5. Weight - formula
3 – 12 months = age in months + 9
2
1 – 6 years = age (yr) x 2 + 8
7 – 12 years = age (yr) x 7 – 5
2
6. Weight gain
Newborn
10% of birth weight is lost initially
Regain birth weight by 10 days
200 gm / week – 1st three months (30g/day)
150 gm / week – 2nd three months (20g/day)
100 gm / week – next 6 months (15g/day)
7.
8. Normal – Height
At birth – 50 cm
3 months – 60 cm
9 months – 70 cm
1 year – 75 cm
2 years – 90 cm
4 ½ years – 100 cm
Till 10 years – 5 cm / year
9.
10. Weight/ Height
A value below 90.5% indicates malnutrition
Value >120% indicates over wt or obesity
15. Arm span
Tips of middle fingers when the arms are
stretched out
It is equal to height at 10 yrs
In earlier years it is 1-2cms less than ht/length
After 12yrs it is 1-2cm>height
17. Head Circumference
• Brain growth is rapid during infancy and it is unaffected by
mild to moderate degree of malnutrition
• Should not be measured with in 24 hrs after birth
• Boney land marks – superior orbital ridge (ant), occipital
protuberance (post)
18. Normal head circumference
Birth – 35 cm
3 months – 40 cm
12 months – 45 cm
2 years – 48 cm
12 years – 52 cm
2 cm / month in 1st 3 months
1 cm / month in next 3 months
0.5 cm / month in 6 months
19. Chest circumference
At the level of nipple in a plane at right angle to the spine. Measured
the mid respiration
At birth HC is more than CC (by about 2.5cm)
By 6 to 12 months HC=CC
At 1st yr CC > HC (larger by 2.5cm).
At 5yrs CC >HC (by 5cm)
In PEM CC may continue to be less than HC
20. Mid arm circumference
Age independent criteria
Mid point between acromian process and olecranon
1 – 5 years : Arm Circumference fairly constant
>13.5 cm - Normal
12.5 – 13.5 cm : moderate malnutrition
<12.5 cm : severe malnutrition
21. MAC - Shakir’s Tape
It is a plastic tape with colored zone –
green, yellow & red
eindicateseverema12.5cm
Yellow indicates moderate malnutrition
(12.5-13.5cm)
reendica13.5cm
23. Length / Height
• < 2 years – recumbent length using infantometer
• > 2 years – standing height – Stadeometer
Formula : 2 – 12 yrs = age in years x 6 + 77 (in cm)
• In girls at 2yrs - half of adult height is attained.
• In boys at 2 ½ yrs - half of adult height is attained
24. • What are the common causes of growth retardation in a child
Dept of Pediatrics, AFMC
26. • Can you apply the term Failure to thrive for this patient
• Descriptive term for < 5 yr
• Organic or Non organic(80%)
27. • How do you define short stature
• Ht below 3rd centile or more than 2 standard deviations below the
mean ht for that age and sex according to population standard
28. Salient Points in History
• Well till 5 - 6 yrs of age
• Behavior changes
• Constipation
• Puffiness of face and swelling hands and feet
• Dry skin
• 2 yrs younger sister is taller than her
• History of delayed dentition
Dept of Pediatrics, AFMC
29. • What are the common dentition problems in children
• Delayed eruption
- Hypothyroidism
- Hypoparathyroidism
- familial
- Idiopathic
• Early Exfoliation
- Histiocytosis
- Leukemia
- cyclic neutropenia
31. • How do we differentiate between Familial and Constitutional delay in
growth?
Dept of Pediatrics, AFMC
32. Feature Constitutional Familial
Height Short Short
Height Velocity Normal Normal
Family history Delayed puberty short stature
Bone Age < CA Normal
Puberty Delayed Normal
Final Ht Normal Low
(normal TH)
Dept of Pediatrics, AFMC
33. Anthropometry
• Weight- 22.9 kg (52% of 50th centile)
• Height- 113 cm (<3rd centile)
• US/LS = 1.1
• Arm span- 112 cms
• Weight for height – 19 kg
• Height age corresponds – 6 yrs
• Weight age corresponds – 8 yrs
• Wt age > Ht age
• MPH – 149.5 cm
33
Dept of Pediatrics, AFMC
37. • What are the conclusions derived from US LS ratio
• Decreased US LS ratio
- spondyloepiphyseal dysplasias
- vertebral anomalies
• Increased US LS ratio
- rickets
- Congenital hypothyroidism
- achondroplasia
38. • How do we calculate Mid Parental Height
• Boys – mothers ht + father’s ht
------------------------------ + 6.5
2
Girls – mother’s ht + father’s ht
------------------------------ - 6.5
2
39. • What is the interpretation of wt for ht in children with short stature
• Decreased wt for ht
- malnutrition, chronic illnesses
• Increased wt for ht with short stature
- Endocrinopathies
- Syndromes
- Skeletal dysplasias
40. • How do we plot target ht on the growth chart
52. Causes of short stature in renal disease
• Poor nutrition
• Metabolic acidosis
• Osteodystrophy (rickets)
• Anemia
• Decreased IGF level
• Hypothyroidism
• Proteinuria
53. Who is Short?
• If child is below 3rd percentile
• But target height is also below 3rd percentile
• HEREDITORY SHORT STATURE
• REASSURANCE
54. Who is Short ?
• If child above 3rd percentile with target height
percentile above it
• Observe after initial screening
• Quarterly height measurement for height velocity
• It should be > 4 cm/year
55. Who is Short ?
• If child below 3rd percentile with target height
percentile above it
• height velocity < 4 cm/year
• Then he/she is short
56. What Next ?
Look at the child
• Whether upper body and lower body is proportionate or
disproportionate
• Disproportionate
• Skeletal Causes
• Proportionate
• Systemic or Endocrinal causes
57. Upper/Lower Ratio
• Normal
• 1.7 at Birth ,1.3 by 4 year, 1.0 by 7 years
• Increased Ratio
• Skeletal Dysplasia
• Turner’s Syndrome
• Cretinism
• X-Linked Hypophosphatemic Rickets
• Decreased Ratio
• Mucopolysaccharidosis
• Spondylo-epiphyseal dysplasia
58.
59.
60. What Next ?
Again look at the child
• Whether child is mentally retarded
or normal
• If Mentally Retarded
• Chromosomal Abnormality
• Genetic Syndrome’s
• Cretinism
61. Then ?
Calculate BMI
• If Low : Systemic Illness
: Anorexia Nervosa
• If Normal : Endocrinal
DICTIM: All obese children are taller than counterparts,
and if Short indicate endocrinal disease
64. Bone Age Estimation
• X-Ray left hand with wrist
• Scoring system of each of 20 individual hand bones
(Tanner-Whitehouse Method, TW2), a technique that has
been adapted for computerized assessment
• BA is a better predictor pubertal milestones than CA
65.
66. Possibilities
• BA = HA = CA
• Normally growing child
• BA = HA < CA
• Delayed Growth (Constitutional)
• BA = CA < HA
• Hereditory Short Stature
• Intrinsic Short Stature (Genetic)
• BA < HA < CA
• Delayed/Attenuated Growth (Pathological)
67. Dysmorphic Features
• Epicanthal fold
• Hypertelorism
• Auricular Malformation
• Facial Asymmetry
• Teeth Dysplasia
• Webbing of Neck
• Polydactyly
• Abnormal Crease of Palm
• Nail abnormality
70. Intrinsic Short Stature
• Single Gene Defects
• Down’s Syndrome
• Turner’s Syndrome
• Mucopolysaccharidosis
• Polygenetic or Unknown
• Prader Willi Syndrome
• Noonan’s Syndrome
• Progeria
• Silver Russell Syndrome
71. Idiopathic Short Stature
• Short Stature otherwise Healthy child
• Exclusion of Other causes
• Bone age within 2 SD of CA
• Normal GH Response to test
• For Treatment
• HA < 2.25 SD for age and sex
• Open Epiphyses
• Unable to achieve normal height with current Height
velocity
72. Further Evaluation
• Referral to Endocrinologist
• T3, T4, TSH
• IGF-1, IGF-BP3
• GH Stimulation
• Cortisol Evaluation
if Cushing’s syndrome is suspected
73. Diagnosis of growth failure
IGF 1 & BP3
IGF deficiency
ruled out
Normal
GH testing
Low
Increased basal
and stimulated
GH insensitivity
Peak < 10
Pit/ Hypothalamic
Peak 10 - 40
Functional
75. Follow Up
• 6-12 monthly
• Clinical evaluation
• Assessment of side effects
• IGF-1 levels
• Lipid Profile
• Fasting B Glucose
• BMD if initial was abnormal
76. SIDE EFFECTS
• Malignancy
• Benign Intracranial Hypertension
• Slipped Epiphysial Disc
• Fluid Retention
• Increase in naevi
• Gynaecomastia
• IGT & DM (Aggravation of Retinopathy)
• Predisposition of hypothyroidism & ACTH
deficiency
77. Confirmation of GHD: IGF-I
• Polypeptide, synthesized by liver and also locally in peripheral tissue
• Locally synthesized IGF-I – 20% of serum level
• Mediates growth promoting actions of GH
• Single sample for estimation
• Assay – difficult as extraction step is required
Williams text book of Endocrinology, 10th Ed
78. Factors affecting IGF-I levels
• Age
• Nutrition
• Genetic factors, ethnicity
• GH
• Insulin, cortisol, thyroxine, estrogen, androgen
• Catabolic state
• IGFBP
Williams text book of Endocrinology, 10th Ed
79. Indications and Goals of GHD Rx
• Patients with proven GHD - treated with GH as soon as possible
• Primary objectives of the therapy of GHD are:
- Normalization of height during childhood
- Attainment of normal adult height and genetic potential!!
80. GH Dosing
• O.025-0.035mg/kg daily subcutaneously in the evening
• 0.17 – 0.35 mg/kg/week (Summary statement, GH Research
Society 2000)
• Few studies – 0.3 mg/kg/wk better result than 0.17 mg/kg/wk (GH-IGF Res
1998)
81. Duration of GH therapy
• Improvements in linear growth have been almost the sole indication for the
use of GH in pediatric practice.
• Treatment is initiated as soon as possible once
• GH should be continued until the attainment of final height.
• Final Ht - slowing of growth to an annualized HV of <1 cm/yr or fusion of the
long bone epiphyses.
• Ideally – life long
