clinical methods in paediatrics department of paediatrics chinese university of hong kong
TRANSCRIPT
Clinical Methodsin Paediatrics
DEPARTMENT OF PAEDIATRICS
CHINESE UNIVERSITY OF HONG KONG
Methods in Clinical medicine
History prenatal, natal, postnatal development social allergy and drugs family hx, enviromental hx F/E
Physical examination + Investigations
An example
Growth problem in paediatrics
Why do we need to understand growth problems in Paediatrics?
Parental concerns
Almost all chronic childhood disorders can affect growth
Most children with “growth problems” actually DO NOT have problems and NEED NO investigations.
Questions
What is normal growth? Pattern ,
charts - normal reference
Normal variations of growth
Questions
What is normal growth? Pattern ,
charts - normal reference
Normal variations of growth?
What influences normal growth?
Growth Disorders - Physiology
Nutrition Diseases
Hormones Normal Growth
Genetics Puberty
Normal Growth
Biological variations
Arbitrary: 3% - 97% = “Normal”
Normal Growth
Trend of growth: Serial data
: changes over time
Charts - for comparison of an individual to a reference population: assumption < 3% or > 97% = likely to be abnormal. i.e. disease
* * Biological variations
* Arbitrary : 3rd% to 97%= normal
Short stature
Definition Children with heights below the 3%tile
MAJORITY >90% due to familial short stature or constitutional
growth delay others -Pathological short stature
Familial short statureConstitutional growth delay with delayed puberty
Familial Short Stature
Family history - positive a height within the target height defined by
the parental size
Target Heights
Ht (boy) = Ht (mom) + Ht (dad) +12
2
Ht(girl) = Ht (mom) + Ht (dad) -12
2
Familial Short Stature
Family history - positive a height within the target height defined by
the parental size
Normal growth velocity
Normal age of onset of puberty
Bone age consistent with chronological age
Constitutional growth delay with delayed sexual maturation
Familial condition with hereditary delay in growth and maturation
Short stature during childhood
Delayed onset of puberty
Bone age - retarded for chronological age but appropriate for height age
Normal adult height
Differential Diagnoses
Short Stature
Normal Abnormal
-familial R/O Disproportionate
-constitutional short stature
*F Hx, Growth rate - Rickets :Vit. D, PO4
- Skeletal dysplasia
(check upper , lower segments )
Proportionate short stature
> 90% < 10%
Proportionate Short Stature
Prenatal onset Postnatal Onset
-Syndromes::Down’s, Russell-silver -Chronic illness
-Chromosome: Trisomies GI, CVS, Renal,
Chest, Hema
-IUGR
Fetal: intrauterine infection -Endocrine: thyroid
Maternal: toxemia G.H.
Combined -severe malnutrition
Skeletal Dysplasia
developmental defects of skeletal growth leading
to disproportionate short stature and deformity
> 200 types
e.g. Achondroplasia, most common 1/ 25000
CLINICAL APPROACH TO SHORT STATURE
1. Onset: Since when ?
2. ? Growth arrest: e.g. no growth for the past 2 years
3. Prenatal history: Intrauterine growth retardation- drugs, smoke, alcohol, illness, rash, weight gain
4. Natal history - Birth weight, length
5. Postnatal history -Medical illness CNS - irradiation, Cardiac, Pulmonary, Renal, G.I.
History
CLINICAL APPROACH TO SHORT STATURE
6. GROWTH DATA FROM THE PAST- Plot the growth curve- Calculate the growth rate (normal = 4-6 cm/year 4 years to prepuberty)
7. Family history -Short stature, growth delay, menarche
8. Systemic enquiry: e.g.Symptoms of Hypothyroidism
9. Social history: assess impact of short stature
History
SHORT STATURE - PHYSICAL EXAMINATION
1. Dysmorphic features suggesting syndromes:
Turner, Noonan, Russell-Silver
2. Midline defects - Cleft lip/palate: Hypopituitarism
3. Visual field defects
4. MEASUREMENT- HT, WT, Arm-span, upper & lower segments, sitting height , proportions
AGE U/L RATIOBIRTH 1.73 years 1.3>7 years 1.1
5. ? Goitre and signs of hypothyroidism
6. Careful systemic examination:Heart, Lungs, Abdomen examination to detect possible organic cause
5. Pubertal status -BREAST, PUBIC HAIR, GENITAL STAGE, TESTES
INVESTIGATIONS FOR SHORT STATURE
1. MAJORITY OF CASES- NONE - If Hx is compatible with normal variants i.e. Familial or constitutional - Growth rate - NORMAL
2. Recheck patient in 6 months to calculate the growth rate
3. INVESTIGATES IF- Very short: > 3 s.d. below mean(many cm below
the 3rd%tile or history of growth arrest or history and physical abnormalities suggestive of endocrine
disorders or other systemic disorders
TESTS - FOR SHORT STATURE BONE AGE: X-ray left hand and wrist
BLOOD COUNT, URINALYSIS, RFT
STSH, FT4
KARYOTYPE FOR GIRLS (TURNER)
If patient has - Delayed bone age- Normal screening investigations
- No other medical cause - abnormal growth rate THEN consider growth hormone testing
As a GP, when to refer?
Height ‘way below’ 3rd %
Growth arrest
Obvious chronic problems-poorly controlled
Social reason: Unable to settle the extreme parental anxiety .
DO NOT USE tests to reassure the parents
Summary
Variations and control of normal growth
Approach to short stature (proportionate or disproportionate types)
DDx of short stature History taking & physical examination Investigations and follow-up
Rickets
Clinical signs -stature, frontal bossing
wrist, bow legs , ribsBiochemical abnormalities:
Bone profile: Ca, phosphate, ALP
Radiological signs of rickets
Summary
Normal Growth
Approach to short stature
History, physical , investigations
DDx, Rickets
Examples of proportionate or
disproportionate short stature