Growth failure in Children.pptx

growth failure in children

1. Dr.Azad A Haleem AL.Mezori MRCPCH,DCH, FIBMS Assistant Professor University Of Duhok College of Medicine Pediatrics Department [email protected] Growth Failure in Children

2. Growth Growth refers to an increase in physical size of the whole body or any of its parts. It is simply a quantitative change in the child ’ s body. It can be measured in Kg, pounds, meters, inches, … .. etc

3. Development Development refers to a progressive increase in skill and capacity of function. It is a qualitative change in the child ’ s functioning. It can be measured through observation.

4. Introduction Growth failure is one of the most common presentation to a pediatrician . Most short children have physiological causes not requiring evaluation . The aim of evaluation of growth failure is to avoid unnecessary work - up in children with physiological causes while not missing a pathological cause . 

5. Definition Short child: Any child whose height falls below the 3rd centile for his/her community. Failure of physical growth The term ‘Dwarfism’ is no longer used for short stature Approximately 3% children in any population will be short .

6. PATHOPHYSIOLOGY  An understanding of growth physiology is of most importance for successful management of growth disorders .

7. GROWTH PATTERN: Growth is characterized by phases of rapid growth ( intrauterine , infancy and puberty ) interspersed with reduced growth ( childhood ) Maximum linear growth happens in the fetal period with increase of 50 cm . Fetal growth is regulated by intrauterine environment with limited impact of growth hormone and thyroxine . Infancy is associated with gain of 25 cm in first year and 12 cm in the second. Growth during this period is largely driven by nutrition .

8. Childhood growth contributes significantly to adult height and occurs at a steady rate of 5-6 cm per year . Puberty accounts for 20-25 cm of growth . Pubertal growth spurt starts at breast stage II in girls and testicular volume of 10 ml in boys and lasts for two years . It peaks at breast stage IV 6 months prior to menarche with a rate of 9 cm / year in girls and a testicular volume of 15 ml with a rate of 11 cm / year in boys . 

9. GROWTH REGULATION  Final height is determined by genetics explaining 60-80 % variation . Within this framework growth represents an interaction of nutrition and endocrine factors . Nutrition plays vital role in growth regulation . Type 1 nutrients ( vitamins , calcium , iodine and magnesium ) play a role in specific processes . There deficiency disrupts a unique facet with normal overall growth . Type II nutrients are the building blocks of body ( proteins , electrolytes , zinc , phosphorus and sulfate ) . Their deficiency causes global reduction in growth . 

10. ENDOCRINE REGULATION  Growth is regulated by the GHRH - GH - IGF1 axis with inputs from nutritional signals , sex steroids and thyroxine .  Growth hormone - IGF1 axis  Hypothalamic GHRH acts on pituitary to produce growth hormone . Growth hormone is secreted in pulsatile fashion with maximum release at night . Growth hormone acts on the liver to produce IGF I , which acts on the type I IGF receptor on the growth plate to induce growth . 

11. Nutritional influence  Malnutrition is a growth hormone resistant state with high GH and low IGF1 levels. GHD may therefore be missed in children with malnutrition . Overnutrition is a growth hormone sensitive state with high IGFI and low growth hormone levels . This may lead to erroneous diagnosis of growth hormone deficiency in obesity. Increased insulin in obesity stimulates growth by raising free IGF1 levels and acting on the type I IGF receptor .

12. CRITERIA  Growth failure evaluation is required for children who are: very short ( height less than 1st percentile) , short and not growing ( height between 1 to 3rd percentile and not growing at all ( crossing two or more major percentile lines between the age of 2 years and puberty ) . Growth velocity should be measured over a period of at least 6 months to one year with age specific cutoff for identification of disorder . 

13. ETIOLOGY  Growth is controlled by multiple factors and abnormality in any of these may cause growth failure .

14. Short child Six GOLDEN POINTS 1- Accurate & Serial measures. 2-Pubertal assessment  3- Mid Parental Height (MPH). 4- Height age. 5- Bone Age. 6- appropriates Investigations.

15. Important definitions Chronological age – Actual age of the child. Height age – it’s the age at which the height of the child is at 50 th centile. Bone age - is an indicator of skeletal maturation. Target MPH : F+M/2 +6.5 for boys and -6.5 for girls. Then plot the result on Growth Chart at Age 20 to form Family chart ±10 to form centile

16. Assessment of a child with short stature Accurate height measurement& height velocity Height plotted on appropriate growth chart.

17. Normal Measuring Supine length < 2 y of age For measurement of supine length it is best to use a firm box with an inflexible board against which the head lies, with a movable footboard on which the feet are placed. Erect height > 2 y The head is held in a horizontal plane Upward pressure is applied to the mastoid processes in order to encourage the child to stand up straight.

18.  Growth charts  The key aspects to look in a growth chart include absolute status compared to population ( percentile ) , effect of parental height ( growth chart for the family ) and relative impact on height and weight ( height age and weight age ) . Greater compromise of weight than height in a short child suggests nutritional cause ( malnutrition , infection , renal tubular acidosis or celiac disease ) while height is more affected in endocrine causes .

19.  Pubertal assessmen  

20.  Pubertal assessment  Breast stage II ( elevation of papilla ) suggests that a girl has entered puberty and marks the initiation of growth spurt . Thelarche should be differentiated from lipomastia by palpating breast tissue between thumb and index finger . Breast stage IV ( secondary mound ) and vaginal discharge predict menarche within the next six months . Post menarchal growth is limited to 5-8 cm .

21. First sign of puberty in boys is increase in testicular size followed by appearance of pubic hairs and increase in penile length and thickness . Pubertal onset is marked by a testicular volume of 4 ml with growth spurt starting at 10 ml . Importantly growth velocity is lowest just before the onset of puberty . This results in frequent presentation of prepubertal boys with short stature . Spermarche is a terminal event indicating limited growth potential . 

22. Mid parental height (MPH) Comparison with child’s own genetic potentia Mid parental height for boys MPH = mother's height + father's height /2 + 6.5cm Mid parental height for girls MPH = mother's height + father's height /2 – 6.5cm Then plot the result on Growth Chart at Age 20 to form Family chart ±10 ( 6 )

23. Family Chart Example: 3 Y – girl – Ht=85 cm --Wt=10 Kg Father Ht= 165 cm Mother Ht= 155 cm MPH= 160-6.5= 153.5 Plot on age 20 153.5 ±10 143.5 – 163.5 3 rd MPH= 153.5±10

24. Height age Height of a person at the 50 th percentile for their age.

25. Height age Examples: Girl- Age = 5 y Ht= 95 cm Height age= ?

26. Bone age assessment  X ray of the non - dominant ( conventionally left ) hand and wrist is used for bone age assessment . The fingers should be widely spread to allow visualization of all bones separately . Given the difficulties of formal bone age assessment for busy physicians , practical method has been devised to provide quick overview of skeletal maturation . This involves selection of area of interest , comparison of different areas and overall estimation of bone age . The Greulich and Pyle Method The Tanner–Whitehouse Method Computerized Automatic Systems 

27. Carpal bones are preferred in infancy ( up to 10 months in girls and 14 months in boys ) followed by phalangeal epiphysis ( till 2 years in girls and 3 years in boys ) . Comparison of the size of epiphysis to metaphysis is indicated in pre - puberty to early / mid puberty . Epiphyses are smaller than metaphysis till seven years of age in girls and nine years in boys . They become equal to metaphysis by 10-12 years , bigger beyond 12 years with capping and fusion by 14 years of age. Fusion of distal epiphysis is assessed during late puberty ( 13-15 years in girls and 14-16 years in boys with focus on long bones subsequently .

28. epiphysis to metaphysis

29. PHYSIOLOGICAL CAUSES  These represent the vast majority of children with growth failure . Their identification limits unnecessary work - up for causes of growth failure

30. Familial Short Stature  In contradistinction to CDGP , children with familial short stature have normal bone age and puberty . The disorder is characterized by early onset growth failure , family history of short stature , normal growth velocity and compromised final height . Consideration for genetic cause of short stature should be given if either of the parent is very short ( height below -3 SDS ) or has characteristic clinical picture.

31. Is she short? Example: 3 Y – girl – Ht=85 cm --Wt=10 Kg Father Ht= 165 cm Mother Ht= 155 cm MPH= 160-6.5= 153.5 Plot on age 20 153.5 ±10 143.5 – 163.5 Bone Age = normal 50 th 3 rd MPH= 153.5±10 Familial short stature

32. Constitutional Delay Of Growth & Puberty ( CDGP )  CDGP is one of the commonest cause of growth failure . It is due to delayed onset of puberty due to genetic factors . Growth is normal in the initial phase with faltering by seven years of age . The child remains behind his peers despite a normal growth rate . Final height is normal as bone age is delayed and growth continues for a longer period than other children . Family history of delayed puberty ( delayed menarche in mother ; delayed onset of shaving and continued growth in college years in father ) is present . CDGP is common in boys but also frequently observed in girls.

33. Is she short? Example: 5.5 Y – girl Ht= 98 cm --Wt=13 Kg Father Ht= 175 cm Mother Ht= 165 cm MPH= 170-6.5= 163.5 ±10 HT Age=3.5 years Bone Age=3.5 years 50 th 3 rd MPH= 163.5 ±10 Constitutional short stature

34. Is she short? Example: 5 Y – girl – Ht= 98 cm --Wt=15 Kg Father Ht= 175 cm Mother Ht= 165 cm MPH= 170-6.5= 163.5 ±10 HT Age=3.5 years Bone Age=1 year 50 th 3 rd MPH= 163.5 ±10 Pathological short stature

35. PATHOLOGICAL CAUSES 

36. Endocrine Causes  Endocrine causes of growth failure include hypothyroidism , growth hormone deficiency , pseudohypoparathyroidism and Cushing syndrome . These children have preserved weight with delayed bone age and puberty .  Hypothyroidism-  Pseudohypoparathyroidism Cushing syndrome GH - IGF1 axis disorders

37. ASSESSMENT  Key aspects of evaluation of a short child is to confirm short stature , exclude physiological causes , differentiate nutritional from endocrine etiology and identification of the cause .  IS IT PHYSIOLOGICAL OR PATHOLOGICAL?

38. Investigations  Screening tests include complete blood count, erythrocyte sedimentation rate Electrolytes, calcium , phosphorus and alkaline phosphatase blood sugar creatinine ( chronic kidney disease ) alanine transferase ( liver disease ) free T4 , TSH levels ( hypothyroidism ) celiac disease screening chest X ray blood gas ( renal tubular acidosis ) Karyotype with 50 metaphases should be done in short girls with no apparent abnormality on screening tests to identify Turner syndrome . 

39. Assessment of GH - IGF1 axis  GH - IGF1 axis evaluation should be done only after exclusion of all other causes of growth failure . Basal GH has no role in diagnosing GHD but can help in screening for GH resistance . Normal thyroid and cortisol levels are essential to elicit growth hormone response . 

40. Growth hormone stimulation test is considered the gold standard for identifying GHD . Sex steroid priming is recommended in girls older than 10 years and boy above 11 years who are pre - pubertal and have predicted adult height in the normal range . 17 beta estradiol ( Progynova , 2 mg for two days) can be used in both boys and girls .

41. Commonly used stimuli include: clonidine ( 5 mcg / kg to a maximum dose of 200 mcg ) , glucagon ( 30 mcg / kg with a maximum dose of 1 mg ) and insulin ( 0.1 unit / kg to induce hypoglycemia ) . Complete GHD is defined as peak stimulated growth hormone lower than 5 ng / mL and partial GHD as levels between 5-10 ng / ml . Children with abnormal response to one test should have another dynamic test to establish the diagnosis . 

42. GH dependent peptides  IGF 1 and IGFBP3 are secreted in response to GH and provide information about GH effect . These peptides are used for screening for GHD and monitoring response to GH therapy . IGF 1 is an unreliable marker before two years of age and in those with malnutrition and liver disease . IGFBP3 is a better marker of growth hormone status in younger children including neonates .

43. MANAGEMENT  General measures include nutrition ( protein , zinc , iron and calcium supplementation ) and physical activity . Specific measures include gluten free diet in celiac disease , alkali in RTA , thyroxine in hypothyroidism and supplements and infection control in cystic fibrosis .

44. MANAGEMENT  Growth hormone therapy is indicated in children with: GHD ( benefit of 20-25 cm ) , Turner syndrome ( 10-15 cm ) , SGA without catchup ( gain 7-10 cm ) , chronic kidney disease planned for renal transplant and Prader Willi syndrome with growth failure . GH therapy is being increasingly used in children with idiopathic short stature with height below 1st percentile .

45. THANKS FOR YOUR ATTENTION