Growth disturbances
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Transcript of Growth disturbances
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Growth disturbances
Knut Dahl-JørgensenUnit for Endocrinology and Diabetes
Pediatric Dept.Ullevål University Hospital
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Simple guidelines by short stature
• Examined by the doctor:– All children below 2.5 height percentile– All children decreasing more than two centile chanals
• Refer to Pediatric Dept. by increasing deviation• Enclose by referal :
– Family history (growth and puberty)– History of birth, development and diseases– Growth chart– Eventually Bone age and laboratory test results
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Differential diagnoses by short stature Constitutional Growth DelayFamily Short StatureCombination of the previousNutritional
HypocaloricChronic inflamatory bowel diseaseMalabsorption , Coeliac disease
EndocrineHypothyroidismGrowth Hormone DeficiencyHypopituitarismExcessive cortisolPrecosious puberty
Chromosome defectsTurner Syndrome
Maternal deprivation
Low birth weightSmall for gestagional agePrematurityFetal alcohol syndrome
Bone development disordersRicketsSceletal dysplasias
MetabolicKidney failureHypoxic, CardiacLiver diseasesInborn errors of metabolism
SyndromesNoonansAarskog
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Routine examinations 1
Family history growth and puberty, growth treatment, syndromes
NeonatalGetational age, birth weight, birth length, forceps, Hypoglycemia, hyperbilirubinemia, mikropenis
Gatrointestinal symptomsNeurological symptomsPsycosocial problems
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Routine examinations 2
• Physical examination– Height– Weight– Growth velocity (cm per year)– Tanner stages– Teticular volume– Dysmorphology (evt. sitting height, arm span)– Blood pressure– General physical examination – Neurological examination
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Routine examinations 3
Bone age and final height predictionClinical chemistry
– TSH and free thyroxin– GH, IGF-1, IGF-BP3– At puberty: LH, FSH, estradiol or testosteron– Coeliac screening– Hemoglobin, ferritin, CRP
Chromosomes (girls)Evt. Metabolic screen, liver, kidney, bone (PTH, Vit.D)
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Prediction of final height
Bone age estimation: Greulich & Pyle Atlas Prediction: Bailly and Pinneau Tables
Causion ! Variability in bone age estimation by different radiologistsGreat SD in reference materialTotal variability: Young child + 5 cm, Late puberty + 3 cmIf unpredicted early puberty: Height prediction will decrease.
Other method: Tanner Whitehouse
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Normal growth patterns
Normal early pubertyNormal late pubertyFamilial (genetic) short statureConstitutional delay of growth and pubertyObesity
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Pathological growth patterns
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Growth hormone deficiency
Clinical appearancePuppy childHypoplastic midface ?Evt. Hypoglycemia, hyperbilirubinemia, mikropenis
AuxologyDrop in height percentileGrowth velocity (cm per year) < 10 perc.Delayed Bone Age
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Causes of Growth hormone deficiency
CNS malformations (midline defects)HydrocephalusCNS injuries (birth, forceps)Meningitis, brain edemaCongenital infectionsHypothalamic or hypophyseal tumors Cranial radiationCongenital, genetic
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Indications for Growth hormone treatment
Main indicationGrowth Hormone Deficiency
Other indications:Turner SyndromeKidney failurePrader-Willi SyndromeSmall for gestagional age without catch-up growth ?
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Testing Growth hormone secretion
Physiological testsOne random samplePhysical activityContinuous overnight samplingContinuous 24 hours sampling
Stimulation tests (allways two tests)Insulin iv (hypoglycemia)Arginine ivGlucagone iv or imClonidine (oral)GHRH
IGF-1, IGF-BP3
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Growth hormone treatment
Daily subcutaneous injections
Injection pensDisposable prefilled syringesAutoinjection systems
Dosage: 0.033 mg/kg/day (0.1 U/kg/day)
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