Pediatrics seminar
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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.


    Pediatrics seminar

    Stature


    Pediatrics seminar

    Weight


    Pediatrics seminar

    H.C.


    Pediatrics seminar

    Wt-for-Ht.


    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 charts

    Growth Charts


    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.


    Pediatrics seminar

    • Short stature with normal growth rate and delayed growth spurt with eventual achievement of normal adult stature.

    • “ CONSTITUTIONAL GROWTH DELAY “

    Stature


    Pediatrics seminar

    • Normal growth rate.

    • Short stature in childhood.

    • Short stature in adults.

    • “ Familial Short Stature“

    Stature


    Pediatrics seminar

    “ Acquired Pathologic Short Stature“

    Stature


    Special types of growth

    SPECIAL Types of Growth

    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:

    • 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:short stature


    Short stature5

    Short Stature

    Outlines


    Short stature6

    Short Stature

    Outlines


    Causes

    Causes:


    Causes1

    Causes:


    Causes2

    Causes:

    • Most common.

    • Normal Growth Velocity.

    • Non Pathologic.


    Causes3

    Causes:

    Familial Short Stature

    Constitutional Growth Delay


    Causes4

    Causes:

    Familial Short Stature

    • Short parents.

    • Born short.

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

    • Puberty occurs at time.

    • No treatment is indicated.


    Causes5

    Causes:

    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:


    Causes7

    Causes:


    Causes8

    Causes:

    Prenatal “ Primordial “

    Postnatal


    Causes9

    Causes:

    Prenatal “ Primordial “

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

    • IUGR.

    • Chromosomal: Down syndrome, Turner syndrome.

    • Skeletal dysplasia.

    Proportionate


    Causes10

    Causes:

    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:

    Postnatal

    • Achondroplasia.

    • Rickets.

    • Hypothyroidism.

    Disproportionate


    Short stature7

    Short Stature

    Outlines


    Short stature8

    Short Stature

    Outlines


    Approach assessment of short stature

    Approach & Assessment of:short stature


    A ssessment

    Assessment

    History Taking


    History

    History:

    • 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:

    • 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:

    • Syndromes?

      • Down syndrome, Turner syndrome?...

  • Family History?

    • Short stature?

    • Chronic illnesses.

    • Neglect? Starvation?


  • History3

    History:

    • 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

    Assessment

    Physical Examination


    Physical examination

    Physical Examination:

    • 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:

    • Vital Signs.

    • Anthropometric Measurements:

      • Proportionate / Disproportionate:

        • Upper / lower segment ratio.

        • Arm span minus Height.


    Physical examination2

    Physical Examination:

    • 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:

    • 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

    Assessment

    Investigations


    Investigations

    Investigations:

    • 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:

    • Ca, P, Alkaline phosphatase.

    • LFTs, RFTs.

    • ESR.

    • Sweat chloride test for cystic fibrosis.


    Investigations2

    Investigations:

    • Endocrinal studies:

      • T4, TSH,

      • GH:

        • Basal level.

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


    Short stature9

    Short Stature

    Outlines


    Short stature10

    Short Stature

    Outlines


    Management

    mANAGEMENT


    Management1

    Management:

    • 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….


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