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DISORDERS OF GROWTH AND DEVELOPMENT
BY : DR SANJEEV
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Developmental DelayEvaluation
History Family history, perinatal history, medical
illnesses, environmental factors Physical exam
Growth chart, congenital anomalies, muscle tone, vision, hearing
Labs if indicated Chromosomal studies, metabolic studies,
EEG, MRI of brain
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Short Stature
Definition: Less than 5th percentile for height or deceleration of previously normal growth curve (growth of less than 5cm per year)
Most cases (80%) are due to normal or non-pathologic causes; 20% are due to pathologic abnormalities
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Short Stature: Non-pathologic Familial short stature
Normal bone age and normal growth velocity
Puberty occurs at expected time Final height is usually less than 5th
percentile Constitutional delay
Delayed bone age (consistent with height age) and normal growth velocity
Puberty is significantly delayed
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Short Stature:Pathologic
Pathologic causes usually present with diminished growth velocity
Proportionate (affects all bones) or disproportionate (affects long bones predominantly)
Identify and treat underlying cause Growth hormone injections are
helpful in growth hormone deficiency
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Short Stature:Pathologic (Cont’d)
• Proportionate short stature:– Growth hormone deficiency– Primary hypothyroidism– Cushing’s Syndrome– Precocious puberty– Malnutrition– Chronic systemic diseases
• Disproportionate short stature– Rickets (Vitamin D deficiency)– Achondroplasia( short limbs but normal
trunk )
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Colic
Crying more than 3 hours/day, 3 days/week over 3 weeks Usually early evening;
Occurs in about 1 out of 5 babies Starts within first few weeks Peaks at 2-3 months 30-40% continue into the 4-5th month
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Colic – Suggested Causes
Intolerance to cow’s milk protein Intestinal gas Abnormal GI motility Immature GI or neurological systems Caregiver factors
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Colic:Treatment Colic typically stops as
mysteriously as it starts Symptoms resolve 60% by 3
months, 90% by 4 months Most interventions work in 1/3
of infants; no treatments work for all
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Colic:Treatment (Cont’d) Maternal diet – no milk, eggs, nuts,
wheat; particularly if mother atopic Feeding techniques – vertical position
with curved bottle Parental support – important but doesn’t
colic Anticholinergic drugs {dicyclomine
(Bentyl)} associated with harm – apnea, seizures, coma
Peds 10
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Childhood Obesity
BMI >95th percentile for age (>85th percentile is “at risk”)
Weight to height ratio >95th percentile
>120% of ideal body weight for height and age
30% of adults and 14% of children
Peds 11
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Childhood Obesity (Cont’d)• Primary obesity - cause for >95%
of obesity – Excess calorie intake and/or decreased
activity– Usually normal or increased height for
age• Secondary obesity – extremely rare
– delayed height growth rate– Causes: hypothyroidism,
pseudohypoparathyroidism
Peds 12
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Childhood Obesity (Cont’d)• Primary obesity - cause for >95%
of obesity – Excess calorie intake and/or decreased
activity– Usually normal or increased height for
age• Secondary obesity – extremely rare
– delayed height growth rate– Causes: hypothyroidism,
pseudohypoparathyroidism,
Peds 13
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Childhood Obesity:Evaluation
History: developmental history, parental weights, lifestyle information
Exam: measurement of height/weight, body mass index,
Labs: consider if secondary obesity
Peds 14
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Childhood Obesity (Cont’d) Common complications:
hypertension, hyperlipidemia, type 2 diabetes
Associated disorders: slipped capital femoral epiphysis, obstructive sleep apnea
Obesity is second only to tobacco use for contribution to preventable premature death in adults; may be 1 by 2010
Peds 15
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Childhood Obesity:Management
Behavioral and life style modification Goal in children is slowing weight
gain while allowing normal growth in height
Child and family need to work together to improve eating habits and increase activity
Include counseling or support groups to develop a healthy body image
Peds 16
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Peds 17
Nocturnal Enuresis Primary
Never been persistently dry through the night
Much more common and less likely to have a pathologic cause
Secondary Child starts wetting the bed after one
year of continence Multiple causes: UTI, small bladder
capacity, anatomic abnormalities
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Peds 18
Primary Nocturnal Enuresis: Diagnosis Children >5 who are incontinent of urine
at night Estimated 15-20% of children have some
degree of enuresis Spontaneous resolution is 15% per year
At age 15, only 1-2% still wet the bed
Obtain complete history and physical Other causes must be ruled out
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Peds 19
Nocturnal Enuresis: Treatment Behavioral interventions
Limiting intake of fluids in the evening Age appropriate responsibility for clean-up
Bed-wetting alarms Superiority in terms of cure rates, lack of
side effects and low relapse rates Medications - sometimes indicated
Imipramine (Tofranil) and desmopressin (DDAVP)
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Peds 20
Attention Deficit/Hyperactivity Disorder (ADHD) Diagnosis & etiology
Prevalence is 3-5% of school age children Four times more common in boys than girls Problem persists into adulthood for 40-60%
of children Diagnosis is clinical
Based on history, parent and teacher reports and observation
Must rule out other causes of behavior
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Peds 21
Attention Deficit/Hyperactivity Disorder (ADHD) (Cont’d) Diagnostic criteria (DSM-IV)
Either inattention or hyperactivity/impulsivitySix months duration
Onset no later than age 7 Symptoms in two or more settings
(e.g., school and home) Significant impairment in functioning
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Peds 22
Learning disorders
Conduct disorders
Substance abuse
Anxiety disorders
Affective disordersADHD
Co-Morbidity of ADHD
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Peds 23
Attention Deficit/Hyperactivity Disorder (ADHD): Treatment Medications (psychostimulants)
Alter deficits in inattention, impulsivity, and hyperactivity
Behavioral management Restructuring demands on child and
changing environmental
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Peds 24
Autism Markedly impaired development in
social interaction Markedly impaired communication skills Restrictive, repetitive or stereotyped
behavior, interests or activities Onset prior to age 3
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Clinical feature: Inability to develop normal social skill with lack of eye contact , gesture and facial expression
They understand little or no language Have deficient comprehension and
communicative use of speech and gesture. Etiology : Prenatal factors : intrauterine
rubella ,chromosomal abnormalities. Postnatal condition : phenylketonuria ,
herpes simplex encephalitis
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Management : Early and intensive remedial education that addresses both behavioral and communication disorders.
Drug treatment : Dopamine antagonist (haloperidol) Selective serotonin reuptake inhibitor
(fluroxamine) Prognosis : Children starts to acquire language.
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FAILURE TO THRIVE : Is a term given to infants whose rate of
weight gain is sluggish. Length may or may not be affected Causes : Intrinsic causes: Defects in absorption : celiac disease ,
lactose intolerance , cystic fibrosis. Persistent vomiting : pyloric stenosis ,
gastroesophageal reflux. Metabolic disorders : diabetes mellitus Chronic diseases : heart , lungs , liver and
kidney
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Cont.. Extrinsic causes : Inadequate nutritional intake Social and environmental deprivation or
both . C / F : Looks small for age Weight is below 3rd percentile Expressionless face and avoids direct gaze Response to social stimuli is inadequate.
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Investigation :
Complete blood count Electrolytes Blood urea
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MANAGEMENT : Immediate treatment : Hospitalize for the first 10- 14 days History (dietary and developmental) Physical examination should be done Nutritional problems need to be
appropriately manage Feeds should be thickened to increase the
calorie intake Infant should be fed in the semi upright
position.