Dipesh yadav

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-short stature (disease of height)-failure to thrive (disease of weight)

Dipesh yadav (Roll No:140,Group K, Batch: Aug-10)

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SHORT STATURE

Definition: height below 3rd centile or more than 2 standard deviations below the median height for that age and sex according to the population standard.

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Etiology:Physiological or normal variant short stature:A. FamilialB. Constitutional

Pathological short statureC. Under nutritionD. Chronic systemic illness

• Renal: renal tubular acidosis, chronic renal failure, steroid dependent nephrotic syndrome

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Etiology (cond.)

• Cardiopulmonary: congenital heart disease, cystic fibrosis, asthma

• Gastrointestinal and hepatic: malabsorption, chronic liver disease

• Chronic severe infectionsC. Endocrine causes

• Growth hormone deficiency/ insensitivity• Hypothyroidism• Cushing syndrome• Pseudohypoparathyroidism• Precocious or delayed puberty

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D.Psychosocial dwarfismE. Children born small for gestational ageF. Skeletal dysplasia, e.g.;

achondroplasia, ricketsG.Genetic syndromes, e.g.; Turner

syndrome, Down syndrome

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Feature Familial Short Stature Constitutional Short Stature

1) Sex Both equally affected More common in boys

2) Family History Of short stature Of delayed puberty

3) Height Velocity Normal Normal

4) Puberty Normal Delayed

5) Bone Age Normal Less than chronological age

6) Final Height Short, but normal for targetheight

Normal

Comparison

Detailed historyCareful examinationLaboratory evaluation

Diagnosis

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Assessment of a child who presents with short stature

• Accurate height measurement • Assessment of body proportion• Assessment of height velocity• Comparison with population norms• Comparison with child’s own genetic

potential• Sex maturity rating (SMR): Tanners staging

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Clues to etiology of short stature from history

History Etiology

Low birth weight Small gestational age

Polyuria Chronic renal failure, renal tubular acidosis

Diarrhea, offensive greasy stools

Malabsorption

Neonatal hypoglycemia, jaundice, micropenis

Growth hormone deficiency

Headache, vomiting, visual problem

Pituitary/ hypothalamic space occupying lesion

Lethargy, constipation, weight gain

hypothyroidism

Dietary intake Under nutrition

Social history Psychosocial dwarfism

History for timing of puberty in parents

Constitutional delay of growth

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Clues to etiology of stature from examination

Examination finding Etiology

Disproportion Skeletal dysplasia, rickets, hypothyroidism

Dimorphism Congenital syndromes

Pallor Chronic anemia, chronic renal failure

Hypertension Chronic renal failure

Frontal bossing, depressed nasal bridge, crowed teeth, small penis

Growth hormone deficiency

Goiter, coarse skin Hypothyroidism

Central obesity, striae Cushing syndrome

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Investigation:Level 1 ( essential investigations):

1.Complete hemogram with ESR

2.BONE AGE

3.Urinalysis ( Microscopy, pH, Osmolality)

4.Stool ( parasites, steatorrhea, occult blood)

5.Blood ( RFT, Calcium, Phosphate, alkaline phosphatase, venous gas, fasting sugar, albumin, transaminases)

Level 2 (investigations for short stature)

1.Serum thyroxin, TSH

2.Karyotype to rule out Turner syndrome in girls

Above is normal and bone age is delayed proceeds to level 2

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Investigation (contd.)

• If above investigations are normal and height between -2 to -3→ observe height velocity for 6-12 months

• If height < -3 SD → proceeds to level 3 investigations

Counselling of parents ( for physiological causes)Dietary advice ( Under nutrition, Celiac disease)Limb lengthening procedures ( skeletal dysplasia )Levothyroxine ( In Hypothyroidism)GH s/c injections ( GH deficiency, Turner syndrome)Monitoring with regular & accurate recording of height

is mandatory for a good outcome in any form of therapy

Management:

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FAILURETO

THRIVE

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Failure to thriveDefinition:• Is a term used for when a child’s weight for age is

below the fifth percentile or crosses two major percentile lines

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Etiology:Organic causes:• Gastrointestinal- gastro esophageal

reflux, malabsorption, inflammatory bowel disease, pyloric stenosis

• Neurological- mental retardation, cerebral palsy

• Renal- renal tubular acidosis, chronic renal failure

• Cardiopulmonary- congenital heart disease, cystic fibrosis, asthma

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• Endocrine- Hypothyroidism, diabetes mellitus, adrenal insufficiency

• Infections- chronic parasitic or bacterial infections of gastrointestinal tract, tuberculosis, infection with HIV

• Genetic- Inborn errors of metabolism, chromosomal anomalies

• Miscellaneous- lead poisoning, malignancy, collagen vascular disease

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Non organic causes:• Poverty• Misperceptions or lack of knowledge about diet and

feeding practices • Lack of breastfeeding, feeding diluted formulae• Dysfunctional parent-child relationship with abuse &

neglect

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• Clinical features: Poor growth Poor development Poor cognitive function

-the degree of FTT is measured by weight, height and weight for height as percentage of median value for age on appropriate growth charts

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• Diagnosis: History Physical examination Observation of parent-child interaction Weight gain in response to adequate calorie

feeding establishes the diagnosis of psychological FTT

• Management: Nutritional rehabilitation T/t of organic causes if present Remedial measures for psychological factors

involved

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Indications for hospitalization • Severe malnutrition• Diagnostic & laboratory evaluation

needed for organic cause• Lack of catch up growth during

outpatient T/t• Suspected child abuse or neglect

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