Growth and Puberty Overview

BSME - School Nursing Course

June 2 2016

David Cremonesini

Topics

• Growth

• Short stature

• Early and late puberty

• Rickets

Familial influence

• Final adult height strongly influenced by genetics

• Mean 2.8cm difference in monozygotic twins yet mean 12cm difference in dizygotic

• 70-90% of child’s final height is genetically determined

• Malnutrition main cause of short stature in developed world

Case 1

• John is 8 years old

• He is shortest in the class

• Mother is worried something is wrong

• What might you ask/do?

Short stature

• Defined by having a height <2nd centile

Examination

• Signs of chronic illness or genetic syndromes

• Serial heights over time, ideally 6 mths apart

• Puberty assessment:

– Boys growth spurt towards end of puberty

typically around 14yrs

– Girls puberty earlier so spurt typically 12 yrs, 1

year before menstruation

Parental heights

• Check mother and father’s height

• Work out height range based on

measurements and then can see if childs

current centile within range

• Then likely familial short stature

Investigations

• Blood count

• Renal/Liver profile

• Thyroid function

• ESR

• Bone profile

• Coeliac screen

• IGF-1 – can’t measure Growth Hormone

• Karyotype in girls – rule out Turners XO

Further investigations

• Bone age

– If bones same age as chronological age, normal

growth but can be 18 months either side

• Growth Hormone stimulation test

Final Height predictor

Puberty

• Precocious (early) puberty defined as:

– In girls < 8 years appearance of secondary sexual characteristics (or < 9 years menarche)

– In boys < 9 years

• Delayed puberty defined as:

– In girls no breast development by 13years, normal age around 11 years

– In boys no evidence of testis growth by 14 years (normally starts 11-12 years)

Assessing puberty

• Tanner staging where pre-puberty is Stage

1, maturity stage 5

• Or can ask if not examine

Treatment of delayed puberty

• Exclude serious organic disease/chromosomal

abnormality

• Reassure if above normal, but delay can

produce anxiety, low self-esteem, school

refusal. Counselling an option

• May consider low dose testosterone in boys to

boost growth/pubertal progress

• Treatment rare for girls but consider oestradiol

Rickets

• Either due to deficiency of calcium: – Nutritional Vit D deficiency

– Liver/kidney disease Vit D deficiency

• Or due to phosphate deficiency – Nutritional

– Genetic syndromes leading to kidney losses

Signs and symptoms

• Infancy

– Soft skull bones leading to craniotabes

– Forehead bossing

– Widening of wrists

– Delayed closure of fontanelle

– Delayed teeth growth with enamel hypoplasia

Signs and symptoms

• Toddlers/young children:

– Short stature

– Bow legs

– Delayed walking

• Older children

– Knock knees

– Bone pain / fatigue

Investigations

• Vit D, calcium, phosphate, parathyroid

hormone, x-rays.

Vit D deficient rickets treatment

• Sunlight exposure. In UK 15 mins exposure of hands, arms, face or back 2-3x a week april-september is sufficient.

• May need longer for dark-skinned children

• Foods – oily fish, fish oils, eggs

• Fortified foods like cereals / formula milk

• Vitamin D replacement (keep > 50nmol/L)

• Give to high risk groups up to age 4 eg breastfed babies