Normal growth Dr fatholahpour pediatric endocrinologist Kordestan university of medical science

Agenda INTRODUCTION Phases of growth EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS 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

Agenda INTRODUCTION Phases of growth EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS 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 Average Growth Velocity / Year 1st year 25cm 2nd year 12-13cm 3rd & 4th year 6-7 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

Agenda INTRODUCTION Phases of growth EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS OF NORMAL GROWTH

EVALUATION OF GROWTH The history : The physical examination : 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

Agenda INTRODUCTION Normal Growth velocities EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS 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- score Exact percentile Rounded percentile o 50th -1 15.9 -2 2.3 3th -3 0.1 1th

Z-Score Z-score Exact percentile Rounded percentile 50th +1 84.1 85th 50th +1 84.1 85th +2 97.7 97th +# 99.9 99th

Agenda INTRODUCTION Normal Growth velocities EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS 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 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

Agenda INTRODUCTION Normal Growth velocities EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS 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.

Agenda INTRODUCTION Normal Growth velocities EVALUATION OF GROWTH STANDARD GROWTH CURVES Important terminologies & facts while evaluating Short Stature RADIOLOGIC EVALUATION OF GROWTH VARIANTS 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.