Physical

GROWTH
AND
PUBERTY
Aditiawati
Division of Pediatric
Endocrinology
Dept of Child Health
FK Unsri- RSMH
 Learning objective

Explain the importance of

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

Genetic

Factors

Nutrition
Hormonal
Well being (incl Health and psychological)

Periode Intrauterin
Extrauterin
GENETIC
GENETIC
GENETICALLY HEIGHT POTENTIAL
Boys predicted stature :

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

2

Girls predicted stature :

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

2

Mid parental height

(GENETIC POTENTIAL)
 NUTRITION
Chronic nutrition defisiency
Chronic disease

Body height/ stature

Body weight
Usia (tahun)
HEALTH

SPORT -
EXERCISE
 HORMONAL
( GH, thyroid, cortisol ,sex hormon, insulin, leptin )

PENDEK

NESTLE-HERMINA 2005
 LOVE
(PSYCHOSOCIAL)

NESTLE-HERMINA 2005
 Monitoring of growth
Growth chart ( body weight, height, circumference of
head, BMI)
Evaluation of osseous maturation bone age
Evaluation of Dental

Optimal growth need :

* Correct measurement
* Correct recording medical record
* refference
Optimal growth

Factor of growth
Growth is a sensitive indicator of a child's
state of health and nutrition
Growth Chart
Body proportions
(upper-lower segmen)
Body proportions
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)
 GROWTH MECHANISM

Environment

Nutrition Well being

GROWTH
Hyperplasia
Hypertrophy
Matrix deposisiton

Genetic Hormone

GH-IGF axis
Endocrinology of growth in childhood
 Growth hormone-releasing hormone
(GHRH) produced in the hypothalamus
stimulates GH secretion
GHRH stimulates GH gene transcription
GH released into the blood in pulses (due
to pulsatile release of GHRH into portal
system)
50 % of daily GH secretion occurs during
the early hours of the night following the
onset of deep sleep
 Growth Parameters
Size - Stature
Velocity - Growth
Proportion
Bone Age

Potential Genetic Height

Mid Parental Height
 1. Size - Stature
Statistical Concept
Normal
Tall > p97
Short < p3
Sex & race
2. Velocity
I-C-P Model

INFANT CHILDHOOD PUBERTAL

 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
INFANT PHASE (0-2 yrs)
Decreasing growth velocity
Rapid increase in weight and length
Channelling

CHILDHOOD PHASE (2-11 yrs)

Growth velocity constant / linear
Growth according to genetic channel
GH dependent & thyroid hormone (partially)

PUBERTAL PHASE
Growth spurt / growth acceleration
Dependent upon action of sex hormone and GH
Deceleration and termination of growth
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
 REFERENSI
Usia Kecepatan Tinggi
0-6 bulan 32 cm/tahun
6-12 bulan 16 cm/tahun
1-2 tahun 10-12 cm/tahun
2-3 tahun 6-8 cm/tahun
3-10 tahun 5-7 cm/tahun
 Body weight
5 month : double birth weight
1 years : triple birth weight
At birth : 3.25 kg
3-12 month : age (month) + 9
2

1-6 yr : age ( yr) X2 + 8

7 -12 yr : age (yr) x 7 5

2
 Head circumference

At birth : 34-35 cm
6 month : 44 cm
1 years : 47 cm
Estimating formula (First year only)

Length (cm) + 9.5 +/- 2.5

2
 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
Growth Chart
 Stature and growth
(A) (B)

14-15 Maret 2007

Who is havingUKgrowth
Endokrinologi problems?
Anak & Remaja IDAI Who is short
Jaya
GROWTH MONITORING
What is your impression
of this childs growth?
GROWTH MONITORING
 NORMAL LINEAR GROWTH
Weight
twice birth weight at 4-5 months
3 times birth weight at age year
4 times at age 2 years
> 2 yrs old weight increases 2.5-3 kg
year until onset of puberty
Birth length is 50 cm,
at 1 yr old 75 cm,
at 4 yrs old 100 cm
at 8 yrs old 125 cm.
Growth velocity 5-7 cm/year until
onset of puberty
Pre pubertal dip
3. Proportion
 4. Bone age
Growth of
ossification centre
Equivalent to
biological age
Predict Final Height
(BA>6 yrs old)
Methods: GP, TW II,
2 yrs 6 m. 10 yrs 12 yrs
RWT
Left wrist
 A Diagnostic Algorithm for
Stature
Growth Failure/Short Stature

Disproportionate Proportionate

Skeletal dysplasias Psychosocial Psychosocial Growth

Achondroplasia Assessment Retardation
Hypochondroplasia Karyotype (girls) Turner Syndrome
Rickets
Tests for Chronic Renal Insufficiency
Systemic Disorders Gastrointestinal Disease
Nutritional Deficiency
Tests for Hypothyroidism
Endocrine Disorders Hypercortisolism

IGF-I/IGFBP-3
GH Stimulation Test Insensitivity/Resistance
MRI Scan

GH Deficiency Idiopathic Short Stature


Conclusion:
1. Hormone is central to growth
2. ICP model is useful clinically
3. Charts should be used in assessing growth
NORMAL PUBERTY
 Learning Objectives

Physiology of puberty
H-P-G axis
Hormonal changes
Physical changes
Somatic changes
Secondary sexual characteristics (Tanner staging)
Schedule of puberty
 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
 INTRODUCTION
Puberty HORMONAL
Transition period GROWTH LH, FSH, SEX STEROID

between childhood to HORMONE DHEAS

adult
Maturation of PHYSICAL
reproductive organs GROWTH REPRODUCTIVE ORGAN
and attainment of SPURT SECONDARY SEX

fertility
Termination of linear
growth
MATURE
FINAL HEIGHT FERTILITY
 Introduction

Onset
Female : 8-13 years old
Male : 9-14 years old
Basic changes
neuroendocrine : gonadotropin, sex steroid, and GH
biologic/physical : linear growth, body composition, reproductive
organs
 INTRODUCTION
Puberty is complex process, which involve the activation
of hypothalamic function and maturation of the pituitary-
gonadal 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
 Introduction
Reactivation of GnRH secretion - Hypothesis
Height & weight ratio (nutritional factors).
Maturation of hypothalamus .
CNS neurotransmitter output .
Onset of adrenal androgen activity
 HPG Axis

LHRH/GnRH

LH/FSH

Estrogen/
Testoteron
 Factors onset of puberty
RACE
Genetic

PSYCHO
SOCIAL SOCIAL
Onset of
puberty

EXERCISE
NUTRICIONA
L CHRONIC
DISEASE
 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 ). .
 Hormonal changes at puberty
Prepubertal
LH/FSH levels low
insufficient to initiate gonadal
function
Onset of puberty
activity GnRH pulse
generator
frequency & amplitude
GnRH pulses, especially
during sleep progressive
LH/FSH initiate gonadal
function
nocturnal gonadotropin
pulses (onset) daytime
gonadotropin pulses
 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)
 Normal pubertal development
Boys Girls

Onset (yrs)
12.5 11.5
(9 - 14) (8-13)

1st sign of puberty Testes volume Breast budding

( 4ml)

Max growth velocity (cm/yr) 10.3 9.0

(Tanner III-IV) (Tanner II-III)

Duration of puberty (yrs) 3.2 1.8 2.4 1.1

 SOMATIC CHANGES

Pubarche: development of pubic hair

Thelarche: development of breast in females
Gynecomastia: development of breast tissue in males
Menarche: first menstruation
 Tanner staging (girls)
Stage 1
Prepubertal; no breast tissue (M1)
None (P1)

Stage 2
Areolar enlargement with breast bud (M2)
A few darker hairs along labia (P2)

Stage 3
Enlargement of breast & areola as single mound (M3)
Curly pigmented hairs across pubes (P3

Stage 4
Projection of areola above breast as double mound (M4)
Small adult configuration (P4)

Stage 5
Mature adult breast with single contour (M5)
Adult pubic hair distribution (P5)
 Female Puberty landmark
Breast budding
1st sign of puberty
Menarche
2 yrs > onset of puberty
Ovulation-
2 yrs > menarche
Growth spurt
early Tanner stage
Final Height -
Puberty in male
LH, FSH and Testosterone and
PUBERTAL STAGE
Tanner staging (Boys)
Stage 1
Prepubertal; testicular length <2.5 cm (G1)
None (P1)

Stage 2
The testes >2.5 cm in the longest diameter, and the scrotum thinning and reddening
(G2)
Sparse growth of slightly pigmented, curved pubic hair, mainly at the base of the
penis( P2)
Stage 3
Growth of the penis in width and length, and further growth of the testes noted (G3)
Thicker, curlier hair spread to the mons pubis (P3)

Stage 4
Penis further enlarged, and testes larger, with darker scrotal skin color (G4)
Adult-type hair, which does not yet spread to the medial thighs (P4)

Stage 5
Genitalia adult in size and shape (G5)
Adult-type hair spread to the medial thighs (P5)
 Male Puberty Landmark
Testes enlargement
1st sign of puberty
Spermache
Wet dream
Age 12-14 yrs
Growth spurt
late Tanner stage
Final Height
Age 18 20 yrs
 Stretched Penile Length

AGE SPL (cm)

Newborn 30 wk 2.5
Newborn 40 wk 3.5
0-5 mo 3.9
6-12 mo 4.3
1-2 y 4.7
2-3 y 5.1
3-4 y 5.5
5-6 y 6.0
10-11 y 6.4
Adult 12.4
Precox
puberty
Delayed
puberty
 CONCLUSION
Puberty progress in a
orderly schedule
Reproductive function
& adult height is
attained at end of
puberty