1. Normal growth Rafat Mosalli MBBS FRCPC FAAP Rafat Mosalli MBBS FRCPC FAAP 5Th Year Medical students

2. Lecture and session roles Punctuality Punctuality Dress code Dress code Body hygiene Body hygiene Preparation Preparation participation participation

4. objectives What is normal child growth? What is normal child growth? How do we assess for growth? How do we assess for growth? Why growth chart is important? Why growth chart is important? What is the normal growth rate ? What is the normal growth rate ? What is the importance of : What is the importance of : Upper: lower segment ratio(U:L) and Bone age Upper: lower segment ratio(U:L) and Bone age What is abnormal growth? What is abnormal growth?

5. Normal growth Facts It is dynamic process. It is dynamic process. It is not only gaining Height! It is not only gaining Height! Appropriate wight,hight,HC for age. Appropriate wight,hight,HC for age. Normal growth pattern: between the 3 rd and the 97 th percentiles Normal growth pattern: between the 3 rd and the 97 th percentiles Very important to measure each visit and exam (make it routine!) Very important to measure each visit and exam (make it routine!)

6. Growth Measurements Weight: appropriate scale and naked Weight: appropriate scale and naked Length: stature of a supine child(<2y) Length: stature of a supine child(<2y) Height: stature of standing child(>2y) Height: stature of standing child(>2y) HC ( head &brain growth) : Occipitofrontal Circumference HC ( head &brain growth) : Occipitofrontal Circumference average of 3 measurements average of 3 measurements Growth velocity: annual linear growth rate Growth velocity: annual linear growth rate

7. Growth assessment Plotting Wt,Ht,HC in serial measurement on the growth chart. Plotting Wt,Ht,HC in serial measurement on the growth chart. Longitudinally along a time line (pattern) Longitudinally along a time line (pattern)  to assess growth rate  to assess growth rate Growth rate in Boys differ from female! Growth rate in Boys differ from female!

8. Growth spurt and peak Ht velocity Girls always earlier Pubertal growth: 11 years in boys Vs 9 years for girls Peak Ht Velocity In Female 11.5 Vs Male 13.5y In Female 11.5 Vs Male 13.5y Female stop growing by 14y Vs 17y in Male Female stop growing by 14y Vs 17y in Male

9. Growth charts Importance Importance Objective,continuous assessment Objective,continuous assessment Comparison and follow up Comparison and follow up Detect growth deviation Detect growth deviation Detect disproportionate growth Detect disproportionate growth - It is based on population size!

12. Rules of thumb for Growth rate (1) Weight: -Wt loss for the first few days: 5-10% of BWT -Return of BWT at 7-10 days of age -Double BWT by 5-6m -Triple BWT by 1 y -Quadruple by 2y -Daily Wt gain: 20-30g /d (first 4m) 20-30g /d (first 4m) 15-20g/d (first year) 15-20g/d (first year) -Annual Wt gain is 2kg between 2y-Puberty

13. Rules of thumb for Growth rate (2) Average Height: Length at birth 50cm at birth,75cm at 1y Length at birth 50cm at birth,75cm at 1y At age 3 y is 90cm At age 3 y is 90cm At age 4y is 100 cm (double Birth length) At age 4y is 100 cm (double Birth length) Annual Ht increase: 5-7cm (4y-puberty) Annual Ht increase: 5-7cm (4y-puberty)

14. Rules of thumb for Growth rate (3) Head circumference At Birth 35 cm At Birth 35 cm Increase 1cm/mo for first yr = 47cm Increase 1cm/mo for first yr = 47cm the first 3m of life is the highest (2cm/m ) the first 3m of life is the highest (2cm/m ) For the rest of life only 10 cm

15. Upper: lower segment ratio(U:L) A ratio of Upper length (Distance from the top of the head to the top of the pubis)to the lower length distance from the top of the pubis to bottom of the feet) A ratio of Upper length (Distance from the top of the head to the top of the pubis)to the lower length distance from the top of the pubis to bottom of the feet) It vary with age: the younger the higher. It vary with age: the younger the higher. At birth 1.7:1  At 10 y 1:1 At birth 1.7:1  At 10 y 1:1 Importance? Importance? causes of disproportionate short stature? causes of disproportionate short stature?

16. Teeth First teeth at 5-8m:central mandibualr incisor First teeth at 5-8m:central mandibualr incisor Permanent teeth appear at 5-7y:first molar Permanent teeth appear at 5-7y:first molar Not helpful to assess rate of growth Not helpful to assess rate of growth

17. Bone age (BA) A measure of somatic maturity and growth potential A measure of somatic maturity and growth potential radiographs of the hand &wrist compared with a standards one. radiographs of the hand &wrist compared with a standards one. Result compared with Chronological age(CA) Result compared with Chronological age(CA) Diagnostic key in evaluating short stature. Diagnostic key in evaluating short stature.  Genetic (BA=CA)  Constitutional (BA<CA)

18. Mid Parental height Best predictor of eventual expected adult height. Best predictor of eventual expected adult height. Girls (father Ht-13)+(Mother Ht ) Girls (father Ht-13)+(Mother Ht ) 2 Boy (mother Ht+13)+(father Ht) Boy (mother Ht+13)+(father Ht) 2 -Give an average of (+/- 5cm ) of expected potential adult Ht

19. Abnormal growth 1-Height: Short stature Short stature Tall stature Tall stature2-Weight: Failure to Thrive(FTT) Failure to Thrive(FTT) Overweight(110-120% of BMI) Overweight(110-120% of BMI) Obesity (>120% of BMI) Obesity (>120% of BMI)(3)HC: Microcephaly vs Macrocephaly Microcephaly vs Macrocephaly

20. Short stature Causes Genetic Genetic Constitutional (late bloomer) Constitutional (late bloomer) Chronic diseases Chronic diseases Syndromes Syndromes Endocrine Endocrine Psychological Psychological Intrauterine (SGA,IUGR Intrauterine (SGA,IUGR

21. Short stature Causes

23. Evaluating short stature 1-History is the most important? family Hx, parent puberty family Hx, parent puberty2-Examination Dysmorphology, Weight, HC,U/L ratio, Mid parental Height) Dysmorphology, Weight, HC,U/L ratio, Mid parental Height) 3-Investigations 4- Bone age

25. We Talked about What is normal child growth? What is normal child growth? How do we assess for growth? How do we assess for growth? Why growth chart is important? Why growth chart is important? What is the normal growth rate ? What is the normal growth rate ? What is the importance of : What is the importance of : Upper: lower segment ratio(U:L) and Bone age Upper: lower segment ratio(U:L) and Bone age What is abnormal growth? What is abnormal growth?

26. Remember ! Growth is dynamic process. Growth is dynamic process. To measure growth parameters and plot it every visit (growth rate) To measure growth parameters and plot it every visit (growth rate) Rule of thumb for growth rate. Rule of thumb for growth rate. Large shifts in growth and large discrepancy in percentiles warrant an immediate attention and investigations! Large shifts in growth and large discrepancy in percentiles warrant an immediate attention and investigations!

27. Remember in Short stature -Bone age is diagnostic key in Short stature - FH is key - FTT suggest organic,malnutrition causes Vs overweight  endocrine cause - Constitutional delay is not uncommon &need Fu/4-6m and usually no treatment - Endocrine causes is rare

28. References Nelson essential Nelson essential Questions? Questions? drmosalli@hotmail.com drmosalli@hotmail.com