How to approach a child with growth concern

Transcription

1 How to approach a child with growth concern Alaa Al Nofal, MD Assistant Professor of Pediatrics Pediatric Endocrinology Sanford Children Specialty Clinic

2 Nothing to disclose Disclosure

3 Objectives To understand the normal patterns of growth throughout childhood When to get concerned about the child s height How to evaluate a child with short stature? Management of short stature

4 When do children have the fastest rate of growth? 1) First year of life 2) Second year of life 3) Third year of life 4) 4 years-puberty 5) Puberty

5 When do children have the fastest rate of growth? 1) First year of life 2) Second year of life 3) Third year of life 4) 4 years-puberty 5) Puberty 25 cm/year 12 cm/year 8-10 cm/year 5-7 cm/year 8 cm/year for girls 10 cm/year of boys

6 Growth Velocity

7 14 year old girl, who is new to your practice, is coming to the clinic for a regular annual checkup Patient and her family have no concerns today Family reports patient has been growing along the 10 th percentile Patient has just had menarche

8 What is the next step in management: 1. Karyotype 2. Check TSH 3. Bone age 4. Bone age, TSH, FT4, IGF1, IGFBP3, MRI brain and referral to endocrinology 5. Plot her height on a CDC growth chart for girls

9 10 year old boy is coming to the clinic for a regular annual checkup He was seen by you 2 months ago for strep throat Patient and his family have no concerns today Patient has no signs of puberty on exam

10 What is the next step in management: 1. Dietician consult 2. Check TSH 3. Bone age 4. Bone age, TSH, FT4, IGF1, IGFBP3, brain MRI and referral to endocrinology 5. Recheck the child s height

11 Accurate height or length measurements are essential Inaccurate measurement or graph plotting is one of the more common causes of apparent growth failure

12 Measuring length and height Length: Used for children younger than 2 years of age When measured, the length should be plotted on the WHO growth chart for length At any age, measurement of length is approximately 1 cm greater than measurement of height

13 Measuring length and height Height: Height measurement is recommended for children over 2 years of life if possible When measured, the height should be plotted on the CDC growth chart for height

14 Measuring length and height Length: Recumbent position using calibrated lengthboard Fixed headpiece and movable footpiece Infant should be wearing disposable diaper with/without undershirt

15 Measuring length and height Height Movable head projection Hats/hair ornaments removed Head in line with head plate Horizontal axis of vision Measurer applies gentle traction beneath the jaw to maintain position Fixed measuring device attached to a wall Head, shoulders, buttocks and heels in contact with the vertical surface Shoes off Heels together

16 A 9 month old infant who was born to a diabetic mother is brought to the clinic for a well child checkup He has a history of transient hypoglycemia after birth Birth weight and birth length were both on the 90 th percentile He is currently on the 50 th percentile for length and 60 th percentile for weight He is healthy otherwise

17 What is the next step in management: 1. Dietician consult 2. Check TSH 3. Bone age 4. Bone age, TSH, FT4, IGF1, IGFBP3, MRI brain, abdominal US and referral to endocrinology 5. None of the above

18 It can be normal for young infants 0-6 months of age to cross percentiles on the weight or length curve Up to two-thirds of the infants at this age group are likely to cross 2 major weight for length percentiles Mei Z et al, Pediatrics. June 2004;113(6):e617-e627. Al Nofal A et all, Nut Clin Pract. Dec 2013 ;28(6):651-8

19 11 year old boy is new to your practice, coming for a well child checkup Mother reports that he has not been growing well He feels fine Past medical history is unremarkable Patient is pre-pubertal

20 What is the next step in management: 1. Dietician consult 2. Check TSH 3. Reassurance 4. MRI brain

21 Growth velocity is a more sensitive index of growth than is a single measurement Current growth measurements should be compared to previous growth measurements to determine the interval growth velocity

22 5 year old girl is coming with concern about short stature She has no symptoms Patient is pre-pubertal

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24 Mother is 5 8 and father is 6 3

25 Mid-parental height/target height Girls: Father s height + Mother s height 13 cm (5 in) 2 Boys: Father s height + Mother s height + 13 cm (5 in) 2

26 Mid-parental height/target height Our patient s mid-parental height: ( )/2 =69

27 What is the next step in management: 1. Dietician consult 2. Reassurance 3. Bone age 4. Follow up in 1 year Predicted midparental height

28 Assuming father s height is 5 7 and mother s height is 5 feet tall Mid-parental height: ( )/2 = 61 inches (5 1) What is the next step in management: 1. Dietician consult 2. Reassurance 3. Bone age 4. Follow up in 6 month Predicted mid-parental height

29 Projected height Projected height for a child is determined by extrapolating the child's growth along the current channel to the 18 to 20 year mark If the child s projected height is within 8.5 cm (3-4 inches) of the midparental height, then the child's height is within the expected range for the family If the projected height is more than 8.5 cm below the midparental height, then the child can be considered abnormally short for his or her family

30 14 year old boy is coming to the clinic today for concerns about short stature He used to be following the 25 th percentile on the height s growth chart until 11 years of age, but currently he is on the 5 th percentile Otherwise he is a healthy boy No signs of puberty Case presentation

31 What is the next step in management: 1. Dietician consult 2. Check TSH 3. Bone age 4. Bone age, TSH, FT4, IGF1, IGFBP3, MRI brain, abdominal US and referral to endocrinology 5. Insulin like growth factor 1 (IGF1) level

32 Teenagers with constitutional delay may appear to be crossing percentiles Bone age: Determined from a radiograph of the left hand and wrist Requires expert interpretations If the bone age is delayed or advanced, the projected height should be recalculated based on the bone age rather than the chronologic age Al Nofal A et all, Nut Clin Pract. Dec 2013 ;28(6):651-8

33 10 year old girl is coming to the clinic for a regular checkup Family is concerned about her growth She is a picky eater No signs of puberty

34 What is the next step in management: 1. Endocrine referral 2. Reassurance 3. Bone age 4. Detailed diet history, medications list and GI symptoms 5. Follow up in 1 year

35 10 year old girl is coming to the clinic for a regular checkup Family is concerned about her growth She eats well No signs of puberty

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37 What is the next step in management: 1. Endocrine workup 2. Reassurance 3. GI referral 4. Detailed diet history, medications list and GI symptoms 5. Follow up in 3 months

38 A pediatric endocrinologist is checking his patients schedule for next week A patient is scheduled to see him for obesity No outside records available except for a growth chart

39 The most likely cause of this patient s obesity is: 1. Severe hypothyroidism 2. Cushing disease 3. Genetic cause of obesity (Prader Willi syndrome) 4. Exogenous obesity

40 A pediatric endocrinologist is checking his patients schedule for next week A patient is scheduled to see him for obesity No outside records available except for a growth chart

41 The most likely cause of this patient s obesity is: 1. Cushing disease 2. Genetic cause of obesity (Prader Willi syndrome) 3. Exogenous obesity 4. Normal weight gain with start of puberty

42 3 year old child is brought to the clinic for concerns about obesity Past medical history is significant for hypotonia and feeding difficulty during infancy, for which he required G-tube Family now hides food from the child because he never seems to be full Patient has small hands and small feet

43 The most likely cause of this patient s obesity is: 1. Cushing disease 2. Genetic cause of obesity (Prader Willi syndrome) 3. Exogenous obesity 4. Normal weight gain

44 Short stature workup Before starting workup for patients with growth concerns, the following questions need to be answered: 1. Is the child short? 2. Is the child s height velocity impaired? 3. Is the child s growth within range for the family? 4. Is the child in puberty? (Is there evidence of delayed or accelerated growth?)

45 Differential diagnosis for short stature Short child + Normal rate of growth + short family + normal bone age Familial short stature Short child for his family + Normal rate of growth + delayed bone age Short child for his family + subnormal rate of growth + normal bone age Short child for his family + subnormal rate of growth + delayed bone age + normal weight gain Short child for his family + subnormal rate of growth + delayed bone age + poor weight gain Constitutional delay of growth and puberty Genetic cause of short stature (e.g. Turner s, Noonan Syndrome) Endocrine cause or systemic disease cause of short stature GI cause or systemic disease cause for short stature

46 Short stature workup Bone age CBC, CMP, ESR, CRP Celiac screen Thyroid function IGF1, IGFBP3 Growth hormone stimulation test Brain MRI Genetic testing

47 FDA approved indications for growth hormone Growth hormone deficiency Growth failure due to chronic kidney disease Growth failure in children born small for gestational age Prader-Willi syndrome in children Turner s syndrome Noonan syndrome Idiopathic short stature Short stature due to homeobox containing gene deficiency

48 Growth hormone adverse effects In addition to being a daily injections (or 6 days a week): Headaches usually benign Idiopathic intracranial hypertension Slipped capital femoral epiphysis Worsening of existing scoliosis Insulin resistance (low clinical significance) Rare adverse effects: Pancreatitis, transient gynecomastia, increase in the growth and pigmentation of nevi without malignant degeneration, etc? Cancer risk Cost!

49 Take home points When evaluating a child s height, it s crucial to accurately measure and plot the child s height The following information are needed when evaluating a child with growth concern: Current height Growth velocity Mid-parental height Pubertal stage Bone age is a tool that helps estimate the projected height Not every short child can be treated with growth hormone

50 Thank you Questions?