Growth and puberty Flashcards
What is growth?
- Growth means an increase in some quantity over time.
- The quantity can be physical (e.g., growth in height, growth in an amount of money) or abstract (e.g., a system becoming more complex, an organism becoming more mature).
How do we measure growth?
-Height
=Wall mounted stadiometer preferred
=Reproducible technique most important
-Length
=In those less than 2 years or cannot stand
=Requires an assistant
-Weight
=In underclothing or light clothing (from age 6 months)
When should a child be measured for growth?
- All children should have their height and weight charted when they visit their doctor for any reason
- Serial measurements are most valuable as they allow assessment of rate of growth ( = growth velocity)
- Need to plot and interpret the data
What charts are recorded in measuring growth?
-Growth charts =Plot height and weight -Height velocity charts =Assess rate of growth – cm/year -BMI charts =Identify BMI out with normal range
What information is needed from both parents?
-Need height of each parent
-For a girl:
=plot mums height on chart
=plot dads height MINUS13 cm
-For a boy:
=plot Dads height on chart
=plot Mums height PLUS 13 cm
-Midpoint between the two = mid parental centile – plus or minus 6 cm
What are the 3 stages of growth?
- Infancy: 0 - ~2 years
- Childhood: 2 years – prepuberty
- Puberty: onset until reached final height and sexual maturation
What is faltering growth?
- A baby or toddler is not growing at the rate that you would normally expect (not enough calories)
- 5% of children under the age of two at some point.
- It is not a condition in itself – there are lots of different possible explanations, with feeding problems being the most common
What are the causes for lack of weight gain in infancy?
- Too little intake
- Failure to absorb
- Chronic disease
What are the key indicators of pathological growth in childhood?
- Stature out with parental target height
- Slow growth or rapid growth (not being short or tall)
What needs to be asked in a history for growth disorders?
- Duration
- Severity
- Emotional/ psychological
- Developmental history
- Social circumstances
- Diet
What needs to be asked in a perinatal history?
- Birth weight and length
- Gestation
- Drugs
- Delivery
- Infection
- Jaundice
- Oedema
- Hypoglycaemia
- Micropenis
What needs to be asked in a family history?
- Short stature
- Timing of puberty
- Heritable disease
- Endocrine disease
What systemic symptoms are noted in growth disorder history?
- Chronic illness
- Neurological and nutritional review
Describe examination of growth disorders
-Measurement
=height, weight, head circumference, body proportions (arm span)
-Body habitus
=broad chest, truncal obesity, muscle bulk
-Dysmorphism
=facial, midline defects, ears, palate, others
-Hands and feet
=short metacarpals, clinodactyly, palmar creases, lymphoedema, clubbing
-Neurological
=Visual fields, acuity, fundi, nystagmus
-Puberty and genitalia
=Pubertal staging, penis size
-Signs of systemic illness
What is puberty?
-Period in the growth and
development of a child which encompasses the initiation and progression of sexual and physical maturation/ sexual maturation occurs resulting in the capacity for reproduction
What does puberty involve?
-Growth and maturation of primary sexual characteristics
(gonads and genitals)
-Appearance of secondary sexual characteristics
(sexual hair, female breast development, voice change etc)
-Stimulation of gonadal activity is by pulsatile
gonadotropin release from the pituitary gland
Describe a history relating to puberty
-Family history of puberty
=Mother - menarche, growth spurt, cessation of growth
=Father - growth spurt, shaving cessation of growth
-History in the child
=Onset and progression of pubertal characteristics
=Pubic hair, axillary hair
=Breast development - usually recalled
=Onset of genital enlargement in boys - rarely recalled
How is puberty examined?
- Parent present, privacy, appropriate simple explanation
- Self staging using growth chart pictures if examination declined
What is examined in girls for puberty?
- Breast staging (buds)
- Pubic hair
- Axillary hair
- Acne
- Body habitus
What is examined in boys for puberty?
- Testicular volumes 4 ml (or length)- 10ml when growth spurt happening
- Genital stage
- Pubic hair
- Axillary hair
- Acne
- Facial hair
- Body habitus
What are the normal ranges for boys?
-Testicular volumes = testosterone production
=Onset puberty = 4mls: age 11 yrs
=Onset growth spurt at 10 mls: age 13 yrs
=Adult male volumes of 25mls: age16 yrs
-Normal range start = 9-14 yrs
=Onset puberty pre 9yrs = precocious
=Onset puberty after 14 yrs = delayed
-Takes 5 yrs! Pubertal height gain 25 cm
What are the normal ranges for girls?
-Oestrogen production (ovaries enlarging) =Onset puberty = breast bud and onset of growth spurt = 10.5 years =End puberty = onset menses = 13 years -Normal range to start = 8 - 13 yrs -Onset puberty before 8 yrs = precocious -Onset puberty after 13 yrs = delayed -Takes 2.5 yrs =Growth after onset menses ~ 6 cm
What is adrenarche?
- Onset of production of adrenal androgens – 2 years or more – prior to onset of puberty.
- Due to maturation of adrenal cortex – zona reticularis
- Begins by 6-8 yrs in normal individuals
- Presence or absence does not influence onset of true puberty
What are the clinical features of adrenarche?
- Axillary and/or pubic hair, greasy hair & skin, acne, body odour
- > 95% variant of normal
-When should you worry?
=Sign of virilisation or rapid growth
-Pathological diagnoses:
=Androgen secreting tumour or late onset CAH
-Parents worry: onset of puberty – but ONLY if also signs of testicular enlargement or breast development
Describe menstruation
- Occurs at end of sexual maturation – B4-5
- Mean age = 13 years
- Range of normal: 11-15 yrs
- Irregular cycles common
- Depends on ethnicity (African American younger)
What are pathological causes of growth disorders?
-Slow growth and thin?
=Chronic disease e.g. Coeliac disease, IBD
-Slow growth and fat?
=Endocrine problem e.g. hypothyroidism
-Rapid growth in childhood?
=Sex steroid exposure e.g. precocious puberty
What is central precocious puberty?
-gonadotrophin dependent
=onset breast development before 8yrs
=Testicular volumes >3mls before 9yrs
=Central activation of pubertal axis
=Gonadal enlargement
=Normal sequence of events
What is pseudopuberty?
-gonadotrophin independent
=disharmonious pubertal events
=Eg vaginal bleeding without breast development
=Peripheral activation of sex steroids =Not centrally activated =Incomplete pubertal sequence =No gonadal enlargement =eg. congenital adrenal hyperplasia =ovarian tumour
What concerns are raised by possible precocious sexual development?
- Possible sinister underlying cause
- Psychologically unacceptable – embarrassment of inappropriately early sexual changes, excessive tall stature, early onset menstruation.
- Long term sequelae – short stature (but only if age at onset is < 7yrs in girls and < 8 yrs in boys
What concerns are raised by delayed or incomplete sexual development?
- Possibly a sinister underlying cause eg acquired hypothyroidism
- Emotional and psychological upset of immaturity, esp when associated with short stature
- Long term sequelae
How does obesity affect puberty?
- Increased linear growth rate
- Just get there sooner [earlier puberty] or at same time [blunted puberty growth spurt]
How does McCune-Albright syndrome present?
-Large pigmented lesions
=Ovaries switch themselves on
Describe hypopituitarism
- Congenital – single or multiple pituitary deficiencies or SOD (septo-optic dysplasia)
- Acquired - craniopharyngioma
-Presents as
=Height <1st centile
=Fat
=Prepubertal
How does Turner’s syndrome present?
-Always short and growing more slowly
-No dysmorphic features
=Short, broad chest, webbed neck, increased carrying angle, hyperconvex nails, low posterior hair line, cardiac defects, renal anomalies
Describe Acquired hypothyroidism
- Often family history
- May be overweight
- Growth rate would be slow – unlike simple obesity where growth is faster.
