Measure growth patterns at eachwell-child visit and each health care encounter
Measure growth patterns at eachwell-child visit and each health care encounter: Excerpt from Avoiding Common Pediatric Errors
Author:
Anjali Subbaswamy, MD
What to Do - Gather Appropriate Data
Normal patterns and variations of growth will assist clinicians in understanding subtle changes in body chemistry that may not manifest themselves
forconsiderableperiodsoftime(e.g.,hypothyroidism,otherendocrineproblems). Discuss normal variations in growth.
Assessing a child's growth pattern gives a picture of the child's overall health. In fact, some suggest that growth be viewed as a vital sign. It is
a sensitive indicator of general health. Abnormal growth may be the first
manifestation of pathology. Despite this fact, a survey of primary care practices in the United States showed that 10% of pediatric practices and 40%
of family practices did not measure children at well-child visits. It is often
difficult to distinguish between normal and abnormal growth. Short stature
may represent a normal variant or signify underlying disease.
In utero growth is influenced by nutrition, uterine size, and the
metabolic environment. Insulin, insulinlike growth factor (IGF), and their
binding proteins are important for fetal growth. Growth hormone (GH) and
thyroid hormone do not have a role in growth in utero; however, they are
major influences for normal postnatal growth. GH circulates free and bound
and induces growth of chondrocytes at the growth plate. It also stimulates
secretion of IGF-1, which mediates many of GH's growth-promoting
actions. During the postnatal period, there is rapid linear growth velocity
that declines after birth. A child's linear growth velocity averages 25, 12, and
8 cm/year during the first 3 postnatal years. From this time until the onset
of puberty, linear growth occurs steadily at a rate of 4 to 7 cm annually;
weight gain averages 2.5 kg annually. At puberty, sex hormones (testosterone
and estrogen), coupled with GH, thyroid hormone, and nutrition, result
in an accelerated rate of growth—the pubertal growth spurt. In girls, this
usually occurs during sexual maturity rating (SMR) 3 for breast; the growth
spurt in boys typically occurs during SMR 4 in boys. Following puberty,
growth ultimately ceases secondary to closure of the epiphyseal plates
due to the effects of estrogen. Growth represents an intricate connection
between genetics, hormones, nutrition, and environment. Physicians must
accurately assess growth during every well-child visit and know when
further evaluation is needed.
When evaluating a child with a possible growth problem, the accurate
analysis of the growth curve is crucial. Four aspects of the growth curve
should be evaluated:
1. Reliability of measurements.
2. Absolute height relates to the likelihood of an existing pathologic condition (i.e., a child with an absolute height 3 standard deviations (SDs)
below the mean is more likely to have underlying disease than one with
an absolute height 1 SD below the norm).
3. Height velocity refers to the observation of a child's height over time.
It is the most important of the four aspects, and requires at least 4 to 6
months of observation. A deceleration in height velocity (crossing percentiles) between 3 and 12 to 13 years is pathologic until proven otherwise. A normal height velocity regardless of absolute height is usually not
pathologic.
4. A weight to height relationship assists in evaluating the cause of growth
delay in the short child. Systemic disorders are associated with lower
weight to height ratios (impairment of weight gain greater than that of
linear growth). Endocrine disorders are usually associated with preservation of weight gain (higher weight to height ratios).
Target height is also useful in determining a patients genetic potential for
growth. It is calculated by the following equations:
Target height in boys =
(father's height [cm] + mother's height [cm] + 13)/2
Target height in girls =
(father's height [cm] + mother's height [cm] - 13)/2
Most children reach heights within 10 cm of the target. Bone age is a method
of evaluating bone and skeletal maturity by comparing the patients epiphyseal centers obtained via radiograph with age-appropriate standards. The
commonly used method assesses the bones of the hand and wrist. If there
is short stature, and a delayed bone age, the short stature is somewhat "reversible." However, a normal bone age and short stature is a greater concern.
Assessing the upper-to-lower body segment (U/L) ratio demonstrates
if the short stature is proportional. Skeletal dysplasias involving the spine
typically have decreased U/L ratio for age; those involving the long bones
(i.e.,achondroplasia)typically haveincreasedU/L ratio.Precociouspuberty
may present with an increased U/L ratio for age. A decreased ratio may be
seen in Klinefelter or Kallmann syndrome.
Constitutionaldelayofgrowth(CDGA)andfamilialshortstature(FSS)
are considered normal variations of growth. In CDGA, growth is characterized by: (a) normal birth length; (b) slowing linear growth during the first
3 years of life (weight and height decline across percentiles); (c) normal or
near-normalrateoflineargrowthbelowbutparalleltofifthpercentileduring
prepubertal years; (d) delayed bone age and pubertal maturation coincides
with bone age, not chronologic age; and (e) final adult height is usually normal. This is the "late bloomer." Typically, the father of the child was a short
child and experienced puberty late. Bone age is always delayed. The growth
pattern of FSS is quite similar to CDGA until puberty. They have normal
height and weightat birth, and tend to cross linear growth percentiles during
the first 2 years of life (fulfilling genetic appropriate growth). At this point,
a child with FSS has steady growth below, but parallel to, normal growth
curve.Pubertycoincideswithchronologicage,andfinaladultheightisshort,
but appropriate based on parental height. Bone age is typically normal. See
Figure 126.1 below for causes of growth delay/retardation.
Suggested Readings
Grimberg A. "Growth Curves: Are we missing the picture?" American Academy of Pediatrics
Section on Endocrinology. 2003 vol 11 p. 15. http://www.aap.org/sections/endocrinology/
Endonewsspring03.pdf. Accessed January 7, 2008.
Rose SR, Vogiatzi MG, Copeland KC. A general pediatric approach to evaluating a short child.
Pediatr Rev. 2005:26:410–420.
Vogiatzi MG, Copeland KC. The short child. Pediatr Rev. 1998;19:92–99.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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