Download - Clinical Methods in Paediatrics
![Page 1: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/1.jpg)
Clinical Methodsin Paediatrics
DEPARTMENT OF PAEDIATRICS
CHINESE UNIVERSITY OF HONG KONG
![Page 2: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/2.jpg)
Methods in Clinical medicine
History prenatal, natal, postnatal development social allergy and drugs family hx, enviromental hx F/E
Physical examination + Investigations
![Page 3: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/3.jpg)
An example
Growth problem in paediatrics
![Page 4: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/4.jpg)
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.
![Page 5: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/5.jpg)
Questions
What is normal growth? Pattern ,
charts - normal reference
Normal variations of growth
![Page 6: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/6.jpg)
Questions
What is normal growth? Pattern ,
charts - normal reference
Normal variations of growth?
What influences normal growth?
![Page 7: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/7.jpg)
Growth Disorders - Physiology
Nutrition Diseases
Hormones Normal Growth
Genetics Puberty
![Page 8: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/8.jpg)
Normal Growth
Biological variations
Arbitrary: 3% - 97% = “Normal”
![Page 9: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/9.jpg)
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
![Page 10: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/10.jpg)
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
![Page 11: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/11.jpg)
Familial Short Stature
Family history - positive a height within the target height defined by
the parental size
![Page 12: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/12.jpg)
Target Heights
Ht (boy) = Ht (mom) + Ht (dad) +12
2
Ht(girl) = Ht (mom) + Ht (dad) -12
2
![Page 13: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/13.jpg)
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
![Page 14: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/14.jpg)
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
![Page 15: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/15.jpg)
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%
![Page 16: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/16.jpg)
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
![Page 17: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/17.jpg)
Skeletal Dysplasia
developmental defects of skeletal growth leading
to disproportionate short stature and deformity
> 200 types
e.g. Achondroplasia, most common 1/ 25000
![Page 18: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/18.jpg)
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
![Page 19: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/19.jpg)
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
![Page 20: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/20.jpg)
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
![Page 21: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/21.jpg)
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
![Page 22: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/22.jpg)
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
![Page 23: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/23.jpg)
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
![Page 24: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/24.jpg)
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
![Page 25: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/25.jpg)
Rickets
Clinical signs -stature, frontal bossing
wrist, bow legs , ribsBiochemical abnormalities:
Bone profile: Ca, phosphate, ALP
Radiological signs of rickets
![Page 26: Clinical Methods in Paediatrics](https://reader035.vdocuments.us/reader035/viewer/2022081501/56812c32550346895d90b4f6/html5/thumbnails/26.jpg)
Summary
Normal Growth
Approach to short stature
History, physical , investigations
DDx, Rickets
Examples of proportionate or
disproportionate short stature