DISORDERS OF GROWTH AND DEVELOPMENT

BY : DR SANJEEV

Developmental DelayEvaluation

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

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

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

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

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 )

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 4-5th month

Colic – Suggested Causes

Intolerance to cow’s milk protein Intestinal gas Abnormal GI motility Immature GI or neurological systems Caregiver factors

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

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

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

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

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

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

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

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

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

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

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)

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

Peds 21

Attention Deficit/Hyperactivity Disorder (ADHD) (Cont’d) Diagnostic criteria (DSM-IV)

Either inattention or hyperactivity/impulsivitySix months duration

Onset no later than age 7 Symptoms in two or more settings

(e.g., school and home) Significant impairment in functioning

Peds 22

Learning disorders

Conduct disorders

Substance abuse

Anxiety disorders

Affective disordersADHD

Co-Morbidity of ADHD

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

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

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

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.

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

Cont.. Extrinsic causes : Inadequate nutritional intake Social and environmental deprivation or

both . C / F : Looks small for age Weight is below 3rd percentile Expressionless face and avoids direct gaze Response to social stimuli is inadequate.

Investigation :

Complete blood count Electrolytes Blood urea

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.