Growth Charts (Kaulfers)

Kaulfers

You can see that the average height of boys and girls are about ___ inches (__ cm) apart.

5

13

Weigh a baby with only a _____ on

diaper

For children that are standing, measure the height ____ times and take the average

three

Most Important Feature of growth chart is the Growth ______

velocity 

Boy height velocity

Girls’ height velocity

Ages 5-puberty: __ cm/year is typical

5

Puberty: rapid growth again, ___ cm/year for boys and __ cm/year for girls.

10 

8

Infancy and childhood: very rapid growth, so you don’t “calculate” a growth velocity until after age _ years old

3

Boys stop growing around ___; Girls stop growing around ___

16

14

Height velocity: __ cm/year

Normal for most ages: ___-__ cm/year

During pubertal growth spurt: ___-__ cm/year

5

4-8 (about 2 inches)

8-12 (about 4 inches)

Things that warrant a medical evaluation:

• Poor height velocity (falling percentile lines)

• Height “below the curve” (below -2 SD for age)

• Height below the child’s genetic potential

95% of children will come within __ inches of this number for their final adult height

2

Girls height calculation

(Dad’s ht minus 5 inches) + Mom’s ht, divided by 2

Boys height calculation

(Mom’s ht plus 5 inches) + Dad’s ht, divided by 2

On curve, Falling percentiles, below curve 

Falling percentiles: Always worked up, could be brain tumor, growth hormone deficiency, hypothyroid, excess cortisol

Genetic potential aka

Mid-parental height

Target height

True Endocrine disease only accounts for __% of the causes of short stature

5

_________ is a major cause of short stature worldwide

Malnutrition

Most cases of short stature are either ______ short stature or _______ delay of growth (late bloomer)

familial 

constitutional 

If you are malnourished, the ____ will not work

GH growth hormone

Familial short stature 

• Normal Bone Age

• Normal Labs

• Growth curve is at the level of the Target Height

Familial short stature

Constitutional Delay of Growth

“Late Bloomer”

• Delayed Bone Age

• Normal Labs

• Poor growth, or growth along the bottom of the curve until the child hits puberty (after age 14 years usually) then has catch-up growth quickly and the adult height is equal to the target height

Constitutional Delay of Growth

“Late Bloomer”

Late bloomer child will have normal size at birth, and then fall to the bottom of the curve by __ years of age.

5

Some late bloomers can benefit from a short course of Testosterone therapy to induce the ______ changes – you can refer them to Endocrinology.

Pubertal

Constitutional delay of growth

Late bloomer 

Tallest Turner’s girl on average is

5 foot most well in 4 foot range

Need both Xs to get tall
Can benefit from growth hormone

Falls off around 5 years old

Growth Hormone deficiency

• Delayed bone age

• Height falling percentiles

• Height below target

• Weight percentile is more than height percentile for age

• Normal labs except low IGF-1 and low IGF-BP3

Growth hormone deficiency

Weight percentile is more than height percentile for age

Growth hormone deficiency

Growth hormone deficiency normal labs except low _____ and low _____

IGF-1

IGF-BP3

In 35% of growth hormone deficiency cases is due to brain _____or brain _____.

tumors 

radiation 

In 20% of the growth hormone deficiency cases are _______.

Congenital

Most cases of growth hormone deficiency are ______

Idiopathic

Growth hormone deficiency

Weight did not stop but height did

Growth hormone deficiency

GH tells the _____ to make IGF-1 and IGF-BP3

Liver

IGF-BP3 binds up most of the IGF-1 and gives it to the ______, so the ____ can grow

Bones

Before birth, and up to the first year of life, the body is not dependent on ___

Growth hormone 

GH in infancy controls _____ ____

Blood sugar

Usually due to hypopituitarism and can be associated with midline structural defects

Congenital growth hormone deficiency

Congenital growth hormone deficiency can be associated with ______ structural defects

Midline

(single central incisor, abnormal midbrain, nystagmus) 

low body temp, poor IQ, prolonged jaundice 

No TSH 

small penis, no palpable testes

No LH or FSH

low blood sugar, normal birth length

No GH

low blood sugar

No ACTH

usually high due to feedback issues in congenital growth hormone deficiency

Prolactin

If all hormones are normal except GH, growth failure won’t be noticed until age ___-__ years

2-3

Usually due to a brain tumor, traumatic brain injury, or possible ADHD or ADHD meds

Acquired Growth Hormone Deficiency

Common brain tumor that causes acquired growth hormone deficiency

craniopharyngioma

Normal growth until the tumor develops or until the brain injury occurred, or the meds were started, then will have progressive growth failure

“Falling percentile lines”

Acquired growth hormone deficiency 

Tumors can cause complete hypopituitarism, but usually it just knocks out ___

GH

Short stature, delayed bone age, low IGF-1, REALLY, REALLY HIGH growth hormone levels on a stimulation test

Laron’s dwarfism

Treated with pure IGF-1, called Increlex

Acquired Hypothyroidism

Other Endocrine Cause of Growth Failure

Most common cause of hypothyroidism is

Hashimoto’s hypothyroidism

Hashimoto’s hypothyroidism 1-2% of children, with females being __ times more likely to get this condition

4

Children will usually NOT have the typical symptoms of fatigue and weight gain

Growth Failure may be the only symptom

Acquired hypothyroidism most commonly Hashimoto’s hypothyroidism

High TSH low thyroid levels

Acquired Hypothyroidism

either from taking high dose oral steroids too long or from a tumor, called Cushing’s syndrome

Glucocorticoid Excess

Other Endocrine Cause of Growth Failure

can be from an ACTH-producing brain tumor or a primary adrenal tumor

Cushing’s syndrome

Growth failure, truncal obesity with thin limbs, round facies, “buffalo hump”, delayed puberty, striae, easy bruising, glucose intolerance, osteoporosis, high blood pressure.

Cushing’s syndrome

Diagnose with a 24-hour urine for free cortisol

Cushing’s syndrome

The growth chart will look identical to someone with growth hormone deficiency or acquired hypothyroidism.

Cushing’s syndrome 

The receptor on bones that waits for IGF-1 so it can grow is the same shape as an insulin receptor. So the excess insulin pretends to be IGF-1 and tells the bones to grow

Too much insulin too many carbs

Too much insulin will cause too much growth and your bone age will advance so fast that you will go into _____ early and fuse your growth plates early, so you will end up being ____ as an adult

puberty

short

A tall overweight child

needs to go to a dietician

over nutrition

A short overweight child

needs to go to Ped Endo

A short thin child

needs to go to Ped GI

Malnutrition

Things that medication can’t fix:

If you were born early/preterm

Genetic syndromes – Down’s

Short parents (Familial short stature)

Poor social situation – Psychosocial dwarfism

Weird bones – Scoliosis, achondrodysplasia

Late bloomer (Constitutional delay of growth)

Adopted kids that did not get love 

Psychosocial dwarfism  

poor weight AND poor height

Reasons for not growing that are not hormone related

• Celiac disease – gluten allergy

• Liver or kidney disease

• Heart or lung disease – cystic fibrosis

• Stomach problems

  • Inflammatory bowel, Crohn’s, food allergies, “short gut”, etc

Endocrine causes of growth failure:

poor height but INCREASED weight

Thyroid hormone deficiency

Growth hormone deficiency

Syndrome of excess cortisol (Cushings)

Problems that qualify for growth hormone therapy:

Turner’s syndrome, Noonan’s syndrome, Kidney disease, AIDS wasting, Prader-Willi syndrome, SHOX deficiency, SGA, idiopathic short stature

Upper body is longer than lower body until age __, then it should be equal

10

Arms are shorter than body before age 10-11 years, then it is arms are equal to the body from age 10-__ years, then after age __ years, arms are longer than the body.

14

Men’s arms are ___ cm more than their height, and girls arms are ___ cm more than their height

5

1.2

palmer crease, Trisomy 21

Down’s syndrome

Short 4th metacarpal, wide arm carrying angle, low posterior hairline, high arched palate, wide spaced nipples, webbed neck, very curvy nails

Turner’s syndrome – 45 X,O

Incurving of the fifth finger, small triangular face, one limb bigger than the other

Russell-Silver syndrome

Diagnostic algorithm 

Lab work for short stature 

•Bone age xray

•CBC with differential (edema, chonic disease), ESR (inflammatio) , chem-14 (liver), Total IgA and TTG IgA (celiac)

•TSH and Free T4, IGF-1 and IGF-BP3

•Can’t measure “growth hormone” levels, because it is secreted in a pulsatile fashion

• Child has evidence of growth failure

• Delayed bone age

• Normal labs except low IGF-1 and IGF-BP3

Next step:

GH stimulation test

It’s the only way to actually measure growth hormone, since it is pulsatile in secretion

• Give 2 drugs while fasting: clonidine, L-dopa, arginine, glucagon, insulin, or exercise

• Measure GH levels every 30 minutes for 3 hours

• If GH levels don’t get above 10 ng/ml, you are diagnosed with Growth Hormone Deficiency

GH stimulation test

Craniopharyngioma

Craniopharyngioma

Growth hormone, or ______, is given by a SQ injection once a day

Somatotropin

Cost of growth hormone

It costs $100 per milligram

Most kids are on 1-2 mg per day

This is $100 a day, minimum

That is $3000 a month, minimum

$36,000 - $72,000 a year per child

Some insurance plans – patient pays 20% of the cost of the drug ($600-1000/month cash)

__ causes all body tissues to grow faster

GH

Prostate and Breast Cancers have high levels of ____

IGF-1

Side effects of GH therapy

• Headaches “Pseudotumor cerebri”

• Joint pain

• Diabetes

• Worsening scoliosis

• Decrease fat mass

• Increased muscle mass

GH deficiency in adults (usually from a brain injury, such as a car crash)

• If they can make a little bit of GH, they will be okay, but if they have absolutely no GH, then they do have other medical problems

• They get excess fat, have very little muscle mass (weak and tired), weak bones (fracture), poor heart health (high cholesterol, high triglycerides, high LDL, low HDL)