![Page 1: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/1.jpg)
Growth disturbances
Knut Dahl-Jørgensen
Unit for Endocrinology and Diabetes Pediatric Dept.
Ullevål University Hospital
![Page 2: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/2.jpg)
Simple guidelines by short stature
• Examined by the doctor:– All children below 2.5 height percentile– All children decreasing more than two centile chanals
• Refer to Pediatric Dept. by increasing deviation• Enclose by referal :
– Family history (growth and puberty)– History of birth, development and diseases– Growth chart– Eventually Bone age and laboratory test results
![Page 3: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/3.jpg)
Differential diagnoses by short stature
Constitutional Growth DelayFamily Short StatureCombination of the previousNutritional
HypocaloricChronic inflamatory bowel diseaseMalabsorption , Coeliac disease
EndocrineHypothyroidismGrowth Hormone DeficiencyHypopituitarismExcessive cortisolPrecosious puberty
Chromosome defectsTurner Syndrome
Maternal deprivation
Low birth weightSmall for gestagional age
Prematurity
Fetal alcohol syndrome
Bone development disordersRickets
Sceletal dysplasias
MetabolicKidney failure
Hypoxic, Cardiac
Liver diseases
Inborn errors of metabolism
SyndromesNoonans
Aarskog
![Page 4: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/4.jpg)
Routine examinations 1
Family history growth and puberty, growth treatment, syndromes
NeonatalGetational age, birth weight, birth length, forceps,
Hypoglycemia, hyperbilirubinemia, mikropenis
Gatrointestinal symptoms
Neurological symptoms
Psycosocial problems
![Page 5: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/5.jpg)
Routine examinations 2
• Physical examination– Height
– Weight
– Growth velocity (cm per year)
– Tanner stages
– Teticular volume
– Dysmorphology (evt. sitting height, arm span)
– Blood pressure
– General physical examination
– Neurological examination
![Page 6: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/6.jpg)
Routine examinations 3
Bone age and final height prediction
Clinical chemistry– TSH and free thyroxin
– GH, IGF-1, IGF-BP3
– At puberty: LH, FSH, estradiol or testosteron
– Coeliac screening
– Hemoglobin, ferritin, CRP
Chromosomes (girls)Evt. Metabolic screen, liver, kidney, bone (PTH, Vit.D)
![Page 7: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/7.jpg)
![Page 8: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/8.jpg)
Prediction of final height
Bone age estimation: Greulich & Pyle Atlas
Prediction: Bailly and Pinneau Tables
Causion ! Variability in bone age estimation by different radiologists
Great SD in reference material
Total variability: Young child + 5 cm, Late puberty + 3 cm
If unpredicted early puberty: Height prediction will decrease.
Other method: Tanner Whitehouse
![Page 9: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/9.jpg)
![Page 10: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/10.jpg)
Normal growth patterns
Normal early puberty
Normal late puberty
Familial (genetic) short stature
Constitutional delay of growth and puberty
Obesity
![Page 11: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/11.jpg)
![Page 12: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/12.jpg)
![Page 13: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/13.jpg)
![Page 14: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/14.jpg)
![Page 15: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/15.jpg)
![Page 16: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/16.jpg)
Pathological growth patterns
![Page 17: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/17.jpg)
![Page 18: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/18.jpg)
![Page 19: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/19.jpg)
![Page 20: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/20.jpg)
![Page 21: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/21.jpg)
![Page 22: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/22.jpg)
![Page 23: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/23.jpg)
![Page 24: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/24.jpg)
Growth hormone deficiency
Clinical appearancePuppy child
Hypoplastic midface ?
Evt. Hypoglycemia, hyperbilirubinemia, mikropenis
AuxologyDrop in height percentile
Growth velocity (cm per year) < 10 perc.
Delayed Bone Age
![Page 25: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/25.jpg)
Causes of Growth hormone deficiency
CNS malformations (midline defects)
Hydrocephalus
CNS injuries (birth, forceps)
Meningitis, brain edema
Congenital infections
Hypothalamic or hypophyseal tumors
Cranial radiation
Congenital, genetic
![Page 26: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/26.jpg)
Indications for Growth hormone treatment
Main indicationGrowth Hormone Deficiency
Other indications:Turner Syndrome
Kidney failure
Prader-Willi Syndrome
Small for gestagional age without catch-up growth ?
![Page 27: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/27.jpg)
Testing Growth hormone secretion
Physiological testsOne random samplePhysical activityContinuous overnight samplingContinuous 24 hours sampling
Stimulation tests (allways two tests)Insulin iv (hypoglycemia)Arginine ivGlucagone iv or imClonidine (oral)GHRH
IGF-1, IGF-BP3
![Page 28: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/28.jpg)
![Page 29: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/29.jpg)
![Page 30: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/30.jpg)
![Page 31: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/31.jpg)
![Page 32: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/32.jpg)
![Page 33: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/33.jpg)
Growth hormone treatment
Daily subcutaneous injections
Injection pens
Disposable prefilled syringes
Autoinjection systems
Dosage: 0.033 mg/kg/day (0.1 U/kg/day)
![Page 34: Growth disturbances Knut Dahl-Jørgensen Unit for Endocrinology and Diabetes Pediatric Dept. Ullevål University Hospital](https://reader036.vdocuments.site/reader036/viewer/2022070323/56649e185503460f94b04cae/html5/thumbnails/34.jpg)