Assessing Child Growth in Primary Care

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Assessing Child Growth in Primary Care

• Ramesh Mehay, Bradford

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Introduction

• There should be no hesitation in referring short
  children.
• Children with hormonal deficiencies need
  treatment as early as possible
• Each year that passes without appropriate
  replacement therapy represents some loss in final
  adult height.

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Why are boys taller than girls after Puberty?

• Growth Spurt boys enter this spurt 2 years
  later than girls
• During 2 year period, boys grow at 5cm/y (10cm
  total) girls grow at 8cm/y (16cm total)
• Age 14 girls stop growing boys now growing
  8cm/ year (16 cm)
• Because boys stop growing 2y later, (5cm/year)
  they are at least 10cm taller

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Facts n Figures who is bigger than who?

• Average heights (UK) F 5 4 M 5 9
• lt 11 BG
• 11-14 GgtM
• gt14 BgtG (by around 5)
• Complete fusion
• Girls 16-18 Boys 18-21

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• A 12 year old girl is referred to you after a
  school medical because of concerns about short
  stature. How would you assess her

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Measuring Procedure

• Remove the childs shoes
• Ask him to stand with heals against wall or plate
• As an assistant to hold the feet on the ground,
  so that the childs heels do not rise when you
  ask him to stretch upwards
• Make sure the child is standing straight. Press
  the thighs and pelvis gently backwards against
  the surface of the wall or measuring device
• Ensure that the upper margin of the auditory
  meatus is in a line with the angle of the orbit
• Stretch the child gently upwards with traction
  under the angle of the jaw and ask him to take a
  deep breath
• Measure with your eye in line with the scale to
  avoid parallax errors
• Plot on chart

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Plotting stuff on a chart

• Use charts to assess growth
• Supine length up to age 2 standing height
  thereafter
• Take 2 measurements in a 12 month period
• Accuracy is the key
• Correct for prematurity
• Plot mid parental height but remember not that
  accurate, 0.7 correlation

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The Assessment Worry or Not?

• HISTORY
• Find out the reasons for parental concern take a
  review of systems enquiry gut, heart, chest,
  GUS, CNS
• A good screening question is the child growing
  out of his trousers or shoes
• EXAMINATION
• If you suspect short stature look for additional
  signs and symptoms (dysmorphic syndromes)
  examine for asymmetry, limb or spine shortening,
  general appearance (triangular facies and
  clinodactyly of Silver-Russell syndrome),
  evidence of systematic illness, heart murmurs
  (congential heart disease), Nail changes (
  spooning turners, renal failure finger
  clubbing ?IBD ), early pubertal changes,
  webbed neck and wide carrying angle (Turners)

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• MEASUREMENTS
• Record plot the birthweight and gestation
• Note parental heights plot mid parental height
  (expect most children to reach a height at full
  growth within 8cm of mid parental height centile)
  (MAKE SURE PARENTS DONT HAVE A GROWTH DISORDER)
• Get past growth records
• Ascertain past or present illnesses
• Take two measurements to assess growth velocity
  (but think about early referral too)
• Crossing the centile lines for height is worrying
  and usually demands investigations PROVIDING the
  measurements are take over 12 months apart

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Comparing Height Weight

• If WgtH primary growth problem likely
• (familial, genetic, bone dysplasia, syndromal or
  hormonal)
• If WH primary growth problem possible
• If WltH primary growth problem unlikely

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Tests

• FBP, UE, creatinine, Ca, Phosphorus, Alk Phos,
  TFTs. Skeletal Survey (anthropometry) (latter
  child development centres) other lab tests as
  per clinical findings
• Turners refer for chromosomal analysis
  (karyotyping)
• GH deficiency refer for provocation test
• X-rays for bone age

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More Facts n Figures

• At age 4 height birth length x 2
• At age 13 height birth length x 3
• Puberty causes a brief acceleration of the
  height velocity (usually 5cm but can be up to
  10cm per year)

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Important Causes of Short Stature

• Short stature height below the 3rd centile
• Genetic familial
• IUGR
• Malnutrition Psychosocial Deprivation
• Endocrine (hypothyroidism, GH deficiency)
• Chronic Diseases
• Chondrodystrophies

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Whats This?
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Whats this?
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Tall Stature

• Usually a rare complaint. Often when parents are
  worried about their daughters becoming too tall.
• Refer as soon as the problem is presentated
  early treatment is essential if the aim is to
  reduce the adult height by any significant amount
• CAUSES
• Genetic Familial
• Marfans
• Klinefleters
• Thyrotoxicosis
• Growth Hormone Excess
• Precociouc Puberty

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Excellent resources on

• www.bradfordvts.co.uk
• click online resource gt clinical stuff gt paeds
• Lets look at some charts