Normal growth Dr fatholahpour pediatric endocrinologist Kordestan university of medical science

Normal growth

Dr fatholahpour pediatric endocrinologist Kordestan university of medical science

AgendaINTRODUCTION Phases of growthEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

INTRODUCTION Normal growth is the progression of

changes in height and weight that are compatible with established standards for a given population

Understanding the normal patterns of growth can prevent the unnecessary evaluation of children with acceptable normal variations in growth.

INTRODUCTION

Most healthy infants and children grow in a predictable fashion, following a typical pattern of progression in weight, length, and head circumference

AgendaINTRODUCTIONPhases of growthEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

Phases of growth

Infantile

Childhood

pubertal

Phases of growth

The infantile phase is characterized by rapid but decelerating growth during the first two years of life

Phases of growth

The childhood phase is characterized by growth at a relatively constant velocity of 5 to 7 cm per year

Normal Growth velocities at different ages

AgeAverage Growth Velocity / Year

1st year25cm

2nd year12-13cm

3rd & 4th year6-7 cm

5 years- till onset of puberty 5cm/year

The Growth Velocity may fall to as low as 4cm/year just before the pubertal spurt

NORMAL PUBERTAL GROWTH

Pubertal growth accounts for approximately 20 percent of final adult height

The pubertal growth spurt is immediately preceded by a decrease in height velocity

NORMAL PUBERTAL GROWTH

The pubertal growth spurt in girls:

Tanner stage II and III

23 to 28 cm during puberty

average peak height velocity of 9 cm/year

NORMAL PUBERTAL GROWTH

The pubertal growth spurt in boys :

Tanner stage III and IV 18 to 24 months after the spurt in girls 26 to 28 cm during puberty average peak height velocity of 10.3 cm per year

The later onset, longer duration, and increased velocity of the pubertal growth spurt in boys accounts for their taller stature (an average of 12 to 13 cm greater than that of girls

Typical Pattern of Growth Rate Through Adolescence

Normal Growth The linear growth of normal infants (up to 8 months) may

move to higher or lower percentile due to physiologic shift from intrauterine influences to the child’s inherent growth potential

A child’s growth curve follows along the same channel or percentile from 2-9 years of age

Crossing channels during puberty may be due to differential onset & extent of the pubertal growth spurt

Thus, excepting infancy, subnormal growth velocity is the hallmark of postnatal pathologic Short Stature

AgendaINTRODUCTIONPhases of growthEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

EVALUATION OF GROWTH

The history : The weight, length, and head circumference at

birth Developmental history Family history, including parental heights,

parental growth patterns, and timing of pubertal onset in parents

The physical examination : measurements of weight, length, and head

circumference

EVALUATION OF GROWTH

Measurements of length: In children younger than two years:

child supine on a horizontal rule that has a movable plate perpendicular to the feet and a stationary plate at the head. The older child:

standing position, preferably with a stadiometer The child's heels should be placed against the wall

with the ankles together; the knees and spine should be in a straight line

The height of an individual child should be measured at the same time of day (eg, morning or afternoon) at each visit if possible since the measurement may be greater in the morning than at the end of the day

AgendaINTRODUCTIONNormal Growth velocitiesEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

STANDARD GROWTH CURVES

Weight, height, and head circumference should be plotted on the appropriate respective growth curve at each well-child visit and as indicated at interval visits

The accurate charting of growth may prevent the unnecessary evaluation of a child who has a normal pattern of growth.

Z-score

Z- scoreExact percentileRounded percentile

o50th50th

-115.915th

-22.33th

-30.11th

Z-Score

Z-scoreExact percentileRounded percentile

050th50th

+184.185th

+297.797th

+#99.999th

AgendaINTRODUCTIONNormal Growth velocitiesEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

Important terminologies & facts while evaluating Short Stature

Mid-parental height (MPH):

The child’s probable inherited growth potential can be estimated by mid-parental height percentile.

MPH range for boys = (mother’s height+13cm)+ father’s height  + 8cm 2 MPH range for girls = Mother’s height + (father’s height- 13cm) + 8cm

2

The 13 cm represents the average difference in height of men and women

Important terminologies & facts while evaluating Short Stature

PREDICTION OF ADULT STATURE

Important terminologies & facts while evaluating Short Stature

Height Age - The age at which the patient’s height is at the 50th percentile .

Bone age - Refers to the age at which the skeletal maturation shown in patient’s radiographs is normally

attained .Greulich Pyle charts are the most commonly used method, which examines the epiphyseal maturation of

the hand & wrist .

Important terminologies & facts while evaluating Short Stature

Growth velocity / Height velocity :

Observation of a child’s height over a period of time or height velocity is the most important aspect of assessment of Short Stature

Determination of height velocity requires at least 6 months of observation.

Important terminologies & facts while evaluating Short Stature

Standard Deviation Scores: (SDS)= (x-X)/SD x: Child height X: Mean height SD: Standard deviation for the child sex and

age;0.3-50/2

Weight-for-height A weight-for-height: between the 5th and 95th percentile normal variation less than the 5th percentile: undernutrition greater than the 95th percentile : obesity

The weight-for-height typically is normal in children who have constitutional growth delay or familial short stature

Children with endocrine disorders, such as Cushing's syndrome, growth hormone deficiency, and hypothyroidism are usually overweight-for-height.

Upper segment/lower segment ratio

The lower segment is measured from the top of the symphysis pubis to the plantar surface of the foot

The upper segment is calculated by subtracting the lower segment from the child's height

Normal ratios are as follows: Birth – 1.7

3 years – 1.33 5 years – 1.19 10 years – 1.0

The US/LS ratio is abnormal in children who have skeletal dysplasia, rickets, Turner syndrome, and Marfan syndrome

AgendaINTRODUCTIONNormal Growth velocitiesEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

RADIOLOGIC EVALUATION OF GROWTH

The bone age is the most important lab test in the evaluation of growth

Bone age : comparing the epiphyses or shapes of bones on a radiograph with standards for a given age

The left hand and wrist typically are used Radiographs of the knee may provide additional

information in infants and adolescents The Greulich and Pyle atlas of radiographs

of the left hand and wrist is the standard

RADIOLOGIC EVALUATION OF GROWTH

A bone age that is more or less than two standard deviations from the mean is considered abnormal

One standard deviation is approximately 10 percent of the child's chronologic age

Bone age is delayed in children with constitutional growth delay, hypothyroidism, GH deficiency, or chronic disease, particularly gastrointestinal disease.

AgendaINTRODUCTIONNormal Growth velocitiesEVALUATION OF GROWTHSTANDARD GROWTH CURVESImportant terminologies & facts while evaluating Short StatureRADIOLOGIC EVALUATION OF GROWTHVARIANTS OF NORMAL GROWTH

VARIANTS OF NORMAL GROWTH

The most common causes of short stature beyond the first year or two of life :

familial (genetic, intrinsic) short stature

delayed (constitutional) growth

Normal variant of Short Stature

Familial short stature (FSS) A child who has FSS is short for general population

but is normal for the family pedigree. The birth length tends to be small. The child’s projected adult height falls within the mid

parental height range. The bone age & growth velocity are normal. Growth proceeds along a channel below but parallel to

the 3rd percentile curve. The final height of such a child will be short.

Normal variant of Short Stature

Constitutional growth delay (CGD) Typically, the child, is a normal looking who is

described as a ‘late bloomer’. There is often a family history of father being short

as a child & experiencing a late pubertal spurt. The bone age is delayed & corresponds to the

height age. The birth length is normal but typically slows down

to fall below 5th percentile in the first three years of life.

Although puberty is delayed, the final adult height and sexual development are normal.