Keyword – Pedi: Growth & Nutrition

Keyword – Pedi: Growth & Nutrition

CDC Growth Charts
1. http://www.cdc.gov/growthcharts
WHO Growth Charts
1. http://www.who.int/childgrowth/standards/en

Jaudice: causes of neonatal jaundice, physiologic vs non-, breast milk vs breast feeding jaundice, early (3–4th day = breast feeding, need more feeding 8-12/d) vs late onset (3-4th week = ) breast feeding jaundice (?), diagnostic labs, bilirubin, Hb & reticulocyte, blood type & Coomb, peripheral blood smear

Source UTD “Normal Puberty”

puberty, onset, sequence, tempo
10.5 years, 11.5 years, +/- 2 years
precocious evaluation, breast development before 8-year, testicular enlargement before 9-year, actually 6-8 years
girl thelarge, breast/areolar development, 15% pubic hair
girl menarche, after 2.6 years puberty, 0.5 year peak height velocity
boy maturation, testicular volume first, penile growth, pubic hair, sperm in urine, nocturnal sperm emission, peak height velocity
growth spurt / peak height velocity, precocious puberty, reduced adult height, epiphyseal closure

Source FPN – Sexual Development

“arche”+ pub-, gonad-, thel- (breast), adren-
gonarche, GnRH, LH (testos production, corpus luteum), FSH (sperm maturation, estrogen and follicle formation)
adrenarche, axillary and pubic hair, skin oiliness, acne, body odor
precocious or delayed puberty, 8-9 years, 13-15 years, 14-year

Source FPN – Male Tanner Stage

5 stages, care only stages 2-3-4, testis size
Tanner-1, 5-6 cm/y
Tanner-2, 5-6cm/y, 11.5 year
Tanner-3, adrenarche, 14-year, 7-8cm/y, gynecomastia, voice, axillary hair, acne, body odor, muscle mass
Tanner-4, peak at 10-cm/y, 14-year, hair not speading to medial thigh
Tanner-5, no further hight 17-year, gynecomastia disappear
testis size, <3.5 cm, 4-5 cm long, 3 cm wide and deep
growth peak 13.5-year, 9.5 cm/y, Tanner 3-4
basal growth 5-6 cm/y, from 4-y to puberty
pubertal linear growth, 17 years, 8.5 – 9.5 – 10.3 cm/y

Source FPN – Female Tanner Stage

Tanner-1, 5-6 cm/y
Tanner-2, 7-8 cm/y, Thelarche marks onset, 10.9 years, 24-months preceding menarche, white 1-y black 2-y earlier
Tanner-3, peak hight 8-cm/y, 11.9 years, adrenarche 13.1 years (axillary hair, acne, body odor)
Tanner-4, 7-cm/y, 12.9 years, pubic hair adult not to medial thigh
Tanner-5, no height after 16, pubic hair adult distribution
Peak heigh velocity, 11.5 years, 8.3 cm/y, Tanner 2-3
Basal growth, 5-6 cm/y, 4 years to puberty
Pubertal Linear Growth, completed by 15; 7.5 – 8.3 – 9.0 cm/y

FPN – Precocious Puberty

benign central cause (90% girl), pathologic peripheral cause (50% boy)
constitutional vs idiopathic precocious puberty
benign premature adrenarche, 6 years, only secondary characteristics, no sexual development, bone age consistent chronological age
benign premature thelarche, 18-months!, only breast contour, no puberty signs
precocious girl, 8 years for breast, 10 years for menarche, pubic hair 6-7 years (black-white)
precocious boy, before 9 years, testis >2.5 cm / pubic hair
exam, calculate “growth velocity”, “midparental height”, “growth curve”
lab/imaging, FSH, LH, TSH, HCG, Estradiol (girl) Testosterone (boy), possible GnRH Stimulation Test, Left Wrist Bone Age X-ray

FPN – Pubertal Delay

No breast development by 13 or 5-year after menarche, no mense by 15, testicular length <2.5 cm by 14
Lab/imaging, FSH, LH, TSH, Estradiol/testosterone, Prolactin, IGF-I, possible chromosome analysis, GnRH Stimulation Test, Left Wrist Bone Age X-ray, Heard MRI

FPN – Failure to Thrive & Failure to Thrive Causes & Red Flags & Evaluation

inadequate weight gain (not height), malnutrition, head circumference, cognition, developmental milestones, length
< 5 percentile: weight for age (gender and corrected age), weight for length, and BMI, grow velocity
normal physiologic vs nonorganic (80%) vs organic (insufficient caloric intake) causes
evaluation, plot of height, weight, & head circumference, expected gain, corrected premature infant gestational age
management, 150% of RDA, formula of calory replacement, 22 calorie/ounce formula, weekly pediatric follow-up

FPN – Short Stature

aka. delayed linear growth
small gestational age SGA, 90% catch-up by 2 years, no evidence of catch-up by first 6-months = pathologic
familial vs idiopathic vs constitutional short statures
evaluation: height below 2 SD, velocity < 5-cm/y, projected height < 2 SD of mid-parent height
most common reason, familial short stature

FPN – Growth Physiology

hormonal factors, GH & IGF-I, thyroid hormone, vitamin D, sex hormones
genetic factors, osteochondrodystophies
nutritional factors, adequate total calorie intake, essential amino acids, bile salts, fat absorption, minerals (Ca, Zn, Cu)
primary growth determinants by age, catch up genetically programmed growth by 2 years, catch up growth 6-18 months

FPN – Infant Feeding

10% weight loss, regain week-2, 30/20/10-g/d, double by 6-month, triple by 12-month, expected clear urine 6-8 times/d
supplements, vitamin D 200 U/d, 2-month, premature
preterm, preterm feeding protocol, feed on demand q2-4h, 120-150 ml/kg/d, 20 – 22 calories/ounce, iron supplement 2mg/kg/d
birth to 4-m, avoid honey and water supplementation and semi-solid food
4 to 6-m, iron-fortified cereal (iron, vitamins B), rice (avoid barley, oats, wheat), unsweetened fruit juices (avoid other juices orange, pineapple, grapefruit, tomato)
older than 6-m, introduce solid food, water and fluoride supplementation, initiate dental care

FPN – Breast Feeding Problems for the Mother

nipple, inverted, sore, milk blebs or blisters
breast engorgement, frozen cabbage leaves
decreased milk production, hydration, caffeine, frequent nursing, avoid meds (OCPs, diphenhydramine, pseudoephedrine), unproven (metoclopramide, fenugreek, brewer’s yeast)
mild stasis or blocked, measures (massage, heat, vibration, alternate breasts, frequent nursing or bumping, no constrictive clothes, ibuprofen, lecithin 1200-mg TID-QID, milk blebs, latch-on, breast pump flange
milk let down, warm shower, privacy and comfortable, heat, relaxation
medications in lactation, avoid (oxycodone, codeine), caffeine <2/d

FPN – Breast Feeding Technique

holding positions, cradle, cross-cradle, football / clutch, side-lying, Australian
LATCH score, latch, audible swallowing, type of nipple, comfort of mom, help required, 3 points each
effective breast feeding, q1.5-3 hours (8-12 times/d), stools (1-2 stools/first 2 days then 6-8 stools/d), urine output (wet diapers 6-8x/d), baby’s suckling and swallowing, expected weights
clinic follow up within 48-h of discharge

FPN – Infant Nutritional Sources

breast milk: term vs preterm human breast milk
formula: cow’s milk infant vs soy-based infant vs preterm infant
calories/ounce for term 18-20 (higher for preterm 22-24)
carbohydrate: lactose or glu poly vs. “soy” (sucrose and corn)
protein (casein) and fat: human milk, nonfat cow’s milk, soy (phytates)
human vs cow: lower renal solute load 91 mosm (124-171); higher linoleic acid 30-g/L (5.8-8.7); lower Ca/Phosphorus 400/200 (510/390 mg/L); much higher whey to casein ratio 70:30 (18:82)

FPN – Breast Feeding Jaundice

early vs late breast feeding jaundice, initial decreased calorie intake, fatty acids in breast milk
management: early onset, nurse frequently (8-10 x/d), monitor bilirubin daily
management: late onset, monitor bilirubin 12-24 hours

FPN – Lactation Vitamin Supplementation

only vitamin D need < 6 months, exclusively breast feeding
vitamin K, newborn
iron, by 6 months
vitamin B12, vegetarian mom
fluoride, > 6 months

FPN – Medications in Lactation

just before or after lactation, before infant’s longest sleep
safe CV meds, ACE-I (captopril, enalapril) avoid first 6-week in premature infants, HCTZ, methydopa
caffeine no more than 2 /d
LacMed: Drug and Lactation Database

FPN – LATCH Score for Breastfeeding Assessment

latch, audible swallowing, type of nipple, comfort of mom, help required