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GROWTH ANDPUBERTY
Aditiawati
Pediatricendocrinolo
gy
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Learning objective
• Explain the importance of monitoring growth in a child
• Know the sequence and timingof changes in normal puberty
( tanner stages)
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GROWTH
* HYPERPLASIA AND HYPERTROPHYPROCESS
* SIZE/LENGTH/ORGAN HEIGHT ANDWEIGHT/BODY
* NORMAL GROWTH LINIER : PARALELWITH NORMAL GROWTH CHART
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• One of the aspects that makes the field Pediatrics
different from adult medicine is that children are
constantly changing.
• They grow at a tremendous rate, especially during
the first few years of life.
• During this period, they also go through the
stages of physical and mental development.
• An important role of the pediatric check-up is to
make sure that children are growing and
developing normally.
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• When a child is assessed, three importantmeasurements are taken:
height, weight and head circumference
• Whether a child is growing normally or not depends
on the rate of growth over time as comparedwith the average or normal rates for a child's age.
•
Boy is different than girls• Every child is different!
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Optimal growth
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It is important to understandthat each child is unique.Parents should not compare
one child to another. This isnot the purpose of growthcharts who's role is to help
make sure that a child isgrowing at a normal rate.
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Factor of growth
Growth is a sensitive indicator of a child's
state of health and nutrition
GENETIC
NUTRITION
PSYCHOSOSIAL
HEALTH
HORMONE
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GENETIC
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GENETICALLY HEIGHT POTENTIAL
Boy’s predicted stature :
• ( father’s height +13) + mother’s height ± 8,5 cm2
Girl’s predicted stature :
• (father’s height -13) + mother’s height ± 8,5 cm2
Mid parental height(GENETIC POTENTIAL)
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NUTRITION
NESTLE-HERMINA 2005
Defisiensi Nutrisi kronis
Penyakit Kronis
Tinggi Badan
Berat Badan
Usia (tahun)
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HEALTH
SPORT -
EXERCISE
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HORMONAL( GH,thyroid,cortisol,sex hormon,insulin, leptin)
NESTLE-HERMINA 2005
PENDEK
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Endocrinology of growth in childhood
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LOVE(PSYCHOSOCIAL)
NESTLE-HERMINA 2005
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Monitoring of growth
Pemantauan optimal perlu
1. Pengukuran yang benar
2. Pencatatan yang benar
3. Referensi yang benar
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REFERENSI
Usia Kecepatan Tinggi
0-6 bulan 32 cm/tahun 6-12 bulan 16 cm/tahun 1-2 tahun 10 cm/tahun 3-4 tahun 7-8 cm/tahun
5-10 tahun 5-7 cm/tahun
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Growth in Children
• Growing is an essential part ofchildhood.
• Children's most dramatic growth phases
occur during fetal development, thefirst few years of life, and at the onsetof puberty.
• The rate at which a child grows is anindividual process, based partly onheredity, gender, and environmental
factors such as nutrition.
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GROWTH
• GROWTH is sensitive indicator of child health
• PRIMARY IMPORTANCE IN CHILDREN
• GROWTH is one of the key features of childhood, andchanges in the normal pattern of child’s growth may bean early manifestation of an underlying pathologicprocess
• GROWTH is a COMPLEX PROCESS and INVOLVE THEINTERCTION OF MULTIPLE FACTORS
FREQUENT AND ACCURATE ASSESMENT OF GROWTHAS PART OF ROUTINE HEALTH MAITENANCE
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• Understanding the normal pattern of growth
prerequisite to the diagnosis of growth
disorder
• Deviation from the normal pattern of growth
is frequently the first manifestation of a
wide variety of disorder
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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
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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/yrb. Growth during Childhood 5 to 6.5 cm/yr
c. Growth during Puberty :
8.3 cm/yr (girls)9.5 cm/yr (boys)
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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
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Growth during Infancy
• Growth deceleration
• 1 years body length : 1,5 x birth body length or 25cm 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 : analyzegenetically height potential canalization
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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
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Growth during Puberty
•
Growth acceleration or growth spurt andgrowth deceleration
• Growth hormone and sex steroid
• Mid pubertal phase growth velocity ( girl12 y, boy 14 y)
• Maximal growth velocity :Female: menarcheMale : testis volume 12-14 ml
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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 pubertyMaximal growth velocity
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When does growth stop?
• As a general rule, growth in heightstops shortly after puberty when the
influence of hormones fuse the endsof the bones. However, bonescontinue to mature and increase indensity (bone thickness) for 5- 8
years after puberty. Bone densityespecially in the post pubertal yearsis very important for long term bone
health.
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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
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NESTLE-HERMINA 2005
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Age (years)
0 2 4 6 8 10 12 14 16 18
Males,Heightvelo
city(cm/yr)
0
2
4
6
8
10
12
14
0
2
4
6
8
10
12
14
50
75
97
25
3
E a r l y
m a t u r e r s
L a t e m
a t u r e r s
MALES HEIGHT VELOCITY
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Age (years)
0 2 4 6 8 10 12 14 16 18
Fem
ales,Heightve
locity(cm/yr)
0
2
4
6
8
10
12
14
0
2
4
6
8
10
12
14
50
75
97
25
3
L a t e m
a t u r e r s E
a r l y
m a t u r e r s
FEMALES HEIGHT VELOCITY
Predominant influences on growth
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Predominant influences on growthPre-natal
Maternal factors
Placental factorsGenetic factors
Post-natalHeredo-constitusional, Genetic factors
Race, congenital anomaly, syndromeEnvironmental factors
Nutrition, emotional environment, exercise,disease, socio economicEndocrine function
(GH,Cortisol,Thyroid,insulin,sex
hormon/ puberty)
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puberty
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Puberty
• Puberty is the stage of life when thereproductive system matures together withcompletion of somatic growth and sexualmaturity
• Puberty is defined as when physical changesbegin, reflecting underlying hormonalstimulation
• The onset of puberty ( normal age of puberty)a. Girl : 8-13 years
b. Boy : 9-14 years
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Puberty• 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 resultof 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
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Puberty
Onset of puberty --> Factor :
• Race
•
Social• Psychosocial
• Nutritional
• chronic disease
• Exercise
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Aksis H-H-A
LHRH/GnRH
LH/FSH
gonadTESTOTERON/ESTROGEN
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Puberty
• Three kinds of physical changes occur duringthis period of life:
•
1) the adolescent growth spurt,• 2) the development of primary sex
characteristics (The changes that mark thebeginning of puberty for girls and boys),
• 3) the appearance of secondary sexcharacteristics (Other external changes thatmake adolescents look like mature men and
women ). .
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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 isadult)
• The marker of puberty ( the first sign )
for girl : breast development(Development of breast bud)
for boys : genital growth
(Enlarge of the testes)
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Stadium Pubertas
Tanner
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Puberty
Height and height velocity need to be interpreted in thecontext of pubertal status
Stage of puberty correlates better with bone age thanchronological age
Girls: Breast development mean age 11.0 years3rd to 97th percentiles 8.8 to 13.0 yrs
Males: Testicular enlargement mean age 11.5 years
Volume 4mls or moreLength 2.5 cm or more3rd to 97th percentiles 9.5 to 13.5 yrs
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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
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