TOW#36: Short stature

This week we review another very relevant growth topic, short stature, that may cause disproportionate parental concern. Let’s review definitions and most common causes/ concerning findings related to evaluation of short stature.

Materials for this week:

Take-home points for short stature in childhood:

  1. Epidemiology: Most short stature represents familial short stature or constitutional growth delay. Incidence of growth hormone deficiency is pretty rare at 1 in 4,000 to 10,000 short children.
  2. What’s the clinical definition of short stature?: Short stature refers to a child who is 2 standard deviations below the mean height for age and sex (<3rd percentile).
  3. What are patterns of growth with familial short stature and constitutional growth delay? Familial short stature typically follows a pattern of proportional wt/ht growth along a curve below normal that starts before age 3, but with a normal bone age and, ultimately, shorter adult height. Children with constitutional growth delay (“late bloomers”) also slow down before age 3, but follow a normal rate of growth around 5th percentile and catch up later. They often have delayed puberty and below-normal bone age, but ultimately adult height in the normal range. Use mid-parental height to determine what is expected height growth (most children are within 10cm of mid-parental height).
  4. When to do a work-up? Work-up is recommended when the child’s height deficit is severe (<1st percentile for age), the child falls off the curve, especially after age 3 (more concerning for acquired growth hormone deficiency), the growth rate is abnormally slow (<10th percentile for bone age), predicted height differs substantially from mid-parental height, or body proportions are abnormal. Work-up includes bone age x-rays, may include labs (if suspicious for another diagnosis: CBC, ESR, renal function, calcium, phosphorus, TFTs, TTG antibody, sweat test, karyotype, IGF-1, IGFBP-3), referral to endocrinologist.
  5. How do we treat? Most children with short stature can be observed and offered reassurance. Evidence is lacking that short stature causes psychological harm or that there is a long-term psychosocial benefit with growth-enhancing therapy. In a few children who are very short, hormone treatment may be helpful. Human growth hormone treatment increases the growth rate, modestly increases adult height, and is mostly considered safe, but it is expensive (~$50K per inch of height!) and the long-term risk:benefit ratio for essentially healthy children remains unclear. Low-dose oral oxandrolone is a relatively inexpensive option to accelerate growth, but has not been shown to increase adult height. It’s important to support children who may be smaller than classmates; some may need extra help coping with differences based on size.

TOW #35: Urinary incontinence / enuresis

Next week we cover another bread and butter topic in gen peds – urinary incontinence, especially during sleep, which is termed “enuresis.” Below I try to digest some of the notably esoteric-sounding definitions from the International Children’s Continence Society (ICCS), which is the main organization that deals with related diagnoses in children. Understanding differences in degree and type of enuresis helps with determining appropriate treatment. Big take-aways are the importance of treating underlying constipation, being aware of other lower urinary tract symptoms, and associated behavioral diagnoses like ADHD.

Materials for this week:

Take-home points on enuresis:

  1. What are the definitions of incontinence and enuresis? Urinary incontinence is the involuntary leakage of urine, which can be continuous or intermittent and can occur during the day or at night. Generally, urinary incontinence is not considered pathologic until a child reaches age 5 years, according to the DSM-5. Enuresis refers to intermittent incontinence that happens while the child is asleep (mostly at night but can also happen with daytime naps). Lower urinary tract (LUT) symptoms should be assessed (frequency, urgency, hesitancy, dysuria, etc). Primary monosymptomatic nocturnal enuresis (PMNE) is defined as “lifelong continuous enuresis without any other history of lower urinary tract symptoms and without a history of bladder dysfunction.” Children with enuresis and any LUT symptoms have nonmonosymptomatic enuresis (NMSE) (This was formerly called diurnal enuresis). Recent stressors, UTI, and constipation can all lead to secondary enuresis, which is enuresis occuring after a period of regular bladder control.
  2. How many children are affected by bedwetting? What are other associated conditions? 15% of children will have primary monosymptomatic nocturnal enuresis (PMNE) at age 6 years, but only 1% to 2% of adolescents will continue to have wetting by the late teen years. About 1/3 of children who have bedwetting 2 or more nights per week also have daytime urinary symptoms (thus classified as NMSE). Children with enuresis have a ~20% to 30% incidence of comorbid behavioral conditions, such as ADHD, oppositional defiant disorder, and conduct disorder.
  3. What screening questions can distinguish type of enuresis? Ask about whether patients have 1) been previously dry for 6 months, 2) have daytime urine control issues, 3) constipation or fecal soiling, and/or 4) severe recent stress.
  4. How do we treat primary nocturnal enuresis (PMNE)? We are seeking to treat 3 primary physiologic disturbances involving the kidney, brain, and bladder: nocturnal polyuria, diminished sleep arousal, and reduced nocturnal bladder capacity or bladder overactivity. As far as fluid intake, a good guideline is to drink two thirds of daily fluid during school, and then one-third of the fluid in the afternoon/ evening, with no fluid an hour before bed. Children should go to the bathroom before bed and anytime they wake up. The bedwetting alarm is 1 of 2 first-line treatments recommended by the ICCS, and has the best long-term outcomes. It helps by improving arousal from sleep. Effective bed alarms use vibratory or auditory stimuli or both. Some experts believe the auditory alarms may be more effective because they alert parents as well. The alarm should be used consistently, and the child should be motivated to participate. Oral desmopressin (DDAVP) is the other first-line treatment, with caution used because of hyponatremia (intranasal is no longer recommended due to more severe hyponatremia). If used, limit fluid consumption in evening (ICCS suggests 200mL) starting 1 hour before the medication is given and until the child wakes the next morning. Long-term use does not seem to be harmful, but many of the guidelines suggest trial off the medication every 3 months to see if the child still needs it.
  5. How do we treat NMSE? Treatment includes addressing 1) Underlying constipation or fecal incontinence, 2) LUT dysfunction and daytime voiding symptoms, 3) Behavioral conditions. Urotherapy is recommended for LUT symptoms, which involves parent and patient education on normal elimination habits and a structured behavioral program to improve bladder and bowel function. A 48-hour daytime frequency and volume chart over a weekend period is recommended to provide more details to evaluate LUT dysfunction.

TOW #34: Sibling rivalry

Sibling rivalry is an issue near and dear to my heart as we often meet the criteria for intense sibling rivalry at our house! Seriously, how many times do I have to say that it’s not okay to hit your sister?! I vow to remember to call out the sweet hugs more often. 🙂

I love Maya Angelou’s writing, and her quote certainly resonates for this topic: “I don’t believe an accident of birth makes people sisters or brothers. It makes them siblings, gives them mutuality of parentage. Sisterhood and brotherhood is a condition people have to work at.”  ~Maya Angelou

Sibling rivalry materials are provided thanks to our beloved Dr. McPhillips who developed teaching for this topic. Materials for this week:

Take-home points for sibling rivalry:

  1. Frequency: Sibling rivalry is a predictable, normal and healthy response to the birth of a new brother or sister. Check out this pretty hilarious ad about what it feels like to have a new sibling!
  2. Why it’s normal: Sibling rivalry demonstrates that an older child is appropriately attached to his/her parents and that he/she is able to respond to a perceived threat to this relationship. Absence of sibling rivalry is worrisome!
  3. Risk factors: More common in same sex siblings. More common in girls than boys. The smaller the age difference—the greater the rivalry (and the closer the friendship). There is no “ideal” spacing of children, although experts suggest that 3 or more years between kids may decrease some rivalry.
  4. Natural history: Less common as children become older, especially after about 8 years old (friends, school and outside interests more important to sense of place in world).
  5. How to address: Involve older children in age-appropriate care for their younger child/infant so they feel included, provide special time for the older child, acknowledge feelings, point out all the wonderful things the older child can do that they younger one will want to emulate. Based on her research, Brené Brown recommends setting clear limits about zero tolerance for name calling and hurtful physical aggression between siblings.