1. Common Disorders of Growth and Puberty
Atanu Dutta
Queen Mary’s Hospital for Children

2. Learning Objectives: Normal growth Common Growth disorders Puberty
Common problems with puberty

4. Height velocity charts

5. Growth charts: son of Count Phillip de Montbeillard 1759-1777

7. The ICP model of growth
PUBERTY
CHILDHOOD
INFANCY

8. Height Velocity chart for Boys and Girls in UK

9. Growth Assessment
Building
evidence

10. Growth Assessment The Six blocks:
History inc red book
Clinical examination
Measurement (Anthropometry)
Parental height
Bone age
Pubertal development

11. Common things first !!! Include a system check: Look out for
Asthma CF
Coeliac
IBD
Psychosocial
Syndromes are rare

12. Growth Assessment History inc red book Clinical examination
Measurement (Anthropometry)
Parental height
Bone age
Pubertal development

13. Anthropometry Use every opportunity to measure height not done often!!
Calibrated instrument
Proper positioning

14. Growth Assessment History inc red book Clinical examination
Measurement (Anthropometry)
Parental height
Bone age
Pubertal development

15. Using parents height, we can calculate a target range or 95 % tolerance limit for their expected heights of their children
A) Fathers height
B) Mothers height
C) A + B
D) C divided by 2
E) D – 7 cm (Mid parental height)
F) E +/- 8.5 cm = Target centile range

16. Using parents height, we can calculate a target range or 95 % tolerance limit for their expected heights of their children
A) Fathers height
B) Mothers height
C) A + B
D) C divided by 2
E) D + 7 cm (Mid parental height)
F) E +/- 10 cm = Target centile range
91st – 9th centile

17. Growth Assessment History inc red book Clinical examination
Measurement (Anthropometry)
Parental height
Bone age
Pubertal development

18. Bone age Compare maturity of epiphyseal centres with standard
Growth better viewed in relationship to their physical maturity than chronological age
Possible to predict early vs late developers, final adult stature
Advanced in girls
Does not make a diagnosis
Adds to the evidence

19. Done where indicated
If concerned, preferable to have BA done
Info included in ref if possible
+ parental heights
+ growth charts

20. Growth Assessment History inc red book Clinical examination
Measurement (Anthropometry)
Parental height
Bone age
Pubertal development

22. Change from childhood to adulthood
Hormonal
sexual maturation
physical – body shape/image
psychological
Emotional
experimentation

25. Puberty

26. Prader Orchidometer
Also known as
“Prader balls”
Endocrine rosary

28. Growth: Clinical problems

30. Short stature
“ absolute height which is < - 2 SDS for age, and or a linear growth velocity consistently < - 1 SDS for age”
Significant SS is ht < SDS and ht velocity < SDS

31. Short stature – Normal appearance
Short for parents
Looks normal
Normal growth velocity
Low growth velocity
Fat
Thin
Endocrine
Systemic causes

32. Systemic causes of short stature
CNS
Developmental
Cardiovascular
Heart disease
Respiratory
CF/ Asthma GI
Coeliac / IBD
Renal
CRF/ RTA
Psychosocial
Emotional deprivation, anorexia
Often delayed skeletal maturation
Potential to catch up remains if underlying cause treated

33. Psychosocial S S
Psychosocial and emotional deprivation commonly recognised
Short stature, skeletal delay
Older children may experience delayed puberty
Endocrine dysfunction may be seen

34. Endocrine causes Hypothyroidism Isolated GH deficiency
Multiple pituitary deficiency
GH resistant states
Puedohypoparathyroidism
Cushings syndrome
SGA

35. Non endocrine causes Constitutional Growth delay Turners syndrome
Skeletal dysplasias and bone disorders
Russell Silver Syndrome
Noonan's syndrome
Neurofibromatosis

36. Constitutional Growth delay

37. CDGP After 13 in girls and 14 in boys
Growth rate and bone age usually 2 SD below
However, NORMAL growth rate for bone age
Often a family history of delayed puberty

38. Constitutional vs Familial

39. Short stature – Abnormal phenotype
Short for parents
Looks abnormal
Dysmorphic
Disproportionate
Recognisable syndrome
Skeletal dysplasia
Endocrine
Systemic causes

41. Variation in Pubertal development
Delayed Puberty
Precocious Puberty
Premature thelarche
Premature menarche
Premature adrenarche
Adolescent gynaecomastia

42. Delayed Puberty Constitutional Hypogonadotrophic hypogonadism
Hypergonadotrophic hypogonadism

43. Hypogonadotrophic hypogonadism
Isolated deficiency
MPH deficiency
PWS, LMB
Hypothyroidism
CNS tumours
Anorexia, increased physical activity

44. Hyper gonadotrophic hypogonadism
Klinefelters
Anorchia/ Cryptorchidism
Turners
Other forms of primary testicular/ovarian failure
XX and XY Gonadal dysgenesis

45. Sexual Precocity Complete (True) Precocious
Incomplete Precocious puberty

46. Complete Precocious Puberty
Constitutional
Idiopathic
CNS disorder:
Severe hypothyroidism
Following androgen exposure, CAH

47. Incomplete Precocious puberty (1)
MALES
Gonadotrophin secreting tumours
Excessive androgen production
Premature maturation of Leydig cells/germinal cells

48. Incomplete Precocious puberty (2)
Females
Ovarian cysts
Oestrogen secreting neoplasms
Secondary to exogenous gonadotrophin or exposure to sex steroids
Mc Cune Albright

49. Treatment of Sexual precocity
Depends on
GnRH dependent true or central precocious puberty
GNRH AGONISTS
GnRH independent incomplete sexual precocity
Medroxy progesterone acetate
Testolactone
Ketoconazole
Cyprotone acetate

50. Variation in Pubertal development
Delayed Puberty
Precocious Puberty
Premature thelarche
Premature menarche
Premature adrenarche
Adolescent gynaecomastia

51. Basic steps in growth assessment
Measure the height. Assess puberty
Parental height and calculate MPH
Compare Childs height with MPH
Re measure Childs height after period of time
Calculate present growth velocity
If abnormally slow or rapid = Investigate

52. Case scenario (1) Paul is 8 yrs old Always short than his peers
Healthy but teased
Parents ask
Cant you give him something to make him grow better ?

53. Mother = 166 cm Father = 169 cm Mothers parents Father’s parent
150 and 160 cm
Father’s parent
155 and 160 cm
Physical exam: N
Bone age = 7.5 years
Testis = 2 mls

54. Diagnosis?

55. Case scenario (2) Steven is 14.5 yrs
Hardly grown at all during the last year
Almost all are taller than him currently

56. Father = 173
Mother = 171
Father had late puberty
Physical exam = N
No pubertal development
BA = 10 yrs
Bloods = N
LHRH shows not yet in puberty

57. Diagnosis?
Any treatment

58. Thank You