1. DISORDERS OF GROWTH AND DEVELOPMENT BY : DR SANJEEV

2. Developmental Delay Evaluation  History  Family history, perinatal history, medical illnesses, environmental factors  Physical exam  Growth chart, congenital anomalies, muscle tone, vision, hearing  Labs if indicated  Chromosomal studies, metabolic studies, EEG, MRI of brain

3. Short Stature  Definition: Less than 5th percentile for height or deceleration of previously normal growth curve (growth of less than 5cm per year)  Most cases (80%) are due to normal or non- pathologic causes; 20% are due to pathologic abnormalities

4. Short Stature: Non-pathologic  Familial short stature  Normal bone age and normal growth velocity  Puberty occurs at expected time  Final height is usually less than 5th percentile  Constitutional delay  Delayed bone age (consistent with height age) and normal growth velocity  Puberty is significantly delayed

5. Short Stature: Pathologic  Pathologic causes usually present with diminished growth velocity  Proportionate (affects all bones) or disproportionate (affects long bones predominantly)  Identify and treat underlying cause  Growth hormone injections are helpful in growth hormone deficiency

6. Short Stature: Pathologic (Cont’d) Proportionate short stature: – Growth hormone deficiency – Primary hypothyroidism – Cushing’s Syndrome – Precocious puberty – Malnutrition – Chronic systemic diseases Disproportionate short stature – Rickets (Vitamin D deficiency) – Achondroplasia( short limbs but normal trunk )

7. Colic  Crying more than 3 hours/day, 3 days/week over 3 weeks  Usually early evening;  Occurs in about 1 out of 5 babies  Starts within first few weeks  Peaks at 2-3 months  30-40% continue into the 4-5 th month

8. Colic – Suggested Causes  Intolerance to cow’s milk protein  Intestinal gas  Abnormal GI motility  Immature GI or neurological systems  Caregiver factors

9. Colic: Treatment  Colic typically stops as mysteriously as it starts  Symptoms resolve 60% by 3 months, 90% by 4 months  Most interventions work in 1/3 of infants; no treatments work for all

10. Colic: Treatment (Cont’d)  Maternal diet – no milk, eggs, nuts, wheat; particularly if mother atopic  Feeding techniques – vertical position with curved bottle  Parental support – important but doesn’t  colic  Anticholinergic drugs {dicyclomine (Bentyl)} associated with harm – apnea, seizures, coma Peds 10

11. Childhood Obesity  BMI >95th percentile for age (>85th percentile is “at risk”)  Weight to height ratio >95th percentile  >120% of ideal body weight for height and age  30% of adults and 14% of children Peds 11

12. Childhood Obesity (Cont’d) Primary obesity - cause for >95% of obesity – Excess calorie intake and/or decreased activity – Usually normal or increased height for age Secondary obesity – extremely rare – delayed height growth rate – Causes: hypothyroidism, pseudohypoparathyroidism Peds 12

13. Childhood Obesity (Cont’d) Primary obesity - cause for >95% of obesity – Excess calorie intake and/or decreased activity – Usually normal or increased height for age Secondary obesity – extremely rare – delayed height growth rate – Causes: hypothyroidism, pseudohypoparathyroidism, Peds 13

14. Childhood Obesity: Evaluation  History: developmental history, parental weights, lifestyle information  Exam: measurement of height/weight, body mass index,  Labs: consider if secondary obesity Peds 14

15. Childhood Obesity (Cont’d)  Common complications: hypertension, hyperlipidemia, type 2 diabetes  Associated disorders: slipped capital femoral epiphysis, obstructive sleep apnea  Obesity is second only to tobacco use for contribution to preventable premature death in adults; may be 1 by 2010 Peds 15

16. Childhood Obesity: Management  Behavioral and life style modification  Goal in children is slowing weight gain while allowing normal growth in height  Child and family need to work together to improve eating habits and increase activity  Include counseling or support groups to develop a healthy body image Peds 16

17. Peds 17 Nocturnal Enuresis Primary Never been persistently dry through the night Much more common and less likely to have a pathologic cause Secondary Child starts wetting the bed after one year of continence Multiple causes: UTI, small bladder capacity, anatomic abnormalities

18. Peds 18 Primary Nocturnal Enuresis: Diagnosis Children >5 who are incontinent of urine at night Estimated 15-20% of children have some degree of enuresis Spontaneous resolution is 15% per year At age 15, only 1-2% still wet the bed Obtain complete history and physical Other causes must be ruled out

19. Peds 19 Nocturnal Enuresis: Treatment Behavioral interventions Limiting intake of fluids in the evening Age appropriate responsibility for clean-up Bed-wetting alarms Superiority in terms of cure rates, lack of side effects and low relapse rates Medications - sometimes indicated Imipramine (Tofranil) and desmopressin (DDAVP)

20. Peds 20 Attention Deficit/Hyperactivity Disorder (ADHD) Diagnosis & etiology Prevalence is 3-5% of school age children Four times more common in boys than girls Problem persists into adulthood for 40-60% of children Diagnosis is clinical Based on history, parent and teacher reports and observation Must rule out other causes of behavior

21. Peds 21 Attention Deficit/Hyperactivity Disorder (ADHD) (Cont’d) Diagnostic criteria (DSM-IV) Either inattention or hyperactivity/impulsivity Six months duration Onset no later than age 7 Symptoms in two or more settings (e.g., school and home) Significant impairment in functioning

22. Peds 22 Learning disorders Conduct disorders Substance abuse Anxiety disorders Affective disorders ADHD Co-Morbidity of ADHD

23. Peds 23 Attention Deficit/Hyperactivity Disorder (ADHD): Treatment Medications (psychostimulants) Alter deficits in inattention, impulsivity, and hyperactivity Behavioral management Restructuring demands on child and changing environmental

24. Peds 24 Autism Markedly impaired development in social interaction Markedly impaired communication skills Restrictive, repetitive or stereotyped behavior, interests or activities Onset prior to age 3

25. Clinical feature:  Inability to develop normal social skill with lack of eye contact, gesture and facial expression  They understand little or no language  Have deficient comprehension and communicative use of speech and gesture.  Etiology :  Prenatal factors : intrauterine rubella,chromosomal abnormalities.  Postnatal condition : phenylketonuria, herpes simplex encephalitis

26. Management :  Early and intensive remedial education that addresses both behavioral and communication disorders.  Drug treatment :  Dopamine antagonist (haloperidol)  Selective serotonin reuptake inhibitor (fluroxamine)  Prognosis :  Children starts to acquire language.

27. FAILURE TO THRIVE :  Is a term given to infants whose rate of weight gain is sluggish.  Length may or may not be affected  Causes :  Intrinsic causes:  Defects in absorption : celiac disease, lactose intolerance, cystic fibrosis.  Persistent vomiting : pyloric stenosis, gastroesophageal reflux.  Metabolic disorders : diabetes mellitus  Chronic diseases : heart, lungs, liver and kidney

28. Cont..  Extrinsic causes :  Inadequate nutritional intake  Social and environmental deprivation or both.  C / F :  Looks small for age  Weight is below 3 rd percentile  Expressionless face and avoids direct gaze  Response to social stimuli is inadequate.

29. Investigation :  Complete blood count  Electrolytes  Blood urea

30. MANAGEMENT :  Immediate treatment :  Hospitalize for the first 10- 14 days  History (dietary and developmental)  Physical examination should be done  Nutritional problems need to be appropriately manage  Feeds should be thickened to increase the calorie intake  Infant should be fed in the semi upright position.