Is my child too short - PowerPoint PPT Presentation

1 / 34
About This Presentation

Is my child too short


Recurrent URI's including AOM x 3 (eventually leading to diagnosis of mild, ... FH: 4 y/o brother had Kawasaki's, now doing well. Uncle with asthma. ... – PowerPoint PPT presentation

Number of Views:173
Avg rating:3.0/5.0
Slides: 35
Provided by: Ther193
Tags: child | kawasaki | short


Transcript and Presenter's Notes

Title: Is my child too short

(No Transcript)
Is my child too short?
  • Theresa A. Allison, M.D., M.Mus.
  • UCSF/CHN Family Practice Residency Program
  • Patient Care Conference

The CaseT.T.
  • ID/CC Vietnamese boy with devoted parents (born
    in June, 2003) first seen in my clinic at 14
    months of age for routine well-child care
  • PMH
  • Pulmonic stenosis, followed at UCSF
  • Recurrent URIs including AOM x 3 (eventually
    leading to diagnosis of mild, intermittent
  • S/P term NSVD to a 38 y/o G3P1?2 with mild
    neonatal hyperbilirubinemia, and a negative r/o
  • Micrognathia, 5th digit campylodactyly
    brachydactyly evaluated by Genetics at birth

The Case T.T.
  • FH 4 y/o brother had Kawasakis, now doing
    well. Uncle with asthma.
  • SH lives with parents, both Vietnamese, and one
    sibling. Supportive home environment
  • ROS poor eating during multiple URIs, including
    3 episodes AOM, and 2 episodes of gastroenteritis
  • Clinical concern Falling off his growth curve

Is the child too small?
  • Standardized Growth Charts
  • Individual curves
  • Failure to Thrive (FTT) and Idiopathic Short
    Stature (ISS)

Growth Chart from Birth to 15 months
Growth Chart from Birth to 15 months
Growth Chart from Birth to 15 months
Growth Chart from Birth to 15 months
Failure to Thrive Syndrome
  • Less than 3rd or 5th percentile by weight or
  • Growth curve that has crossed two standard
    deviations in a short time2,3,6,7
  • A fall to less than 75 of median weight-for
    height in children less than 2 y/o7
  • Caveats no underlying medical disorder and
    lasting at least 12 months7

Failure to Thrive
  • Differential Diagnosis
  • Environment
  • Nutrition
  • Disease
  • Hormonal Deficiencies
  • Genetic Disorders

1. Environment
  • Neglect inadequate intake equals inadequate
    resources for growth
  • Growing evidence that growth hormone, like the
    rest of the HPA, is affected by stress levels
  • Psychological dwarfism obscene extreme of
    neglect, marked by short stature, bizarre
    behavior and limited speech
  • (Remember, this child has devoted parents! The
    above is for learning, and is not this patients

2. Nutrition
  • (Excluding neglect)
  • Affected greatly by acute illnesses, like URIs
    and gastroenteritis
  • Inadequate food choices and intake Toddlers are
    notoriously picky but, over time, they tend to
    get what they need

3. Disease
  • Nelson Textbook of Pediatrics (Table 36-1) Major
    Organic Causes of Failure to Thrive
  • System Cause
  • Gastrointestinal Gastroesophageal reflux, celiac
    disease, pyloric stenosis, cleft palate/cleft
    lip, lactose intolerance, Hirschsprung's disease,
    milk protein intolerance, hepatitis,
    cirrhosis, pancreatic insufficiency, biliary
    disease, inflammatory bowel disease,
    malabsorption, food alkalines
  • Renal Urinary tract infection, renal tubular
    acidosis, diabetes insipidus, chronic renal
  • Cardiopulmonary Cardiac diseases leading to
    congestive heart failure, asthma,
    bronchopulmonary dysplasia, cystic fibrosis,
    anatomic abnormalities of the upper airway,
    obstructive sleep apnea (snoring)
  • Endocrine Hypothyroidism, diabetes mellitus,
    adrenal insufficiency or excess, parathyroid
    disorders, pituitary disorders, growth hormone

3. Disease
  • Nelson Textbook of Pediatrics (Table 36-1) Major
    Organic Causes of Failure to Thrive
  • (continued)
  • System Cause
  • Neurologic Mental retardation, cerebral
    hemorrhages, degenerative disorders
  • Infectious Parasitic or bacterial infections of
    the gastrointestinal tract, tuberculosis,
    human immunodeficiency virus disease
  • Metabolic Inborn errors of metabolism
  • Congenital Chromosomal abnormalities, congenital
    syndromes (fetal alcohol syndrome), perinatal
  • Miscellaneous Lead poisoning, malignancy,
    collagen vascular disease, recurrently infected
    adenoids and tonsils

First Interlude
  • Birth and routine well-child care
  • At delivery, the patient was found to have a
    harsh III/VI systolic murmur and he had
    evaluation by the Cardiology and Genetics
    services (ruled out for genetic issues)
  • At his outpatient visits (up to 1 year), T.T.s
    growth was on a reasonable curve, so no workup
    was initiated
  • Lead and anemia screening, per routine for WIC
    Hgb/HCT 11.6/31.8 MCV 69.7
  • Empiric initiation of iron was discussed with
    T.T.s mother, as there was no FH of thalassemia

3. Disease as a nutrition issue
  • Anemia ? the oxygen-carrying component Includes
    sickle cell anemias, thalassemias and iron
    deficiency anemia
  • Celiac and other GI Disease ? inadequate
    absorptive ability secondary to gut lining issues
  • Chronic Kidney Disease ? protein deficiency due
    to protein loss

3. Disease as a nutrition issue
  • Chronic Lung Disease (cystic fibrosis and
    asthma) ? hypoxia and breathing requirements
    interfere with the mechanics of eating
  • Congenital Heart Disease (cyanotic lesions and
    left-to-right shunts) ? oxygenation requirements
    interfere with both the mechanics of eating and
    the metabolic requirements of digestion
  • Illness and injury ? Decreased ability to take in
    nutrients and increased metabolic requirements

Second Interlude
  • T.T. has pulmonic stenosis, initially moderate,
    improving with growth to a mild case. At this
    point, he does not require balloon valvuloplasty
    per his mother
  • Parent agrees to bring in contact information for
    Pediatric Cardiologist at UCSF to discuss
    patients case (last consult note from 11/2003)

Pulmonic Stenosis
  • Differs from other cardiac lesions with respect
    to growth
  • One study suggests that mild PS has a near normal
    distribution of growth, and
  • Severe PS actually is marked by small but
    significant increase in growth for unclear

4. Hormonal deficiencies
  • Isolated Growth Hormone Deficiency the hot
    topic, as the availability of manufactured GH
    opens up the option of cosmetic endocrinology
  • Hypothyroidism Acquired hypothyroidism can
    present as early as the first 2 years of life
    with deceleration of growth as the first
  • Any derangement of the HPA axis via alterations
    in metabolic state and feedback mechanisms that
    involve growth hormone

5. Genetic Disorders
  • When to suspect the zebras?
  • Dysmorphic features
  • Developmental delay
  • Cosanguinity
  • Family History

5. Genetic Disorders
  • Turners syndrome
  • Downs syndrome
  • Achondroplasia and other Skeletal dysplasias
  • Zebras Many rare genetic disorders, only some of
    which have associations with other disabilities

Constitutional Short Stature (ISS)
  • In the rush to give everything a diagnosis, we
    even have a name for normal, idiopathic short
  • As long as the child is staying on a curve, we
    are reassured
  • Once a child falls off of the curve or loses
    weight, we need to think about the appropriate

Third Interlude
  • At his most recent visit, TTs mother says But
    he is bigger than the 16 month old Vietnamese
    girl he usually plays with. What does that
  • Is the child the right size for that child, or is
    he developing as normally as he should?
  • At what point do we need to embark on a workup?

Vietnamese Growth Chart
The Workup for FTT
  • Labs CBC, LFTs, Renal panel, urinalysis.
    Consider TSH, ESR, Insulin Growth Factor-BP3
    (IGF-BP3), Insulin Growth Factor 1 (IGF-1),
    specific antibody testing for celiac disease,
    karyotyping. In this case consider a hemoglobin
  • Do not do a growth hormone stimulation test1
  • Bone age plain film left hand to evaluate
    ossification, consider a skeletal survey
  • Referral to the appropriate specialty as indicated

Treatment Options at SFGH
  • UCSF Pediatric Gastroenterology Because so much
    of growth failure is due to nutritional issues,
    our pediatrics GI service has a formed strong
    collaborative program with Nutrition in order to
    maximize nutritional status
  • UCSF Pediatric Endocrinology If indicated, may
    require evaluation for growth hormone replacement
  • UCSF Genetics UCSF has leading experts in both
    dysmorphology and genetic testing

Workup and Treatment for T.T.
  • Re anemia, T.T.s mother had opted to increase
    organ meats in his diet and had not started
    FeSO4. Contracted with mother to initiate FeSO4
    while awaiting results. Screen for thalassemia
    because a positive result ? d/c FeSO4
  • Re Asthma 6M clinic had referred patient to
    Asthma clinic for further evaluation and testing.
    He received one home visit but did not f/u in
    clinic. Appointment now scheduled for March
  • Flu vaccine, childhood immunizations up to date

Workup and Treatment for T.T.
  • At his last visit, the 19 month old pt ate a
    good-sized peanut butter sandwich during the
    history, and per mothers report feeding is no
    longer an issue
  • Given ABSENCE OF WEIGHT GAIN, check bone age and
    labs to rule out anything ominous or treatable
  • Lots of reassurance, as this child may well be
    just the right size for himself and recovering
    from an illness-malnutrition cycle
  • Weight check in one month

Is my child too small?
  • Research on the psychological effects of short
  • Controversy over use of growth hormone for ISS
  • Childs sense of his/her own size appears to be
    more important than actual size in terms of
  • Data on psychological effects of short stature is
    for the most part of poor quality design8. There
    is no solid evidence that short stature is
    inherently, psychologically damaging.

  • Badaru, A. and D.M. Wilson. Alternatives to
    Growth Hormone Stimulation Testing in Children.
    Trends in Endocrinology and Metabolism. 15(6)
    252-258. 2004.
  • Behrman, R.E. et al. Nelson Textbook of
    Pediatrics, 17th ed. PhiladelphiaSaunders. 2004
  • Blair, P.S., et al. Family, Socioeconomic and
    Prenatal Factors Associated with Failure to
    Thrive in the Avon Longitudinal Study of Parents
    and Children (ALSPAC). International Journal of
    Epidemiology. 33(4) 839847. 2004.
  • Erling, A. Why Do Some Children of Short Stature
    Develop Psychologically Well While Others Have
    Problems? European Journal of Endocrinology.
    151S35-S39. 2004.

References, continued
  • Ferber, B. et al. Accelerated Weight Gain with
    Pulmonic Stenosis. Pediatric Cardiology.
    18(1)8-10. 1997.
  • Gunn, V.L. and C. Nechyba, eds. The Harriet Lane
    Handbook A Manual for Pediatric House Officers.
    Philadelphia Mosby. 2002.
  • Perrin, E.C. et al, investigators. Criteria for
    Determining Disability in Infants and Children
    Failure to Thrive. Evidence Report/Technology
    Assessment. Number 72. Rockville, MD Agency for
    Healthcare Research and Quality. 2003.
  • Voss, L.D. and D.E.Sandberg. The Psychological
    Burden of Short Stature Evidence Against.
    European Journal of Endocrinology. 151S29-S33.

(No Transcript)
Write a Comment
User Comments (0)