Paediatrics ESSAYS - Есета по Педиатрия на английски език

1. Growth and Puberty

Normal growth
• Can be divided into 2 phases:
o Pre-natal/ foetal growth:
▪ Maternal factors most important
o Postnatal growth:
▪ Infantile (birth → 2 yrs). Decelerating growth rate. Dependent on nutrition, insulin and
thyroxine.
▪ Childhood: slow steady growth velocity. Dependent on GH and thyroxine.
▪ Puberty: dependent on GH and sex hormones (testosterone/ oestrogen).

• Recording growth:
o UK-WHO growth charts for children aged 0-4.
▪ Ethno-specific growth charts
• Tall = Dutch, Afro-Caribbean
• Short = Gujurati, Urdu, Punjabi
o On the growth chart, plot:
▪ Head circumference:
• OFC (occipital-frontal circumference)
• 33-35cm at birth
• 1cm/ month for first year.
▪ Length/ height:
• Height at birth + 2cm a month
• 0-2yo: lying naked infant with head and feet held
• Head → HEEL.
• >2yo: wall mounted stadometer. Shoes and socks off. Eyes at ear level.
▪ Weight:
• Naked on scales
• Normal = 3.5kg at term
• <2.5kg = low birth weight
o <1.5kg = very low
o <1kg = extremely low
• Small for gestational age = <10
th centile.
o Weight gain:
▪ Normal to lose <10% of weight in 2 weeks after birth.
▪ X2 at 6mo; x3 at year.
▪ Normal rates of weight gain:
• 1
st 3 mo: 30g/ day
• 3-6 mo: 20g/day
• 6-12 mo: 15g/ day
o BEWARE of centile crossing: can indicate pathology
▪ E.g. head circumference → hydrocephalus?

o Plotting preterm infants:
▪ Use a separate low birth-weight chart for <32 weeks
▪ Pre-term section only has charts for WEIGHT and OFC.
▪ Use preterm sections of WHO chart for <37 weeks (≤36)
• Use up until EDD + 2 weeks
▪ >42 weeks, plot on with gestational correction (also do this if they are pre-term):
• Draw dot on actual age in weeks
• Then draw arrow backwards/ forwards to how old they should be.
• Continue gestational correction until:
o 1 year if 32-36
o 2 years if <32
• Correction is made around 40 weeks, i.e. if born at 34 weeks, draw back 6
weeks.
Height/ weight/ OFC
should not be further than
2 centile marks apart, i.e.
9
th
/ 25
th
/ 50
th
/ 75
th
.

Failure to thrive/ faltering growth
• Mostly due to under-nutrition
• Can also be due to feeding behaviour ± organic disease:
o If they continue along the same centile, probably just small
o If falling centile → refer.
• Separate growth charts for:
o Down’s
o Turner’s
o Achondroplasia.

Organic causes of faltering growth
Inadequate food
intake
• Breast feeding – inadequate supply, poor technique
• Formula feeding – milk too dilute
• Anorexia – from chronic illness
• Unable to feed – cleft palate, cerebral palsy
• Vomiting- GORD
• Neglect/ abuse
Malabsorption • Coeliac disease
• Cystic fibrosis
• Short gut (post-op)
• Cow’s milk protein allergy
• Parasites
• Cholestasis/ biliary atresia
retention • Diarrhoea
• DM
Increased energy
requirements
• Chronic illness:
o CF, Congenital heart disease, chronic renal
failure
o Hyperthyroidism
o Malignancy
o Eczema


Growth predictions
• Mid-parental centile comparator:
o Can use special chart where you mark the mother’s on one side, and the father’s on the other,
and draw a line between. Mid parental percentile = where it crosses the line in the middle.
o Most children are ±2 centiles of mid-parental centile.
• Mid-parental height:
o Boys: [Mother’s height + father’s height]/2 +6.5cm
o Girls: [Mother’s height + father’s height]/2 -6.5cm
• Target range = MPH ± 10cm.

Plotting pre-term infants
Transfer preterm to infancy section
Born 6 weeks preterm
Plot on preterm section of
chart until 42 weeks (EDD+2)
Then plot on infancy section
using gestational correction
Must use DOTS to
plot on growth chart.
Same as IDA

SHORT STATURE
• = height <3
rd percentile. (MU-PLOVIDV <2
nd percentile)
• Correct for height using MPH.
• Causes:
o Familial
o Constitutional delay in growth and puberty
o Psychological neglect (→GH)
o IUGR
o Other endocrine:
▪ Hypothyroidism
▪ Cushing’s
▪ GH deficiency: bitemporal homonymous hemianopia. DO insulin tolerance test: should
cause a rise.
• At birth → neonatal hypoglycaemia + jaundice
• Doll-like face.
• Grow normally for first 12 months
• MARKEDLY REDUCED BONE AGE
o Dysmorphic syndromes:
▪ Turner’s
▪ Noonan
▪ Down’s
o Coeliac
o Chronic renal failure
o Chronic inflammatory disease:
▪ IBD
▪ Rheumatic disease
o Other chronic disease:
▪ Asthma
▪ HF
o Skeletal dysplasia:
▪ Achondroplasia (AD dwarfism)
▪ Hypochondroplasia
o Metabolic disease:
▪ X-linked hypophosphataemic rickets
o Malnutrition.
• Ix:
o U&E
o FBC and CRP
o Calcium and phosphate
o Karyotype
o TFTs
o Serum IGF-1
o Coeliac Ab screen
o Urinalysis.

TALL STATURE
• Height >97
th percentile
• Majority = inherited.
• Other causes:
o Early puberty
o Obesity
o Endocrine disorders:
▪ Precocious puberty
▪ GH excess
▪ Pituitary adenoma
▪ Androgen excess
▪ CAH
▪ Hyperthyroidism
▪ Aromatise enzyme deficiency
≤2
nd
percentile = -2SD
≥98
th
percentile = +2SD
For GH:
- Initial scree: IGF-1 (will be low)
- Then do insulin tolerance test,
measuring GH and IGF-1 after 2h.
Short stature is NOT
associated with
prematurity.

▪ Oestrogen receptor defects
▪ Primary hyperinsulinaemia
o Kleinefelters (XXY)
o Marfan’s
o Homocysteinuria
o Soto syndrome: large head, characteristic facies and LD
o Beckwith-Wiedemann syndrome
o Maternal DM
• Ix:
o Karyotype
o TFTs
o Serum IGF-1
o Sex hormones/ LH/ FSH
o Androgen levels
o OGTT → test GH levels (should be suppressed).
• Mx: low dose sex steroids can be given to fuse growth plates, but usually avoided as major SEs.

ABNORMAL HEAD GROWTH
• Posterior fontanelle closed at 8 weeks
• Anterior closed at 12 – 18 mo.
• 33-35cm at birth; 1cm/ month for first year.
• Microcephaly:
o = head circumference ≤2
nd percentile.
o Causes:
▪ Familial
▪ If with developmental delay → Patau (trisomy 13)
▪ Congenital infection
▪ Insult to developing brain, e.g. cerebral hypoxia (accompanied by cerebral palsy)
▪ Craniosynostosis: one or more sutures fuses prematurely.
• Foetal alcohol syndrome:
o Short palpebral fissure
o Hypoplastic upper lip
o Absent philtrum
o Small eyes
o IQ
o Cardiac malformations
• Macrocephaly:
o OFC ≥98
th percentile
o Causes:
▪ Tall stature
▪ Familial
macrocephaly
▪ ICP → MRI/ CT
▪ Hydrocephalus
▪ Subdural haematoma
▪ Cerebral tumour
▪ NF
▪ Cerebral gigantism (Soto syndrome – also tall stature)
• Plagiocephaly:
o Wonky head
o in incidence due to sleeping babies on their back to SIDS
o Can also indicate neglect/ baby left alone for long period of time
o Improves by age 3-5
o Advise to turn cot around; give time on front in day.

• Findings AT BIRTH:
o Caput seccadenium: normal. Crosses suture lines.
o Chignon: from ventouse
o Cephalohaematoma: does not cross suture lines.

OBESITY
• Overweight = BMI ≥85
th percentile (BMI >25)
• Obese = BMI ≥95
th percentile (BMI >30)
• Exogenous causes rare: Hypothyroid, Cushings & Prader-Willi
• Associated with: Asian, female, tall children.
• Complications:
• Ortho: SUFE/ tibia vara/ abnormal foot structure & function
• Benign intra-cranial HTN
• Hypoventilation syndrome: daytime somnolence; sleep apnea; snoring; hypercapnia; HF
• Gall bladder disease
• PCOS/ DM2/ HTN
• Psychological sequelae
• Mx:
• Lifestyle changes
• Healthy eating/ exercise/ ↓periods of inactivity
• Success enhanced with family support.

BMI centiles: where weight and height centiles cross, follow line up.

Define growth Increase in dimensions, body weight and proportions.
Phases of normal
growth
1. Fetal
• Fastest period of growth - accounts for 30% of height
• Size at birth is determined by the size of the mother and by placental nutrient supply.
• Low birthweight increases the later metabolic risk of childhood obesity.
2. Infantile phase
• Rapid but decelerating growth rate and accounts for about 15% of eventual height.
3. Childhood phase
• Slow, steady but prolonged phase that contributes to 40% of final height.
• Pituitary growth hormone is the main determinant of a child's rate of growth,
provided there is adequate nutrition and good health. Thyroid hormone, vitamin D
and steroids also affect cartilage cell division and bone formation.
4. Puberty growth spurt
• Sex hormones, mainly testosterone and estradiol, cause the back to lengthen and
boost GH secretion. This adds 15% to final height. The same sex steroids cause
Factors that affect
growth
• Intrinsic
• Hormones
• Insulin - main regulator of metabolism, regulates fats and proteins
• Thyroid hormones after birth
• Growth hormones
• Steroid hormones
• Extrinsic
• Food and nutrition
Teeth
Formula for approximately how
many teeth they might have:
Age in months - 6

• Diseases which may interfere with growth
Normal Values • Height (48-52cm)
• Should gain 2cm in a month
• So 25 cm per year
• 75cm at one year
• Growth slows down to 7cm a year
• Problems
o Intrauterine growth retardation
o Congenital infection
o Feral alcohol syndrome
• If child is treated with corticosteroids they will be taller for their age but final height
will be less
• Thalassemia patients are shorter
o Iron overload due to blood transfusions
o Endocrine glands differ
o Heart and liver impairments
o They have diabetes
o Would need hormonal replacement therapy
o Chelating agent to take out excess iron
• Causes of short stature
o Genetic or delayed bone age
o Endocrine disorders
• GH deficiency
• Glucocorticoid excess
• Diabetes mellitus
• Vitamin D resistant rickets
o Skeletal dysplasia - osteogenesis imperfecta, achondroplasia
o Lysosomal storage diseases - mucopolysaccharidosis
o Syndromes of short stature
• Turner syndrome
• Noonan syndrome
• Autosomal trisomy 13,18,21
• Prader-Willi syndrome
• Weight
• Normal - 2.5-4.5 kg
• Can be more in mothers who are diabetic
o Due to increased insulin which can increase GH
• After first week they will loose fluids (7%)
• Head circumference
• 34-35 cm
• Grows 1cm a month
• Essential to measure in 1st year as
o Slow growth (microcephaly)
o Fast growth (hydrocephalus)
• Chest circumference
• 33-35cm

Puberty in
pediatrics
In Boys
• Grow taller
• Oily skin - pimples
• Voice gets deeper
• Facial hair
• Pubic hair
• Broader shoulder
• Pollutions
• Penis/Testes get bigger
• Sexual thoughts
• Concerned about looks
• In Girls
• Breasts develop
• Hips get wider
• Menstruation starts
• Sexual feelings/thoughts
• Mood swings
• Wants more independence
• Grow taller
• Pubic hair
• Concerned about looks
• Start ovulation





Early puberty
changes
• Thelarche - Breast budding under the areola
• Adrenarche or pubarche - pubertal fine straight pubic hair over the mons pubis.
Growth spurt in
girls
• The peak growth spurt usually occurs approx. 1 year after thelarche.
• Females grow 5-7cm/year during growth spurt and only 2-5cm in height after menarche
Menarche • Is a relatively late pubertal event
• 12.9 years average
Growth spurt in
boys
• Is a relatively late event
• Occurs from 10.5 - 16 years
Body composition
changes
• In females, fat deposition begins sooner and remains
• In males it begins later and then is lost
Psychological and
behavioral changes
• Intellectual ability
• Preference of abstraction
• Increased capacity for making judgments
• Interest in sexual activity
• Sexual orientation
• Gender identity
Hormonal • The hypothalamus is responsible for the initiation of puberty
• GnRH (Gonadotropin releasing hormone)
• FSH and LH -> gonadal sex steroids
• Targets of testosterone, Estrogen include
o Genitourinary ducts
o Hair follicles
o Apocrine glands
o Fat and muscle cells
o Bones
o Brain
o Growth spurt
• ACTH -> DHEA and DHEAS (dehydroepiandrosterone)
• Secretion of DHEA and DHEAS leads to pubic and axillary hair
• Thelarche is also dependent on adrenarche-adrenal androgens are