Is my child too short

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Is my child too short?

• Theresa A. Allison, M.D., M.Mus.
• UCSF/CHN Family Practice Residency Program
• Patient Care Conference

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The CaseT.T.

• ID/CC Vietnamese boy with devoted parents (born
  in June, 2003) first seen in my clinic at 14
  months of age for routine well-child care
• PMH
• Pulmonic stenosis, followed at UCSF
• Recurrent URIs including AOM x 3 (eventually
  leading to diagnosis of mild, intermittent
  asthma)
• S/P term NSVD to a 38 y/o G3P1?2 with mild
  neonatal hyperbilirubinemia, and a negative r/o
  sepsis
• Micrognathia, 5th digit campylodactyly
  brachydactyly evaluated by Genetics at birth

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The Case T.T.

• FH 4 y/o brother had Kawasakis, now doing
  well. Uncle with asthma.
• SH lives with parents, both Vietnamese, and one
  sibling. Supportive home environment
• ROS poor eating during multiple URIs, including
  3 episodes AOM, and 2 episodes of gastroenteritis
• Clinical concern Falling off his growth curve

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Is the child too small?

• Standardized Growth Charts
• Individual curves
• Failure to Thrive (FTT) and Idiopathic Short
  Stature (ISS)

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Growth Chart from Birth to 15 months
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Growth Chart from Birth to 15 months
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Growth Chart from Birth to 15 months
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Growth Chart from Birth to 15 months
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Failure to Thrive Syndrome

• Less than 3rd or 5th percentile by weight or
  length2,3,6,7
• Growth curve that has crossed two standard
  deviations in a short time2,3,6,7
• A fall to less than 75 of median weight-for
  height in children less than 2 y/o7
• Caveats no underlying medical disorder and
  lasting at least 12 months7

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Failure to Thrive

• Differential Diagnosis
• Environment
• Nutrition
• Disease
• Hormonal Deficiencies
• Genetic Disorders

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1. Environment

• Neglect inadequate intake equals inadequate
  resources for growth
• Growing evidence that growth hormone, like the
  rest of the HPA, is affected by stress levels
• Psychological dwarfism obscene extreme of
  neglect, marked by short stature, bizarre
  behavior and limited speech
• (Remember, this child has devoted parents! The
  above is for learning, and is not this patients
  problem)

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2. Nutrition

• (Excluding neglect)
• Affected greatly by acute illnesses, like URIs
  and gastroenteritis
• Inadequate food choices and intake Toddlers are
  notoriously picky but, over time, they tend to
  get what they need

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3. Disease

• Nelson Textbook of Pediatrics (Table 36-1) Major
  Organic Causes of Failure to Thrive
• System Cause
• Gastrointestinal Gastroesophageal reflux, celiac
  disease, pyloric stenosis, cleft palate/cleft
  lip, lactose intolerance, Hirschsprung's disease,
  milk protein intolerance, hepatitis,
  cirrhosis, pancreatic insufficiency, biliary
  disease, inflammatory bowel disease,
  malabsorption, food alkalines
• Renal Urinary tract infection, renal tubular
  acidosis, diabetes insipidus, chronic renal
  insufficiency
• Cardiopulmonary Cardiac diseases leading to
  congestive heart failure, asthma,
  bronchopulmonary dysplasia, cystic fibrosis,
  anatomic abnormalities of the upper airway,
  obstructive sleep apnea (snoring)
• Endocrine Hypothyroidism, diabetes mellitus,
  adrenal insufficiency or excess, parathyroid
  disorders, pituitary disorders, growth hormone
  deficiency

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3. Disease

• Nelson Textbook of Pediatrics (Table 36-1) Major
  Organic Causes of Failure to Thrive
• (continued)
• System Cause
• Neurologic Mental retardation, cerebral
  hemorrhages, degenerative disorders
• Infectious Parasitic or bacterial infections of
  the gastrointestinal tract, tuberculosis,
  human immunodeficiency virus disease
• Metabolic Inborn errors of metabolism
• Congenital Chromosomal abnormalities, congenital
  syndromes (fetal alcohol syndrome), perinatal
  infections
• Miscellaneous Lead poisoning, malignancy,
  collagen vascular disease, recurrently infected
  adenoids and tonsils

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First Interlude

• Birth and routine well-child care
• At delivery, the patient was found to have a
  harsh III/VI systolic murmur and he had
  evaluation by the Cardiology and Genetics
  services (ruled out for genetic issues)
• At his outpatient visits (up to 1 year), T.T.s
  growth was on a reasonable curve, so no workup
  was initiated
• Lead and anemia screening, per routine for WIC
  Hgb/HCT 11.6/31.8 MCV 69.7
• Empiric initiation of iron was discussed with
  T.T.s mother, as there was no FH of thalassemia

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3. Disease as a nutrition issue

• Anemia ? the oxygen-carrying component Includes
  sickle cell anemias, thalassemias and iron
  deficiency anemia
• Celiac and other GI Disease ? inadequate
  absorptive ability secondary to gut lining issues
• Chronic Kidney Disease ? protein deficiency due
  to protein loss

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3. Disease as a nutrition issue

• Chronic Lung Disease (cystic fibrosis and
  asthma) ? hypoxia and breathing requirements
  interfere with the mechanics of eating
• Congenital Heart Disease (cyanotic lesions and
  left-to-right shunts) ? oxygenation requirements
  interfere with both the mechanics of eating and
  the metabolic requirements of digestion
• Illness and injury ? Decreased ability to take in
  nutrients and increased metabolic requirements

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Second Interlude

• T.T. has pulmonic stenosis, initially moderate,
  improving with growth to a mild case. At this
  point, he does not require balloon valvuloplasty
  per his mother
• Parent agrees to bring in contact information for
  Pediatric Cardiologist at UCSF to discuss
  patients case (last consult note from 11/2003)

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Pulmonic Stenosis

• Differs from other cardiac lesions with respect
  to growth
• One study suggests that mild PS has a near normal
  distribution of growth, and
• Severe PS actually is marked by small but
  significant increase in growth for unclear
  reasons5

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4. Hormonal deficiencies

• Isolated Growth Hormone Deficiency the hot
  topic, as the availability of manufactured GH
  opens up the option of cosmetic endocrinology
• Hypothyroidism Acquired hypothyroidism can
  present as early as the first 2 years of life
  with deceleration of growth as the first
  manifestation6
• Any derangement of the HPA axis via alterations
  in metabolic state and feedback mechanisms that
  involve growth hormone

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5. Genetic Disorders

• When to suspect the zebras?
• Dysmorphic features
• Developmental delay
• Cosanguinity
• Family History

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5. Genetic Disorders

• Turners syndrome
• Downs syndrome
• Achondroplasia and other Skeletal dysplasias
• Zebras Many rare genetic disorders, only some of
  which have associations with other disabilities

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Constitutional Short Stature (ISS)

• In the rush to give everything a diagnosis, we
  even have a name for normal, idiopathic short
  stature
• As long as the child is staying on a curve, we
  are reassured
• Once a child falls off of the curve or loses
  weight, we need to think about the appropriate
  workups

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Third Interlude

• At his most recent visit, TTs mother says But
  he is bigger than the 16 month old Vietnamese
  girl he usually plays with. What does that
  mean?
• Is the child the right size for that child, or is
  he developing as normally as he should?
• At what point do we need to embark on a workup?

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Vietnamese Growth Chart
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The Workup for FTT

• Labs CBC, LFTs, Renal panel, urinalysis.
  Consider TSH, ESR, Insulin Growth Factor-BP3
  (IGF-BP3), Insulin Growth Factor 1 (IGF-1),
  specific antibody testing for celiac disease,
  karyotyping. In this case consider a hemoglobin
  electophoresis
• Do not do a growth hormone stimulation test1
• Bone age plain film left hand to evaluate
  ossification, consider a skeletal survey
• Referral to the appropriate specialty as indicated

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Treatment Options at SFGH

• UCSF Pediatric Gastroenterology Because so much
  of growth failure is due to nutritional issues,
  our pediatrics GI service has a formed strong
  collaborative program with Nutrition in order to
  maximize nutritional status
• UCSF Pediatric Endocrinology If indicated, may
  require evaluation for growth hormone replacement
• UCSF Genetics UCSF has leading experts in both
  dysmorphology and genetic testing

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Workup and Treatment for T.T.

• TREAT WHAT YOU KNOW
• Re anemia, T.T.s mother had opted to increase
  organ meats in his diet and had not started
  FeSO4. Contracted with mother to initiate FeSO4
  while awaiting results. Screen for thalassemia
  because a positive result ? d/c FeSO4
• Re Asthma 6M clinic had referred patient to
  Asthma clinic for further evaluation and testing.
  He received one home visit but did not f/u in
  clinic. Appointment now scheduled for March
• Flu vaccine, childhood immunizations up to date

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Workup and Treatment for T.T.

• At his last visit, the 19 month old pt ate a
  good-sized peanut butter sandwich during the
  history, and per mothers report feeding is no
  longer an issue
• Given ABSENCE OF WEIGHT GAIN, check bone age and
  labs to rule out anything ominous or treatable
• Lots of reassurance, as this child may well be
  just the right size for himself and recovering
  from an illness-malnutrition cycle
• Weight check in one month

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Is my child too small?

• Research on the psychological effects of short
  stature
• Controversy over use of growth hormone for ISS
• Childs sense of his/her own size appears to be
  more important than actual size in terms of
  self-image
• Data on psychological effects of short stature is
  for the most part of poor quality design8. There
  is no solid evidence that short stature is
  inherently, psychologically damaging.

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References

• Badaru, A. and D.M. Wilson. Alternatives to
  Growth Hormone Stimulation Testing in Children.
  Trends in Endocrinology and Metabolism. 15(6)
  252-258. 2004.
• Behrman, R.E. et al. Nelson Textbook of
  Pediatrics, 17th ed. PhiladelphiaSaunders. 2004
• Blair, P.S., et al. Family, Socioeconomic and
  Prenatal Factors Associated with Failure to
  Thrive in the Avon Longitudinal Study of Parents
  and Children (ALSPAC). International Journal of
  Epidemiology. 33(4) 839847. 2004.
• Erling, A. Why Do Some Children of Short Stature
  Develop Psychologically Well While Others Have
  Problems? European Journal of Endocrinology.
  151S35-S39. 2004.

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References, continued

• Ferber, B. et al. Accelerated Weight Gain with
  Pulmonic Stenosis. Pediatric Cardiology.
  18(1)8-10. 1997.
• Gunn, V.L. and C. Nechyba, eds. The Harriet Lane
  Handbook A Manual for Pediatric House Officers.
  Philadelphia Mosby. 2002.
• Perrin, E.C. et al, investigators. Criteria for
  Determining Disability in Infants and Children
  Failure to Thrive. Evidence Report/Technology
  Assessment. Number 72. Rockville, MD Agency for
  Healthcare Research and Quality. 2003.
  www.ahrq.gov.
• Voss, L.D. and D.E.Sandberg. The Psychological
  Burden of Short Stature Evidence Against.
  European Journal of Endocrinology. 151S29-S33.
  2004.

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