1 / 115

Growth (Short Stature, Obesity) Diabetes Mellitus in Children

Growth (Short Stature, Obesity) Diabetes Mellitus in Children. Sioksoan Chan-Cua, MD Associate Professor Pediatric Endocrinologist. Learning Outcomes. Short stature Identify causes of short stature Acquire skill in history-taking, physical examination in a child with short stature

bevis
Télécharger la présentation

Growth (Short Stature, Obesity) Diabetes Mellitus in Children

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Growth (Short Stature, Obesity)Diabetes Mellitus in Children Sioksoan Chan-Cua, MD Associate Professor Pediatric Endocrinologist

  2. Learning Outcomes Short stature • Identify causes of short stature • Acquire skill in history-taking, physical examination in a child with short stature • Diagnose pathologic short stature • Propose diagnostic work-ups • Provide treatment plan

  3. Growth - Height • Normal growth • Short stature • Causes • Diagnosis • history and physical examination • work-up • treatment / management plan

  4. Growth Rate Through Adolescence At birth, full-term baby’s Length: 50 cm (20 in ) Weight: 3 kg (7 lb) Birth to 1 year: 18 - 25 cm (7 - 10 inches ) 1 to 2 years: 10 to 13 cm (4 to 5 inches) 2 years to pre-puberty : 5 to 6 cm (2 to 2.5 inches) Puberty: • Girls (11 yr) 6 - 11 cm 2.5 - 4.5 in • Boys (13 yr)  7 - 13 cm 3 - 5 in

  5. DEFINITIONS • SHORT STATURE • Height < 3rd percentile for age • GROWTH FAILURE • Growth rate < 5 cm/year after age 2 years Short Stature with Slow Growth Rate

  6. Factors Affecting Growth • Nutrition (malnutrition) • Diseases (chronic diseases) • Genes/ heredity • Hormones • Psychological factors

  7. Genetic Control of Growth • Chromosomes • Abnormalities – missing, or trisomy • Genes • normal development & function of the pituitary • growth hormone / insulin-like growth factor axis • Mutations of these genes • responsible for abnormal growth • Growth hormone deficiency • GHD IA: AR, complete GH-1 gene deletion • GHD IB: AR, point mutation • GHD II: AD • GHD III: x-linked inheritance

  8. Play a role in determination of pituitary cell lineages Pituitary-specific transcription factors

  9. Hormones Affecting Growth • Growth hormone (GH) • Thyroid hormone • Glucocorticoids • Sex hormones • Insulin – important fetal growth factor (infant of diabetic mother is macrosomic)

  10. Hormonal Control of GrowthPituitary Gland and GH GH is a protein with 191 amino acids and its secretion is pulsatile. GH may be influenced by ghrelin levels in the hypothalamic-pituitary portal circulation and the systemic circulation

  11. Causes of Short Stature

  12. Familial Short Stature

  13. FAMILIAL SHORT STATURE • Growth may be reduced between 6 & 18 months then growth becomes steady but below the 5th P • No weight deficits for height and no bone age delay (BA = CA) • TREATMENT: • None • Long term GH results in very modest height increase

  14. Constitutional Growth Delay

  15. CONSTITUTIONAL GROWTH DELAY • A common cause of short stature & sexual infantilism in the adolescent • Normal growth progression paralleling a lower percentile curve until catch up growth occurs • Usually occurs in boys; occurs occasionally in girls • (+) family history • TREATMENT: • Reassurance • Testosterone only if BA > 12 years for 4-6 months

  16. CAUSES of SHORT STATURE PATHOLOGICAL • Disproportionate • Bone development disorders (Skeletal dysplasia) • Achondroplasia • Rickets • Other skeletal disorders

  17. CAUSES of SHORT STATURE PATHOLOGICAL • Proportionate • Chromosome defects • Endocrine disorders • Low birth weight short stature (IUGR) • Nutritional deficiency • Chronic systemic disease • Psychosocial deprivation

  18. Chromosomal Abnormality • Somatic • Down syndrome • Sex chromosome • Turner syndrome • Short stature (< 144cm) • Gonadal dysgenesis • Skeletal deformity • Cubitus valgus • Short metacarpals

  19. Prader-Willi Syndrome • Obesity - hyperphagia • Moderate mental retardation • Short stature • Hypogonadism • Small hands and feet • Facies with narrow bifrontal diameter, almond eyes, full cheeks

  20. Russell-Silver Syndrome • Intrauterine growth retardation • Postnatal short stature • Small triangular facies • Limb asymmetry

  21. Endocrine Causes of Short Stature • Hypopituitarism - GH deficiency (GHD) • Hypothyroidism • Hypercortisolism • Hypogonadism

  22. PITUITARY DWARFISM • PRIMARY PITUITARY DISEASE • Pituitary hormone deficiency • Intrasellar tumor • Other destructive processes (infection, trauma) Short stature secondary to hypopituitarism is due to lack of stimulation of growth of long bone

  23. CHARACTERISTICS OF GHD • Diminished growth rate • Delayed bone age • GH (<10 μg/L) • Growth response to treatment with hGH EARLY CLUES TO GH DEFICIENCY • Hypoglycemia • Micropenis • Facial midline malformation • Neonatal injury

  24. Hypothyroidism • Hypothyroidism → short stature • Congenital • Acquired

  25. Congenital Hypothyroidism History • Autoimmune thyroid disease in the family • Intake of anti-thyroid medication in the mother • Familial congenital hypothyroidism • Presence of congenital hypothyroidism associated with deafness and goiter • Prolonged jaundice in the neonate • Poor suck in the neonate • Poor cry in the neonate • Constipation in the neonate

  26. Congenital Hypothyroidism PE • Hypothermia • Mottled, dry, coarse skin • Jaundice • Large fontanelle • Macroglossia • Hoarse cry • Distended abdomen • Umbilical hernia • Hypotonia •  Goiter

  27. Hypercortisolism – Cushing syndrome • Excessive cortisol • Short and obese • Causes: • Endogenous: tumor • Exogenous: prolonged steroid intake

  28. Abnormal levels of Sex Hormone Hypogonadism- • both growth and sexual development may be retarded Turner syndrome • insufficient amounts of the female sex hormone, estrogen • delays in growth and sexual development • Precocious puberty • Early growth spurt and premature closure of epiphyses • Adult height: Short

  29. HISTORY • Birth weight & birth length • Previous height and weight data (growth velocity) • Time of adolescent development • Dietary history • Past Illnesses • School performance • Family patterns of growth • the heights of parents, grandparents, siblings, and other close relatives • any history of early or late puberty (growth spurt and sexual development) in family members

  30. Physical Examination • Height • Weight • Arm span • Upper & lower body segment • Dysmorphic features • Associated anomalies

  31. Work-ups • X-ray for bone age • Imaging – CT scan / MRI of sella • Blood tests: • Blood chemistry • Chromosomal analysis • Hormonal stimulation tests Bone age delayed compared to chronological age in GHD and hypothyroidism

  32. Blood Tests • Blood tests • BUN, Cr, Ca, P, alk phosphatase, SGPT • TSH, T4 • Cortisol • insulin-like growth factor I (IGF-I) • Chromosomal analysis • Tests for GH SecretionGH Stimulation tests • GH<10 μg/L

  33. Treatment of Short Stature • Depends on etiology • Hypothyroidism: levothyroxine • Growth hormone deficiency: GH • Cushing syndrome • Tumor removal • Adjust dosage of steroid • Turner syndrome/ Prader Willi syndrome: GH • Achondroplasia: limb lengthening

  34. Indications of GH Use in Children • Growth hormone deficiency • Turner syndrome • Small for gestational age (not catching up in height) • Prader-Willi syndrome • Chronic renal insufficiency • Idiopathic short stature – • expected to grow shorter than • 5’3” for boys • 4’11” for girls

  35. PHYSIOLOGIC EFFECTS OF GH • Short-term administration of GH promotes • Lipolysis • loss of visceral adipose tissue - the most dramatic metabolic effect of GH • stimulates protein synthesis • increases lean body mass • stimulates bone turnover • causes insulin antagonism • alters total body water

  36. Summary • Normal growth • Growth velocity • Factors affecting growth • Short stature • “normal” variants • Pathological short stature needs evaluation • History, PE • Treatment depends on etiology • GH therapy is approved in some conditions

  37. Childhood Obesity Sept,2, 2009

  38. Learning Outcomes Obesity • Identify causes of obesity • Acquire skill in history-taking, physical examination in a child with obesity • Use growth charts and BMI charts • Propose diagnostic work-ups • Provide treatment plan

  39. Childhood Obesity • Definition • Epidemiology • Physiology • Causes • Evaluation • Treatment

  40. Definition of Overweight and Obesity Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007;120;S164-S192.

  41. Growth (Height and Weight ) Charts CDC Measurements of weight and height. Plot data on the growth charts. OK135S057

  42. Body Mass Index (BMI) BMI = Weight (kg) Height (m2) BMI charts – examples: CDC, WHO

  43. In children, BMI is age and gender specific BMI percentile can be used to identify childhood obesity Obesity 95th P 85th P Overweight http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm OK135S060

  44. WHO BMI Cut-offs • Overweight: > +1SD (= =BMI 25 kg/m2 at 19 years) • Obesity: > +2SD (= BMI 30 kg/m2 at 19 years) • Thinness: < -2SD • Severe thinness: < -3SD

  45. Obesity Overweight Normal Thinness Severe Thinness

  46. Epidemiology Prevalence of overweight and obesity • Of the world’s children and adolescents aged 5 -17 years, about 10% estimated to be overweight among them, 1/4 obese (30-40 million) Report of the International Obesity Task Force to the WHO.Obesity Reviews, 2004 Globally, generally there is 2-3 x ↑ Lancet 2002; 360:474

  47. Epidemiology In the Philippines, 7th National Nutrition Survey (FNRI): Prevalence of overweight • 2.0% among 0-5 years-old children • 1.6% among 6-10 years-old children • 4.6% among 11-19 year-old adolescents

  48. 80% 60% 40% 20% 0% <5th 5th-84th 85-94th ≥95th Prevalence of overweight and obesity Among 2022 adolescents (10-19 years) in private and public schools, Metro Manila (2007-2008) • 13% overweight (BMI 85-94th P) • 8% obesity (BMI ≥95th P) Cua S. 2008

  49. Study (S Cua, 2008):Adolescents (n=2022; age: 11-18 yr) from 6 high schools (3 private, 3 public) The prevalence of overweight about 3-fold higher in the private school students The prevalence of obesity: 5-fold higher in the private school students

  50. Prevalence of overweight among students was higher in Private Schools in Metro Mla • R. Florentino, et al, (2002) • 1208 male and female students, aged 8-10 yr • the prevalence of overweight (BMI ≥ 95th P) among private school children was almost 4 x higher than those in public school

More Related