Role of Supplements in Growth Failure in Children .pptx
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1. Growth failure refers to a lack of increase in physical size and can be caused by endocrine disorders like growth hormone deficiency or hypothyroidism. 2. Evaluating a child with growth failure involves accurately measuring height and growth velocity over time, performing screening tests, and growth hormone stimulation tests if endocrine disorders are suspected. 3. Treatment depends on the underlying cause but may involve supplements, hormone therapy like growth hormone, addressing nutritional deficiencies, or treating specific conditions.
Role of Supplements in Growth Failure in Children .pptx
- 1. [email protected] [email protected] Dr.Azad A Haleem AL.Mezori FRCPCH,DCH, FIBMS Assistant Professor University Of Duhok College of Medicine Pediatrics Department Role of Supplements in Growth Failure in Children Scan For Contact
- 2. Growth • Growth refers to an increase in physical size of the whole body or any of its parts. • It is simply a quantitative change in the child’s body. • It can be measured in Kg, pounds, meters, inches, ….. etc
- 3. Development • Development refers to a progressive increase in skill and capacity of function. • It is a qualitative change in the child’s functioning. • It can be measured through observation.
- 4. • GROWTH PATTERN: • Growth is characterized by phases of rapid growth ( intrauterine , infancy and puberty ) interspersed with reduced growth ( childhood ) • Maximum linear growth happens in the fetal period with increase of 50 cm . • Fetal growth is regulated by intrauterine environment with limited impact of growth hormone and thyroxine . • Infancy is associated with gain of 25 cm in first year and 12 cm in the second. • Growth during this period is largely driven by nutrition.
- 5. • Childhood growth contributes significantly to adult height and occurs at a steady rate of 5-6 cm per year . • Puberty accounts for 20-25 cm of growth . • Pubertal growth spurt starts at breast stage II in girls and testicular volume of 10 ml in boys and lasts for two years . • It peaks at breast stage IV 6 months prior to menarche with a rate of 9 cm / year in girls and a testicular volume of 15 ml with a rate of 11 cm / year in boys .
- 6. Growth hormone • Growth is regulated by the GHRH - GH - IGF1 axis with inputs from nutritional signals , sex steroids and thyroxine . • Growth hormone - IGF1 axis • Hypothalamic GHRH acts on pituitary to produce growth hormone . • Growth hormone is secreted in pulsatile fashion with maximum release at night . • Growth hormone acts on the liver to produce IGF I , which acts on the type I IGF receptor on the growth plate to induce growth .
- 7. NON AUXOLOGICAL EFFECTS • GH plays an important role in regulation of bone mineralization , adipose tissue and glucose metabolism . • GH treatment increases bone mass while reducing fat mass . • Growth hormone deficiency is therefore associated with increased adiposity and cardiovascular adverse effects in adulthood. • HGH stimulates lipolysis, which is the breakdown of fatty acids in fat tissue. This can lead to weight loss. • Increased muscle mass • Improve memory and learning. • Improved wound healing • Improved bone health
- 8. GH LEVELS ACROSS LIFE SPAN • GH levels rise immediately after birth due to lack of inhibitory effect . • GH production rate increases from 25-30 µg / kg / day during childhood to 45-50 µg / kg / day during puberty . • After puberty it declines to 200 µg / day in adulthood and 100 µg / day in old . • Physiological replacement of GH requires the use of 25-30 µg / kg / day with higher doses during puberty .
- 9. GROWTH REGULATION • Final height is determined by genetics explaining 60-80 % variation . • Within this framework growth represents an interaction of nutrition and endocrine factors . • Nutrition plays vital role in growth regulation . • Type 1 nutrients ( vitamins , calcium , iodine and magnesium ) play a role in specific processes . There deficiency disrupts a unique facet with normal overall growth . • Type II nutrients are the building blocks of body ( proteins , electrolytes , zinc , phosphorus and sulfate ) . Their deficiency causes global reduction in growth .
- 10. • Nutritional influence • Malnutrition is a growth hormone resistant state with high GH and low IGF1 levels. • GHD may therefore be missed in children with malnutrition . • Overnutrition is a growth hormone sensitive state with high IGFI and low growth hormone levels . • This may lead to erroneous diagnosis of growth hormone deficiency in obesity. • Increased insulin in obesity stimulates growth by raising free IGF1 levels and acting on the type I IGF receptor .
- 11. ENDOCRINE REGULATION • Growth is regulated by the GHRH - GH - IGF1 axis with inputs from nutritional signals , sex steroids and thyroxine .
- 12. Growth assessment • Growth assessment involves measurement of length and weight along with monitoring of growth velocity. • Regular monitoring is mandatory to ensure early identification of growth disorders. • When to assess growth? • Growth should be assessed at each outpatient visit irrespective of the presenting complaint. • Routine growth assessment is indicated at birth, at each immunization visit (6, 10 and 14 weeks), six months of age, six-monthly for the ages 1-8 years and annually thereafter.
- 13. Assessment of a child with Growth failure • Accurate height measurement& height velocity • Height plotted on appropriate growth chart.
- 14. Growth failure • Growth failure is one of the most common presentation to a pediatrician . • Most short children have physiological causes not requiring evaluation . • The aim of evaluation of growth failure is to avoid unnecessary work - up in children with physiological causes while not missing a pathological cause .
- 15. CRITERIA • Growth failure evaluation is required for children who are: very short ( height less than 5th percentile) , short and not growing ( crossing two or more major percentile lines between the age of 2 years and puberty ) . • Growth velocity should be measured over a period of at least 6 months to one year with age specific cutoff for identification of disorder .
- 16. ETIOLOGY • Growth is controlled by multiple factors and abnormality in any of these may cause growth failure .
- 17. Endocrine Causes • Endocrine causes of growth failure include: • These children have preserved weight with delayed bone age and puberty . • Growth hormone deficiency • Hypothyroidism. • Pseudohypoparathyroidism • Cushing syndrome • GH - IGF1 axis disorders
- 18. Investigations • Screening tests include • complete blood count, erythrocyte sedimentation rate • Electrolytes, calcium , phosphorus and alkaline phosphatase • blood sugar • creatinine ( chronic kidney disease ) • alanine transferase ( liver disease ) • free T4 , TSH levels ( hypothyroidism ) • celiac disease screening • chest X ray • blood gas ( renal tubular acidosis ) • Karyotype with 50 metaphases should be done in short girls with no apparent abnormality on screening tests to identify Turner syndrome .
- 19. • Growth hormone stimulation test is considered the gold standard for identifying GHD . • Sex steroid priming is recommended in girls older than 10 years and boy above 11 years who are pre - pubertal and have predicted adult height in the normal range . • 17 beta estradiol ( Progynova , 2 mg for two days) can be used in both boys and girls .
- 20. • Commonly used stimuli include: • clonidine ( 5 mcg / kg to a maximum dose of 200 mcg ) , • glucagon ( 30 mcg / kg with a maximum dose of 1 mg ) and • insulin ( 0.1 unit / kg to induce hypoglycemia ) . • Complete GHD is defined as peak stimulated growth hormone lower than 5 ng / mL and partial GHD as levels between 5-10 ng / ml . • Children with abnormal response to one test should have another dynamic test to establish the diagnosis .
- 21. • GH dependent peptides • IGF 1 and IGFBP3 are secreted in response to GH and provide information about GH effect . • These peptides are used for screening for GHD and monitoring response to GH therapy . • IGF 1 is an unreliable marker before two years of age and in those with malnutrition and liver disease . • IGFBP3 is a better marker of growth hormone status in younger children including neonates .
- 22. MANAGEMENT • Specific measures include gluten free diet in celiac disease , alkali in RTA , thyroxine in hypothyroidism and supplements and infection control in cystic fibrosis .
- 23. MANAGEMENT • Growth hormone therapy is indicated in children with: • GHD ( benefit of 20-25 cm ) , • Turner syndrome ( 10-15 cm ) , • SGA without catchup ( gain 7-10 cm ) , • chronic kidney disease planned for renal transplant and • Prader Willi syndrome with growth failure . • GH therapy is being increasingly used in children with idiopathic short stature with height below 1st percentile . • GH use in skeletal dysplasia , glucocorticoid induced growth failure , Russell Silver syndrome and while for hypophosphatemic rickets remains experimental .
- 24. MANAGEMENT • General measures include nutrition ( protein , zinc , iron and calcium supplementation ) and physical activity.
- 25. Natural ways to boost HGH • Exercise is a powerful stimulator of GH release. • Intermittent fasting • Reduction in sugar intake, which will lower the need for insulin, may help to increase levels of HGH. • Sleep: Research notes that HGH levels increase during sleep due to the influence of melatonin
- 26. Micronutrients • Zinc the pituitary growth hormone (GH)–insulin- like growth factor-I (IGF-I) axis is responsive to zinc status. • Both increased and decreased circulating concentrations of GH have been observed in zinc deficiency, although circulating IGF-I concentrations are consistently decreased. • Other micronutrients like calcium, magnesium, and phosphorus are involved in bone and muscles health, which are central to growth.
- 27. • B12 as an essential vitamin that positively regulates postweaning growth and bone formation through taurine synthesis and suggests potential therapies to increase bone mass. • Vitamin A Deficiency is associated with abnormal nocturnal GH secretion. • Dietary supplementation of Vit. E and/or Se improve and upregulate the growth-related genes without effect on the general health status .
- 28. • Vitamin D : Both vitamin D and GH metabolism influences each other: • on the one hand, vitamin D supplementation increases IGF-1 levels , and • on the other hand, IGF-1 stimulates the activity of the 1α-hydroxylase enzyme that, in turn, regulates the renal production of vitamin D: 1,25(OH)2D or calcitriol. • Additionally, GH itself has a direct stimulatory action on the production of 1,25(OH)2D.
- 29. Amino acids • The amino acids arginine , lysine , orthenine and glutamine have been associated with the release of HGH. • For nutritional purposes, amino acids are divided into three categories: • Nonessential: Your body can produce these in sufficient amounts to meet the body’s needs. • Essential: Your body can’t produce these, so you need to get them from foods. • Semi-essential: These amino acids aren’t essential under normal circumstances, but may be in certain situations.
- 30. Arginine • Arginine is a semi-essential amino acid because it’s typically needed for children’s growth, but is nonessential for healthy adults. • The effective dose: 250 mg/kg/day • Turkey: One cooked breast has 16 grams • Chicken: One chicken breast has 9 grams • Pumpkin seeds: One cup of pumpkin seeds has almost 7 grams. • Soybeans: One cup of roasted soybeans has 4.6 grams. • Peanuts: A cup of peanuts contains 4.6 grams. • Spirulina: One cup of spirulina has 4.6 grams. • Dairy: One cup of milk contains about 0.2 grams. • Chickpeas: One cup of cooked chickpeas contains 1.3 grams. • Lentils: about 1.3 grams per cup
- 31. Supplements • The amino acids arginine , lysine , orthenine and glutamine have been associated with the release of HGH. • Resting GH secretion could potentially be stimulated by administration of various amino acids such as arginine (ARG), methionine, phenylalanine, lysine, or histidine . • Some studies have shown the effectiveness of oral ingestion of ARG on GH release. • Some studies have indicated that the combination of ARG with some amino acids such as glutamine or lysine or some hormones such as GHRH has led to higher GH secretion. • Recent study showed that ARG supplementation increased significantly the levels of GHRH, GH and IGF-1.
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