兒童生長評估 小兒科 蔡孟哲

Outlines Growth curve Growth mechanisms Growth evaluation Height, weight, BMI and head girth Growth mechanisms Growth evaluation

Normal height curve (M)

Normal height curve (F)

Growth measurement

Height velocity 0-1 year: 25 cm/yr 1-2 year: 10 cm/yr Puberty: 20-30 cm (total) M: 7-13 cm/yr F: 6-12 cm/yr

Normal weight curve (M)

Normal weight curve (F)

Weight gain Rule of thumb 3 kg  birth 4.5 kg  1 m/o 6 kg  3 m/o 9 kg  1 y/o 12 kg  2 y/o 15 kg  3.5 y/o 18 kg  5 y/o 2.5 kg/yr  >5 y/o

Child growth Infancy childhood transition Infancy childhood transition

Body mass index Overweight At risk for overweight

Adiposity rebound Obesity (Silver Spring) 2009;17:1310

Head circumference

Growth factors GROWTH Intrauterine Endocrine Chromosome Nutrition Gene Disease Stress

Growth hormone axis Ant.

Hormonal action IGF-1 MelinePlus Protein synthesis Gluconeogenesis Cartilage growth Protein synthesis Lipolysis MelinePlus

Etiology Genetic Chromosomal Hormonal Nutritional Intrauterine Russell-Silver syndrome, Prader-Willi syndrome Chromosomal Down syndrome, Turner syndrome Hormonal GH deficiency, hypothyroidism Nutritional Intrauterine Medication Steroid, chemotherapy Systemic illness Renal disease, congenital heart disease, achalasia Psychological

Structural Evaluation 詳盡的病史 生長發育紀錄 (生長曲線表及生長速率)，過去病史，用藥紀錄，營養狀況，家人的生長紀錄 身體檢查 包括：身高、體重、頭圍、外觀畸形、全身理學檢查、心雜音及其他內臟器官狀況等 父母親身高 Target height (TH): Mid-parental height +/- 6.5cm Final height: TH +/- 5-7 cm 實驗室檢查 Screening test for height: Hb, T4, TSH, IGF-1, chromosome (female), Bone age Screening test for weight: Albumin, blood gas, TG, CHOL, dry blood MS

Bone Age

Height Estimation Projectile Greulich and Pyle Tanner-Whitehouse Dependent on ethnic-specific growth chart Greulich and Pyle 97% FH at 14 y/o for girl and at 16 y/o for boy Tanner-Whitehouse Complicated calculation

Growth Stimulation Test Methods: Clonidine test L-DOPA test Insulin-tolerance test Glucagon test Arginine test Interpretation: At least 2 consistent tests GH < 7 ng/ml 來源:兒童生長協會衛教手冊: 生長激素的不足與治療

Clinical Scenario (1) A 6-y/o boy was found to have cryptorchidism and short stature. Otherwise, he is healthy. His height <3rd %; weight = 10th %; HV = 3.4 cm/yr Father’s height = 50th %; mother’s height 25th %; Unremarkable family history Lab data: T4 2.35 ug/dl; TSH 2.29 uU/ml; IGF-1 152 ng/ml; Cs 14.3 ug/dl Bone age: 3 y/o What ‘s your thought and management about his problem?

Clinical Scenario (2) Stimulation test: after thyroxine supplement Clonidine test: GH 1.1  4.4  2.3 ng/mL L-DOPA test: GH  7.0  4.8 ng/mL; Cs 11.16  17.15 ug/dL Diagnosis: Combined pituitary hormone deficiency Brain MRI: Ectopic pituitary bright spot Source:Yahoo Picturs

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