Growth

Growth

•Growth is a continuum that involves changes in body size and form, changes in physiologic function, and biologic maturation •A corresponding increase in cell size and number; no true normal, rather an “average” (50th percentile) plus or minus two standard deviations

Body Mass Index (BMI) = weight (kg) / height (m)2 For children, BMI is age and gender specific; so BMI-for- age is the measure used in growth chart

Anthropometric Index Indicator

Percentile Cut-off Value

BMI-for-Age

Nutritional Status

≥ 95th Overweight Weight-for-Length

BMI-for-Age

≥ 85th and < 95th

BMI-for-Age Weight-for-Length

< 5th

Underweight

Stature/Length-for-Age

< 5th

Short Stature

Head Circumference- for-Age

< 5th and > 95th

> 95th

At Risk of Overweight

Developmental Problems

35 30 25

5th

20 15 10

95th

30

50th

BMI

Weight (kg)

35

95th

25

50th

20

5th

15

5 0 80 90 100 110 120 130 Stature (cm)

10 24

72

120 168 216

Age (months)

For Children, BMI Changes with Age BMI

BMI

Example: 95th Percentile Tracking

Boys: 2 to 20 years

BMI

BMI

Age

BMI

2 yrs 4 yrs 9 yrs 13 yrs

19.3 17.8 21.0 25.1

Can you see risk? • •

This boy is 3 years, 3 weeks old. Is his BMI-for-age - >85th to <95th percentile: overweight?

at risk for

Plotted BMI-for-Age BMI

BMI

Boys: 2 to 20 years

Measurements:

Age=3 y 3 wks Height=100.8 cm (39.7 in) Weight=18.6 kg (41 lb) BMI=18.3 BMI-for-age= >95th percentile overweight

BMI

BMI

Can you see risk? • •

This girl is 4 years, 4 weeks old. Is her BMI-for-age - >85th to <95th percentile: overweight?

at risk for

Plotted BMI-for-Age Measurements: BMI

BMI

Girls: 2 to 20 years

Age= 4 y 4 wks Height=106.4 cm (41.9 in) Weight=15.7 kg (34.5 lb) BMI=13.9 BMI-for-age= 10th percentile Normal

BMI

BMI

Can you see risk? • •

This girl is 4 years old. Is her BMI-for-age - >85th to <95th percentile: overweight?

at risk for

Plotted BMI-for-Age BMI

BMI

Measurements:

Age=4 y

Height=99.2 cm (39.2 in)

Girls: 2 to 20 years

Weight=17.55 kg (38.6 lb) BMI=17.8 BMI-for-age= between 90th –95th percentile At risk for overweight BMI

BMI

Summary of Using BMI-for-Age • BMI-for-age is the recommended method for screening overweight and underweight • For children, BMI is age and gender specific; for adults there are fixed cut points • Accurate and periodic measurements are important elements of any anthropometric screening

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Obtain accurate weight and height measurements Select the appropriate growth chart Record the data Calculate BMI Plot measurements Interpret plotted measurements

Short stature Measurement that falls below the 3rd – 5th percentile for height is the short stature Risk factors/etiology: •Pathologic (postnatal onset) •Constitutional growth delay

•Familial short stature •Prenatal onset short stature (IUGR)

Presentation: Pathologic : Starts with the patient in the normal range for height Over time, starts falling off the height curve, crossing percentiles Constitutional: Starts with the patient in the normal range for height Over time, normal final adult height is reached , but the growth spurt and puberty are delayed

Causes of short stature A. Genetic-familial short stature  B. Constitutional growth delay  C. Endocrine disturbances    1. Growth hormone deficiency   2. Hypothyroidism   3. Excess cortisol—Cushing disease and Cushing syndrome (including iatrogenic causes)   4. Precocious puberty   5. Diabetes mellitus (poorly controlled)   6. Pseudohypoparathyroidism   7. Rickets

Causes of short stature (contd…) D. Intrauterine growth restriction    1. Intrinsic fetal abnormalities—chromosomal disorders   2. Syndromes (eg, Noonan )   3. Congenital infections   4. Placental abnormalities   5. Maternal abnormalities     a. Hypertension/toxemia     b. Drug use     c. Malnutrition

Causes of short stature (contd…) E. Inborn errors of metabolism    1. Mucopolysaccharidosis   2. Other storage diseases F. Intrinsic diseases of bone    1. Defects of growth of tubular bones or spine (eg, achondroplasia)   2. Disorganized development of cartilage and fibrous components of the skeleton (eg, multiple cartilaginous exostoses, fibrous dysplasia with skin pigmentation)

Causes of short stature (contd…) G. Short stature associated with chromosomal defects    1. Autosomal (eg, Down syndrome, Prader-Willi syndrome)   2. Sex chromosomal (eg, Turner syndrome-XO) H. Chronic systemic diseases, congenital defects, and cancers (eg, chronic infection and infestation, IBD, hepatic disease, CVS disease, hematologic disease, CNS disease, pulmonary disease, renal disease, malnutrition, cancers, collagen vascular disease)  I. Psychosocial short stature (deprivation dwarfism) 

Familial: Stays parallel to the growth curve Strong family history of short stature Prenatal short stature: Parallel to the growth curve but much more marked

Diagnostic tests •Growth chart •Physical exam •Karyotype (Turner syndrome) •X-ray (left hand and wrist ) for bone age Treatment: •Correction of the underlying disease state •Growth hormone in selected cases D/D: Work-up for short stature

•Familial: A normal variant, •Exogenous obesity •Endocrine: growth hormone excess (gigantism, acromegaly) •Androgen excess (tall as children but short as adults) •Hyperthyroidism •Genetic syndromes metabolic disorders: homocystinuria, cerebral gigantism , BeckwithWiedemann, Weaver-Smith, and Klinefelter syndrome

A. Constitutional (familial)  B. Exogenous obesity C. Endocrine causes    1. Growth hormone excess (pituitary gigantism)   2. Precocious puberty   3. Hypogonadism D. Nonendocrine causes    1. Klinefelter syndrome   2. XYY males   3. Marfan syndrome   4. Cerebral gigantism (Soto syndrome)

Homocystinuria: •Autosomal recessive •Incidence 1:200,000 •Marfanoid appearance •mental retardation or psychiatric illness Cerebral gigantism (Sotos syndrome) •Large for gestational age, •Mental retardation •Mild hydrocephalus

Growth velocity: Yearly increments of growth; should follow a growth curve Chronologic age (CA): Actual age Bone age (BA): X-ray of left hand and wrist Ideal : CA= BA with normal growth velocity

CA> BA •With normal growth velocity: constitutional delay •With abnormal growth velocity: chronic systemic disease endocrine disorders CA = BA •With normal growth velocity: genetic short stature •With abnormal growth velocity: genetic, chromosomal, syndrome CA< BA •With normal growth velocity: obesity •With abnormal growth velocity: precocious puberty, congenital adrenal hyperplasia (CAH) , hyperthyroidism

Failure to thrive is the failure to gain weight or deceleration of weight growth Risk Factors/ etiology: •Malnutrition (starvation, deprivation, abuse) •Malabsorption (from infection, celiac disease, cystic fibrosis, disaccharidase deficiency, proteinlosing enteropathy) •Allergies •Immune deficiency states •Chronic disease

Presentation: Growth charts •In infants, birth weight is doubled by 4-5 months of age and tripled by 1 year •Patients may show little subcutaneous fat, muscle wasting, rashes , poor tone, weak cry Diagnostic tests: •Hospitalization for documentation of caloric intake and weight gain •CBC, urinalysis, LFT, serum protein •Sweat chloride

•A generalized, excessive over-accumulation of fat •May result from an increase in number or size of adipocytes Risk factors/ etiology: •Parental obesity and family inactivity •Feeding babies as a generic response to any crying •Too much fruit juice in the first year of life •Some syndromes

Presentation: •Tall stature may sometimes be seen •Boys may present with increased adipose tissue in the mammary area •Abdominal striae •A large pubic fat •Puberty may come early •Associated obesity of the proximal extremities common

Diagnostic tests: Body mass index (BMI) > 95% for age/sex or > 30 in adolescents Treatment Exercise and a balanced diet

Complications: •Increased risk for becoming obese adults •Cardiovascular (HTN, increased cholesterol) •Hyperinsulinism •Slipped capital femoral epiphysis •Sleep apnea D/D: •Endocrine causes (Cushing, hypothyroidism, Prader-Willi) •Genetic causes (Turner, Laurence-Moon-Biedl)