DISORDERS OF GROWTH AND DEVELOPMENT BY : DR SANJEEV

1. DISORDERS OF GROWTH AND DEVELOPMENT BY : DR SANJEEV

2. 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

3. 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

4. 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

5. 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

6. 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 )

7. 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

8. Colic – Suggested Causes Intolerance to cow’s milk protein Intestinal gas Abnormal GI motility Immature GI or neurological systems Caregiver factors

9. 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

10. 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

11. 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

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

13. 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,

14. Childhood Obesity:Evaluation History: developmental history, parental weights, lifestyle information Exam: measurement of height/weight, body mass index, Labs: consider if secondary obesity

15. 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

16. 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

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

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

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)

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

21. Attention Deficit/Hyperactivity Disorder (ADHD) (Cont’d) • Diagnostic criteria (DSM-IV) • Either inattention or hyperactivity/impulsivity Six months duration • Onset no later than age 7 • Symptoms in two or more settings (e.g., school and home) • Significant impairment in functioning

22. Co-Morbidity of ADHD Anxiety disorders ADHD Conduct disorders Affective disorders Substance abuse Learning disorders

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

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

25. 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

26. 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.

27. 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

28. 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.

29. Investigation : Complete blood count Electrolytes Blood urea

30. 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.