GROWTH AND PUBERTY

Aditiawati
Pediatric endocrinolo gy

Learning objective

Explain the importance of monitoring growth in a child Know the sequence and timing of changes in normal puberty ( tanner stages)

GROWTH
* * * HYPERPLASIA AND HYPERTROPHY PROCESS SIZE/LENGTH/ORGAN HEIGHT AND WEIGHT/BODY NORMAL GROWTH LINIER : PARALEL WITH NORMAL GROWTH CHART

 One of the aspects that makes the field Pediatrics different from adult medicine is that children are constantly changing. They grow at a tremendous rate, especially during the first few years of life. During this period, they also go through the stages of physical and mental development. An important role of the pediatric check-up is to make sure that children are growing and developing normally.

 When a child is assessed, three important measurements are taken:

height, weight and head circumference

Whether a child is growing normally or not depends on the rate of growth over time as compared with the average or normal rates for a child's age. Boy is different than girls Every child is different!

Optimal growth

It is important to understand that each child is unique. Parents should not compare one child to another. This is not the purpose of growth charts who's role is to help make sure that a child is growing at a normal rate.

Growth is a sensitive indicator of a child's state of health and nutrition

NUTRITION

Factor of growth

HEALTH

GENETIC
HORMONE

PSYCHOSOSIAL

GENETIC

Boys predicted stature :

GENETICALLY HEIGHT POTENTIAL

( fathers height +13) + mothers height 8,5 cm 2

Girls predicted stature :

(fathers height -13) + mothers height 8,5 cm 2

(GENETIC POTENTIAL)

Mid parental height

NUTRITION
Defisiensi Nutrisi kronis Penyakit Kronis
Tinggi Badan

Berat Badan

Usia (tahun) NESTLE-HERMINA 2005

HEALTH

SPORT EXERCISE

HORMONAL
( GH,thyroid,cortisol,sex hormon,insulin, leptin

PENDEK

NESTLE-HERMINA 2005

Endocrinology of growth in childhood

LOVE (PSYCHOSOCIAL)

NESTLE-HERMINA 2005

Monitoring of growth
Pemantauan optimal perlu 1. Pengukuran yang benar 2. Pencatatan yang benar 3. Referensi yang benar

REFERENSI
Usia 0-6 bulan 6-12 bulan 1-2 tahun 3-4 tahun 5-10 tahun Kecepatan Tinggi 32 cm/tahun 16 cm/tahun 10 cm/tahun 7-8 cm/tahun 5-7 cm/tahun

Growth in Children
Growing is an essential part of childhood. Children's most dramatic growth phases occur during fetal development, the first few years of life, and at the onset of puberty. The rate at which a child grows is an individual process, based partly on heredity, gender, and environmental factors such as nutrition.

GROWTH
GROWTH is sensitive indicator of child health PRIMARY IMPORTANCE IN CHILDREN GROWTH is one of the key features of childhood, and changes in the normal pattern of childs growth may be an early manifestation of an underlying pathologic process GROWTH is a COMPLEX PROCESS and INVOLVE THE INTERCTION OF MULTIPLE FACTORS FREQUENT AND ACCURATE ASSESMENT OF GROWTH AS PART OF ROUTINE HEALTH MAITENANCE

 Understanding the normal pattern of growth prerequisite to the diagnosis of growth disorder Deviation from the normal pattern of growth is frequently the first manifestation of a wide variety of disorder

Phases of Normal Growth

1. Prenatal growth 2. Postnatal growth a. Growth during Infancy ( 0 to 2 years) b. Growth during Childhood (prepuberty) c. Growth during Puberty

Adult period : no discussion

The

infancy- childhood- puberty (ICP) MODEL by Karlberg

Average growth velocity at different phases

1. Prenatal growth 1.2 to 1.5 cm/wk 2. Postnatal growth a. Growth during Infancy 23 to 28 cm/yr b. Growth during Childhood 5 to 6.5 cm/yr c. Growth during Puberty : 8.3 cm/yr (girls) 9.5 cm/yr (boys)

Prenatal growth
The most rapid phase of human growth Body weight increase 17x106 gram Body length increase 5x103 cm Fastest growth on second semester Influenced by mother ( uterus, placenta, nutrition) and baby (chromosomal disorder, syndromes) Factors : Insulin and IGF II

Growth during Infancy

Growth deceleration

1 years body length : 1,5 x birth body length or 25 cm growth velocity in the first year. 0-12 month ( mostly the first 6 month) growth influenced by maternal and nutrition factors Hormonal factor (Growth Hormone) influenced the second 6 month of life, thyroid hormone
Second years growth velocity 50% from first year growth velocity : 12,5 cm ( 7.5 to 13 cm/yr) 2 y old body height 50% of final height catch-up and catch down Phenomena : analyze genetically height potential canalization

Growth during Childhood (prepuberty)

Growth velocity 5-7,5 cm/y respectively Body height 2x birth body length on 4 y old, Body height 3x birth body length on 13 y old, Growth deceleration phase before puberty ( girl 11,5 y old, boy, 10 y old) Final body height about 86% final height Growth hormone !!! Thyroid hormone , sex hormone

Growth during Puberty

Growth acceleration or growth spurt and growth deceleration Growth hormone and sex steroid

Mid pubertal phase growth velocity ( girl 12 y, boy 14 y) Maximal growth velocity : Female: menarche Male : testis volume 12-14 ml

Growth during Puberty

Body height achievement on puberty : Female 18-23 cm, Male 25-30 cm Maximal growth velocity : Female 8,3 +/- 1,2 cm/y, Male 9,5 +/- 1,3 cm/y Secondary sex appearance Male & female difference Pre puberty Maximal growth velocity

When does growth stop?

As a general rule, growth in height stops shortly after puberty when the influence of hormones fuse the ends of the bones. However, bones continue to mature and increase in density (bone thickness) for 5- 8 years after puberty. Bone density especially in the post pubertal years is very important for long term bone health.

However, growth can be affected and, sometimes, stopped by many disorders and diseases, including the following:
hormone deficiencies nutritional deficiencies intestinal disorders kidney, lung, and heart diseases bone disorders diabetes or other blood sugar disorders any severe form of a disease severe stress or emotional trauma

NESTLE-HERMINA 2005

MALES HEIGHT VELOCITY

ma tur ers

14 12 10 8 6 4 2 0 0 2 4 6 8 10

14
s La te m atu rer

Males, Height velocity (cm/yr)

Ea rly

97 75 50 25 3

12 10 8 6 4 2 0

12

14

16

18

Age (years)

Females, Height velocity (cm/yr)

8 6 4 2 0 0

50 25 3

La te m

10

atu rer s

97 75

Ea rl

12

ym

atu

14

rer s

FEMALES HEIGHT VELOCITY

14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 16 18

Age (years)

Predominant influences on growth

Pre-natal Maternal factors Placental factors Genetic factors

Post-natal Heredo-constitusional, Genetic factors Race, congenital anomaly, syndrome Environmental factors Nutrition, emotional environment, exercise, disease, socio economic Endocrine function (GH,Cortisol,Thyroid,insulin,sex hormon/ puberty)

puberty

Puberty
Puberty is the stage of life when the reproductive system matures together with completion of somatic growth and sexual maturity Puberty is defined as when physical changes begin, reflecting underlying hormonal stimulation The onset of puberty ( normal age of puberty) a. Girl : 8-13 years b. Boy : 9-14 years

Puberty
Puberty is complex process, which involve the activation of hypothalamic function and maturation of the pituitarygonadal axis 1. Resetting of the gonadostat 2. Neuroendocrine manifestation of puberty, is the result of an increase in LHRH ( the central nervous system) acetylcholine, catecholamine, aminobutiric acid , opioid peptides, prostaglandins, serotonin 3. Peripheral factors that influence GnRH activity : steroid, peptide hormone, body mass, nutritional factors, natural/synthetic environmental substances

Puberty
Onset of puberty --> Factor : Race Social Psychosocial Nutritional chronic disease Exercise

Aksis H-H-A LHRH/GnRH

LH/FSH

gonad TESTOTERON/ESTROGEN

Puberty
Three kinds of physical changes occur during this period of life: 1) the adolescent growth spurt, 2) the development of primary sex characteristics (The changes that mark the beginning of puberty for girls and boys), 3) the appearance of secondary sex characteristics (Other external changes that make adolescents look like mature men and women ). .

Physical changes of puberty

The change of puberty may be very gradual Described by method developed by Tanner to describe the maturation of secondary sexual characteristics ( stage 1 is prepubertal, stage 5 is adult) The marker of puberty ( the first sign ) for girl : breast development (Development of breast bud) for boys : genital growth (Enlarge of the testes)

Stadium Pubertas Tanner

Puberty
Height and height velocity need to be interpreted in the context of pubertal status Stage of puberty correlates better with bone age than chronological age Girls: Breast development mean age 3rd to 97th percentiles Males: 11.0 years 8.8 to 13.0 yrs 11.5 years

Testicular enlargement mean age Volume 4mls or more Length 2.5 cm or more 3rd to 97th percentiles

9.5 to 13.5 yrs

Pubertal approach to the age of puberty

Hormone changes of puberty Physical change characteristic of puberty Pubertal growth 3 phase
1. A period minimal growth velocity 2. The time of most rapid growth ( earlier in girl) 3. A final phase growth with progressive deceleration)

Skeletal Age ( bone age) Shift an body composition Bone density Psychological factors and sexual behavior