PEDIATRICS SEMINAR

P R E S E T E D BY : F

A H D AL A R E A S H I &

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CASE SCENARIO:

• A 10-year-old girl presents to the clinic with her parents.

• Her parents report that she is the shortest in her class.

• However, they have become concerned because her 8-year-old sister is now the same height as she is.

• The patient has not yet attained menarche and her mother reports no breast development.

• She has been well with no chronic medical problems, no hospitalizations, and no surgeries.

CASE SCENARIO:

• She lives with her mother, father, and sister .

• She is currently in the fifth year elementary school and she always scores grade A.

• Her mother is 173 cm (5'8") and weighs 68 kg (150 pounds). She had menarche at age 12.

• The patient's father is 185 cm (6'1") and weighs 95 kg (210 pounds).

• There is no family history of any medical problems.

CASE SCENARIO:

• On further history, you find that your patient was 43 cm (17 inches) long at term (average is 49.5 cm, 19.5 inches).

• P/E:• General:

• Conscious.• Looks girl.• No apparent distress.

• Vital signs:• Temperature: 37◦ C.• Pulse: 90 bpm.• BP: 100/60 mmHg.• RR: 18 breaths/min.

CASE SCENARIO:

• P/E:

• Growth Parameters:• Height: 120 cm.• Weight: 23 Kg.• Head Circumference: 52 cm.

Stat

ure

Wei

ght

H.C

.

Wt-f

or-H

t.

CASE SCENARIO:

• P/E:

• Head & Neck:• Neck is supple and webbed. • Low posterior hair line.

• Chest:• Heart: Normal S1 & S2, No additional sound.• Lungs are clear.

• Abdomen:• Soft.• No masses.

CASE SCENARIO:

• P/E:

• Breast:• Tanner I.• Wide spaced nipples are evident.

• Pubic Hair:• Tanner I.

CASE SCENARIO:

• INVESTIGATIONS:

• Her growth chart is reviewed which demonstrates:• an average growth velocity: 3cm/year.

• Bone age:• 8 years & 6 months.

• CBC: normal.• ESR: normal.• TFT's: normal.• UA: normal.• Serum electrolytes: normal.

CASE SCENARIO:

• INVESTIGATIONS:

• Chromosomal analysis:• 45 XO.

• ► Diagnosis of Turner Syndrome is made.

• She is referred for a renal ultrasound, cardiology evaluation, and a hearing screen.

• She is also seen by the pediatric endocrinologist and is started on growth hormone.

AN APPROACH TO

SHORT

STATURE

P R E S E T E D BY : F

A H D AL A R E A S H I

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

SHORT STATURE:

• A child whose height is below the 3rd percentile for age and sex.

GROWTH FAILURE:• Slow growth rate regardless of the

stature.

• Ultimately, a slow growth rate leads to short stature.

•A Growth Chart is used to show:• A child's current height.• Growth Velocity : how fast the child is growing.

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

GROWTH CHARTS

GROWTH CHARTS:• Growth charts are a standard part of

any checkup.

• They show health care providers how kids are growing compared with other

kids of the same age and gender.

DIFFERENT TYPES OF GROWTH CHARTS:

Weight-for-Age Height-for-Age

HC-for-Age

MALEGROWTHCHARTS

Weight-for-Height

FEMALEGROWTHCHARTS

DIFFERENT TYPES OF GROWTH CHARTS:

Weight-for-Age Height-for-Age

HC-for-Age

Weight-for-Height

GROWTH CHARTS:• Assessment:

•Short Stature: Height < 3rd percentile.

•Growth Failure:• Height crossing 2 major percentiles.

•Low growth velocity: Rate < 25th percentile.

Stat

ure

• Short stature with normal growth rate and delayed growth spurt with eventual achievement of normal adult stature.

“ CONSTITUTIONAL GROWTH DELAY “

Stat

ure

•Normal growth rate.• Short stature in childhood.•Short stature in adults.

“ Familial Short Stature“

Stat

ure

“ Acquired Pathologic Short Stature“

SPECIAL T

YPES OF G

ROWTH

• special growth charts available for these conditions.

• These children grow along percentiles specific to their condition.

Turner

syndrom

e, A

chon

droplas

ia,

Down sy

ndrome

MID-PARENTAL HEIGHT:• Children are usually in a percentile between their

parents' height.

• The Expected Height of the child as adult lies between ± 5 cm from the Mid-parental age:

Girls:

= 2

Boys:

= [Mother’s Height + Father’s Height + 13]

[Mother’s Height + Father’s Height - 13]

2

CAUSES OF:SH

ORT STAT

URE

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

CAUSES:

Normal Variants

Pathologic

CAUSES:

Normal Variants

Pathologic

CAUSES:

Normal Variants

• Most common.

• Normal Growth Velocity.

• Non Pathologic.

CAUSES:

Normal Variants

Familial Short Stature

Constitutional Growth Delay

CAUSES:

Normal Variants

Familial Short Stature

• Short parents.

•Born short.

•Bone age (X-ray): Chronological age.

•Puberty occurs at time.

•No treatment is indicated.

CAUSES:

Normal Variants

Constitutional Growth Delay

• Bone age is delayed.

•Puberty is delayed.

•Hx. of delayed puberty in parents.

•Normal adult height.

•May require short term therapy with

androgens/estrogens.

CAUSES:

Normal Variants

Pathologic

CAUSES:

Normal Variants

Pathologic

CAUSES:Pathologic

Prenatal “ Primordial“

Postnatal

CAUSES:Pathologic

Prenatal “ Primordial“

•IUGR.•Chromosomal: Down syndrome, Turner syndrome.•Skeletal dysplasia.

•All parameters are affected; Height, weight, & head circumference.

Proportionate

CAUSES:Pathologic

Postnatal • Endocrine:• GH deficiency.• Hypopituitarism.• Cushing

syndrome.

• Chronic Diseases:• Cyanotic

congenital heart diseases.

• Celiac diseases, IBD, cystic fibrosis.

• Chronic infections.

• Chronic renal failure.

• Psychosocial neglect:

Height > Weight“Short & Fat”

Weight > Height“Short & Skinny”

Weight & Height are decreased

Proportionate

CAUSES:Pathologic

Postnatal

• Achondroplasia.• Rickets.• Hypothyroidism.

Disproportionate

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

APPROACH & ASSESSMENT

OF:SHORT

STATURE

ASSESSMENT

Hist

ory Ta

king

HISTORY:• Antenatal History:

• IUGR?• Any complications: pre-eclampsia, hypertension, anemia,

maternal history of smoking, alcohol & infections, drugs?

• Delivery:• Gestational age?• Mode of delivery?• APGAR score.• Complications?• Hypoglycemia.

HISTORY:• Nutritional History?

• Symptoms suggesting systemic chronic diseases:• Dyspnea?• Sweating with feeding?• Recurrent respiratory infection?• Chronic diarrhea?• Fatigue, cold intolerance? “hypothyroidism”• Recent weight gain, acne, mood swing? “Cushing”

HISTORY:• Syndromes?

• Down syndrome, Turner syndrome?...

• Family History?• Short stature?• Chronic illnesses.• Neglect? Starvation?

HISTORY:• Drug History?

• Corticosteroids?• Insulin?

• Development History?• Delayed?

• Systemic Review:• A complete review of systems needs to be undertaken in order

to help exclude an undiagnosed syndrome or chronic medical condition

ASSESSMENT

Physica

l Exa

mination

PHYSICAL EXAMINATION:• Vital Signs.

• Anthropometric Measurements:• Height:

• Plotted on growth chart.• Height velocity growth chart in the 6 – 12 months.

• Nutritional Assessment:• Mid arm circumference.• Weight for age and weight for height.

PHYSICAL EXAMINATION:• Vital Signs.

• Anthropometric Measurements:• Proportionate / Disproportionate:

• Upper / lower segment ratio.• Arm span minus Height.

PHYSICAL EXAMINATION:• Vital Signs.

• Anthropometric Measurements:

• Calculate Mid-parental Age:

Girls:

= 2

Boys:

= [Mother’s Height + Father’s Height + 13]

[Mother’s Height + Father’s Height - 13]

2

PHYSICAL EXAMINATION:• Dysmorphic Features?

• Down Syndrome? Turner Syndrome?• Single palmar crease, webbed neck, low hairline,..• Moon face “Cushing”?

• Puberty Assessment (Tanner Staging):

• Examinations for systemic illnesses.

ASSESSMENT

Inve

stigati

ons

INVESTIGATIONS:• Bone age.

• Wrist X-ray for rickets:

• Skeletal survey for skeletal dysplasia:• a series of X-rays of all the bones in the body, or at least the axial

skeleton and the large cortical bones.

• Karyotyping.

INVESTIGATIONS:• Ca, P, Alkaline phosphatase.

• LFTs, RFTs.

• ESR.

• Sweat chloride test for cystic fibrosis.

INVESTIGATIONS:• Endocrinal studies:

• T4, TSH,

• GH:• Basal level.• Level after pituitary stimulation: exercises, clonidin or arginin.

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

SHORT STA

TURE

• Definition

• Growth Charts

• Causes

• Approach

• Management

Outlines

MANAGEMENT

MANAGEMENT:• Non-pathological short stature:

• No treatment is required.

• Pathologic short stature:• Manage the underlying cause.• Growth Hormone GH:• GH Therapy if the following criteria are met:• GH shown to be deficient by 2 different stimulation tests.• Patient is short, insufficent growth velocity, <3rd percentile.• Bone age x-rays show unfused epiphyses• Turner syndrome, Noonan syndrome, chronic renal failure.

THE E

ND

.…