1. GROWTH
   1. Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt

• A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential?

• DDx: non-organic, celiac, IBD, CF, T1DM, haematologic, malignancy, liver disease, obstructive uropathy
• Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca²⁺, Vit ADE

• 14yo at 3^rd %ile weight + 10^th %ile height is not eating well. What are 3 possible causes?

• See above

• A full term baby presents with an eating disorder (i.e. FTT). What is your DDx?

• ↓intake: non-organic, GERD, structural, CNS, genetic
• ↓absorption: CF, CMPA, short gut, biliary atresia, GI
• ↑loss: gastroenteritis
• ↑demand: cardiac, ↑THY, infection, respiratory
• Ineffective use: inborn error of metabolism
  2. Obesity

• 14yo ♂ with weight of 67 kg, height 150cm.

• Calculate BMI: 29.8 kg/m²
• 4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver
• 3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S

Newborn Growth Parameters
Weight
• At birth = 3.0‐3.5kg (avg)
• Normal to lose up to 10% of birth weight in first 4‐7 days
o BUT should return to birth weight no later than 10‐14 days
• Doubles birth weight by 4‐6 months; triples birth weight by 1 year
• Quadruples birth weight by 2 years
Head Circumference
• At birth = 35cm (avg)
o <32cm 􀃆 small head = small brain until proven otherwise
• May be inaccurate at birth due to caput succedaneum, molding
• 0‐3mths = +2cm/mth
• 3‐6mths =+1cm/mth
• 6‐12mths = +0.5cm/mth
Height
• At birth = 50cm (avg)
• Doubles height by 4 years
• Measure recumbent length until 2 years, then standing height

Normal Growth Velocity


Growth Charts
• Critical to use gender and age appropriate growth charts
• In 2010, the CPS, RCFPC and the Dieticians of Canada, recommended
the use of the 2006 WHO Growth Standards and Reference charts
• WHO Growth Standards based on longitudinal data from solely breast
fed for first six months, healthy children from diverse ethnic and
geographic backgrounds; use BMI after age 10.
• Growth charts are also available for premature infants and certain
syndromes
• Use corrected age up to 2 years for plotting premature infants

Failure to Thrive
Definition
• Weight < 3%ile (the further below the curve the more likely to be
pathologic in origin)
• Weight falls across major %ile lines
• Weight < 80% of ideal body weight*
* use appropriate growth charts for gender and certain genetic conditions
Factors Affecting Physical Growth
• Genetics
• Intrauterine factors
• "Internal time clock"
• Nutrition
• Endocrine hormones
• Chronic infections/diseases
• Psychosocial factors
Etiology
• Inadequate intake: insufficient provision of food, vomiting, oro‐motor
dysfunction
• Inadequate absorption: pancreatic insufficiency, celiac disease
• Increased utilization: chronic diseases, hyperthyroidism
• Ineffective utilization: chromosomal disorders
• Increased losses: chronic diarrhea, urinary losses
Differential Diagnosis
Nonorganic/
Psychosocial
Most common cause of FTT, often seen in conjunction with organic FTT
Specific Organic Diseases
• Genetic: Turner/Downs/Russell Silver Syndrome, FAS, TORCH
• Cardiac: Chronic cardiac failure
• Pulmonary: Recurrent or chronic infections, Cystic Fibrosis
• GI: GERD, vomiting, IBD, chronic liver disease, malabsorption
syndromes (Celiac Disease, CF, Schwachman Diamond syndrome)
• Renal: Chronic renal failure, obstructive uropathies
• Endocrine: Hyperthyroidism, hypopituitarism, DM‐1, DI
• CNS: Difficulty coordinating swallow, MR, CP, Diencephalic Syndrome
• Haematology: Chronic hematologic disorders, malignancies
• Inflammatory/Immune: SLE, immunodeficiencies

Risk Factors
Child Factors
• Premature, low birth weight
• Feeding, sleep or elimination problems
• Recurrent illness
• Developmental delay
Parental Factors
• Parents abused or neglected as children
• Unwanted, unplanned pregnancy
• Marital problems, single parent
• Drugs/alcohol
• Young inexperienced parents
• Unwell/stressed parent
• Poor follow‐up, uncooperative parents
• Misconceptions of eating habits and nutrition
Child and Parental Factors
• Difficulty feeding, refusal to feed
• Colic, sleep problems
• Behavioural issues
• Parent not able to recognize child’s needs and respond to child’s cues
Environmental Factors
• Low SES, unemployment
• Lack of support, social isolation
• Lack of access to consistent medical care

History
• Duration of problem, detailed dietary and feeding history, appetite,
behavior before and after feeds, BM history, vomiting
• Pregnancy, birth, birth weight, postpartum history, developmental
history, growth patterns
• Family patterns of growth including parental heights and age of
puberty
• Current illnesses, symptoms, past medical history
• Family relationships, detailed social history
• Assess child’s temperament, child‐parent interaction, feeding
behaviour, parental psychosocial issues
Physical Exam
• Ht/Wt/HC‐ plot on growth chart; compare to prior values
• HR, RR, BP
• Complete general physical examination

Investigations/Imaging
• Use your history and physical exam to guide your choice of
investigations
• Consider investigations to look for etiology and investigations to assess
for other deficiencies
• CBC, lytes, urea, creatinine, TSH, T4, U/A, celiac screen, vitamin A,D,E,
ferritin, calcium
• Consider karyotype, microarray, bone age (AP x‐ray of L hand and
wrist) if also short stature
Management
• Treat underlying cause
• Provide education about age‐appropriate foods, mealtime scheduling
and behaviour
• Caloric fortification of food
• May need referral to dietitian, social work

Overweight and Obesity
Introduction
• Growth monitoring should be performed at primary care visits for
children and youth ages 17 and younger
• BMI = mass (kg) / height (m2)
o WHO Growth Charts for Canada are recommended which have
different cutpoints for the definition of overweight and obesity
than the US‐based CDC charts
• Cut‐off points for overweight and obese depend on age and BMI (WHO)
o Birth to 2 years
‐ Risk of overweight – Weight for length > 85th
‐ Overweight – Weight for length > 97th
‐ Obese – Weight for length > 99.9th
o 2 to 5 years
‐ Risk of overweight – BMI > 85th
‐ Overweight – BMI > 97th
‐ Obese – BMI > 99.9th
o 5 to 19 years
‐ Overweight – BMI > 85th
‐ Obese – BMI > 97th
‐ Severely obese – BMI > 99.9th
• Over 60% of overweight children will have at least one CV risk factor

History
• What concerns, if any, do you have about your child’s weight? When
did weight gain start? Has gain been slow over time or sudden?
• What, if any, past attempts at weight loss have been made?
• Review of systems for comorbidities and etiologies of obesity:
o Headaches, blurred vision (hypertension, intracranial
hypertension)
o Breathing pauses when sleeping, snoring, daytime sleepiness (OSA)
o Joint pain (slipped femoral capital epiphysis, blount disease)
o Menstrual history, hirsutism, acne (hyperandrogenism, PCOS)
o Polyuria, nocturia (T2DM)
o Increased fatigue, cold intolerance, constipation, dry skin
(hypothyroidism)
o Stunted growth, striae (Cushing’s)
• Family History
o Identify obesity in first degree relatives
o Evaluate history of cardiovascular disease, type 2 DM, cancer in
first degree or second‐degree relatives
• Diet
o Identify caretakers who feed the child
o Identify foods high in calories and low in nutritional value that can
be reduced, eliminated, or replaced
o Assess eating patterns (e.g. timing, content, location of meals and
snacks)
o Estimate the type and quantity of beverage intake (sugar
sweetened beverages, juice, pop)
o Frequency of dining out
• Activity
o Identify barriers to walking or riding a bike to school
o Evaluate time spent in play
o Evaluate school recess and physical education (frequency, duration
and intensity)
o Assess after‐school and weekend activities
o Assess screen time (television, computer, movies, video games)
• Assess psychological impact of weight on child (bullying, depression,
anxiety, social isolation etc.)

Physical Exam
• Obtain and plot weight, height, BMI on WHO Growth Charts for Canada
Complete physical exam
• Findings to look for
o Hypertension
o Enlarged thyroid
o Acanthosis nigricans (insulin resistance)
o Striae
o Hepatomegaly
o Hirsutism
o Hip/knee pain or decreased ROM (Blounts, SCFE)
o Sexual maturity rating

Investigations
• Investigations can be performed for children who meet cut‐off point
for obesity
• Lipid profile, glucose, HbA1C
• Liver enzymes (specifically ALT) every 2 years
• Consider ultrasound of liver if liver enzymes are abnormal
• Fasting lipid profile every 2 years
• Fasting plasma glucose, HbA1C every 2 years, if severe obesity
(consider 2 h OGTT (1.75 mg/kg upto max 75 g)
• Sleep study if symptoms present

Management
• Structured behavior programs should not be offered to children/youth
who are at a healthy weight to prevent obesity
• The subject of talking about a patient’s weight can often be a very
sensitive topic.
o Ask for permission to discuss weight
o Assess obesity related risk and potential ‘root causes’of weight gain
o Advice on obesity risks, discuss treatment benefits and options
o Agree on a realistic SMART plan to achieve health behavior
outcomes
o Assist in addressing drivers and barriers, offer education and
resources, refer as necessary and arrange follow‐up
• Stress the importance of achieving behavioural and health‐related
improvements rather than focusing primarily on numbers on a scale.
• Behaviour modification – can produce weight loss of 5‐20% over 3‐6
months
• Lifestyle modification strategies can be broadly categorized as:
o Controlling the environment – include the entire family in healthy
changes rather than child alone
o Monitoring behavior
o Assessing motivation
o Setting realistic goals
o Rewarding successful changes in behavior
o Arrange short‐term follow‐up to review progress
• Involve a multidisciplinary team (dietitian, exercise therapist, social
worker, psychologist)
• There is no role of medications (such as orlistat) for healthy weight
management in children 2‐11 years old or for routine use in youth 12‐
17
• Surgical management can be offered in a select group of adolescents –
there is no role for routine referral for surgical management for
overweight/obesity

Healthy Active Living
Syllabus: Lipnowski et al. Healthy Active Living: Physical activity guidelines for
children and adolescents . Paediatr Child Health. 2012;17(4):209.
Introduction
• ‘Healthy living’ is described by Health Canada as making choices that
enhance physical, mental, social and spiritual health
• Health care professionals should be promoting physical activity and
reducing sedentary time in children and adolescents

Canadian guidelines for physical activity and sedentary behavior


Short stature: differential ABCDEFG:
Alone (neglected infant)
Bone dysplasias (rickets, scoliosis, mucopolysaccharidoses)
Chromosomal (Turner's, Down's)
Delayed growth
Endocrine (low growth hormone, Cushing's, hypothyroid)
Familial
GI malabsorption (celiac, Crohn's)