Growth - Paediatrics

Growth

·        Growth velocity = change in height over time. Declines till about 4, levels out, spike at puberty then zero 

·        Factors influencing growth:

o  Genetic potential

o  Psychosocial factors (eg psychosocial dwarfism)

o   Nutrition (including in utero): adequate calories, balance of nutrition 

o   Diseases in major systems: uses energy (eg ­ respiratory effort) and nutritional effects (eg GI)

o   Hormones and Growth factors

·        Measurement:

o   Method: Use stadiometer, fixed to wall, feet together, knees straight, lift mastoid processes

o   Accuracy and reliability: 

§  SD of a single measurement ~ 0.25 cm. In a 5 year old this can cause a range in growth velocity from 10^th to 50^th centile 

§  Taller in morning than at night 

o   Minimising error: Same measurer, calibrate regularly, careful measurement, don‟t look at last measurement, measure at beginning and at end of exam

Short Stature

·        Definition:

o   > 2 standard deviations below the mean = below 5^th centile 

o   Reduced growth velocity

·        Exclude failure to thrive

·        Growth pattern is more important than height

·        Normal variants:

o   Familial (genetic) short stature

o   Constitutional delay of growth and development.  Presents mid to late childhood 

·        Pathological causes:

o   Systems: eg subclinical GI or renal disease (reflux, coeliac, malabsorption, CF, etc)

o   Psychosocial

o   Genes:

§  Turner syndrome: webbed neck, wide nipples, wide carrying angle

§  Skeletal dysplasia: eg achondroplasia

§  Syndromes

o   Hormones: Thyroid or GH deficiency, glucocorticoid excess

o   Drugs: Steroids

·        Assessment:

o   History:

§  Height: measured accurately and over time 

§  Mid-parental height: assessment of genetic potential (adjusted so both parents are same sex as child. Male = female + 13 cm or average their centiles) 

§  Family history: eg constitutional delay

§  Systems

§  Psychosocial

§  Development

o   Examination:

§  Growth parameters 

§  Dysmorphic features ® ?syndrome 

§  Proportions: limbs vs trunk, eg arm span vs height, or upper segment (head to pubic bone) vs lower segment (pubic bone to floor)

§  Blood pressure (?renal disease)

§  Fundi and visual fields (?pituitary tumour)

§  General

o   Investigations:

§  Bone age: accurate to about 3 months 

§  Specific depending on history/exam, eg renal ® creatinine, coeliac ® antibodies

§  Karyotype in girls

·        Treatment:

o  Treat cause

o  Growth hormone:

§  Effective in GH deficiency and Turner‟s syndrome 

§  May help in chronic renal failure, intrauterine growth retardation and severe idiopathic short stature

o  Androgens: consider in constitutional delay – won‟t influence final height but get there faster.

Tall Stature

·        Arbitrary definition

·        Associated stigma (females more often seek help)

·        Causes:

o  Familial/genetic

o  Over-nutrition

o  Syndromes (eg XXY, Marfan‟s, Homocystinuria) 

o  Precocious puberty (tall early, but stop growing ® eventually short)

o  Growth hormone excess is extremely rare

Growing Pains *

·        Occurs frequently: 15% of children with peak age of 11 

·        Diagnosis of exclusion – no organic pathology usually found. ?Child more vulnerable to pain and stress-induced exacerbations

·        Occurs at least monthly for a three-month period.  Between times the child is well

·        Differential:

o  Orthopaedic disorders

o  Collagen vascular disease

o  Infection

o  Neoplastic disorders

·        Management:

o  Reassure, even if you can‟t find a cause

o  Symptom diary (also check for psycho-social stressors)

o  Symptomatic relief