What are important points to obtain on history of child presenting with slow growth or short stature?
Growth History & Familial Patterns of growth
Intake history
- Breast feeding - frequency/duration, issues, exclusive vs partial, timing of solids
- Formula - type, amount, dilution method
- solids - when, what, range of foods
- Behavioural issues with feeding
- Milk consumption
Output history - bladder, bowels, vomiting
ROS - general and signs of puberty
FHx - digestive, hormonal, autoimmune issues, short stature
social hx - any child protection issues?
What are important points to obtain on examination of child presenting with slow growth or short stature?
Growth charts
- Slow growth (‘failure to thrive’) if child is <3rd percentile for weight or drops >= 2 percentiles height and head circumference are initially well preserved
- Further investigation required if child below the 25th percentile on growth velocity chart
Expected height
- Determine mid-parental height and plot on growth chart to compare expected growth
- Child’s height should be within one SD of the MPH (+/- 7.5-8cm)
Nutritional status
Signs of child abuse
Behaviour/parental interaction
Systems to exclude organic i.e. abdo, endocrine
What are red flags for children presenting with slow growth or short stature?
- Signs of abuse or neglect
- Poor carer understanding e.g. non-English speaking, intellectual disability
- Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support
- Signs of poor attachment
- Parental mental health issues
- Already/previously case managed by child protection services
- Did not attend or cancelled previous appointment/s
- Signs of dehydration
Signs of malnutrition or significant illness
What are DDx for slow growth/FTT?
Malabsorbtive diseases Dentition/oral structural issues Breast feeding/formula issues Psychosocial factors, restrictive diet Genetic and metabolic conditions
What are DDx for short stature?
Physiological
a. Constitutional delay of growth & puberty
b. Familial short stature
Intrauterine
a. Placental insufficiency
b. Russell-Silver syndrome
Skeletal
a. Bony dysplasia
b. Spinal irradiation
Nutritional
a. Malabsorption
b. Rickets
c. Malnutrition
Chronic illness
Iatrogenic - Corticosteroids
Chromosomal/genetic
a. Turner syndrome
b. Down syndrome
c. Prader-Willi
d. Others
Endocrine
a. Hypothyroid
b. GH deficiency
c. Cushing syndrome
d. Pubertal delay/arrest
Features of constitutional delay of growth & puberty?
- Common normal variant
- Usually FHx of delayed puberty
- Growth slows around 2 years old fall in height percentile
- Growth is thereafter parallel to 3rd centile
- Prepubertal decline in growth exaggerated and onset of pubertal growth spurt is later than average
- Bone age is delayed height for bone age usually within normal mid-parental range
Final likely in keeping with family members
Features of familial short stature?
- Several adult family members are short
- Skeletal proportions & growth velocity normal
- Bone age equivalent to chronological age
May have constitutional delay in maturation
