COPP MODULE

COMMON OFFICE PRACTICE PEDIATRIC PROBLEMS[A MODULE OF IAP TAMILNADU STATE CHAPTER 2017]

TEAM• Scientific advisors Dr P Ramachandran, Dr S Balasubramanian

• Conveners Dr S Thirumalai Kolundu, Dr Sunil Srinivasan

• Scientific Coordinator Dr A Somasundaram

• Academic coordinators Dr S Narmada, Dr R.V Dhakshayani

• Academic committee [MODERATORS]• Dr NC Gowrishankar,• Dr T N Manohar,• Dr K Nedunchelian,• Dr Rema Chandramohan,• Dr R Somasekar,• Dr S Thangavelu,• Dr V V Varadarajan

CONTRIBUTORSDr RV Dhakshayani Dr A SomasundaramDr Giridhar Dr Somu SivabalanDr Hemchand K Prasad Dr S SrinivasDr E Mahendar Dr P SudhakarDr S Mangalabharathi Dr Sudharshana skanda Dr Manikandan Dr B SumathiDr Manikumar Dr Suresh Dr S Narmada Dr VenkateshwaranDr Palaniraman Dr C VijayabhaskarDr R Selvan

Dr.Hemchand MBBS,MD,Fellow in Pediatric Diabete,PDCC

• Head of the Department and Consultant-in-charge, Department of pediatric endocrinology and diabetes, Mehta Children’s Hospital

• Trained under Dr. Vaman Khadilkar• Speaker in International and National forums• 12 peer reviewed publications in Pediatric endocrinology• 76 state, national and international lectures in paediatric

endocrinology• 26 chapters in paediatric endocrinology in various text books.

GROWTH MONITORING

Dr Hemchand K PReviewed by

Dr Thangavelu S

Why should a paediatrician monitor growth of a child under his care?

• Barometer of well being in a given child. • Important pillar of preventive care. • Helps - reassure normalcy• Helps - identify growth disorders, nutritional

disorders & systemic diseases, early.

Khadilkar V, Khadilkar A. Growth charts: A diagnostic tool. Indian J Endocr Metab. 2011;15(Suppl 3):S166–71.

What is the difference between growth standard and reference?

Growth reference• Descriptive chart - from a

population which is believed to be growing under optimal health and nutrition.

• Eg: Old IAP charts

Growth standard• Prescriptive standard from a

population where - possible environmental & nutritional variables controlled

• Sole independent instrument upon which decisions are made

• Eg: WHO Standards from MGRS study

Vaman Khadilkar, Supriya Phanse. Growth charts from controversy to consensus. Indian J Endocrinol Metab 2012 Dec; 16 (Suppl 2): S185-S187

Why should all paediatricians use the same chart and cut-offs for interpretation?

10 year old boy with height of 124 cm

10 year old boy BMI 19.1 kg/sq m

IAP 3rd percentile 123.6 – NOT SHORT CDC – shortWHO 2007 – short

Khadilkar charts – short (< 124.3 cm)Marwah charts - short (< 125.4 cm)

CDC (20.4) – NormalIOTF using adult 25 kg/sq m – Normal

Marwah 85th percentile – NormalKhadilkar 75th percentile - Normal

K N Agarwal (18) – OverweightIOTF using adult 23 kg/sq m – Overweight

Marwah 85th percentile – OverweightWHO 2007 - Overweight

What are the anthropometric measures a paediatrician should record in his office practice?

IAP growth monitoring guidelines for paediatricians in 2007.

A - Note – even if the child < 2 years can stand – prefer to use the lengthKhadilkar V, Khadilkar A, Choudhury P, Agarwal A, Ugra D, Shah N. IAP Growth Monitoring Guidelines for Children from Birth to 18 Years. Indian Pediatr. 2007;44:187–97.

Age Measurement Frequency

0-2 years

2-5 years

>5 years

Length(A) weight and head circumference

height, weight and head circumference

height, weight, BMI

SMR (Tanners stage)

0, 6, 10 and 14 weeks, 6, 9, 15, 18 months (every vaccination visit)

every 6 months

every 6 months till 9 years and annually there after

Every year

What growth charts should a paediatrician use in office practice?

Combined IAP – WHO charts from birth to 18 years (0-5 WHO and 5-18 IAP) are also made available for continuous growth monitoring

Onis M, Garza C, Onyango AW, Martorell R. WHO Child growth standards. Acta Pediatr. 2006;95(Suppl 450):S1–101.Khadilkar V, Yadav S, Agarwal KK, Tamboli S, ,Banerjee M, Cherian A et al. Revised IAP growth charts for height, weight and body mass index for 5- to 18-year-old Indian children. Indian Pediatr 2015; 52(1):47-55.

Age Chart recommended

< 5 years IAP modified WHO charts> 5 years IAP 2015 5-18 charts

Why has IAP made this recommendation?

WHO 2006 standards IAP 2015 references

Nature Prescriptive Prescriptive for BMI; descriptive

for other aspects of growth

Norm Breast feeding Good nutrition and health

Statistical methods LMS method of statistics LMS method of statistics

Exclusion of obese Yes Yes

IAP 2015 references – most recent, prescriptive for BMI, excludes obese, robust.Statistical tools – recommended by the IAP

WHO charts (IAP modified)

• Please enter the name and DOB• Single page – assesses – Height/ length, weight and

head circumference• Back side – Weight for height• ONLY 4 LINES (4 percentiles) – for convenience• Expressed both percentile and Z score• Vertically – 1 dark line – 15 days• Vertically – 1 light line – 1 week• Horizontally – 1 line represents 1 cm or 1 kg

15

16

How should a paediatrician plot on the growth chart?• Enter the name, date of birth on the chart. • Growth is marked with a dot (not circle or cross) at point of

intersection of measure (on the y-axis) and the chronological age (on x-axis).

• Each year is divided as 12 months – NOT DECIMAL AGE. • When you make subsequent measurements on same chart,

join the points by a line. • Remind the parents of the next growth measurement and

explain your findings to them and reassure them.

Khadilkar V, Khadilkar A, Choudhury P, Agarwal A, Ugra D, Shah N. IAP Growth Monitoring Guidelines for Children from Birth to 18 Years. Indian Pediatr. 2007;44:187–97.

How To Adjust For The Family Size?

• Target Height also known as the adjusted mid parental height is calculated as follows:

• Boy: (MHT+FHT+13)/2• Girl: (MHT+FHT-13)/2• This height is plotted at 18 years of age on the chart• Target range is 6 cms below and above the target

height

How are the new charts more user friendly and parent friendly?• The IAP modified WHO charts allows one to plot –

weight, height and head circumference on a single page and at convenient 15 day intervals.

• The weight, height (0-18) and BMI (5-18) measurements can be plotted at 6 monthly intervals on the 0-18 year charts.

• The BMI and weight for height charts in 0-18 charts and 0-5 charts are colour coded – red colour indicating obesity.

What is new in these current recommendations?

Previous Current

What chart should be used in a

child <5 years

WHO 2007 standards IAP modified WHO charts

What chart should be used in a

child >5 years

Old IAP charts IAP 2015 charts

Combined WHO-IAP2015 charts

Definition of short stature <3rd percentile in growth monitoring

guideline or <5th percentile on old IAP

charts

<3rd percentile on the new IAP chart

Overweight >85th percentile of BMI >23rd adult equivalent of BMI

Obesity >95th percentile of BMI >27th adult equivalent of BMI

Plotting age Decimal age On accurate months

Target range 8.5 cm above and below target height 6cm above and below target height

Height < 3rd percentile - stunting

Height < 0.1st percentile – severe stunting

Weight < 3rd percentile - underweight

Weight < 0.1st percentile – Severe underweight

How to recognise abnormal growth?

Height < 3rd percentile - stunting

Weight < 3rd percentile – NO INTERPRETATION

Weight for height < 3rd percentile - wasting

Weight for Height < 0.1st percentile – severe wasting

Weight for height > 99th percentile - Obesity

BMI < 3rd percentile - wasting

BMI > 23rd adult equivalent – overweight

BMI > 27th adult equivalent - Obesity

27

< 5 years >5 years

Height Stunting

Severe stunting

< 3rd percentile

< 0.1st percentile

< 3rd percentile

-

Weight Under weight

Severe underweight

< 3rd percentile

< 0.1 percentile

-

-

BMI(Weight for height is < 2 years)

Wasting

Severe wasting

Overweight

Obesity

< 3rd percentile

< 0.1 percentile

>97th percentile

> 99th percentile

< 3rd percentile

-

>23rd adult equivalent

>28 adult equivalent

Crossing of 2 major percentiles

Abnormal growth 6 month period (infancy)

1 year period (older child)

What should a paediatrician do in case of recognition of abnormal growth?• Check the accuracy measurement/ plotting• Look at the trend of deviation (a single cross

sectional measure has limitations - growth does not always follow a smooth curve)

• A line is drawn from the plotted point to the 50th percentile and vertically downwards to touch the x- axis

• This is the corresponding height age (HA) & weight age (WA)

• CA (chronological age) = HA = WA – in a normal child

CA > HA > WA – has nutritional deprivation or systemic disease

CA > WA > HA – has endocrine disease

WA > HA > CA – has nutritional obesity

WA > CA > HA – has endocrine obesity

HA > WA > CA – has precocious puberty

Abnormal growth Interpretation Disorder

CA = HA = WA

CA > HA > WA

CA > WA > HA

WA > HA > CA

WA > CA > HA

HA > WA > CA

No growth abnormality

Poor growthWasted more than stunted

Poor growthStunted more than wasted

OvergrowthTall and obese

OvergrowthShort and obese

OvergrowthIsolated tall stature

Normal child

Nutritional / systemic

Endocrine/ skeletal disorder

Nutritional obesity

Pathological obesity

Precocious puberty

Summary of interpretation of abnormal growth

What is the role of bone age in growth assessment?

• Bone age complements growth assessment. • Speaks of the growth potential of a given child. • Bone age should be assessed using the Tanner

whitehouse method or a Greulich pyle atlas.• Bone age is plotted at the point of intersection of

current height (y-axis) and bone age (x-axis).

Greulich WW, Pyle SI: Radiographic atlas of skeletal development of the hand and wrist, 2nd edn. Stanford, CA: Stanford University Press, 1959. Tanner J, Oshman D, Bahhage F, Healy M: Tanner- Whitehouse bone age reference values for North American children. J Pediatr 1997; 131:34-40.

How should a paediatrician assess the growth of a LBW preterm baby?

The growth curves for preterm babies have been developed similar to the WHO 2007 standards – intergrowth 21st post natal standards. These standards must be used in preterm babies will they reach term gestational age. Downloadable from: https://intergrowth21.tghn.org/articles/

Villar J, Giuliani F, Fenton TR, Ohuma EO, Ismail LC, Kennedy SH. INTERGROWTH-21stConsortium. INTERGROWTH-21st very preterm size at birth reference charts. Lancet 2016;387:844-5.

Miscellaneous tit bits

• All girls must have their growth plotted on pink chart and boys on the blue chart. Plotting growth on the chart for opposite sex is unacceptable.

• Weight should not be measured more than once in 15 days and 30 days – during and beyond infancy, respectively. This is to avoid unnecessary anxiety.

• It is preferred to interpret weight in conjunction with height and not in an isolated perspective.

• Practical difficulty exists in plotting children < 5 years on 0-18 charts

Miscellaneous tit bits• Crossing two major percentiles in 6 months and 1 year is pathological

in infancy and childhood.

• The growth charts committee recommends Weight for height to diagnose wasting and obesity in the under 5 age group.

• The term Severe Acute Malnutrition (SAM) was defined by WHO for health workers based on Weight for Height Z-score <-3 - should be used beyond 6 months.

• Percentiles and Z-scores are interchangeable. For uniformity and ease, percentiles are preferable

• IAP growth charts app (for android phones) available for growth monitoring of Indian children

Well child in a paediatricians clinic

<2 years - height, weight and head circumference every vaccination visit2-5years – height, weight and head circumference every 6 months>5 years – height, weight, BMI and SMR (every 6 months till 9 years and annually thereafter)Target height in > 5 year age group

<5 years – IAP modified WHO charts >5 years – use combined WHO-IAP

2015 charts from 0-18 years

Height 3rd to 97th percentile

Weight 3rd to 97th percentile

BMI/ weight for height 3rd to 97th percentile/ 23rd adult equivalent

Follow up Calculate height age, weight

age and chronological age

CA > HA > WA – has nutritional deprivation or systemic diseaseCA > WA > HA – has endocrine disease HA > WA > CA – has precocious pubertyWA > CA > HA – has endocrine obesityWA > HA > CA – has nutritional obesity

NoYes

Summary

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