Post on 16-Dec-2015
PEDIA
TRIC
S SEMIN
AR
PR
ES
ET
ED
BY :
F AH
D A
L AR
EA
SH
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.
Sta
ture
Weig
ht
H.C
.
Wt-
for-
Ht
.
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 APP
ROACH TO
SHORT S
TATU
RE
PR
ES
ET
ED
BY :
F AH
D A
L AR
EA
SH
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
CHART
S
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.
Sta
ture
• Short stature with normal growth rate and delayed growth spurt with eventual achievement of normal adult stature.
“ CONSTITUTIONAL GROWTH DELAY “
Sta
ture
•Normal growth rate.• Short stature in childhood.•Short stature in adults.
“ Familial Short Stature“
Sta
ture
“ Acquired Pathologic Short Stature“
SPECIA
L TYP
ES O
F GROW
TH
• special growth charts
available for these conditions.
• These children grow along
percentiles specific to their
condition.
Turn
er s
yndro
me,
A
chon
dropla
sia,
Down s
yndro
me
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:
SHORT S
TATU
RE
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
STA
TURE
ASSESSMENT
His
tory
Tak
ing
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
Physic
al E
xam
inat
ion
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
In
vest
igat
ions
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
END
.…