20 - growth, puberty and paediatric problems

how is normal growth measured

length and height

head circumference (routine in children <2years)

puberty staging

bone age

growth velocity

tanner staging of puberty

B 1-5 = breast development

G 1-5 = genital development

PH 1-5 = pubic hair

AH 1-3 = axillary hair

T 2-20ml = testosterone

factors affecting height

age

sex

race

nutrition

parent height

puberty

bone age

general health

bone/growth disorders

socio-economic status

emotional wellbeing

what are the most important pubertal stages

tanner B2 in girls - breast budding

tanner G2, T3-4ml in boys - testicular enlargement

indications for referral for diagnosis of growth disorders

extreme tall or short stature off centiles

height below target

abnormal height velocity - crossing centiles

history of chronic disease obvious dystrophic syndrome

early/late puberty

causes of short stature

familial

constitutional

SGA/IUGR (Small for Gestational Age), (Intrauterine Growth Restriction))

pathological causes of short stature

under nutrition

chronic illness - Juvenile Chronic Arthritis, IBD, coeliac

iatrogenic - steroids

psychological and social

hormonal e.g. GHD, hypothyroid

turner syndrome

Prader willi syndrome

noonan’s syndrome

achondroplasia

early and late puberty in boys

early <9yrs

late >14 yrs

early and late puberty in girls

early <8yrs

late >13yrs

what is constitutional delay of growth and puberty (CDGP)

a disorder affecting mainly boys with a family history in dad or brothers

- bone age delay

-need to exclude organic disease

causes of delayed puberty

constitutional delay of growth and puberty

gonadal dysgenesis - Turner, Klinefelter

chronic disease - crohns and asthma

impaired HGP axis - (septo-optic dysplasia, craniopharyngioma, kallman’s syndrome)

peripheral - (cryptochidism, testicular irradiation) 

causes of early breast development

infantile thelarche - breast tissue development under 3

thelarche variant - Breast development without pubic or axillary hair and accelerated growth velocities or advanced bone age.

true central precocious puberty

causes of early secondary sexual characteristics

exaggerted adrenarche - early activation of adrenal androgen production, causing signs like pubic hair, body odor, and oily skin in young children

precocious pseudopuberty - abnormal sex steroid hormone secretion

causes of early PV bleeding

premature menarche

what is central precocious puberty

early puberty, gonadotrophin dependent

- breast development and testicular enlargement

what causes central precocious puberty

girls

- idiopathic, can do pituitary imaging

boys

- usually underlying cause like brain tumour

management of central precocious puberty

GnRH agonists

what is precocious pseudopuberty

abnormal sex steroid hormone secretion

• gonadotrophin independent

• development of secondary sexual characteristics

• Virilising or feminasing  

what do you do to exclude pathological source in precocious puberty

urine steroid profile

ambiguous genitalia management

do not guess sex of baby

- MDT approach

- examination of gonads/internal organs

- karyotyping

- exclude congenital adrenal hyperplasia as risk of adrenal crisis in first 2 weeks (life threatening)

endocrine problems seen in paediatrics

congenital hypothyroidism

acquired hypothyroidism

thyroid deficiency

obesity

causes of obesity in children

growth hormone deficiency

hypothyroidism

Down's syndrome

Cushing's syndrome

Prader-Willi syndrome

Laurence-moon-biedl syndrome  

Pseudohypoparathyroidism type 1 

diabetes

drugs

syndromes

hypothalamic damage

what drugs cause obesity

insulin

steroids

anti-thyroid drugs

sodium valproate

tx of obesity

diet

exercise

psychological input

what is simple obesity

obesity related to excessive nutrition

lack of physical activity

poor balance between intake and outtake

family history of obesity  

if a child is obese + short

abnormal

spot and refer quickly

pathological cause might require specific treatment

overweight value

BMI >85th centile or

Standard Deviation >1.04 

obesity value

BMI >97.5 centile or SD >2 

how to assess a child for obesity

weight, height and BMI (plotted in chart because BMI varies with age as a child) 

what congenital hypothyroidism is

causes

no thyroid gland or not working thyroid gland

athyreosis/hypoplastic ectopic (thyroid dysgenesis, error embryologically)

physical complications of obesity on childhood growth

slipped capital femoral epiphysis and tibia vara

what chart types are used until age 4 for growth

WHO standard

what chart types are used after age 4 for growth

UK90 reference

what chart types are used for older children for growth

RCPCH UK 2-18

what should growth be compared against

mid-parental height and target centiles

normal growth pattern

infantile phase - rapid growth following birth

childhood phase - steady period of growth

pubertal phase - growth spurt and development or secondary sexual characteristics