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Approach to Paediatric Growth and Development 2
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- 3. Stages of Growth Zygote Embryo •1st 8 weeks of gestational life Fetus Neonate • 1st 28 days of life Infant • 1st year of life Toddler • 1 – 3 years of life Preschool age • 3 – 6 years of life School going age • 3 – 9 years old Adolescent • 10 – 19 years (WHO definition)
- 4. Factors affecting growth Congenital Hereditary GeneticRacial Sex Non- hereditary Intrauterine factors Environmental Nutritional availability Psychosocia l
- 5. Is growth uniform throughout life? 2growth spurts throughout life 1st – 2 years of life 2nd – near adolescence NO
- 6. What are thegrowth domains? Growth Anthropometric s Osseous growth Teething Fontanelles
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- 8. Weight Upon birth Changes in body water composition • Term neonates: 1st 7 - 10 days of life lose 10 - 15% of their birth weight Regain birth weight by 2nd week 1st 3 months of life 25 gm/day (Paediatric Protocol) • *Gomella Neonatology Textbook : 10 – 20g/day Double the BW by 5 months old Triple the BW by 1 year of age • Preterm: loose more weight and gain slowly Weight estimation for children (in Kg): Infants: (Age in months X 0.5) + 4 Children 1 – 10 years: (Age in yrs + 4) X 2
- 9. Height and length •Length • Better indicator of lean body mass and long term growth • Not influenced by fluid status • Preterm: 0.8 – 1.0cm / week • Term: 0.69 – 0.75cm/week • 1st 6 months: 2.5cm/month • 2nd 6 months: 1.25cm/month 2 - 10 years old : Crude Height (cm) = (Age(years) X 5) + 80 Upper segment to lower segment ratio Age Upper Segment (Crown to symphysis pubis) Lower Segment (Symphysis pubis to heel) At Birth 1.7 1 At 3 years old 1.3 1 At 7 years old 1 1
- 10. Head Circumference • 0.5-0.8cm /week Intrauterinehead growth • Reduces with age. • Follows that of term infants when chronological age reaches term • If >1.25cm/week abnormal (hydrocephalus/IVH) Preterm infants 1 cm/week • 6 cm in first 3 months • 3 cm in second 3 months • 3 cm in last 6 months Increases by 12 cm in the 1st year of life
- 11. Mid Upper ArmCircumference (MUAC) • Valid from 3 months till 5 years of age • Measured midway between shoulder and elbow • Objective measure of the muscle bulk of the child • Used to assess malnutrition • WHO Arm Circumference for age growth charts Normal Impending Malnutrition Established Malnutrition Severe Malnutrition 12 – 14cm 10-12cm 9-10cm <9cm
- 12. Osseous Maturation • Basedon number of Carpal Bones that appear (Request X-ray of wrist) • She - Scaphoid – appear at 6 months • Looks - Lunate – appear at 1 year • Too - Triquetral - @ 2 yo • Pretty - Pisiform - @ 3 yo • Try - Trapezium - @ 4 yo • To - Trapezoid - @ 5 yo • Catch - Capitate - @ 6 yo • Her - Hammate - @ 7 yo • Bone age = chronological age + 1 • E.g. 3yo bone age 4 (i.e. 4 carpal bones have developed) 10yo ?
- 13. Abnormal Bone Age RetardedBone Age (e.g. 3 yo bone age 3 ) Advanced Bone Age Prematurity Post maturity Protein energy malnutrition Adrenogenital syndrome Hypothyroidism Hyperthyroidism Hypopituitarism Hyperpituitarism
- 14. Teething Milk/Diceduous teeth Permanentteeth White, Small Yellowish, Bigger Weak Strong 20 in number 32 in number 1st tooth to appear – Central lower incisor – at 6 months 1st permanent tooth to appear 1st premolar – at 6 years old Delayed teething no teeth eruption yet at 1 year must investigate / refer dental causes: Systemic causes: Ricketts, achondroplasia, osteogenesis imperfecta Local causes: Rigid gums, cyst, supernumerary teeth
- 15. Natal and neonatal teeth •Cause: • Idiopathic • Underlying syndromes: Soto’s syndrome(cerebral gigantism), chondro ectodermal dysplasia ( Ellis Van Crevald $) • Baby born with 1 or 2 tooth – natal tooth • 1 or 2 incisors erupt anytime during neonatal period – neonatal tooth • If there is no root for these teeth remove to prevent risk of aspiration • If root present can keep the teeth
- 16. Fontanelles • 6 fontanelles •Anterior • Posterior • Rt and Lt Sphenoid fontanelle • Rt and Lt mastoid fontanelle • Ant. Fontanelle –at birth 3FB every 3 months, reduces in size by 1 FB closes by 18 months old • Abnormal • Wide / Closed early • Bulging /Depressed • Post. Fontanelle normal closes at birth can be present up till 2 months and not more that 0.5cm wide • Abnormal • Open after 2 months old, regardless of size • > 0.5cm regardless of age
- 17. Delayed fontanelle closurePremature closing of fontanelle/suture (Craniosynostosis) abnormal head shape Achondroplasia Hypothyroidism Down syndrome Increased intracranial pressure Rickets Hyperthyroidism Hypophosphatasia Hyperparathyroidism Crouzon / Apert’s Syndrome
- 18. Growth charts illustratingcommon conditions
- 21. Failure to thrive Clinical evaluationadvisable: Weight below 2nd centile Height below 2nd centile Crossing down 2 centiles for height or weight No established criteria Failure to grow & failure of emotional and developmental progress
- 23. What to lookfor in clinical evaluation? 1 Differentiate normal baby who is crossing centile from baby who is failing to thrive 2 Identify clinical signs/symptoms of organic pathology 3 Only perform lab ix if there are clinical leads in history/examination Identify psychosocial problem which affect growth
- 24. History • Nutritional hx •Feeding diffulties • Food diary • Review of symptoms • Diarrhea, colic, vomiting, irritability, fatigue, chronic cough • Past medical hx • Recurrent illness • Developmental hx 2 reasons • FTT affects developmental progress • Neurodevelopment problems eating difficulties limit nutritional intake • Family hx • Relate growth to other family members same cause of FTT • Social hx
- 25. Examination • Generalobservation • Appearance – neglected, ill, dysmorphic • Malnourished – thin, wasted buttocks, protuberant abdomen, sparse hair • Neglected – unclean, uncared • Mother – maternal-infant attachment difficulties • Growth chart • Weight gain 1st affected Reduction in linear growth and COH developmental delay
- 28. Management Fit to underlyingproblem Dietary advice Psychosocial support Social services in neglect
- 30. Approach to shortstature • 1st and foremost Calculate mid-parental height • Boys (Fcm+Mcm+13) ÷ 2 • Girls (Fcm+Mcm – 13) ÷ 2 • Child’s target height: MPH +/- 10cm
- 32. Approach to tallstature Ht, wt, COH, Pubertal stage, BA Mid parental height and centile Tall for family Dysmorphic Marfan, Homocysteinuria, Klinefelter, Soto Normal facial features Tall and obese Nutritional/ exogeneous Tall but not obese Endocrine causes: CAH, Thyrotoxicosis, Acromegaly Normal for parents familial tall stature
- 33. Approach to microcephaly COH,Ht, Wt – child, parent, family members All 3 parametres small SGA, Russell Silver $ COH small, Ht & wt normal Parents microcephalic, Dev normal Familial Microcephaly Parents Normal, Dev delay Dysmorphic Craniosynostosis, Angleman$, Cornellia de Lange Not dysmorphic Primary microcephaly + Intellectual disability (AR) Secondary Perinatal asphyxia, TORCHES, Fetal alcohol $
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- 35. References • Paediatric Protocolfor Malaysian Hospitals 4th ed • MRCPCH Mastercourse – Malcolm Levene; RCPCH • Neonatology – Management, Procedures, On-call Problems, Disease and Drugs ; Gomella