Growth Abnormalities

• Core 1 (Pre-Clerkship)
  • Integrative Systems
    • Endocrinology - Pituitary Physiology, Pituitary Pathophysiology, Adrenal Physiology, Adrenal Pathophysiology, Growth, Thyroid Physiology and Pathophysiology, Calcium Metabolism
• Core 2 (Clerkship)
• Core 3 (Post-Clerkship)
  • Electives that may further knowledge - Endocrinology

• Microcephaly: A condition where a child's head is significantly smaller than expected (less than the 3rd percentile for age) and may be associated with developmental delays or neurological issues. Early identification is crucial for management and support. 

• Macrocephaly: This refers to an abnormally large head size (greater than the 97th percentile for age), which can be due to various factors including genetic conditions, hydrocephalus, or brain tumors. Monitoring growth patterns is essential to determine the underlying cause. 

• Failure to Thrive or Growth Faltering: A term used when a child does not gain weight or grow as expected. It can result from inadequate caloric intake, malabsorption, or underlying medical conditions. Early intervention can help address nutritional needs and any underlying issues. 

• Familial Short Stature: A condition where a child is shorter than average due to genetic factors within the family, typically resulting in a growth pattern that is consistent with the heights of parents and relatives. 

• Constitutional Growth Delay: A variation of normal growth where a child grows at a slower rate but eventually reaches a normal height. This condition is often familial and typically resolves with time. 

• Precocious Puberty: The onset of secondary sexual characteristics before age 9 in boys and age 8 in girls. This condition can have psychological and physical implications, requiring careful evaluation and management  

• Obesity: An increasing concern in pediatric populations, obesity can lead to various health issues, including diabetes and cardiovascular problems. Monitoring growth patterns and implementing lifestyle changes are essential for prevention and management. 

A 2-month-old male, born at 35 weeks' gestation, presents for a routine well-child check. The parents are concerned because the infant has not gained any weight in the past month. The infant is exclusively breastfed, feeding every 2-3 hours during the day and every 4-5 hours at night. Each breastfeeding session lasts approximately 5-7 minutes, after which the infant appears to fall asleep or pull away from the breast. Parents report that the infant often seems fussy and irritable after feeds, arching his back and crying inconsolably for 20-30 minutes. The parents occasionally notice milk coming back up during or shortly after feeds, described as "spit up" that is sometimes forceful but not projectile. He dislikes lying flat and appears to sleep better when placed in a slightly inclined position, such as in a stroller or caregiver's arms. No signs of choking, gagging, or cyanosis during feeds. 3-4 wet diapers per day. Stools every 3-4 days and they are yellow and seedy. 

History 

Birth history/past medical history:  

• Was the child born premature?  
• Any history of NICU stay or complications after birth (e.g., infections, jaundice) 
• Was the newborn screen normal? 
• Has the child experienced any recent illnesses, fevers, or infections?  
• Any episodes of vomiting, diarrhea, or respiratory symptoms that could contribute to poor weight gain?  

Dietary Intake:  

• What does the child's daily diet look like?  
• If patient is formula feeding, how are the parents mixing the formula and what formulas have they used? 
• Frequency of feeding, duration of feeding sessions? 
• Signs of effective latch if breastfeeding (e.g., audible swallowing, breast softening after feeds)?  
• Any signs of reflux?  
• Any signs of dehydration?  
• Any food aversion? 

Growth Patterns:  

• Has the child followed expected growth trends since birth?  
• Was the baby small for gestational age (SGA) or appropriate for gestational age (AGA) at birth?  
• Any history of weight loss or plateauing growth after discharge from the hospital? 

Family History:  

• Any family history of growth abnormalities, genetic syndromes, or metabolic conditions?  
• Any history of allergies, intolerances, or gastrointestinal disorders (e.g., celiac disease, lactose intolerance)?  
• Parental height and growth patterns (e.g., history of constitutional growth delay or short stature in the family)? 

Physical Examination

• Assess for signs of malnutrition (e.g., skin turgor, muscle wasting)
• Measure height, weight, and head circumference
• Thyroid exam
• Evaluate for any signs of underlying conditions (e.g., neurological assessment for microcephaly or macrocephaly)

Evaluation/Management: 

• Growth Monitoring: Regularly track growth parameters on growth charts. 
• Further Testing: Consider further laboratory tests to evaluate for underlying conditions (e.g., thyroid function tests, metabolic panels). If there are concerns for projectile vomiting and other risk factors, consider ultrasound to evaluate for pyloric stenosis.  
• Consider medication management for reflux with famotidine or proton pump inhibitor. Teach parents other reflux management strategies including keeping baby in an upright position for the first half-hour or so after feeding with close supervision. 
• Consults: 
  • Consult with a dietitian for tailored dietary recommendations for optimal growth. 
  • Consult Feeding Clinic. 
  • Consult Lactation. 
  • Consider referral to GI for reflux management. 
  • If cardiac concerns on further assessment, can consider consulting Cardiology and obtaining an echocardiogram.  

Anticipatory Guidance for Parents on Nutrition and Growth: 

• Timely identification of growth abnormalities can lead to better outcomes through appropriate management and support. 
• Engaging families in the care process is crucial for addressing nutritional and developmental needs effectively. 

• AAP Pediatrics in Review: Failure to Thrive or Growth Faltering: Medical, Developmental/Behavioral, Nutritional, and Social Dimensions 
• AAP Pediatrics in Review: Disorders of Growth and Stature 
• CHOP Inpatient Clinical Pathway for Evaluation/Treatment of Infants with Malnutrition (Failure to Thrive) < 12 months 
• CHOP Outpatient Clinical Pathway for Evaluation/Treatment of Infants at Risk for Malnutrition (Failure to Thrive) 
• CHOP Inpatient Clinical Pathway for the Identification and Diagnosis of Pediatric Malnutrition 
• CHOP ICU and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Malnutrition, Weight Loss, and Eating Disorders 
• AAP Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity