sga growth & puberty sga growth & puberty director prof. sangeeta yadav in charge pediatric...

SGA Growth amp SGA Growth amp PubertyPuberty

Director Prof Sangeeta YadavIn charge Pediatric amp Adolescent

Endocrinology DivisionDepartment of Pediatrics

Maulana Azad Medical College

New Delhi

ISPAE Secretary cum Treasurer 2013-14

DisclosureDisclosure

No conflict of interest

ContentsContents

Introduction Definition Epidemiology

Growth Pathophysiology Comorbidities

Puberty Pathophysiology Comorbidities

Approach Management Take Home Message

Introduction

ldquoSmall for Gestational Agerdquo (SGA) represents a statistical group of infants whose weight andor crown-heel length is less than expected for their gestational age and sex

Being born small for gestational age (SGA) either by weightlength -Risk factor for some growth and development disorders -Chronic diseases later in life SGA children are at higher risk of -Attaining an adult height below their target height -Developing metabolic disorders- obesity diabetes and

cardiovascular

Alkalay AL Graham Jr JM Pomerance JJ Evaluation of neonates born with intrauterine growth retardation review and practice guidelines J Perinatol 199818142ndash51

SGA defined Birth weight or birth length -2 SD below mean for the gestational age based on reference populationBabies subclassified SGA for weight SGA for length or SGA for both weight and lengthSegregation of SGA from normal is somewhat arbitrary -2 SD selected because likely to encompass majority of patients with disordered fetal growth Most studies have selected patients whose birth size is approximately -2 SD or less -To define postnatal growth patterns and -Response to growth promoting therapies

Pediatrics 20011111253-61

Definition of SGA is NOT straightforward requires 1) Accurate knowledge of gestational age ( based on first trimester

ultrasound exam)

2) Accurate measurements at birth of weight length and head circumference

3) Cut off against reference data from the population Set at the 10th centile 3rd centile or at less than ndash2 SD (2nd centile)

Definition of SGA DOES NOT account background growth-modifying factors maternal size ethnicity and parity

EPIDEMIOLOGY Incidence of SGA births lacking as birth length and gestational age

recorded in national databases Estimated that between 23 and 10 of all infants are born SGA

(Rapaport R Tuvemo T Acta Paediatr 2005941348ndash55)

70 of Low Birth Weight (LBW) infants are SGA At 23 incidence of SGA 95000 infants born SGA At 1 in 43 incidence of SGA births is relatively high when compared with other growth disorders

India has about 30 low birth babies (LBW) vs 5-7 in developed countries (BhargavathinspSK Prospective in child Health Ind Pediatr 1991281403ndash10)

Indian hospital based studies incidence of 25 to 284 (Kushwaha KP et al Journal of Neonatology2004181 MehtathinspSthinsp Ind Pediatr 199835423ndash8)

Factors affecting SGAIUGR

bull An optimal birth weight

bull In Indian babies commonest cause of SGA is idiopathic intrauterine growth retardation

bull Most important risk factor for SGAIUGR is pregnancy induced hypertension Narang A et al Small for Gestational Age Babies Indian Scene Indian J Pediatr 199764221-4

Catch up Growth

The rapid infant growth as a compensatory mechanism for prenatal growth deficit is referred to as ldquoCatch-up growthrdquo

Catch up growth (CUG) is significant centile crossing as weight or length gain greater than 067 SDS (which represents the width of each percentile band in standard growth charts)

Typically early postnatal process completed by 2 years In 80 of SGA infants catch-up growth occurs during the first

6 months of life Different growth patterns identified in infants even at 3 mths

Saenger P CzernichowP Hughes I and Reiter EO Small for Gestational Age Short Stature and Beyond Endocrine Reviews 200728219ndash51

Of 3650 children gt86 of term singleton SGA infants catch up in height during the first 6 to 12 months Is independent of whether birth weight length is used to define SGA Of the SGA infants remaining lt-2 SDS at 12 months about 50 short in final height Thus constituting a high-risk population for persistent short stature

The relative risk of being short at different ages for SGA infants in relation to non-SGA infants (ratio is given for a birth length below - 2 SDS (SGAL) or a birth weight below - 2 SDS (SGAw)

175 of PT and 125 of FT SGA infants failed to show full catch-up growth 3rd CentileThus those born SGA and fail to show catch-up growth constitute high proportion of children and adults with short stature

85 SGA infants with postnatal catch-up growth to 3rd centile

Factors influencing catch up growth in SGA

Mechanisms that allow catch-up growth in SGA children or prevent them from achieving a normal height are still unknown

Critical period in development when unfavorable events have the potential to exert their maximal effects

Nutritional or environmental insults in perinatal life cause irreversible long-term consequences

Timing of such insults significant in determining extent of later adverse consequences to health

Nutrition- Significantly influence subsequent development newborn

Poor maternal nutrition during pregnancy

And quality of perinatal nutrition

Nutrition influencing SGALBW catch up growth

Hormonal regulation-Three peptide hormones that share structural homology (IGF-I and -II and insulin) seem to be the most important endocrine regulators in this process

In early postnatal life nutrition insulin and IGF-I regulate growth

Serum IGF-I and IGFBP-3 used as surrogate markers of GH action on growth

Although IGF-I and IGFBP-3 also influenced by factors (eg age nutrition sex hormones) other than GH

Increased concentrations of GH and low levels of IGF-I and IGFBP-3 Suggesting that SGA neonates are GH insensitive IGF-I levels increase in those who show rapid catch up growth Our cohort 15mths IGF1 CUG 566ngml NCUG 87ngml (plt 000)

Hypothalamic-pituitary-adrenal axis- GH the IGF system

Low LC Tam SY Kwan EY Tsang AM Karlberg J Onset of Significant GH Dependence of Serum IGF-I and IGF-Binding Protein 3 Concentrations in Early Life Pediatr Res 200150737-42

Bivariate correlation coefficients of the change in serum GHBP IGF-I and IGFBP-3 concentrations between birth and 6 mo 6 and 12 mo and 12 and 18 mo of age Boys (n = 25) and girls (n =23) are combined

The multiple regression analysis (r2 = 043 p = 00002) Change in serum GH-binding protein and IGF-I concentrations between 6 and 12 mo of age Explains the 43 length gain between 6 and 12 mthThe childhood phase of growth is significantly assoc with GH action on growth


bull So catch-up growth in SGA partly affected by intrauterine reprogramming of hypothalamic- pituitary-adrenal axis

bull Children with increased cortisol secretion being at higher risk of growth failure

bull During the neonatal period cortisol might act by limiting IGFBP-3 proteolysis and therefore reducing IGF bioavailability

Hypothalamic-pituitary-adrenal axis GH the IGF system

Leacuteger J Noel M Limal JM Czernichow P Growth factors and intrauterine growth retardation II Serum growth hormone insulin-like growth factor (IGF) I and IGF-binding protein 3 levels in children with intrauterine growth retardation compared with normal control subjects prospective study from birth to two years of age Study Group of IUGR Pediatr Res 199640101ndash7

Nutritional and hormonal regulation in SGA

Catch up growth- a double edged sword

Metabolic syndrome

Short stature

PUBERTY IN SGA

Studies on pubertal development explore relationship between precociousearly puberty and SGA pubertal growth in children born SGA

Being born SGA predisposes to precocious pubarche and precocious adrenarche

Sequence from a LBW to precocious pubarche has been proposed as classic referral point in the progression to

i) an early menarche ii) a polycystic ovary syndrome phenotype iii)ultimately a shorter adult height

SGA relationship with Precocious Pubarche Adrenarche

Data of lsquoThe Avon Longitudinal Study of Parents and Childrenrsquo (ALSPAC) Ong K Kratzsch J Kiess W Dunger D ALSPAC Study Team Circulating IGF-I levels in childhood are related to both current

body composition and early postnatal growth rate J Clin Endocrinol Metab 2002871041ndash4

Children with rapid postnatal weight gain had the highest adrenal androgen levels

Both lower birth weight and larger body weight at 8 years independently predicted higher adrenal androgen levels

Retrospective Australian study of 89 children with precocious pubarche 35 were born SGA (birth weight lt10th percentile)

Concluded that being born SGA according to weight and or length is an independent risk factor for precocious pubarche

Neville KA Walker JL Precocious pubarche is associated with SGA prematurity weight gain and obesity Arch Dis Child 2005 90258ndash61

bull The possible causes underlying this association are i increased central adiposity ii decreased insulin sensitivity iii increased IGF-I levels between the ages of 2 and 4 yearsbull These metabolic and hormonal patterns are common in SGA

children with excess weight gain in early childhood bull In ALSPAC study also combination of LBW and rapid postnatal

weight gain had predicted increased total and central adiposity and higher IGF-I levels at 5 years of age and lower insulin sensitivity at 8 years of age Ong K Kratzsch J Kiess W Dunger D ALSPAC Study Team Circulating IGF-I levels in childhood are related to both current body composition and early postnatal growth rate J Clin Endocrinol Metab 2002871041ndash4


Onset of Puberty in SGA Children Important determinants of final height are Height and age at onset of puberty and Magnitude and duration of

Pubertal growth Tanaka T Suwa S Yokoya S Hibi I 1988 Analysis of linear growth during puberty Acta Paediatr Scand Suppl 34725ndash29 Bourguignon JP 1988 Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic

implications Endocr Rev 9467ndash88

Timing and progression of puberty in SGA difficult to compare variations in SGA definitions inclusion criteria methodologies and follow-

up periods Height of 140 cm at start puberty compromises adult height Children born SGA on average 4 cm shorter at the onset of puberty than

children without perinatal risk factors Persson I Ahlsson F Ewald U Tuvemo T Qingyuan M von Rosen D Proos L Influence of perinatal factors on the onset of

puberty in boys and girls implications for interpretation of link with risk of long term diseases Am J Epidemiol 1999 150 747ndash755

SGA puberty starts within the normal range of age (based on

chronological age and actual height) but onset is generally earlier relative to AGA

Persson I Ahlsson F Ewald U Tuvemo T Qingyuan M von Rosen D Proos L Am J Epidemiol 1999 150 747ndash755 Lazar L Pollak U Kalter-Leibovici O Pertzelan A Phillip M Pubertal course of persistently short children born small for gestational age (SGA) compared with idiopathic short children born appropriate for gestational age (AGA) Eur J Endocrinol 2003 149 425ndash432Chaudhari S Otiv M Hoge M Pandit A Mote A Growth and sexual maturation of low birth weight infants at early adolescence Indian Pediatr 2008 45 191ndash198

The timing and progression of puberty is linked to being born SGA (according to weight andor length) SGA children are more prone to present with precocious pubarche and show an earlier onset of pubertal development and menarche or faster progression of puberty

Progression of Puberty and Menarche in SGA Girls

No general agreement on the existence of differences in age at menarche between SGA and AGA girls

Several longitudinal follow-up studies (comparing different groups of SGA and AGA children (SGA with short or normal height SGA categorized as full-termpreterm SGA categorized as lightshort for gestational age SGA with or without catch-up growth with AGA children)

Didnot find any significant difference in the progression of puberty or age at menarche between girls born SGA and AGA

Leger J Levy-Marchal C Bloch J Pinet A Chevenne D Porquet D Collin D Czernichow P Reduced final height and indications for insulin resistance in 20-year-olds born small for gestational age regional cohort study BMJ 1997 315 341ndash7

Chaudhari S Otiv M Hoge M Pandit A Mote A Growth and sexual maturation of low birth weight infants at early adolescence Indian Pediatr 2008 45 191ndash198

Girls with BMI above the median at age 8 demonstrated earlier menarche than those girls with BMI below the median

The earliest age at menarche occurred in girls born with Expected BWt below the median along with postnatal BMI above the median

However other studies showed earlier age of menarche in girls with fetal growth restriction relative to girls born AGA

J Clin Endocrinol Metab 92 46ndash50 2007

Indian study evaluating development in PT AGA (n = 79) and Term SGA (n = 45) Menarche occurred 6 months earlier in PT 12 months earlier in the SGA group than FT AGA controls Interval between onset of puberty and menarche was similar

in all groups


Indian Pediatr 1995 32 963ndash970

Menarche before the age of 12yrs was 3-fold more prevalent among girls born SGA (n = 50) Age at menarche was advanced by 8ndash10 months compared with girls of normal birth weight

Distribution of age at menarche in Precocious Puberty girls and in general populationAt 11 years of age 90 arePremenarcheal in both the PP girls and general population By 128 years the fraction of premenarcheal girls is fivefold larger in the general population than among PP girls

About 90 of children born small for gestational age (SGA) have catch-up growth with a height SD score (SDS) of more than ndash2 by 2 yr of age

When catch-up growth does not occur in first two years of life are defined as SGA short stature

Most of the children with SGA short stature remain short as adults constituting about 20 of short adults

SGA have a 5-7 times higher risk of short stature than children born at normal size Albertsson-Wikland K Boquszewski M Karlberg J Children born small-for-gestational age postnatal growth and hormonal status Horm Res 1998497-13

Concluded Low spontaneous GH secretion rate and a disturbed GH secretion pattern with low serum levels of IGF-I IGFBP-3 and leptin

Contribute to reduced postnatal growth in some of the subgroup of children born SGA who remained short during childhood

Growth comorbidities in SGA

Pubertal comorbidities in SGA

Prenatal growth restraint has been shown to be associated with FSH hypersecretion in infancy

Mechanism in SGA infants remains unclear Suggested that sex hormone disorders may cause subsequent fertility and metabolic impairments Higher risk Polycystic ovary syndrome Fertility problems Ovarian dysfunction Reduced fertility and Early menopause

Ibanez L de Zegher F Puberty after prenatal growth restraint Horm Res 2006 65(suppl 3)112ndash115

Sequence from LBW to precocious pubarche Classic referral point for progression to early menarche Then polycystic ovary syndrome phenotype Ultimately shorter adult height Possible mechanisms for this sequence Early accumulation of visceral fat following postnatal CUG Leading to insulin resistance and hyperinsulinism Play pivotal role in development of hyperandrogenic state

in SGA girls

contdPubertal comorbidities in SGA

Conclusion Poor third trimester growth andor low birth weight had no effect on subsequent male reproductive hormones No difference in testosterone or inhibin B levels between SGA and AGA Testicular function not impaired in adolescent males born after compromised fetal growth

(J Clin Endocrinol Metab 92 1353ndash1357 2007)

Evaluating a SGA

CLINICAL EVALUATIONbull Detailed history including family historybull General physical examinationbull Complete anthropometry bull A standard evaluation for short stature should be performed INVESTIGATIONS Hormonal assay bull Growth Hormone status bull Insulin Growth Factor-1bull IGFBP-3bull Leptinbull Insulin sensitivity Bone age

Diagnosis of SGA does not exclude growth hormone (GH) deficiency

Standard evaluation for short stature to be performed

GH assessment Many short patients born SGA have diminished GH output

lack of CUG may be attributable to reduced GH secretion Have depressed circulating concentrations of insulin-like

growth factor-I (IGF-I) Serum concentrations of leptin are also reduced in short

children born SGA

Evaluating a SGA

Studies analyzing bone age development in SGA subjects are scarce

Bone age maturation starts earlier As pubertal height gain may be smaller than

expected in children born SGASo bone age is not a reliable predictor of

height potential in SGA children

Influence of Bone age on SGA

MANAGEMENTGH Treatment in Short Children Born SGA

Children born SGA and not achieved catch-up growth by 2 yr of age relative risk of short stature at 18 yr of age is 52 for those born light and 71 for those born short

So GH treatment for children with SGA short stature was approved for use in US 2001 Europe 2003 Japan 2008

The growth promoting effects of growth hormone in short children born SGA have been confirmed by many clinical studies


A short child born SGA -No catch-up (ie -2 sd below the mean) by 2ndash3 yr of age -Growing at a subnormal rate for age is candidate for GH

therapy GH indicated when other causes of short stature associated

with poor growth have been ruled out Objectives of GH therapy -Catch-up growth in early childhood -Maintenance of normal growth in childhood -Achievement of normal adult height

Ranke MB Lindberg A Cowell CT et al Prediction of response to growth hormone treatment in short children born small for gestational age analysis of data from KIGS (Pharmacia International Growth Database) J Clin Endocrinol Metab 200388125ndash31

Growth prediction model after analyzing data of 613 short SGA (birth weight lt-128 SDS) children treated with GH

bull Correlated annualized growth velocities using multiple regression analysis over first two years of treatment explain 52 of the variability of growth response in

the first year of treatment bull Using four-parameter model I Age at start of treatment II Weight SD score at start of treatment III GH dose accounting for 35 of variability in GH response IV Mid-parental height SD scorebull Model for the second year of GH treatment showed that Growth velocity during the first year of treatment was the most important

predictor of subsequent response

bull Height outcome may be determined by the first-year response to GH which is dose dependentDe Zegher F Albertsson-Wikland K Wollmann HA et al J Clin Endocrinol Metab 2000852816ndash21 De Zegher F Ong K Van Helvoirt M et al J Clin Endocrinol Metab 200287148ndash51

GH Treatment in Short Children Born SGA

Long term experience of improved growth using a dosage range from 024 to 048 mgkgwk

Higher GH doses (048 mgkgwk [02 IUkgd]) are more effective for the short term

Rapaport R Tuvemo T Growth and growth hormone in children born small for gestational age Acta Paediatr 2005941348ndash55

Genetic factors associated with small for gestational age birth and the use of human growth hormone in treating the disorder International Journal of Pediatric Endocrinology 201212 P Saenger and E Reiter

Time to achieve increase in height -2 SDS 25 yr with a GH dose of 0067 mgkgd 55 yr with a dose of 0033 mgkgd

Monitoring is necessary to ensure safety of medication Baseline and follow-up measures of - insulin-like growth

factor-I insulin-like growth factor binding protein- 3 fasting insulin glucose lipid levels and blood pressure

measuredFrequency and intensity of monitoring varies with risk factors

like family history obesity and puberty All aspects of SGA should be addressed with parents

GH therapy provokes a dose-dependent rise in the serum concentrations of both IGF-I and IGFBP-3


US Endocrinology 2010663ndash70


GH both safe and effective in improving height velocity and adult height in children born SGA not adequately catch up To date no persistent adverse metabolic consequences reported Transient increase in insulin resistance seen Long-term surveillance for potential adverse metabolic effects

Tanaka et al Clin Pediatr Endocr 2012

GH significantly improves AH SDS in short SGA children who start treatment around pubertyGH 2 mgm2 d during puberty results in significantly better AH compared with the standard dose of 1 mgm2 GH 2 mgm2 d results in significantly higher IGF-I levels these need to be closely monitored Pubertal children with a poor AH expectation can benefit from combined GHGnRHa treatment


GH Therapy and Pubertal Issues

Boonstra V van Pareren Y Mulder P Hokken- Koelega A J Clin Endocrinol Metab 2003 885753ndash5758


GH therapy has no effect on Pubertal onset Progression of puberty Age at menarche Interval between breast development onset amp menarche No GH dose (1 mgm 2 day or 2 mgm 2 day) effect on the onset or

duration of puberty or pubertal height gain The pubertal height gain was greater in children

younger shorter and greater bone age delay at the onset of puberty

Boonstra V van Pareren Y Mulder P Hokken- Koelega A Puberty in growth hormone treated children born small for gestational age (SGA) J Clin Endocrinol Metab 2003 885753ndash5758

Combined GH and GnRH analog treatment improves adult height in SGA children who are short

At start of puberty (lt140 cm) Have poor adult height expectation Also need a higher GH dose

Management of Pubertal issues

Lem AJ Hokken-Koelega AC et al Adult height in short children born SGA treated with growth hormone and gonadotropin releasing hormone analog results of a randomized dose-response GH trial J Clin Endocrinol Metab 2012 97 4096ndash4105

Metformin therapy was associated with Slower pubertal development Prolonged pubertal height gain Increased near-adult height Relatively lower insulin leptin and IGF-I levels and higher sex

hormone-binding globulin and IGFBP-1 levels Also less atherogenic lipid profile and leaner body

composition

Important role of insulin towards pubertal tempo and pubertal height gain in SGA girls

TAKE HOME MESSAGES

SGA babies should have a regular follow up in high risk clinic for monitoring of their weight and length

Those having rapid postnatal gain in weight or length need more frequent follow ups and further evaluation

General measures to prevent excessive rates of weight gain during infancy

Early surveillance in a growth clinic for those with lack of catch up

A short child born SGA and no catch up by 2 to 3 years catch-up growth has stopped to be referred to pediatrician with expertise in endocrinology

Pretreatment IGF-I levels have a role in predicting responsiveness to GH

In children receiving GH IGF-I monitoring as a tool for dose optimization

The timing and progression of puberty is linked to being born SGA (according to weight andor length)

SGA children are more prone to present with precocious pubarche and show an earlier onset of pubertal development and menarche or faster progression of puberty

TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22

Onset of Puberty in SGA Children

Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52

DisclosureDisclosure

No conflict of interest

ContentsContents





Introduction



cardiovascular





ultrasound exam)














Catch up Growth




































Metabolic syndrome

Short stature

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52

ContentsContents





Introduction



cardiovascular





ultrasound exam)














Catch up Growth




































Metabolic syndrome

Short stature

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52

Introduction



cardiovascular





ultrasound exam)














Catch up Growth




































Metabolic syndrome

Short stature

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52




ultrasound exam)














Catch up Growth




































Metabolic syndrome

Short stature

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52











Catch up Growth




































Metabolic syndrome

Short stature

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52































Metabolic syndrome

Short stature

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52

PUBERTY IN SGA







































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52



































in all groups

















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52















in SGA girls




Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52



Evaluating a SGA







children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52






children born SGA

Evaluating a SGA



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52



















































composition


TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52

TAKE HOME MESSAGES










TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52





TAKE HOME MESSAGES

Slide 1

Disclosure

Contents

Introduction

Slide 5

Slide 6

EPIDEMIOLOGY


Catch up Growth

Slide 10

Slide 11

Slide 12


Slide 14


Slide 16

Slide 17

Slide 18

Slide 19

PUBERTY IN SGA


Slide 22


Slide 24

Slide 25


Slide 27


Slide 29




Slide 33

Evaluating a SGA

Slide 35


MANAGEMENT

Slide 38



Slide 41

Slide 42

Slide 43

Slide 44

Slide 45

Slide 46

Slide 47



Slide 50

TAKE HOME MESSAGES

Slide 52

sga growth & puberty sga growth & puberty director prof. sangeeta yadav in charge pediatric...

Documents