Assessing Child Growth in Primary Care Ramesh Mehay, Bradford

Introduction There should be no hesitation in referring short children. Children with hormonal deficiencies need treatment as early as possible Each year that passes without appropriate replacement therapy represents some loss in final adult height.

Why are boys taller than girls after Puberty? Growth Spurt : boys enter this spurt 2 years later than girls During 2 year period, boys grow at 5cm/y (10cm total) ; girls grow at 8cm/y (16cm total) Age 14 : girls stop growing; boys now growing 8cm/ year (16 cm) Because boys stop growing 2y later, (5cm/year) they are at least 10cm taller

Facts n Figures: who is bigger than who? Average heights (UK): F : 5’ 4” M 5’ 9” < 11 B=G 11-14 G>M >14 B>G (by around 5”) Complete fusion Girls 16-18 Boys 18-21

A 12 year old girl is referred to you after a school medical because of concerns about short stature. How would you assess her

Measuring Procedure Remove the child’s shoes Ask him to stand with heals against wall or plate As an assistant to hold the feet on the ground, so that the child’s heels do not rise when you ask him to stretch upwards Make sure the child is standing straight. Press the thighs and pelvis gently backwards against the surface of the wall or measuring device Ensure that the upper margin of the auditory meatus is in a line with the angle of the orbit Stretch the child gently upwards with traction under the angle of the jaw and ask him to take a deep breath Measure with your eye in line with the scale to avoid parallax errors Plot on chart

Plotting stuff on a chart Use charts to assess growth Supine length up to age 2; standing height thereafter Take 2 measurements in a 12 month period Accuracy is the key Correct for prematurity Plot mid parental height – but remember not that accurate, 0.7 correlation

The Assessment – Worry or Not? HISTORY Find out the reasons for parental concern; take a review of systems enquiry – gut, heart, chest, GUS, CNS A good screening question: “is the child growing out of his trousers or shoes” EXAMINATION If you suspect short stature: look for additional signs and symptoms (=dysmorphic syndromes): examine for asymmetry, limb or spine shortening, general appearance (triangular facies and clinodactyly of Silver-Russell syndrome), evidence of systematic illness, heart murmurs (congential heart disease), Nail changes ( spooning = turners, renal failure; finger clubbing = ?IBD ), early pubertal changes, webbed neck and wide carrying angle (Turner’s)

MEASUREMENTS Record & plot the birthweight and gestation Note parental heights; plot mid parental height (expect most children to reach a height at full growth within 8cm of mid parental height centile) (MAKE SURE PARENTS DON’T HAVE A GROWTH DISORDER) Get past growth records Ascertain past or present illnesses Take two measurements to assess growth velocity (but think about early referral too) Crossing the centile lines for height is worrying and usually demands investigations PROVIDING the measurements are take over 12 months apart

Comparing Height & Weight If W>H: primary growth problem likely (familial, genetic, bone dysplasia, syndromal or hormonal) If W=H: primary growth problem possible If W<H: primary growth problem unlikely

Tests FBP, U&E, creatinine, Ca, Phosphorus, Alk Phos, TFTs. Skeletal Survey (anthropometry) (latter = child development centres); other lab tests as per clinical findings Turner’s = refer for chromosomal analysis (karyotyping) GH deficiency – refer for provocation test X-rays for bone age

More Facts n Figures At age 4 height = birth length x 2 Puberty = causes a brief acceleration of the height velocity (usually 5cm but can be up to 10cm per year)

Important Causes of Short Stature Short stature = height below the 3rd centile Genetic & familial IUGR Malnutrition & Psychosocial Deprivation Endocrine (hypothyroidism, GH deficiency) Chronic Diseases Chondrodystrophies Important Causes of Short Stature Genetic and Familial Remember, 3% of children are below the 3rd centile in height. Nearly all of them are normal short children (and in many cases the parents are also short) Height below 99.6 centile line is very likely to have a specific cause. IUGR Most will recover Malnutrition & Psychosocial Deprivation Usually developing countries with psychosocial deprivation (?asylum seekers). Can happen with developed countries – inappropriate diets (high fibre, little calorific content); Coeliacs Growth Hormone release is depressed in emotionally deprived children but rapidly reverts to normal with they are provided with love and reasonable care. Endocrine These are the most important treatable causes Hypothyroidism- Most are detected in the neonatal period but sporadic cases can occur throughout childhood. Growth hormone deficiency – can present at any age NB If headaches and defective vision, consider craniopharyngioma; rare but important conditions to exclude whenever you suspect secondary hypopituitarism. Chronic Diseases Renal Failure Infalmmatory Bowel Disease Chondrodystrophies Abnormal proportions between limbs and trunk length – usually obvious Important to pick up: genetic counselling; new treatments

What’s This? Turner’s Syndrome: webbing of the neck Easily overlooked – might be missed til age 6/7 Girls Look for webbing of the neck, shield shaped chest, wide carrying angle at elbow, spoon shaped finger nails Special growth charts are available for Turner’s Early referral

What’s this? Silver-Russell Syndrome : triangular facies, short stature

Tall Stature Usually a rare complaint. Often when parents are worried about their daughters becoming too tall. Refer as soon as the problem is presentated: early treatment is essential if the aim is to reduce the adult height by any significant amount CAUSES Genetic & Familial Marfan’s Klinefleter’s Thyrotoxicosis Growth Hormone Excess Precociouc Puberty

Excellent resources on www.bradfordvts.co.uk click online resource > clinical stuff > paeds Let’s look at some charts