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GROWTH
1. 2. 3.
OBJECTIVES
1.
2.
3.
The use and application of the ICP model of growth. Describe and evaluate the influences on growth The use and application of centile charts
INTRODUCTION
Genetic Nutrition Hormonal Well being (incl psychological)
Intrauterin Extrauterin
INTRODUCTION
Growth assessment
Pediatric
intrinsic
care
part of well baby clinics, to detect & intervene in children with growth problems
Community
to
level
measure the prevalence of under-nutrition and over-nutrition to identify groups with increased nutritional and health needs. Growth assessment best defines the health and nutritional status of children
GROWTH MECHANISM
Environmen t
Nutrition
GROWTH
Hyperplasia Hypertrophy Matrix deposition
Well being
Genetic
Hormone
GH-IGF axis
CHILD
GH / IGF-I T4/T3
PUBERTY
GH / IGF-I E2/T Insulin T4/T3
GROWTH HORMONE
I-C-P MODEL
INFANT
CHILDHOOD
PUBERTAL
PUBERTAL PHASE
Growth spurt / growth acceleration Dependent upon action of sex hormone and GH Deceleration and termination of growth
GROWTH PARAMETERS
Size - Stature Velocity - Growth Body Proportion Bone Age Potential Genetic Height Mid Parental Height
SIZE - STATURE
Statistical Concept
(B)
PROPORTION
GROWTH CHART
Growth Chart
VELOCITY
BONE AGE
Growth of ossification centre Equivalent to biological age Predict Final Height (BA>6 yrs old) Methods: GP, TW II, RWT Left wrist
2 yrs 6 m.
10 yrs
12 yrs
Growth Chart
Boys
Exercise Height (father)167.5 cm, Height (mother) 149 cm. Calculate potential height son & daughter.
PGH son= 156,25 173,25 cm PGH daughter= 143,25 160,25 cm
195 190 185 180 175 170 165 160 155 150 145
PGH
Age (years)
VELOCITY
Velocity Chart
BMI
GROWTH MONITORING
GROWTH MONITORING
Weight twice birth weight at age 4-5 months, 3 times birth weight at age 1 year, 4 times at age 2 years > 2 yrs old weight increases 2.5-3 kg year until onset of puberty Birth length is 50 cm, at 1 yr old 75 cm, at 4 yrs old 100 cm, and 125 cm at 8 yrs old. Growth velocity 5-7 cm / year until onset of puberty Pre pubertal dip
BONE GROWTH
Proliferation of chondrocytes, followed by hypertrophy Matrix around hypertrophied chondrocytes calcify. Old chondrocytes disintegrates, leaving a cavity. Periosteal cells migrate into cavity along with osteoprogenitor cells and other cells giving rise to marrow -Osteoblasts lay down bone on calcified cartliage, enlarging marrow cavity. At maximum growth, epiphyseal and diaphyseal cavities. become continuous epiphyseal closure
CONCLUSION
Hormone is central to growth ICP model is useful clinically
PUBERTY
LEARNING OBJECTIVES
Physiology of puberty
H-P-G
Schedule of puberty
INTRODUCTION
Puberty Maturation of reproductive organs and attainment of fertility Termination of linear growth
HORMONAL
GROWTH HORMONE
ADRENARCHE GONADARCHE
PHYSICAL
GROWTH SPURT
REPRODUCTIVE ORGAN SECONDARY SEX
MATURE
FINAL HEIGHT FERTILITY
INTRODUCTION
Onset Female: 8-13 years old Male: 9.5-13.5 years old Basic changes neuroendocrine : gonadotropin, sex steroid, and GH biologic/physical : linear growth, body composition, reproductive organs
INTRODUCTION
Reactivation of GnRH secretion - Hypothesis Height & weight ratio (nutritional factors). Maturation of hypothalamus . CNS neurotransmitter output . Onset of adrenal androgen activity
Loss-of-Function Phenotype
Hypogonadotropic hypogonadism X-linked Kallmanns syndrome: hypogonadotropic hypogonadism Sex reversal and adrenal insufficiency Hypogonadotropic hypogonadism and adrenal insufficiency
Loss-of-Function Phenotype
Hypogonadotropic hypogonadism;
Autosomal dominant Kallmanns syndrome: hypogonadotropic hypogonadism; Hypogonadotropic hypogonadism and obesity Hypogonadotropic hypogonadism and obesity
NUTRITIONAL THEORY
Weight gain & %age body fat prerequisite to puberty critical weight for activation of HPG axis
47-48
kg / 17% fat
obese ( 30% ideal BW) begin puberty
Slightly
GONADOSTAT HYPOTHESIS
Prepubertal: negative feedback regulation of FSH / LH secretion low threshold & sensitive to low levels of steroids Puberty: sensitivity gonadotrophins & sex steroids
Gonadarche
Pulsatile
GnRH secretion leads to stimulation of FSH/LH activation of gonad sex steroids & completion of gametogenesis maturation reproductive organs
HPG axis functions during fetal life & during first few weeks following birth, then becomes quiescent Puberty: reactivation of HPG axis
Prepubertal
frequency & amplitude GnRH pulses, especially during sleep progressive LH/FSH initiate gonadal function nocturnal gonadotropin pulses (onset) daytime gonadotropin pulses
Girls
11.5 (8-13) Breast budding 9.0 (Tanner II-III)
3.2 1.8
2.4 1.1
40
27
SOMATIC CHANGES
Pubarche: development of pubic hair Thelarche: development of breast in females Gynecomastia: development of breast tissue in males Menarche: first menstruation
FEMALE PUBERTY
LH surge initiates 1st ovarian cycle not sufficient for ovulation during 1st cycle estrogen levels in blood increase, due to growing follicles Estrogen induces somatic changes
growth of pelvis deposit of subcutaneous fat growth of internal reproductive organs, external genitalia
androgen release by adrenal glands increases > growth of pubic hair, lowering of voice, growth of bone, increased secretion from sebaceous glands
Stage 5 Mature adult breast with single contour (M5) Adult pubic hair distribution (P5)
Event Thelarche
Pubarche
Growth Spurt Menarche Adult Breast Development Adult Sexual Hair
10.5-11.5
11-12 11.5-13 12.5-15 13.5-16
HORMONAL CHANGES
Breast budding
Menarche
Ovulation
Growth spurt
Final Height -
PUBERTY IN MALES
LH and FSH release increases ~10 yrs. of age spermatogenesis; androgen secretion adrenals also secrete androgens androgens initiate growth of reproductive organs (e.g. prostate, penis), other male characteristics (facial hair, growth of larynx voice changes)
2 4
Stage 3 Growth of the penis in width and length, and further growth of the testes noted (G3) Thicker, curlier hair spread to the mons pubis (P3)
Stage 4 Penis further enlarged, and testes larger, with darker scrotal skin color (G4) Adult-type hair, which does not yet spread to the medial thighs (P4) Stage 5 Genitalia adult in size and shape (G5) Adult-type hair spread to the medial thighs (P5)
Testes enlargement
Spermache
Growth spurt
Final Height
CONCLUSION
Puberty progress in a orderly schedule Reproductive function & adult height is attained at end of puberty