Growth and development

1. September Board Review 2012 Growth and development

2. Test Question What Board Review Topic should we do next? • Allergy & Immunology • Adolescent Medicine and Gynecology

3. Normal Growth

4. Growth • Affected by: • Prenatal factors: • Maternal nutrition and uterine size • Genetic growth potential • Nutrition throughout childhood • Multiple hormones • Growth, thyroid, insulin, sex hormones • Despite all these factors, growth is predictable • Carefully documented growth charts are powerful tool to measure health and well-being

5. Growth • Postnatal growth • Healthy term infants lose 10% of their birth weight in the first days after birth • Regain it back by 2-3 weeks of age • Normal: Gain 20-30g/day for first 3 months • This rapid phase of growth is influenced primarily by growth hormone (GH) and thyroid hormones

6. Question #1 At what age to most healthy, term infants typically triple their birth weight? • 6 months • 12 months • 18months • 2 years • 3 years

7. Growth Milestones • Birth weight triples by 1 year • Birth length doubles by 3-4 years • During puberty: sex hormones become significant factor • Slight deceleration of growth just prior to puberty • Followed by rapid acceleration of growth • Males later than females • Females BEFORE menarche

8. Accurate Measurements • Scales calibrated regularly • Weigh in underwear or diaper • Length/height should be measured supine in age <2 years • Legs fully extended, head resting on unmovable board, moveable footboard • Standing height for >2yrs • Wall-mounted stadiometer • If cannot stand: arm span is good substitute

9. Growth Charts • Growth charts from CDC or WHO • Specific charts for special populations • LBW and VLBW premies • Trisomy 21, Turner, Klinefelter, achondroplasia • Each child should be considered in terms of their genetic growth potential • Estimate with mid-parental height • Boys= [Father’s height(cm) + mother’s height(cm) +13]/2 • Girls = [Father’s height(cm) + mother’s height(cm) -13]/2

10. Growth Charts • Shifts across 2 or more percentile lines may indicate an abnormality in growth • Shifts in the early life can be normal • Birth size reflects maternal factors (uterine size, etc) • Genetic factors take over after birth • Small infant born to large parents catches up around 6mos • Large infant born to small parents slows down around 12 months • After age 3, shifts are uncommon and warrant investigation

11. TH = target height Question#2 What is the most likely diagnosis? • Normal • Constitutional Growth Delay • Familial Short Stature • Hypothyroidism • Cushing syndrome

12. Abnormal growth • Malnourished • Drop in weight first, then height, then head circumference • Linear growth problems • Indicates congenital, genetic, or endocrine abnormality • Hypothyroidism or GH deficiency: normal or elevated weight with decreased height

13. Familial short stature • Height and weight are normal for 2-3 years • Height then drifts downward across percentiles • Growth curve follows normal growth curve at lower percentile • After initial drop off, have normal growth velocity

14. ConstitutionalGrowth Delay • Variation of normal growth • Reduced tempo of development • Height and weight both cross percentiles • Normal or near normal growth rate during prepubertal years • Bone age is delayed • Delayed puberty • Fall further off curve • Complete pubertal growth in late teens/early 20’s • Achieve normal range height (might be slightly lower than MPH)

15. BMI • Begin plotting BMI for every patient at age 2 • Weight (kg)/height(m)2 • 85th-95th %ile = overweight • >95%ile = obseity • <5th%ile = underweight • Does not differentiate lean muscle from fat

16. Head Growth

17. Head size • Normal head circumference of full-term infant at birth • Range 32-38cm • Average 35cm • Microcephaly • 2 SDs below mean for age/sex (<2nd %ile) • Macrocephaly • 2 SDs above mean for age/sex (>98th %ile)

18. Microcephaly • Congenital: • Trisomy 13, 18, 21 • Cornelia de Lange, Smith-Lemli-Optiz, Rett • Inborn errors of metabolism, hypothyroidism • Acquired: • Normal head circumference at birth followed by development of microcephaly over months to years • Lack of brain development or growth • Causes: Stroke, meningitis, encephalitis, toxoplasmosis, rubella, CMV, teratogen exposure in utero, hypoxic-ischemic encephalopathy • MRI most helpful in head size <3SDs below mean and neurologic abnormalities

19. Question #3 Which of the following is commonly associated with hydrocephalus? • Large parental head circumference • Increased amount of brain parenchyma • Normal CNS imaging • Developmental delay, hypertonia, hyperreflexia • Skeletal dysplasias

20. Macrocephalyvs Hydrocephalus • Macrocephaly • Causes range in severity from benign to severe • Familial • Benign • Normal development • Parents with large heads • Accelerated rate of head growth which stabilizes by 12-18 months • Hydrocephalus • Excessive accumulation of CSF • Congenital: present at birth • Acquired: accelerated growth over several months • Irritability, vomiting, bulging fontanelle, upward gaze

21. Macrocephalyvs Hydrocephaly • Can distinguish the two using clinical exam • Look for signs of increased ICP • Developmental delay, hypertonia, hyperreflexia • Imaging • Ultrasound: if fontanelle is open • CT: fast, available, does not always detect posterior fossa pathology • MRI: shows more specific detail, but is not always easily accessible

22. Failure to thrive

23. Question #4 You are seeing an 18 month old child for the first time. She is developing well, and the parents have no concerns. Her growth chart reveals a weight at the 3%, height at the 25%, and HC between the 25-50%. What is the MOST likely cause of this patient’s poor weight gain? • Inborn error of metabolism • Congenital heart defect • Inadequate caloric intake • Growth hormone deficiency • Hypothyroidism

24. Definition • FTT is no longer viewed as simply nonorganic vs. organic syndrome • NOW… • It is a physical sign that a child is receiving inadequate nutrition for optimal growth and development • Causes of this may vary…and it is our job to figure that out • MOST cases are due to inadequate caloric intake (nutritional) • There are medical causes, too

25. Differential Diagnosis • 3 mechanisms can cause under-nutrition • Inadequate intake (Ingesting insufficient nutrients for growth) • Malabsorption • Increased metabolic demands

27. Poor feeding techniques often cause FTT • May be a manifestation of parental neglect/inadequacy • Some clues to the cause may be elicited from simple observation • Oromotor problems • Food aversions • Poor parent/child interaction

28. Question #5 A mom brings in her 2yo boy with Down syndrome. She is concerned that he is not gaining weight well. The nurse plotted him on a typical male growth chart at 5% for weight. He is a picky eater and often spits up after feeds. There is no history of cardiac or intestinal malformation, but he does have a history of frequent otitis media. Of the following, what is the most important next step? • Order an echo to look at his heart • Refer him to a nutritionist for dietary counseling • Send him to ENT for tympanostomy tubes • Plot his growth parameters on a different growth chart • Start Zantac for his reflux

29. Growth Charts • Plotting the weight, length, and head circumference is an important step in assessing a child’s growth. • Remember subtle differences are important • Weight tends to fall 1st with poor caloric intake, then HC and length • For endocrine disorders, the patient is short (<50%) with relative sparing of weight • Special growth charts for certain genetic conditions (Down, Turner, Williams syndromes)

30. Evaluation • In the past, children underwent an extensive medical/lab evaluation for organic causes of FTT • Now…the majority of FTT work-ups are observational with dietary management and can be accomplished in the outpatient setting** • If outpatient management fails, then admission and laboratory evaluation may be needed** • CBC with RBC indices • CMP (test for renal and hepatic function) • Celiac screening • OTHER

31. Long-Term Consequences • Many children who experience FTT in early life eventually seem to have normal function • However…the overall trend is worrisone • Persistent intellectual deficits • Behavioral problems • Conflicting evidence on emotional outcomes or future growth parameters

32. Motor Development

33. Gross Motor • Goal: to gain independent and volitional movement • Primitive reflexes develop during gestation • Prepare the infant for acquisition of skills • Disappear as CNS matures to allow infant to make purposeful movements

34. Question #6 At what age should this reflex disappear? • 1 month • 2 months • 6 months • 9 months • 12 months

35. Reflexes Protective Extension: emerges at 6 - 9mos Moro reflex: Birth – 6 mos Positive support: Birth - 4-6 months

36. Gross Motor Milestones

37. Question #7 A mother brings her child for a health supervision visit. He is able to pull to stand, take a few independent steps, and use his thumb and 2nd digit to grasp a piece of cereal. These milestones are MOST typical for a child who age is: • 6 months • 9 months • 12 months • 15 months • 18 months

38. Gross Motor Milestones • 2 months: lifts head and chest while prone • 4 months: no head lag, steady head control while sitting, rolls front to back, props on wrists • 6 months: sits propped on hands, rolls over in both directions • 9 months: begins creeping, pulls to stand, walks on hands and feet

39. Gross Motor Milestones • 12 months: pulls to stand and cruises well, takes independent steps • 15 months: walks independently, stoops to floor/recovers to standing position • 18 months: walks up steps with hand held, throws ball • 24 months: runs well, kicks ball, jumps with 2 feet off the floor, throws ball overhand

40. Gross Motor Milestones • 3 years: broad jumps, stands momentarily on one foot, pedals tricycle • 4 years: balances on one foot for 3 seconds • 5 years: skips, alternating feet • 6 years: rides bicycle without training wheels, tandem walks

41. Question #8 Of the following scenarios, which is the LEAST concerning? • An 18 month old who cannot walk independently • A 4 month old who lacks steady head control while sitting • A 9 month old who is unable to sit unassisted • A 30 month old who does not run • A 10 month old who does not crawl

42. Fine Motor Development • Use of upper extremities to engage and manipulate the environment • Self-help tasks, play, do work • First play a role in balance and mobility • At birth – no voluntary use of hands • Due to primitive grasp reflex • Can’t hold or transfer objects until this goes away • Once gross motor development allows for stable upright position  hands for more free and purposeful exploration

43. Question #9 You observe a child who is holding two blocks and bangs them together. Then she picks up a cheerio using an immature pincer grasp and feeds it to herself. These milestones are MOST consistent with a child who is: • 4 months • 6 months • 9 months • 12 months • 15 months

44. Development of pincer grasp Raking Scissor Immature Inferior Fine

45. Fine Motor Milestones • 2 months: regards object and follows 180 degrees, hands unfisted 50% of time, hands held together, hands to midline • 4 months: hands open, reaches for objects, clutches at clothes • 6 months: transfers object from one hand to another, reaches with one hand, raking grasp • 9 months: feeds self with fingers, plays gesture games (pat a cake) in imitation, bangs objects together, holds two objects at a time, immature pincer grasp

46. Question #10 You observe a child as he walks into the exam room. He is holding a small ball. When you ask him to let you see the ball, he gives it to you. He stoops to the floor to pick up a crayon and recovers to a standing position. He uses the crayon to scribble on a piece of paper you gave him. When he sees a few blocks on the floor, he picks up two and stacks one on top of the other. These milestones are MOST typical for a child whose age is: • 9 months • 12 months • 15 months • 18 months • 24 months

47. Fine Motor Milestones • 12 months: fine pincer grasp, holds crayon, attempts to scribble after demonstration • 15 months: plays ball with examiner, gives and takes a toy, drinks from a cup, makes a line with a crayon, makes 2-3 cube tower • 18 months: feeds self with spoon, 3-4 cube tower • 24 months: washes and dries hands, removes clothing, 4-6 cube tower, feeds self with spoon and fork

48. Fine Motor Milestones • 3 years: independent eating, helps with dressing (unbuttons clothing, puts on shoes), 10 cube tower, copies circle • 4 years: brushes teeth, copies cross/square, draws simple figure of person (head plus 1 body part) • 5 years: dresses and undresses, cuts with scissors, draws person with 6 body parts, copies triangle, independent dressing • 6 years: , ties shoes, draws diamond, writes first and last name

49. Cognitive Development

50. Cognitive Development • The foundation of intelligence • Progression through developmental stages involves object permanence, causality, and symbolic thinking • Depends on two developmental domains • Language • Both an expressive and a receptive process • Language skills are the SINGLE best indication of intellectual ability • Problem-solving • The manipulation of objects to achieve a specific goal