1. Assessing Child Growth in Primary Care
Ramesh Mehay, Bradford

2. 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.

3. 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

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

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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

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

16. 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

17. Excellent resources on
click online resource > clinical stuff > paeds
Let’s look at some charts