Clinical Methodsin PaediatricsDEPARTMENT OF PAEDIATRICSCHINESE UNIVERSITY OF HONG KONG
Methods in Clinical medicineHistoryprenatal, natal, postnataldevelopmentsocialallergy and drugsfamily hx, enviromental hxF/EPhysical examination + Investigations
An exampleGrowth problem in paediatrics
Why do we need to understand growth problems in Paediatrics?Parental concerns
Almost all chronic childhood disorders can affect growth
Most children with growth problems actually DO NOT have problems and NEED NO investigations.
QuestionsWhat is normal growth? Pattern , charts - normal reference
Normal variations of growth
QuestionsWhat is normal growth? Pattern , charts - normal reference
Normal variations of growth?
What influences normal growth?
Growth Disorders - Physiology Nutrition Diseases
Hormones Normal Growth
Genetics Puberty
Normal GrowthBiological variations
Arbitrary: 3% - 97% = Normal
Normal GrowthTrend of growth: Serial data : changes over time
Charts - for comparison of an individual to a reference population: assumption < 3% or > 97% = likely to be abnormal. i.e. disease* Biological variations
* Arbitrary : 3rd% to 97%= normal
Short statureDefinitionChildren with heights below the 3%tileMAJORITY>90% due to familial short stature or constitutional growth delay others -Pathological short stature
Familial short statureConstitutional growth delay with delayed puberty
Familial Short StatureFamily history - positivea height within the target height defined by the parental size
Target HeightsHt (boy) = Ht (mom) + Ht (dad) +12 2
Ht(girl) = Ht (mom) + Ht (dad) -12 2
Familial Short StatureFamily history - positivea height within the target height defined by the parental size
Normal growth velocity
Normal age of onset of puberty
Bone age consistent with chronological age
Constitutional growth delay with delayed sexual maturationFamilial condition with hereditary delay in growth and maturation
Short stature during childhood
Delayed onset of puberty
Bone age - retarded for chronological age but appropriate for height age
Normal adult height
Differential Diagnoses Short Stature
Normal Abnormal -familial R/O Disproportionate -constitutional short stature *F Hx, Growth rate - Rickets :Vit. D, PO4 - Skeletal dysplasia (check upper , lower segments ) Proportionate short stature> 90%< 10%
Proportionate Short StaturePrenatal onset Postnatal Onset-Syndromes::Downs, Russell-silver -Chronic illness-Chromosome: Trisomies GI, CVS, Renal,Chest, Hema-IUGR Fetal: intrauterine infection -Endocrine: thyroid Maternal: toxemia G.H. Combined -severe malnutrition
Skeletal Dysplasia developmental defects of skeletal growth leading to disproportionate short stature and deformity > 200 types
e.g. Achondroplasia, most common 1/ 25000
CLINICAL APPROACH TO SHORT STATURE 1.Onset: Since when ?
2.? Growth arrest: e.g. no growth for the past 2 years
3.Prenatal history: Intrauterine growth retardation- drugs, smoke, alcohol, illness, rash, weight gain
4. Natal history - Birth weight, length
5.Postnatal history -Medical illnessCNS - irradiation, Cardiac, Pulmonary, Renal, G.I. History
CLINICAL APPROACH TO SHORT STATURE6.GROWTH DATA FROM THE PAST- Plot the growth curve- Calculate the growth rate (normal = 4-6 cm/year 4 years to prepuberty)
7.Family history -Short stature, growth delay, menarche
8. Systemic enquiry: e.g.Symptoms of Hypothyroidism
9.Social history: assess impact of short stature
History
SHORT STATURE - PHYSICAL EXAMINATION1.Dysmorphic features suggesting syndromes:Turner, Noonan, Russell-Silver2. Midline defects - Cleft lip/palate: Hypopituitarism3.Visual field defects4. MEASUREMENT- HT, WT, Arm-span, upper & lower segments, sitting height , proportions AGE U/L RATIOBIRTH 1.73 years 1.3>7 years 1.1
5.? Goitre and signs of hypothyroidism6.Careful systemic examination:Heart, Lungs, Abdomen examination to detect possible organic cause5.Pubertal status -BREAST, PUBIC HAIR, GENITAL STAGE, TESTES
INVESTIGATIONS FOR SHORT STATURE1.MAJORITY OF CASES- NONE - If Hx is compatible with normal variants i.e. Familial or constitutional- Growth rate - NORMAL
2.Recheck patient in 6 months to calculate the growth rate
3.INVESTIGATES IF- Very short: > 3 s.d. below mean(many cm below the 3rd%tile or history of growth arrest or history and physical abnormalities suggestive of endocrine disorders or other systemic disorders
TESTS - FOR SHORT STATUREBONE AGE: X-ray left hand and wrist
BLOOD COUNT, URINALYSIS, RFT
STSH, FT4
KARYOTYPE FOR GIRLS (TURNER)
If patient has- Delayed bone age- Normal screening investigations- No other medical cause- abnormal growth rateTHEN consider growth hormone testing
As a GP, when to refer?Height way below 3rd %
Growth arrest
Obvious chronic problems-poorly controlled
Social reason: Unable to settle the extreme parental anxiety . DO NOT USE tests to reassure the parents
SummaryVariations and control of normal growth
Approach to short stature (proportionate or disproportionate types)
DDx of short statureHistory taking & physical examinationInvestigations and follow-up
RicketsClinical signs -stature, frontal bossingwrist, bow legs , ribsBiochemical abnormalities:Bone profile: Ca, phosphate, ALPRadiological signs of rickets
SummaryNormal Growth
Approach to short stature
History, physical , investigations
DDx, Rickets
Examples of proportionate ordisproportionate short stature
