Atlas of Children's Growth: Normal Variation and Growth Disorders 0126833400, 9780126833409

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ATLAS OF CHILDREN'S GROWTH ormal Variation and Growth Disorders

LATLAS OF CHILDREN'S GROWTH Normal Variation and Growth Disorders

J.M. TAN ER and R.H. WHITEHOUSE Department ef Growth and Development, Institute ef Child Health, University ef London Growth Disorder Clinic, The Hospitalfor Sick Children, London

ACADEMIC PRESS A 'ubsidiary ef Harcourt Brace Jovanovich, Publishers London

C\ York Toronto

ydney an Franci co

7

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Unittd Statu Edition ""h/islud by ACADEMIC PRESS INC. 111 Fiflh Avenue, New York, New York 10003

Copyright © t 982 by ACADEMIC PRESS INC. (LONDON} LTD.

All Rights Rtstrotd o part oflhis book may be reproduced in any form by photostat, microfilm, or any other means without wriuen permission from the publishers

Bn.li.Jh Library Ultaloguing in Publicatiori Data

Tanner,J. M. Atlas of children's growth. 1. Children - Growth 2. Growth disorders I. Title 11. Whitehouse, R.H. 618.9• RJ131 ISBN 0--12-683340--0

Text set in Monophoto Times and printed in Great Britain by William Clowes (Bcccks) Ltd., Bccclcs and London

Contents Chapter 1. Chapt r 2. Chapter 3. Chapter 4. Chapter 5. Chapter 6.

Introduction Growth of ormal Children Variations of Growth and Development at Puberty Growth of Twins and Siblings Growth from 20 to 35 Years Growth Disorder True isolated growth hormone deficiency Growth hormone deficiency plus gonadotrophin deficiency Multiple pituitary deficiencies due to craniopharyngiomas Primary hypothyroidism Constitutional growth delay Constitutional tallness Silver-Russell Syndrome Turner's Syndrome Klinefelter's Syndrome XYY Syndrome Short stature due to psychosocial stress with catch-up on change of environment Coeliac disease Achondroplasia H ypochondroplasia Metaphyseal dysostosis type McKusick (cartilage-hair hypoplasia) Dyschondrosteo is, X-linked hypophosphataemic rickets and cerebral gigantism DeLange's Syndrome Spondyloepiphyseal dysplasia Marfan's Syndrome Prader-Willi Syndrome

References Appendix

138 146 150 152 156 162 164 169 174 176 178 180 182 184 188 190 192 192 192 194

196 1 97

Chapter I. /11troduc1ion We ,an rd ,n tra k mg the course or normal ,•ariauon . This clinic became the cb1er centre ID G reat Britain for the 1 rcatmcn1 of growing hormone deficiency (Tanner ,, al.• 197 1 ) and the model for the e,-cntu:al sethng up of a network of similar clinics covering lhe whole 'nitcd K ingdom. To these clinics come c hildren with all sorts or �°lb disorders, from chondrod) trophies to Marfan•s Syndrome, bcrcditary smallness 10 re, ersible psychosocially-induced growth hormone deficiency. ThtS book presents first, a 1Dtroductory exomplcs, the chans and pictures of a boy and girl followed rrom early childhood 10 maturily. Then follov. the records or 32 normal boys and 20 normal girls, selected on the basis of their physique as young adults. They cover the whole range or body build n:prcscnlcd in our sample (which consi ts of several hundred children). I n heldon somalotypc terms there an: 12 boys high or fairly high in mesomorphy (from 25t3 to 34¼3. nine high or fairly high in cctomorphy ( l l I j 7 to 334\), six high or fairly high in cndomorphy (63 1 t to 42¼4) and five boys with centrally placed somatotypcs (344 to 443). The technique of somatotyping women is less well established than 1hat of somatotyp· ing men, and we have used, as Sheldon originally recommended, similar absolute criteria to those applied 10 men. Thus the range of mcsomorphy is much reduced and the average level of endomorphy much increased. We present three girls high in mesomorphy (43t3 to 3¼34), four high in cctomorphy (435 to 424), ten high in endomorphy (632 to 52¼2} and three centrally placed somatotypes (4t34 to 4½33). Each of these children has two pages 10 him- or herself. On the left-hand page arc charts of the anthropometric measurements, skeletal maturity scores and somatolypes and on the right-hand page photogrammctric pictures. Fourteen measurements were taken on each child at each examination but only height, weight, silting height, subischial leg length (stature less silting height), biacromial (shoulder) width. biiliac (hip) width and triceps skinfold are presented here, together with height velocity, bone maturity score according to the R U S subdivision or the Tanner-W hitehouse system (fanner ti al., 1 975b) and the young adult somatotype according to the Sheldon 1 940 method. Every measuremenl on every occasion has been made by Whitehouse ; bone maturily ratings were all by Whitehouse, somatotypc and pubcny ratings by Tanner. (The raw data for all measurements of these children are in 1he Appendix.) The children were examined every 6 months (and every 3 months during pubcny). We cannot reproduce the pictures for every occasion without making them unacceptably small. Front, side and back views were taken. Eight pictures of front and back views have been fined onto the page. Most are at 2-year intervals, covering a span of 14 years; the remainder are at 1 8-month intervals, covering a 1 0· )'car span. As side views are narrower, they have been reproduced at intervals or I year. We ask forgiveness that occasional pic1ures, though no measurements, are missing; the mechanical apparatus did nol quite match the human in its reliability. I n the las1 pages or Ch. 2 our central theme is more directly stated. Groups or (>.year-old boys and girls are presented, all of whom have the same, or nearly the same, somatotypes when young adults. We have chosen the most extreme adull somatotypes in the sample, so that • number of very mesomorphic, endomorphic and ectomorphic (>.year-olds are shown. The difficulty of assigning correct soma tot ypes at age 6 emerges clearly from this exercise. This difficulty may be because or real changes in shape between 6 and 1 8, or it may renect a lack or the observer's sensitivity to small differences. To throw more hghl on this we give 1he correlation coefficients between 6year-old and adult measurcmenlS ( for the tolal ma1erial of this, plus

another longitudinal senes). Though lhcsc arc high (except for the kinfold) they represent, perhaps, more a consistency or size than or shape. We therefore then examine shape changes in a similar way. Chapter 3 examines in some detail the changes or pubeny and I heir normal vanauons. Puberty I a very special hmc in growth, not only because or lhe development of the reproductive syslem, bul because or the relatively large changes ID size. shape and body composition that also lake place lhen. Furthermore, it is at puberty that 1he individual differences in ralcs or maturing reveal lhcir results mos1 dramatically, making some children early in developing all the changes, and others late. In addition , the various evcnlS of pubeny, such as the growth of breasts and the appearance and development of pubic hair do not take place in an invanablc relationship one to anolhcr. In all normal girls the breasl develops in much lhe same sequence of stages, but the time relat ionship between lhis sequence and the sequence or pubic hair development. for example, varies a good deal. So also docs lhe ac1ual rate al which each single sequence develops. First, lo illustrale the huge variation in liming of pubeny. four boys aged 1 4·5 arc shown. wi1h all stages or pubeny represented ; their ages or peak height velocity varied from 1 2·5 to 1 6·5 years. Similarly, four girls aged 1 2·75 years arc illustraled ; their ages at menarche ranged from 1 1 ·6 to 1 4·7 years. I llustrations of the sys1em for raling stages of breasl, pubic hair and male genitalia are given, then a series or normal adolcsccnlS showing the dilTerent relationships of these various maturational sequences. The intensity and duralion or 1he adolescent growth spurt not only varies greatly from person 10 person bul also is practically independent or the amount of growth before adolescence. Thus the correlation between heighl immediately before the spur! starts and mature height is only about 0·8, a value which reflects considerable alterations of individuals· height positions relative to their coevals as puberly progresses. We illuslrale this by comparing the height curve and pictures of a boy whose spurt at puberty increased his centile position with those of a boy whose spurt decreased it. We then compare the growth curves and pictures of individuals who became relatively long- or short-legged at puberty and relatively wide- or narrow-shouldered. In Ch. 4 some family data are shown. G rowth represents the outcome of a continuous interaction between genetical and environ­ mental forces; in circumstances where nutrition, exercise and the sense of individual security and social integration are assured, differences in growth between children reflect to a great degree differences in genetic endowment. In the face of undernutrition or other environmental pressures it is size which is primarily affected and shape which is preserved. The genotype has a stronger control over shape than over size. The firsl page or Ch. 4 illustrates this by considering two pairs of identical twins. The first pair are extremely similar in all respects, but the second pair differ slightly in size because one had had a better opportunity for growth in the prenatal period and weighed more at birth. In shape 1 however, they were so iden1ical that practically nobody could distinguish between them, something of which they made full and amusing use at school . The next pages show a pair of non-identical twin sisters followed from birth to maturity. They differ considerably in skeletal maturity and in age or puberty, but little in pre-puber1al and posl·pubertal size. There follow two sets of siblings, one of lhree sisters, the other of two sis1ers and three brothers, illustrating the various growth patterns that may occur wilhin a single family. Though the differences look and indeed are large, groups of siblings nevertheless show only aboul half the degree of variation in size, growth rate and maturity that is seen amongst unrelated girls or boys. Chapler 5 presents some ralher limiled dala on growlh during young adullhood. We have followed a fairly small group of our subjects from 20-35 years, mostly at 5-year intervals. I n Ch. 6 we turn lo abnormalities of growlh. Naturally, being pa1ien1s, lhe children differ in lhe age al which I hey were first seen, though after 1hat time examina1ions of the majority were made regularly every 6 monlhs or year (if nol more rrequontly for reasons of lrca1mcnt con1 rol). It was not possible 10 follow every subjecl however, and some, par1icularly of 1he chondrodys1rophics, were only seen once. A few or lheso patienls were measured by Peter H ughes and Noel Cameron, anlhropometrisls in lhc Deparlmcnt of G rowth and Development, 1rnincd by and continuously comparing techniques wilh us.

First, four • ubJCeL5 with isol.lted gro th hormone dcfic�ncy att prcscn1ed, one wnh h1 roono,ygotic, but unJ. ITcclcd, lw,n Two subJCCl.5 with 1row1h hormone plu 1onadolrophm dcfic1enc1c, or unknown origin "" shown. ,1.nd ,,.o with p11n h)pop11u1U1rl!m, 1n each case follow,ng removal of a cranwpharyn JOm.i. E xcepl for 1hc twin. and one other boy ,.,th 1""4tcd growth hormone d•ficicncy, who ar< sull young, all thCK subJCCts ere lre.tl1ques. He has a great deal of subcutaneow fat and might be i mply called a fat man were it not that his whole body, including h11 thoracic and pclvint213l4151617 1819

Biacromial

1

2

3

4

5

6

7

8

--

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Biiliac

36

Norma/ Girl Our first girl, has growth curves which arc a little less close lO average than lhose or the boy on the opposite page~Her height

.

is consistent enough ; it was at the 40th centilc when she was

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first seen at age 2·5 and was at the 40th again at maturity, aged 16. She has a late adolescent growth spu rt, however. so that her heigh, drops temporarily from the 4-0th to1hc I01h. Her height velocity falls gradually from a little above 1he 50th to about the 25th with one odd value at age 8·5: perhaps again of a magni tude too great to be accounted for by measu rement error. It is due toa low value of height at age 8·0, when sitting height. a quite independent measurement, also had a value lower than expected. Thus there may have been an unusual slowing down of growth rrom 7·5 to 8, followed by a ca1ch-up from 8 to 8·5 which returned her on to her regular growth curve. The udolescent growth spurt starts at about 11 ·5 and reaches n mthcr low peak Ill 13•5, which is 1·5 years later than average. The peak is at about the 25th ebly th•n 1h,1 cl t,,..:

d1.1mctcr

Subject No . 13

om1al Bo; 60

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Another a1hle1ic-looking boy, somatolype 3!4J2.

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The last of our series of predominantly mesomorphic boys : his soma101ypc is 3!413 and like the preceding, also mesomorphic. subject (no. 13) he has a broken ann on one occasion. He has a very early adolescent spurt ( + 1·5 SD in timing) and in consequence his height centilc rises from the 10th at age 9 to reach the 50th at 13·5. therearter falling back to the 5th at maturi ty. Peak height velocity reaches the 35th for peak. Sin ing height has a considerable spurt and rises rrom - 2 SD al 8 to - I SD al maturity. Leg length, on the other hand, has a smallspurtandfallsfrom - 0·8SDa1810 - l·SSDatmaturi1y. 11,us though at any given time the difference between the two SD scores is within normal limits (bouom or chart) it changes

from + 1·2 (long legs) at age 8 to - 0·4 at age 18. . Biacromial diameter has a considera ble spurt supenrn~ on an alway grcatcr-lhan-average ve loci1y. Thus from dt 25th ccntile at age 9 it rises to the 50th by the time th< II"" tart • then reaches the 90th and finally endJ at the 7

!

Biiliuc diameter shows no such effecl, beginning al ihe 1 and ending at the 10th. u1lll The skinfold is always ruther low, and the booc "'" th< is always advanced, eventually reaching thc971h ccnultal 1ime of cpiphyscal rusion. nad th< Genitalia and pubic hair stages arc also adv-J ' former to about the 90th ccntilc. the ta uer 10 the 75th.

Subject

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A very early-maturing, predominantly mesomorphic, athletic boy, somatotype 3-!4-!3.

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Subject No. 15

No rmal Boy

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We now turn to a group predominantly ectomorphic somato types. This boy is the highest in ectomorphy in our se ries ; indeed with a so matotypc of l ll !7 he is quite near the European extreme. He is also very tall. because of his extremely long legs. He has a very marked adolescent growth spurt, peak height velocity nearly reaching the 97th ccntile, about a year later than average. Height is already a litt le above the 97th centileat age 8·5 but with pubcny rises to well above the 97th. At puberty this boy seems to have two waves to h.is height spun, with a pause from 13·5 to 14·5 years. This is associa ted with a rise in skinfold such as wou ld occur if the check in height growth were due to a temporary diminution in growth hormone secretion. We have seen the same thing to a greater, indeed unmistakeable, deg.rec in girls in boa rdingschools under the stress of changing schools or seeing their families go overseas. In princip le a double-peak height curve might also be explained by an out-of-phaseness

between sitting height and leg length spurts ~bu11hisdoesDOt occur in this subject. Sining height is initially at + I SD and ends at +t,. SO, whereas leg length is at. +3 SD before puberty and at +4SD after puberty. These arc the so·'

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Anolhcrmesomorphiccctomo rph , but with morccndomorphy than the preceding subject. This boy has a very early spurt, which takes his height from the 75th to the 97th ccntilc and back again . Before puberty, however, the height velocity has been much above average (about the 90th ccntilc) so this subject progresses in height rrom the 30th ccntilc al age 5 to the 75thccntilcat age I 1,a quite unusual type of curve. Indeed of all our subjects, this is the o ne with the highest overall pr-epubertal height velocity. The spurt is scc:n about equally in

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Age,years 2 3

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sitting height and leg length, with the peak about 6 month ea rlier in the legs. The legs arc at first considerably above average length for the size of trunk , but by the end of puberty

proportions arc exactly a,,cragc. Biacromial diameter shows an uacdy iWUbf nuw IO height, rising from the 40th to 1hc 75th o:ntilc bct~ecn Saad 11111 11 , and then reaching I.he 971h. Biiliacdiamctcr5how'5 d lower \'elocity. rising only slightly through the mtlilcs~ puberty. It ends at the 50th as docs. approximately. wcigtll. Triceps skinfold stays around lhe 10th e111213\4151617'6S ,51

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No rmal Girl A second relatively mcsomorphic girl, wllh averagely high cndomorphy (for women). Her height rises from the 75th 10 the 90Lh centile, foils a liute at adolescence. but returns to near the 90th. The height velocity curve is quite unu ual. The initially high velocity (perhaps representing catch-up groWTh in an improved environment) soon se ttles onto the 50th, but the peak height velocity only reaches the 3rd centilc for peak. However the spurt is more prolonged than average, so that us whole cont ribution is greater than that of a truly 3rd ccntilc spurt, and indeed returns the subject at maturi ty to her prepubertal ccntilc. Thus the spun is not small in total effect : it is just very prolonged. The peat seems to be at about the average time. Siu ing height has a prolonged and low-peaked spurt, like height : the leg length spurt is scarcely visible, Both start and finish at + I SD.

ubjecl

o. 36

Biacromial diamc1cr tarts at lhc 7Sth ccntllc bul i rtduced to the 60th by the end of puberty. Bi,hoc d1ammr I gr.ulu3 lly reduced from the 97th ccnule to the 75th. Wc,ght ts at th< 90th c~ntile at first. reduces 10 the 75th and finally roses to the 90th again. Tnccps kinfold remains around the S01h ccnult th r;,;:~~turity ,core is at first odvonccd. but gr.ulually reduces lo the 50th. tab1liles thett for a few ytars and lben drops to lhe251h. Meoarcbc is11 l},7, Brea.st su.ge2i1rcacliQa,years

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() au plotted m Fig. ). &mom r{Jtt TIie fint comparison (Figs Sand 7) as bet-ween fast .tnd ~low deYclopmcnt of genitalia~ the second comparison (Figs 6 and 8) ti bet...,cen fast and ,low development or pubic hair. In each compa.nson the middle ructure reprucnts the first occasion on ...,,h1ch the raung 2 "' li g1vcn . 1hc first picture is a year earlier (for companson w11h the ~nd lo 1l1u5trate how the diagnos111, of 11,tagc 2 ,, madeJ and the 1h1rd picture I year la ter. G,•,1/10/la : ratm I, 2. S and n.unp I, 2, l Puhk l1air r.ttings I. 2, 5 .and ratmgs 1, 2, 3. The raung Pfi2 •~ hard to ice rn photographs, but clear on the subJCCI himself

124

Age, years

12-5

12-0

13-0

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Fig. 4. Subject P2.

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12-8 Fig. 6. Fast pubic hair de .. elopmcnt

Fig. 5. Fast development or genitalia .

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32

Glrls

Fig.. 4 (left to right). Subjects nos P6, 44 (p re-puberty); P6, 44 (post-puberty). The photograph of no . P6 on the far le rt has bee n enlarged so that her biiliac diameter equals that of no. 44 in the adjace nt photograph . The two right-hand photographs were then

enlarged using the sa me magnifica tion. Note grea ter inc rease in shoulder width at pube rty in no. P6.

Age,years 8

2

3

4

5

6

7

8

Age,year,

9 10 11 12 13 14 15 18 17 18 19 20 21

Fig, 5.

16

2

3

◄

5

15

7

8

9 10 11 12 Q '4 15 16 t7 18 19 20 21

Fig. 6,

Va riation in Size and Shape Changes Cau.sed by the Adolescent Spurt (Girls) The first pair of subjects (P4 and PS) 11lus1n11c c hangcs ,n height ce ntile position ::tl pube rty (Figs I, 2. J). Subject no. P4 rises

--'------'-~~, ,,

,--.-.c=rc- :; 1

F,1, 7U,r,

enJiirced w,tor,gbl). SubJecu nos P7. 39 (pre-puberty) : P7, 39 (post-puberty). The photograph of no. P7 on 1hc far left hns been u1., 1h tha1 her lc-g length equal, that of no. 39 in the adjacent photograph. The two right-hand prints were then enlarged

n& e iimt magnification. Lines have been :iddcd to emphasize the greater increase in leg length at puberty in no. 39.

.,~Ult~-.. -....... __ ,.,. ;

123458789K>11t213M1515t71819

Fig , 8,

from the 50th 10 the 75th ccntilc while PS drops from lhc80th 10 the 50th. The heigh t vclocily curvC$ show that m thJ instance the mechanism is not the same as in the pair of boy~ illu~trJtcd in Fig. I, p. 126. The height spurts en the girls are quite s1 m1lar in in1ensi1y, bu t one takes place much CJrhcr than the other. Figure I shows the girls at age 8·5 ond ma1u.nty. The second row (Figs 4. S, 6) hows rcliuivc differences m shoulder and hip width change. Subject no. P6 has u large increase in biacromml di.:ame1er, from 50th to 80th ccntile, wilh a constant biilitlC ccnulc position. Subject no. 44 sinks a fraction in biacrominl ccntilc and rises m biihac. Girl show this shape differentiation much less clearly than boys? and our sample or girls is also rather ·mailer than lhat of boys. The pictures show the compari!.On, with the picture-, enlarged to give equal biillac diameter at the first age, The third row (Figs 7 and 8) illu tralcs dilTcrences m leg length and itting bcigbL SllbJcct no. 39 ha a large increase in kg length while laying at tt nearly constant ccn1ile position in silting height . ub,ccl no. P7 s1ayt practically constant m leg tcng1h and increases lightly her centile pmition in si tt ing height rhe pictures hJve been enlarged to give the same leg length 10 the fint pa11.

127

hapier 4. Growrh o,f Twins and ibling

Age., years

6-0

60

90

9-0

12 0

12-0

15-0

12-0

15-0

'::::-...,

GR.S

15-0

Fig. I. The Jen subject of each pair of twins is no. 45 : th e right no. 61.

Age, years

6-0

12-0

9-0

9-0

6-0

15-0

Fig. 2. The left subjec l of eac h pair of twi ns is no. 45; the right no. 61 .

an,~~~-.--.-.--,--r-..-~~-.--.-.--r--r-,--, 190

1BO

w 23

GIRLS

He;gtn

21 20

!70

19 160

18 17

150

16 140

128

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110 100

A pair of monozygoljc twins followed from age 6 to maturity (subjects4S and 61 ) . All aspects of grow1h show grea1 simila rity; menarche occurred in the same week in both twins, though no. 45 was very slightly ahead in development of breasts and pubic hair, as also in her height spurt. The height \'Clocity curves arc similar (even to the small increase at age 9) except that no. 6 1 has a higher peak. The sining heightneg leng1h c ha rt (Fig. S) shows slightly greater differences in si lting height than in leg length ; both girls have relati vely short legs. Binh•weight.s were both 2320 g. The growth e un·e, of their three sisters a rc given on pp. I32- 133.

·---~, =::-..:= .. ==:.

/,

120

Subjects Nos 45 and 61

\

Height velocity

,/

130

Identical Twins

GIRLS

22

~

90

60 ', 50 '

Age.years

23456789101112t314t516171819

Fig. 3. o subject 45 ; • subject 61.

67891Dffl2131'1i5

Fig. 5. o .ubj- ~hJrpl) on t.reJuncnt &w1c mJturtl) S,COrc (Fig. 6) i JUSt at 1hc 50th 1n Lhc unJ/fn;tcd ,,.,n :ind maKb below thl' .3rd in the affccttJ one ;\fic-r z)ta.rso(trcllmcnt th c affected 1wm h.;b ncarl) c.aucht up to the 3rd The picture on p.. 143 $ho~ the !Jrgc ducrt~OCY ui Silt before trea tment nd 11S gradual reduction on 1rc:J.tmcnt

/. ()/atcd Growth Jlom1onc Deficiency in One of Two Mono zygotic Twins 69

5

0

75

80

S uhjecH 90

8-5

60

65

69

ubject no. 80. Treatmen t commenced u1 6·9.

60

80

90

Su bJect no. 81

6·9

69

76

o · 80 and 81

8-0

8·0

90

90

Age, )curs 1 year before treatment.

Len no. 80, right no. 81.

Beginning of treatment. Left no. 80, right no. 8 1.

I yeu r on 1rcu1men1 . Left no. 80, right no. 81.

2 yean. on tre.itment Left no. 0, right no. 81.

143

~ 23

Ho91I

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GIRLS

22

GAS

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21 20

19 18 17 16 15

14

t30 120

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13

12

110 100 90 80

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lO 60

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6

9 10

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n

121314151617 819 11l2122Zl2'25

21 222324 25

12 13 14 15 16 17 181920 2122 2324 25 Fig. I.

Fig. J.

~ - - - - - - - - - - - -- ~~ 30 80

~ - ., .. ,

AQe.iears

50

Triceps Sklnfold

_.,,..,.,.----------·------·-·

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-8I

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lliactomlal

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GIRLS

9 '

~

7: RUS(TW2) Maturity Score

40

'

111/

,j/ /1' -i

38 36

/

34

J2

30 28

HGH

26

... 22

..._.

10 Age.,.,.,. 4

5

6

7 8

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2

3

,

5

15

7

8

9 10 11 t2 tJ M t5 W fT •

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Fig. 7.

Biillac

32

.,,,.

7

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n JO

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:1 1 3 4

I

7 I

Girt•

t 10 11 12 tJ M t5 • 17 11 18 20 21

Fig.8.

144

j

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Fig. 6.

Girls

20

16

3456789101112\3\.4 '5'161718t92021

Fig. S.

Fig. 4.

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11bjec1 o. 81

Tr11e Isolated Growth Hormone Deficiency A girl with true isolated growth hormone deficiency. a disorder in which boys outnum ber girls by 3: I, for unknown reasons (Ronu und Tanner. 1977). She is a first-born child, of normal pregnancy nnd delivery, wi th 11 birthwcight or 2980 g. The parents .ire unrelated nod there is no family history of short stn lure. Treatment started 111 age 12·6, though bone age (open circles in the height chart. Fig. I) wns only 8·0 "years". There arc two pcriodsofTtrentmcnt, from 13·5 to 14·5nnd 16·5 to 17·5. The heigh1 and heigh! velocity chum (Figs I and 2) show • rai rly rapid catch-up during the firs t period or treatment (9·3 cm/year) and a grQa,yea,s

50

,

2

3

•

s s

1

a

9 10 Fig. I.

n

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a ,.

~

~

11

~

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1 2

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s s

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a s

1

10 Fig. 2.

n

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a

5

19

6

7

8

n

9 10

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Fig. J.

..... 100

Triceps Sklnfold 80

GIRLS

--

~

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.

_;

.

60

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50

RUS(TW2) Maturity Score

-

1

.

•

9

-..........._Thyro1eine

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A,

50

,..._

.....,.... l

2

3

•

5

6

7

8

9'1011121314\516171819

1

23

4

5

6

7

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Thyroxine

9101112t3141516171819'100

Fig. 5.

Fig.6.

Biiliac

Biactomial 34

.. .., ... .

/ ,

.

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,, ; ,,,,,,· / /,

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Girls

. •,~ ~=~=-,~ ~-~,,-u~u-~ , .,.~ ,.~11-.~ .~~~2, Fig. 7.

8

2

3

4

5

e

1

e e

10 11 12 13

Fig. 8.

Subject No. 88

Primary Hypothy roidism

,

/.

..,

154

/

'

Fig. 4.

.

~.f(

w

111 1e 11 18

,a

20 21

A second girl with primary hypothyroidism. The height deficit (Fig. l)at initial diagnosis was much worse than in the preceding subjcc1. Thyroxine causes only a very tr.msjcnt loss of weight und s kinfold . and the height velocity (Fig. 2) rises to high catchup levels almost immediately. Skeletal maturity (Fig. 6) increases to above aver.ige in 2 )'C:trs, but, despite bone age being in advance or chronological age, a perfoctly nonna.1 final height is au aincd, being 1he S01h ccntilc (see also Harnack"' ul., l9n). In th is case there was an unusual discrepancy between bone age und age nt menarche. Despite the bone age ad\•anccmcnt, menarche occum.-d only at I3·9 (20th ccn tilc) and brc:ist and pubic hai r development were equally delayed . This subjec t h11d stri kingly short legs relative to trunk from 1hc tim e of diagnosis up to age 10. The diffe rence between lhe SD scores rcmuins at 1he lower limi ts despite 1rc;11mcn1, the

growth curves of 1hc two segments being parallel durin~ the catch-up phasc. From IO onward the leg become rd.111vely longer, and at maturity sining hcighl (Fig. J) -.as + I and kg length - 0·5 SD, a ditTerca~ well within 1he limtts of normal. There i noth ing to ind icate whether the final sligh t shortn~ of the legs is a persisting effect of early hypo1hyroldi m (as ha.s been alleged) or is simply a normal v1ma1ion. . . 8 iacromial diameter (fig. 7).