pediatrics seminar
DESCRIPTION
Pediatrics Seminar. Preseted by: Fahd Alareashi & ??????????. Case Scenario:. A 10-year-old girl presents to the clinic with her parents. Her parents report that she is the shortest in her class. - PowerPoint PPT PresentationTRANSCRIPT
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PEDIATRICS SEMINAR
P R E S E T E D BY : F
A H D AL A R E A S H I &
?? ? ? ? ? ? ? ? ?
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CASE SCENARIO:
• A 10-year-old girl presents to the clinic with her parents.
• Her parents report that she is the shortest in her class.
• However, they have become concerned because her 8-year-old sister is now the same height as she is.
• The patient has not yet attained menarche and her mother reports no breast development.
• She has been well with no chronic medical problems, no hospitalizations, and no surgeries.
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CASE SCENARIO:
• She lives with her mother, father, and sister .
• She is currently in the fifth year elementary school and she always scores grade A.
• Her mother is 173 cm (5'8") and weighs 68 kg (150 pounds). She had menarche at age 12.
• The patient's father is 185 cm (6'1") and weighs 95 kg (210 pounds).
• There is no family history of any medical problems.
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CASE SCENARIO:
• On further history, you find that your patient was 43 cm (17 inches) long at term (average is 49.5 cm, 19.5 inches).
• P/E:• General:
• Conscious.• Looks girl.• No apparent distress.
• Vital signs:• Temperature: 37◦ C.• Pulse: 90 bpm.• BP: 100/60 mmHg.• RR: 18 breaths/min.
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CASE SCENARIO:
• P/E:
• Growth Parameters:• Height: 120 cm.• Weight: 23 Kg.• Head Circumference: 52 cm.
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Stat
ure
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Wei
ght
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H.C
.
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Wt-f
or-H
t.
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CASE SCENARIO:
• P/E:
• Head & Neck:• Neck is supple and webbed. • Low posterior hair line.
• Chest:• Heart: Normal S1 & S2, No additional sound.• Lungs are clear.
• Abdomen:• Soft.• No masses.
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CASE SCENARIO:
• P/E:
• Breast:• Tanner I.• Wide spaced nipples are evident.
• Pubic Hair:• Tanner I.
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CASE SCENARIO:
• INVESTIGATIONS:
• Her growth chart is reviewed which demonstrates:• an average growth velocity: 3cm/year.
• Bone age:• 8 years & 6 months.
• CBC: normal.• ESR: normal.• TFT's: normal.• UA: normal.• Serum electrolytes: normal.
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CASE SCENARIO:
• INVESTIGATIONS:
• Chromosomal analysis:• 45 XO.
• ► Diagnosis of Turner Syndrome is made.
• She is referred for a renal ultrasound, cardiology evaluation, and a hearing screen.
• She is also seen by the pediatric endocrinologist and is started on growth hormone.
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AN APPROACH TO
SHORT
STATURE
P R E S E T E D BY : F
A H D AL A R E A S H I
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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SHORT STATURE:
• A child whose height is below the 3rd percentile for age and sex.
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GROWTH FAILURE:• Slow growth rate regardless of the
stature.
• Ultimately, a slow growth rate leads to short stature.
•A Growth Chart is used to show:• A child's current height.• Growth Velocity : how fast the child is growing.
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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GROWTH CHARTS
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GROWTH CHARTS:• Growth charts are a standard part of
any checkup.
• They show health care providers how kids are growing compared with other
kids of the same age and gender.
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DIFFERENT TYPES OF GROWTH CHARTS:
Weight-for-Age Height-for-Age
HC-for-Age
MALEGROWTHCHARTS
Weight-for-Height
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FEMALEGROWTHCHARTS
DIFFERENT TYPES OF GROWTH CHARTS:
Weight-for-Age Height-for-Age
HC-for-Age
Weight-for-Height
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GROWTH CHARTS:• Assessment:
•Short Stature: Height < 3rd percentile.
•Growth Failure:• Height crossing 2 major percentiles.
•Low growth velocity: Rate < 25th percentile.
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Stat
ure
• Short stature with normal growth rate and delayed growth spurt with eventual achievement of normal adult stature.
“ CONSTITUTIONAL GROWTH DELAY “
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Stat
ure
•Normal growth rate.• Short stature in childhood.•Short stature in adults.
“ Familial Short Stature“
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Stat
ure
“ Acquired Pathologic Short Stature“
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SPECIAL T
YPES OF G
ROWTH
• special growth charts available for these conditions.
• These children grow along percentiles specific to their condition.
Turner
syndrom
e, A
chon
droplas
ia,
Down sy
ndrome
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MID-PARENTAL HEIGHT:• Children are usually in a percentile between their
parents' height.
• The Expected Height of the child as adult lies between ± 5 cm from the Mid-parental age:
Girls:
= 2
Boys:
= [Mother’s Height + Father’s Height + 13]
[Mother’s Height + Father’s Height - 13]
2
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CAUSES OF:SH
ORT STAT
URE
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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CAUSES:
Normal Variants
Pathologic
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CAUSES:
Normal Variants
Pathologic
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CAUSES:
Normal Variants
• Most common.
• Normal Growth Velocity.
• Non Pathologic.
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CAUSES:
Normal Variants
Familial Short Stature
Constitutional Growth Delay
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CAUSES:
Normal Variants
Familial Short Stature
• Short parents.
•Born short.
•Bone age (X-ray): Chronological age.
•Puberty occurs at time.
•No treatment is indicated.
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CAUSES:
Normal Variants
Constitutional Growth Delay
• Bone age is delayed.
•Puberty is delayed.
•Hx. of delayed puberty in parents.
•Normal adult height.
•May require short term therapy with
androgens/estrogens.
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CAUSES:
Normal Variants
Pathologic
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CAUSES:
Normal Variants
Pathologic
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CAUSES:Pathologic
Prenatal “ Primordial“
Postnatal
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CAUSES:Pathologic
Prenatal “ Primordial“
•IUGR.•Chromosomal: Down syndrome, Turner syndrome.•Skeletal dysplasia.
•All parameters are affected; Height, weight, & head circumference.
Proportionate
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CAUSES:Pathologic
Postnatal • Endocrine:• GH deficiency.• Hypopituitarism.• Cushing
syndrome.
• Chronic Diseases:• Cyanotic
congenital heart diseases.
• Celiac diseases, IBD, cystic fibrosis.
• Chronic infections.
• Chronic renal failure.
• Psychosocial neglect:
Height > Weight“Short & Fat”
Weight > Height“Short & Skinny”
Weight & Height are decreased
Proportionate
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CAUSES:Pathologic
Postnatal
• Achondroplasia.• Rickets.• Hypothyroidism.
Disproportionate
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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APPROACH & ASSESSMENT
OF:SHORT
STATURE
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ASSESSMENT
Hist
ory Ta
king
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HISTORY:• Antenatal History:
• IUGR?• Any complications: pre-eclampsia, hypertension, anemia,
maternal history of smoking, alcohol & infections, drugs?
• Delivery:• Gestational age?• Mode of delivery?• APGAR score.• Complications?• Hypoglycemia.
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HISTORY:• Nutritional History?
• Symptoms suggesting systemic chronic diseases:• Dyspnea?• Sweating with feeding?• Recurrent respiratory infection?• Chronic diarrhea?• Fatigue, cold intolerance? “hypothyroidism”• Recent weight gain, acne, mood swing? “Cushing”
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HISTORY:• Syndromes?
• Down syndrome, Turner syndrome?...
• Family History?• Short stature?• Chronic illnesses.• Neglect? Starvation?
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HISTORY:• Drug History?
• Corticosteroids?• Insulin?
• Development History?• Delayed?
• Systemic Review:• A complete review of systems needs to be undertaken in order
to help exclude an undiagnosed syndrome or chronic medical condition
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ASSESSMENT
Physica
l Exa
mination
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PHYSICAL EXAMINATION:• Vital Signs.
• Anthropometric Measurements:• Height:
• Plotted on growth chart.• Height velocity growth chart in the 6 – 12 months.
• Nutritional Assessment:• Mid arm circumference.• Weight for age and weight for height.
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PHYSICAL EXAMINATION:• Vital Signs.
• Anthropometric Measurements:• Proportionate / Disproportionate:
• Upper / lower segment ratio.• Arm span minus Height.
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PHYSICAL EXAMINATION:• Vital Signs.
• Anthropometric Measurements:
• Calculate Mid-parental Age:
Girls:
= 2
Boys:
= [Mother’s Height + Father’s Height + 13]
[Mother’s Height + Father’s Height - 13]
2
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PHYSICAL EXAMINATION:• Dysmorphic Features?
• Down Syndrome? Turner Syndrome?• Single palmar crease, webbed neck, low hairline,..• Moon face “Cushing”?
• Puberty Assessment (Tanner Staging):
• Examinations for systemic illnesses.
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ASSESSMENT
Inve
stigati
ons
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INVESTIGATIONS:• Bone age.
• Wrist X-ray for rickets:
• Skeletal survey for skeletal dysplasia:• a series of X-rays of all the bones in the body, or at least the axial
skeleton and the large cortical bones.
• Karyotyping.
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INVESTIGATIONS:• Ca, P, Alkaline phosphatase.
• LFTs, RFTs.
• ESR.
• Sweat chloride test for cystic fibrosis.
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INVESTIGATIONS:• Endocrinal studies:
• T4, TSH,
• GH:• Basal level.• Level after pituitary stimulation: exercises, clonidin or arginin.
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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SHORT STA
TURE
• Definition
• Growth Charts
• Causes
• Approach
• Management
Outlines
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MANAGEMENT
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MANAGEMENT:• Non-pathological short stature:
• No treatment is required.
• Pathologic short stature:• Manage the underlying cause.• Growth Hormone GH:• GH Therapy if the following criteria are met:• GH shown to be deficient by 2 different stimulation tests.• Patient is short, insufficent growth velocity, <3rd percentile.• Bone age x-rays show unfused epiphyses• Turner syndrome, Noonan syndrome, chronic renal failure.
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THE E
ND
.…