Click here to load reader

Clinical Methods in Paediatrics DEPARTMENT OF PAEDIATRICS CHINESE UNIVERSITY OF HONG KONG

  • View
    218

  • Download
    1

Embed Size (px)

Text of Clinical Methods in Paediatrics DEPARTMENT OF PAEDIATRICS CHINESE UNIVERSITY OF HONG KONG

  • 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

Search related