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Pediatrics Seminar. Preseted by: Fahd Alareashi & ??????????. Case Scenario:. A 10-year-old girl presents to the clinic with her parents. Her parents report that she is the shortest in her class.

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Pediatrics seminar

Pediatrics Seminar

Preseted by: Fahd Alareashi & ??????????


Case scenario
Case Scenario:

  • A 10-year-old girl presents to the clinic with her parents.

  • Her parents report that she is the shortest in her class.

  • However, they have become concerned because her 8-year-old sister is now the same height as she is.

  • The patient has not yet attained menarche and her mother reports no breast development.

  • She has been well with no chronic medical problems, no hospitalizations, and no surgeries.


Case scenario1
Case Scenario:

  • She lives with her mother, father, and sister .

  • She is currently in the fifth year elementary school and she always scores grade A.

  • Her mother is 173 cm (5'8") and weighs 68 kg (150 pounds). She had menarche at age 12.

  • The patient's father is 185 cm (6'1") and weighs 95 kg (210 pounds).

  • There is no family history of any medical problems.


Case scenario2
Case Scenario:

  • On further history, you find that your patient was 43 cm (17 inches) long at term (average is 49.5 cm, 19.5 inches).

  • P/E:

    • General:

      • Conscious.

      • Looks girl.

      • No apparent distress.

  • Vital signs:

    • Temperature: 37◦ C.

    • Pulse: 90 bpm.

    • BP: 100/60 mmHg.

    • RR: 18 breaths/min.


  • Case scenario3
    Case Scenario:

    • P/E:

      • Growth Parameters:

        • Height: 120 cm.

        • Weight: 23 Kg.

        • Head Circumference: 52 cm.






    Case scenario4
    Case Scenario:

    • P/E:

      • Head & Neck:

        • Neck is supple and webbed.

        • Low posterior hair line.

  • Chest:

    • Heart: Normal S1 & S2, No additional sound.

    • Lungs are clear.

  • Abdomen:

    • Soft.

    • No masses.


  • Case scenario5
    Case Scenario:

    • P/E:

      • Breast:

        • Tanner I.

        • Wide spaced nipples are evident.

  • Pubic Hair:

    • Tanner I.


  • Case scenario6
    Case Scenario:

    • INVESTIGATIONS:

      • Her growth chart is reviewed which demonstrates:

        • an average growth velocity: 3cm/year.

      • Bone age:

        • 8 years & 6 months.

  • CBC: normal.

  • ESR: normal.

  • TFT's: normal.

  • UA: normal.

  • Serum electrolytes: normal.


  • Case scenario7
    Case Scenario:

    • INVESTIGATIONS:

      • Chromosomal analysis:

        • 45 XO.

  • ► Diagnosis of Turner Syndrome is made.

  • She is referred for a renal ultrasound, cardiology evaluation, and a hearing screen.

  • She is also seen by the pediatric endocrinologist and is started on growth hormone.


  • An approach to short stature

    An approach to short stature

    Preseted by: Fahd Alareashi


    Short stature
    Short Stature

    Outlines


    Short stature1
    Short Stature

    Outlines


    Short stature2
    Short Stature:

    • A child whose height is below the 3rd percentile for age and sex.


    Growth failure
    Growth Failure:

    • Slow growth rate regardless of the stature.

    • Ultimately, a slow growth rate leads to short stature.

    • A Growth Chart is used to show:

      • A child's current height.

      • Growth Velocity : how fast the child is growing.


    Short stature3
    Short Stature

    Outlines


    Short stature4
    Short Stature

    Outlines



    Growth charts1
    Growth Charts:

    • Growth charts are a standard part of any checkup.

    • They show health care providers how kids are growing compared with other kids of the same age and gender.


    Different types of growth charts
    Different Types of Growth Charts:

    Male

    Growth

    Charts

    Weight-for-Age

    Height-for-Age

    Weight-for-Height

    HC-for-Age


    Different types of growth charts1
    Different Types of Growth Charts:

    Female

    Growth

    Charts

    Weight-for-Age

    Height-for-Age

    Weight-for-Height

    HC-for-Age


    Growth charts2
    Growth Charts:

    • Assessment:

      • Short Stature: Height < 3rd percentile.

      • Growth Failure:

      • Height crossing 2 major percentiles.

      • Low growth velocity: Rate < 25th percentile.


    Stature


    • Normal growth rate. spurt with eventual achievement of normal adult stature.

    • Short stature in childhood.

    • Short stature in adults.

    • “ Familial Short Stature“

    Stature


    spurt with eventual achievement of normal adult stature.Acquired Pathologic Short Stature“

    Stature


    Special types of growth
    SPECIAL Types of Growth spurt with eventual achievement of normal adult stature.

    Turner syndrome, Achondroplasia, Down syndrome

    • special growth charts available for these conditions.

    • These children grow along percentiles specific to their condition.


    Mid parental height
    Mid-Parental Height: spurt with eventual achievement of normal adult stature.

    • Children are usually in a percentile between their parents' height.

    • The Expected Height of the child as adult lies between ± 5 cm from the Mid-parental age:

    Girls:

    =

    [Mother’s Height + Father’s Height - 13]

    2

    Boys:

    =

    [Mother’s Height + Father’s Height + 13]

    2


    Causes of short stature

    CAUSES of: spurt with eventual achievement of normal adult stature.short stature


    Short stature5
    Short Stature spurt with eventual achievement of normal adult stature.

    Outlines


    Short stature6
    Short Stature spurt with eventual achievement of normal adult stature.

    Outlines


    Causes
    Causes: spurt with eventual achievement of normal adult stature.


    Causes1
    Causes: spurt with eventual achievement of normal adult stature.


    Causes2
    Causes: spurt with eventual achievement of normal adult stature.

    • Most common.

    • Normal Growth Velocity.

    • Non Pathologic.


    Causes3
    Causes: spurt with eventual achievement of normal adult stature.

    Familial Short Stature

    Constitutional Growth Delay


    Causes4
    Causes: spurt with eventual achievement of normal adult stature.

    Familial Short Stature

    • Short parents.

    • Born short.

    • Bone age (X-ray): Chronological age.

    • Puberty occurs at time.

    • No treatment is indicated.


    Causes5
    Causes: spurt with eventual achievement of normal adult stature.

    Constitutional Growth Delay

    • Bone age is delayed.

    • Puberty is delayed.

    • Hx. of delayed puberty in parents.

    • Normal adult height.

    • May require short term therapy with androgens/estrogens.


    Causes6
    Causes: spurt with eventual achievement of normal adult stature.


    Causes7
    Causes: spurt with eventual achievement of normal adult stature.


    Causes8
    Causes: spurt with eventual achievement of normal adult stature.

    Prenatal “ Primordial “

    Postnatal


    Causes9
    Causes: spurt with eventual achievement of normal adult stature.

    Prenatal “ Primordial “

    • All parameters are affected; Height, weight, & head circumference.

    • IUGR.

    • Chromosomal: Down syndrome, Turner syndrome.

    • Skeletal dysplasia.

    Proportionate


    Causes10
    Causes: spurt with eventual achievement of normal adult stature.

    Postnatal

    • Endocrine:

      • GH deficiency.

      • Hypopituitarism.

      • Cushing syndrome.

    • Chronic Diseases:

      • Cyanotic congenital heart diseases.

      • Celiac diseases, IBD, cystic fibrosis.

      • Chronic infections.

      • Chronic renal failure.

    • Psychosocial neglect:

    Height > Weight

    “Short & Fat”

    Weight > Height

    “Short & Skinny”

    Weight & Height are decreased

    Proportionate


    Causes11
    Causes: spurt with eventual achievement of normal adult stature.

    Postnatal

    • Achondroplasia.

    • Rickets.

    • Hypothyroidism.

    Disproportionate


    Short stature7
    Short Stature spurt with eventual achievement of normal adult stature.

    Outlines


    Short stature8
    Short Stature spurt with eventual achievement of normal adult stature.

    Outlines


    Approach assessment of short stature

    Approach & Assessment of: spurt with eventual achievement of normal adult stature.short stature


    A ssessment
    A spurt with eventual achievement of normal adult stature.ssessment

    History Taking


    History
    History: spurt with eventual achievement of normal adult stature.

    • Antenatal History:

      • IUGR?

      • Any complications: pre-eclampsia, hypertension, anemia, maternal history of smoking, alcohol & infections, drugs?

  • Delivery:

    • Gestational age?

    • Mode of delivery?

    • APGAR score.

    • Complications?

    • Hypoglycemia.


  • History1
    History: spurt with eventual achievement of normal adult stature.

    • Nutritional History?

    • Symptoms suggesting systemic chronic diseases:

      • Dyspnea?

      • Sweating with feeding?

      • Recurrent respiratory infection?

      • Chronic diarrhea?

      • Fatigue, cold intolerance? “hypothyroidism”

      • Recent weight gain, acne, mood swing? “Cushing”


    History2
    History: spurt with eventual achievement of normal adult stature.

    • Syndromes?

      • Down syndrome, Turner syndrome?...

  • Family History?

    • Short stature?

    • Chronic illnesses.

    • Neglect? Starvation?


  • History3
    History: spurt with eventual achievement of normal adult stature.

    • Drug History?

      • Corticosteroids?

      • Insulin?

  • Development History?

    • Delayed?

  • Systemic Review:

    • A complete review of systems needs to be undertaken in order to help exclude an undiagnosed syndrome or chronic medical condition


  • A ssessment1
    A spurt with eventual achievement of normal adult stature.ssessment

    Physical Examination


    Physical examination
    Physical Examination: spurt with eventual achievement of normal adult stature.

    • Vital Signs.

    • Anthropometric Measurements:

      • Height:

        • Plotted on growth chart.

        • Height velocity growth chart in the 6 – 12 months.

  • Nutritional Assessment:

    • Mid arm circumference.

    • Weight for age and weight for height.


  • Physical examination1
    Physical Examination: spurt with eventual achievement of normal adult stature.

    • Vital Signs.

    • Anthropometric Measurements:

      • Proportionate / Disproportionate:

        • Upper / lower segment ratio.

        • Arm span minus Height.


    Physical examination2
    Physical Examination: spurt with eventual achievement of normal adult stature.

    • Vital Signs.

    • Anthropometric Measurements:

      • Calculate Mid-parental Age:

    Girls:

    =

    [Mother’s Height + Father’s Height - 13]

    2

    Boys:

    =

    [Mother’s Height + Father’s Height + 13]

    2


    Physical examination3
    Physical Examination: spurt with eventual achievement of normal adult stature.

    • Dysmorphic Features?

      • Down Syndrome? Turner Syndrome?

      • Single palmar crease, webbed neck, low hairline,..

      • Moon face “Cushing”?

  • Puberty Assessment (Tanner Staging):

  • Examinations for systemic illnesses.


  • A ssessment2
    A spurt with eventual achievement of normal adult stature.ssessment

    Investigations


    Investigations
    Investigations: spurt with eventual achievement of normal adult stature.

    • Bone age.

    • Wrist X-ray for rickets:

    • Skeletal survey for skeletal dysplasia:

      • a series of X-rays of all the bones in the body, or at least the axial skeleton and the large cortical bones.

  • Karyotyping.


  • Investigations1
    Investigations: spurt with eventual achievement of normal adult stature.

    • Ca, P, Alkaline phosphatase.

    • LFTs, RFTs.

    • ESR.

    • Sweat chloride test for cystic fibrosis.


    Investigations2
    Investigations: spurt with eventual achievement of normal adult stature.

    • Endocrinal studies:

      • T4, TSH,

      • GH:

        • Basal level.

        • Level after pituitary stimulation: exercises, clonidin or arginin.


    Short stature9
    Short Stature spurt with eventual achievement of normal adult stature.

    Outlines


    Short stature10
    Short Stature spurt with eventual achievement of normal adult stature.

    Outlines


    Management
    mANAGEMENT spurt with eventual achievement of normal adult stature.


    Management1
    Management: spurt with eventual achievement of normal adult stature.

    • Non-pathological short stature:

      • No treatment is required.

  • Pathologic short stature:

    • Manage the underlying cause.

    • Growth Hormone GH:

      • GH Therapy if the following criteria are met:

        • GH shown to be deficient by 2 different stimulation tests.

        • Patient is short, insufficent growth velocity, <3rd percentile.

        • Bone age x-rays show unfused epiphyses

        • Turner syndrome, Noonan syndrome, chronic renal failure.


  • The end
    THE END…. spurt with eventual achievement of normal adult stature.


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