric requirements

  • Cardiopulmonary disorders
    • Congenital heart disease
    • CF (Cystic Fibrosis)
  • Malignancies
  • Hyperthyroidism
  • Chronic recurrent infections
    • HIV
    • Primary immunodeficiency

SIgns of FIT

  • Loss of subcutaneous fat stores
  • Poor muscle mass
  • Loose skin folds
  • Prominent ribs
  • Thin limbs
  • Sparse hair
  • Acrodermatitis enteropathica
  • Pallor
  • Lethargy
  • Decreased appetite and mental abilities

Tools used

Electronic weight scale, infantometer, vernier height gauge, measuring tape

To diagnose abnormal growth pattern for children children

  • Lying >97 percentile or <3 percentile

Indicators to determine:

  • Weight for age
  • Length/height for age
  • Weight-height/length ratio

Other indicators:

  • BMI; used or children above 2 years of age
  • Head circumference for age

Read … Interpretation … Differential diagnosis …

Failure to thrive

Initially malnutrition will result in decrease of weight: wasting/acute malnutrition - measured by weight for age

If not corrected eventually linear growth will be affected (after several months): - Measured by weight for height stunning/chronic malnutrition

  • Projection dropped more than 2-3 percentile totally (Failure to thrive) - i.e. chronic malnutrition if heigh/length is disturbed
  • Patient is dropped to below 3rd percentile
  • Weight, height are both affected

Weight for age: measure of underweight or wasting and stunning combined Head circumference is lastly affected with severe chronic malnutrition

cases on growth

Differential below 3rd percentile: Interpetation Short stature, caxcehcix

Differential

  • Turner syndrome
  • Child Neglect / Abuse
  • Neonatal diabetes
  • Rickets

Management

  • Karyotyping (turners, down)

Differential Above 97 percentile:

  • Giantism

Differential platue:

  • Malnutrition

Acute malnutrtion weight / age

  • Pyloric stenosis
  • Down syndrome
  • Child Abuse

child with diarrhea

  • gastro enteritis

Chronic malnutrtion

  • …

distended abdomen, pathetic face, thin limbs, on off diarrhea, proximal myopathy - anemia

  • celiac disease

above average weight, height short Cushing syndrome differential

All below average from birth

  • TORCH
  • Genetic; down syndrome, sunjet saket syndrome
  • Fetal Alcohol syndrome

Measurement Guidelines

Weight Measurement
  • Age: Over 2 years
  • Tool: Electronic weight scale
Height Measurement
  • Age: Under 2 years
  • Tool: Infantometer for length, otherwise use giraffe
Head Circumference Measurement
  • Position: Ensure the height is in front of you.
  • Units: Use centimeters, not inches.
  • Procedure: 1. Start at the forehead, with no space from the eyebrows. 2. Rotate the measuring tape above the ears. 3. Continue around the occiput (back of the head). 4. Pass the tape over the next to above the ear. 5. Complete the circle back to the starting point.
  • Note Accuracy: Measure three times and calculate the average to account for movement.

Note

if weight normal could be short stature only rather than chronic malnutrition

if growth normally then stopped, growth hormone abnormality. constitution if his puberty caught on the normal variability.

Process

  • Prenatal
  • Nutrition
  • Growth parameters
    • first 2 years of life rapid growth, any diseases - 1st year 25 cm, second year 12.5cm, after which 6 cm and so on…
    • 1.5.-2.5kg
    • 50 cm length
    • 34cm head circumfrence

History taking

Chief of complaint

Short stature

Prenatal History

Prenatal

  • Consanguinity? Neonatal
  • small gestational age (Birth weight [term/preterm])
  • Cessarian
  • Oxygenation, intubation, complications
  • Admissions to NICU

Postnatal

HOPI

  • Jaundice, recurrent hypoglycemia; Hypopituatiry resulting in decreased Growth hormone

  • SOLs; reccurent headache, photophobia

  • Nutrition: formula fed?, breast fed?

  • Hypothyroidism:

  • Celiac Disease:

  • Organ Chronic diseases:

Past History

Medical

  • Admissions

  • Immunization,

  • Surgeries,

  • Transfusions

  • Mid parental height

  • Family Hx of diseases

Drugs:

  • Steroids stunting growth
  • Estrogen, early closure of growth plate

Social:

  • Residency
  • Level of education
  • who takes care of child

Systemic Review

  • CNS
  • Cardiac
  • GI
  • Respiratory
  • Hematological
  • Dermatological
  • Musculoskeletal

Examination

Genereal Appearance

  • Dysmorphic; Turner, nonan??

  • Midline defect: Hypopituitarism - cleft lip & palate, central incisors, Umbilical Hernai, micropenis

  • Disability:

  • Growth chart / Growth parameters: Head Circumference, Length/Height, Weight, BMI - related to age | weight to height below 2 years

Growth charts

Definition of short stature crossing percentile, below 3rd percentile, shorter than expected mid parental height, two standard deviation below mean; 50th percentile

I- Read patient age is 18 months, girl, 75 cm

II- Interpretation Bellow 3rd percentile or between 3rd and 5 if not exact

III- Measure Mid Parental heihgt -+ 13 cm female/male average

IV- Differential diagnosis for short stature

  • Physiological: Familial, constitutional delay of growth and puberty.

  • Pathological: indication to initiate Growth hormone treatment

    • Turner
    • Neonan syndrome
    • Brother willy; Obese & Short

  • Genetic:

    • Down syndrome
    • Any genetic diseases
    • Celiac
    • SSS

  • Chronic diseases

    • Cystic Fibrosis - gene mutiation.

  • Rheumatologic diseases

    • RA
    • SLE
    • IBD

  • Endocrinal

    • Hypothyroidism
    • Hypopituatirism
    • Growth hormone deficiency
    • Cushings
    • Congenital adrenal hyperplasia may appear late

  • Idiopathic: when everything is excluded

Investigations

  • CBC: Anemias

  • LFT, TFT (TSH, T4) , RFT

  • Insulin like growth factor - IGF-1 Growth hormone not usually measure GRH not measured IGF-Binding protein can be measured; differential malnutirtion

  • Electrolytes (Rickets)

  • Celiac investigation: Antibodies tissue tra… initially - diagnostic by biopsy

  • Cortisol - not an early investigation

Initial bone age

  • Left hand X-ray: Early closure of growth plates

    • Increased bone age
      • precinous pubery
      • Estrogen supplementation

  • Atlas:

Further Examination

  • Growth hormone stimulation test (suspected growth hormone deficiencies)
  • Karyotyping (any girl with short stature should be done)

Late

  • MRI - pituitary

growth velocity:??? further exam? Height related - speeding of height increase - every 4 - 6 - 1 yr groowth increase - in one year, till puberty is measured.

Management

  • Malnutiriton: refer to distance, high calorie formula

  • Hormonal:

    • Growth hormone:
      • Daily (daily) / once weekly treatment with Growth hormone
        • small ga turner neonan brother willy, specific gene mutations, idoipathic low growth hormones
        side effects include, scoliosis, …

Differential tall

  • Giantism…

Y ?

Graph View

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