Dr Abdullah Alshaya Pediatric Endocrinologist GROWTH CHART Dr Abdullah Alshaya Pediatric Endocrinologist

Objectives: As a result of this talk, candidate will be able : 1. To monitor and record growth data. 2. To recognize abnormal growth patterns. 3. To identify common etiologies of growth abnormalities. 4. To begin a diagnostic evaluation when a growth disorder is suspected

Comparison of National Center for Health Statistics and World Health Organization growth charts for children Year published NCHS/CDC WHO 2000 2006 Population(s) from which curves were derived General US population (data from the National Health and Nutrition Survey between 1970s and 1990s); includes infants and children from a variety of socioeconomic and ethnic groups Multicentre Growth Reference study (Brazil, Ghana, India, Norway, Oman, United States); population chosen to reflect growth under ideal conditions Age groups 0 to 36 months (cross-sectional data; includes both breastfed and formula-fed infants) 2 to 20 years (cross-sectional data) 0 to 2 years (longitudinal data); infants were exclusively/predominantly breastfed for 4 to 6 months and continued to breastfeed until at least 12 months 2 to 5 years (cross-sectional data)

Growth Charts Easy Instrument Monitoring Growth Velocity Growth Pattern

CDC Growth Charts Tip: Download and print from www.cdc.gov/growthcharts/ Formula to calculate BMI Percentile lines 5th - 10th - 25th - 50th 75th - 85th - 90th - 95th Talking Points: This is the 2 to 20 years: Boys BMI chart. The vertical line represents the BMI number (or value). The horizontal line represents age, so that you are plotting the BMI value relative to the child’s age. The formulas to calculate the BMI value in metric or English measurements are listed below the data entry table. The 5th, 50th, 85th, and 95th percentiles are displayed in bold. Charts with the 5th and 95th percentiles are recommended for CHDP exams and other routine clinical assessments. Charts with the 3rd to the 97th percentile are available for use with children with special health care needs. Children who are growing well generally track along a percentile line or in a percentile channel. Parents may think that the 50th percentile is “normal” or “ideal”. The 50th percentile simply represents the middle of the normal range. The new charts were released in 2000. Check the fine print on the bottom left margin of the growth chart to make sure you are using a chart with the text “Published May 30, 2000” and a modification date between 2000-2001 in parentheses. Published May 30, 2000 (modified 2000-2001)

BMI for Children and Teens Age- and sex-specific Plot BMI on growth chart to find percentile Weight status determined by percentile Weight Status Category Percentile Range Obese ≥ 95th percentile Overweight 85th to < 95th percentile Normal 5th to < 85th percentile Underweight < 5th percentile Talking Points: BMI for children and teens is age- and sex-specific. For children and teens up to age 20, you need to plot BMI on the growth chart to find the percentile. The child’s weight status is determined by the child’s BMI-for-age percentile. The next few slides will explain this further. The weight status categories and percentile ranges for children are: Obese Greater than or equal to the 95th percentile Overweight 85th to below the 95th percentile Normal 5th to below the 85th percentile Underweight Below the 5th percentile

Chart Colors Correctly Step 1: Select Appropriate Growth Chart Birth to 24months: Boys or Girls Length-for-age Weight-for-age Head circumference Weight-for-length 2 to 20 years: Boys or Girls Stature-for-age BMI-for-age Speaker Tip: Refer to worksheets: CDC Growth Chart 2 to 20 Years: Boys and Practice PM 160 for Carlos. Talking Points: Let’s walk through our first example together. For this demonstration, you’ll need the practice growth charts and the practice PM 160s from your packet. For Step 1, select the appropriate growth chart based on the age and gender of the child being weighed and measured. At 2 years of age, the CDC recommends that you begin using the 2-20 years BMI-for-age chart. You no longer need to use the weight-for-length chart. Carlos, pictured here, appeared for his 6 year CHDP exam. Which growth chart is appropriate for Carlos? That’s right. CDC 2 to 20 Years: Boys. Find the growth chart in your packet with Carlos’ name at the top. His measurements and BMI values for his 3 and 4 year exams are plotted. Background Information: In nutritional screening, the word “stature” is used to describe a child’s height. Children ages two years and older should be measured while standing. Measurements should be plotted on the BMI-for-age growth chart. Children up to age three, who cannot stand without help due to special circumstances, can be measured lying down. In this case, the weight-for-length chart continues to be used up to age 36 months.

Growth velocity Normal (cm/yr) 1y: 25 2y: 12 3y: Then until puberty: 6 - cm

FTT Criteria Ht/Wgt < 5th percentile for age on >1 occasion Ht or Wt falling 2 major percentiles Below 10th percentile for ht/wt < 80% of ideal body wt for age Head circumference important, but not part of FTT entity

Definition Standing height > 2SD below the mean (<3percentile) for gender and chronological age. Compare the child’s height with that of a larger population of a similar background and mid-parental target height.

Definition A child whose height is below 2 standard deviations for age and gender -2.0 SD (2.3 percentile) Generally accepted definition of normal range

Target height of the child BOYS: [Father’s ht (cm)+ (mother’s Ht (cm)+ 13)] 2 GIRLS: [(Father’s ht (cm) -13) + mother’s Ht(cm)] 2 Inches: change 13 for 5’’

Approach to a child with short stature History Physical examination Height of the child Height of parents Plotting on growth chart workup

History Birth history Nutritional history Chronic disease history (asthma, CHD, CLD,CRF, chronic diarrhea) Drugs….chronic steroid therapy Family history

Physical examination Weight measurement (fat & short….endocrine, thin & short……under nutrition or chronic illness Systemic examination to rule out systemic illness skeletal system examination including spine Dysmorphic features Tanner staging

Height measurements Heels & back touching the wall Looking straight ahead Gentle but firm pressure upwards applied to the mastoids from underneath US/ LS ratio Total Arm span

velocity impaired? If the growth velocity is subnormal (below the 25th percentile for age) without alternative physiological explanations, the child should be thoroughly investigated

velocity impaired?

Appropiate target height Common causes: Familiar (genetic) Constitutional BA=CA BA<CA N growth veloc Appropiate target height

Case 1 12 month old boy was on breast feeding , Started extra feeding at the age of 6 month , Feeding orally well but having attacks of diarrhea, Presented with this growth chart .

Case 2 Mariam is an 11 year old girl who has always been “short for her age.” Her mother is 150”, her father is 165”. Her physical exam is normal, and her breasts are Tanner II, pubic hair is Tanner II

1. What should you do next? : calculate mid-parental height obtain bone age laboratory screening re-plot on a specialized growth chart

2. The most likely diagnosis is: familial short stature constitutional delay Turner Syndrome Down Syndrome

Case 3 S.T. is an 11 year old girl with short stature and history of recurrent otitis media. Her mother is 158”, and her father is 175”. Her physical exam is remarkable for multiple nevi, low posterior hairline, webbed neck, widely spaced nipples, and increased carrying angle. Her breast and pubic hair development are Tanner I.

The most likely diagnosis is (select one answer): a) skeletal dysplasia b) constitutional delay c) growth hormone deficiency d) Turner’s Syndrome e) chronic disease

Case 4 A 9-year-old boy is referred for evaluation of growth. His height has accelerated from the 25th - 35th percentile, and his weight has increased from the 25th to greater than the 90th percentile over the past 4 years (Figure). His physical examination is significant for mild acanthosis nigricans on the posterior neck, early Tanner stage 1 pubic hair, and 2 cm3 testicular volume. His family history reveals that his mother had menarche at age 11 years. The boy’s bone age is 11 years.

The most likely diagnosis is : Cushing syndrome exogenous obesity hypothyroidism precocious puberty premature adrenarche 

Case 5 K.R. is a 13 year old girl presenting with fatigue. Her review of systems is positive for cold intolerance, dry skin, and constipation. Her physical exam is remarkable for a sallow appearance, waxy dry skin, and coarse hair. Her mother is 155” and her father is 170”

He most likely diagnosis is (select one answer): a) constitutional delay b) hypothyroidism c) non-organic failure to thrive d) channeling (i.e., normal variant) e) skeletal dysplasia

Case 6 A 6-year-old girl is referred for growth evaluation. Her history is significant for a poor appetite, with no specific systemic complaints.birth wighet 3.6 kg. The midparental target height is (160 cm),

Child born small for gestational age Growth hormone gene deletion Pituitary tumor Turner syndrome Undernutrition secondary to gastrointestinal disease

case 7 A 4-year-old boy has a history of severe eczema that has been resistant to moisturizers, low-dose topical steroids, and topical tacrolimus. At 3 years of age, he was seen by another physician and prescribed 0.05% betamethasone diproprionate cream for his eczema. This medication has greatly improved his skin, but you note that his growth velocity has diminished somewhat during the last year Of the following, the MOST likely cause of his diminished growth rate is

A. constitutional delay of growth B. exposure to excess exogenous steroids C. growth hormone deficiency D. inadequate caloric intake E. normal variation in annual growth rate

KEY POINT The boy in the questionhas growth failure that is most likely due to his history of long-term use of glucocorticoids. Betamethasone dipropionate is a potent topical glucocorticoid that should not be used for prolonged periods because there is a risk of developing Cushing syndrome when it is used for extended periods.

Both topical and inhaled preparations of glucocorticoids that are commonly used to manage persistent asthma can also cause systemic supraphysiologic glucocorticoid levels that may result in decreased growth velocity. In addition, these patients may develop adrenal insufficiency if glucocorticoids are abruptly discontinued This complication can be avoided by gradually weaning patients off glucocorticoids to ensure reactivation of a suppressed hypothalamic-pituitary-adrenal axis.

Pathological causes

Thank you !!!