Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty

Rise in plasma growth hormone in response to exogenous LRH in Klinefelter's syndrome

In a group of sixteen patients with Klinefelter's syndrome (KS) aged from 2 years 8 months to 31 years, a study was made of the plasma growth hormone (hGH) response to LRH (50 micrograms/m2 i.v.; n=16), TRH (200 micrograms i.v.; n=14) and insulin-induced hypoglycaemia (0.1 u R.I,/kg i.v.; n=6). There was a rise in hGH following LRH from a level below 5 ng/ml during fasting to a level above 8 ng/ml (P less than 0.001) in nine (56.3%) of the sixteen patients tested; a similar response was found in only one of a control group of fifteen boys matched for age. TRH stimulation led to a rise in hGH in one of the fourteen KS patients tested, with none in the control group. Insulin-induced hypoglycaemia elicited a normal response of hGH in the six KS patients tested, from 1.8 +/- 0.7 to 16.5 +/- 3.7 ng/ml, (M +/- SD, P less than 0.001). Basal prolactin (PRL) levels were normal in the KS patients (9.4 +/- 4.1 ng/ml, M +/- SD) but the response to TRH stimulation was significantly higher (63.3 +/- 40 ng/ml; P less than 0.01) than that of the control group (30 +/- 15 ng/ml). Plasma gonadotrophin levels and the response to LRH stimulation were increased in all of the KS patients except those below the age of 13. Plasma TSH levels and the response to TRH stimulation as well as the levels of serum thyroxine were found to be normal in all the KS patients tested. The abnormal rise of hGH following LRH stimulation and of PRL following TRH stimulation suggests a disturbance in the neuroendocrine regulation mechanisms of these hormones in KS.

Effects of sodium valproate in 100 children with special reference to weight

Excessive weight gain occurred in a patient who was taking sodium valproate and phenytoin. The sodium valproate was therefore withdrawn but the rapid weight loss that ensued led to phenytoin intoxication. Hence a retrospective analysis was conducted of 100 children with epilepsy treated with sodium valproate. Fit control improved in 77 and was best in children with generalised epilepsy. None of the reported severe side effects, such as acute liver disease and pancreatitis, were encountered. Milder but troublesome side effects, however, occurred in 65 patients. The commonest was increased weight gain, which occurred in 44 cases. Others were transient gastrointestinal disturbances (20), lassitude (nine), transient hair loss (six), transient enuresis (seven), and aggressive behaviour (four).

Results of bowel resection for Crohn's disease in the young

Thirty patients (21 boys and 9 girls) underwent bowel resections for Crohn's disease from 1965 to 1979. They ranged in age from 6 to 18 yr. The follow-up period varied from 3 mo to 14 yr. There were no deaths. Seventeen developed clinical or radiologic evidence of recurrent Crohn's disease. Seven of these required reoperation and six are now well without sign of further recurrence. Eleven of 18 achieved catch-up growth in weight; 10 of 15 achieved catch-up growth in height. At the time of follow-up four had active disease, seven had evidence of recurrence but were generally well, and 19 were well without any evidence of recurrence.

Development of eight pubertal males with 47,xxy karyotype

The increasing frequency with which the diagnosis of the 47,XXY karyotype is made requires more knowledge of the prognosis of this condition. We present four 47,XXY boys identified at birth and followed since then (Group I), and four 47,XXY boys diagnosed because of physical and/or emotional problems (Group II). Physical, psychological, language, and hormone data are presented. The physical and intellectual profiles for the two groups are similar. This is in contrast to the very poor school and emotional adjustment of the Group II individuals. These boys were definitely more difficult and problematic for their parents when compared to their siblings and to Group I who were unselected. This further emphasizes that the expression of this karyotype is variable and individuals with behavioral disorders may represent a maladaptive subgroup rather than the entire population of 47,XXY males. Recommendations are given for intervention with attention to learning and language problems, hormone status, and emotional state.

Turner's syndrome associated with growth hormone deficiency

11 out of the 13 children with Turner's syndrome currently attending our endocrine clinic were investigated for possible growth hormone deficiency. The parents of two of the 13 children refused permission for these studies. One child had inadequate hypoglycaemia and the test was not repeated. Six of the ten children with adequate hypoglycaemia had an adequate growth hormone response to hypoglycaemia, while 4 children did not. This contradicts several previous studies on children with Turner's syndrome, which have reported normal growth hormone responses to provocative tests. In the normal population approximately one in 15 has an inadequate growth hormone response to hypoglycaemia.

Pubertal development in children treated for nephroblastoma

Recent improvements in the treatment of children with nephroblastoma have led to an increase in the disease-free survival rate. The late effect of treatment on long-term survivors requires assessment to determine whether avoidable iatrogenic disorders are appearing. The onset of puberty is one measurement of physical development and has been used in the study to assess the progress of 16 children over the age of 12 yr who were treated for nephroblastoma. The method consisted of the measuring body height, weight and testicular size, estimating serum levels of luteinizing hormone, follicular stimulating hormone and testosterone, recording the age at menarche, and staging of pubic hair and breast development. There was evidence of complete ovarian suppression in 3 out of 10 girls and of delayed and testicular function in 1 out of 6 boys. Analysis of the treatment received by the children implicated radiotherapy as the responsible factor causing gonadal suppression.

Hypothalamic-pituitary-gonadotropic function in girls with premature thelarche

Hypothalamic-pituitary-gonadotropic activity was investigated in 9 girls with premature thelarche, and compared with that in 9 healthy girls and 6 girls with true precocious puberty. The gonadotropin stimulation test with luteinising hormone-releasing hormone was used. Girls with premature thelarche showed luteinising hormone response resembling that of normal girls, and follicle-stimulating hormone (FSH) response quite similar to that of girls with precocious puberty. This suggests that in premature thelarche there is a partial activation of the diencephalic-hypophyseal-gonadal axis, which affects FSH only. Premature thelarche therefore, should be considered as one of the disorders due to altered sensitivity of the hypothalamic receptors which regulate sex maturation.

Endocrine and neurologic outcome in childhood craniopharyngioma: Review of effect of treatment in 42 patients

Forty-two cases of craniopharyngioma in children reviewed. Only 9.5% had sought medical attention because of symptoms suggesting hormonal deficit; however, growth retardation was present in 53% and growth hormone deficiency was documented in 72% before treatment. Multiple hypothalamic-pituitary hormone deficiencies were present in all patients after treatment. Eleven percent had normal skull radiographs at presentation; pneumonencephalograms and computed tomographic brain scans were abnormal on every occasion on which they were performed. Recurrence and mortality rates as well as the neurologic outcome of survivors were similar in children treated by radical excision and those treated by limited excision plus radiotherapy. The neurologic prognosis was poorest in those children who had limited excision or drainage without radiotherapy. Additional hypothalamic-pituitary dysfunction following treatment was less common in children who had limited excision plus radiotherapy than in children who had either limited excision or attempted total removal. Unless gross total tumor excision can be readily achieved, limited excision by transsphenoidal microsurgery or craniotomy plus radiotherapy appears to be the treatment of choice for craniopharyngioma in childhood.

Endocrine studies in Blackfan-Diamond anemia: evidence for hypothalamic-pituitary dysfunction under frequent transfusion therapy

A 13 year old boy with Blackfan-Diamond anemia treated with frequent transfusions was investigated for endocrine abnormalities. Prepubertal plasms LH and FSH values, lack of sleep-related hormone rhythms of the gonadotropins, as well as prepubertal responses of LH and FSH to acute stimulation with LHRH strongly suggests that a hypothalamic-pituitary abnormality is the cause of the hypogonadotropic hypogonadism observed in this patient. As a result of impaired stimulation of the gonads plasm testosterone was prepubertal. A three-to fourfold increase of basal plasma PRL values was found without any signs of a typical sleep-dependent increase. Values obtained ranged between 21 ng/ml and 24 ng/ml (normal range 5-8 ng/ml). A normal response to TRH stimulation was found. These results suggest that hemosiderosis may be responsible for the hyperprolactinemia as a result of hypothalamic-pituitary dysfunction. Furthermore, dysfunction is demonstrated by prepubertal responses of LH and FSH to LHRH stimulation.

Prolactin response to exercise, metoclopramide and other provacative agents in children

Metoclopramide (MCP), a derivative of procainamide was compared with exercise, arginine, insulin and thyrotropin releasing hormone (TRH) as a prolactin (PRL) releaser in children. The peak response of plasma PRL after oral administration of MCP was greater than that after strenuous exercise and after i.v. administration of pharmacodynamic agents. Normal PRL and TSH responses were observed after TRH administration in all subjects. Variable PRL responses were seen after exercise and after i.v. administration of arginine and insulin, despite significant growth hormone (GH) release following the administration of these agents. MCP produced no increase in plasma TSH. Metoclopramide may be useful for dynamic testing of PRL release in children. It can be taken orally and is free of side-effects.

Conditional standards for growth in height of British children from 5.0 to 15.99 years of age

Conditional standards giving centiles for height at time (t + 1) given height at time (t) are illustrated and their use discussed with the aid of examples. Charts have been prepared for both sexes covering the age range of t of 5.0 to 15.99 years. In contrast to velocity standards, these standards utilize all the information inherent in height (t) and height (t + 1). The conditions of their use, however, must be carefully considered. It is stressed that they actually test the normality of height (t + 1) for a given height (t). They make no statement about the normality of height (t).

One year's study of growth and total hydroxyproline excretion in scoliotic children

21 children with scoliosis were studied for a year during which time 24-hour urinary total hydroxyproline levels are estimated and anthropometric measurements were made on 4 occasions. The total hydroxyproline levels (using hydroxyproline centiles) and the uncorrected heights of the children were all normal. The sitting heights of the children were below average, but, although the sample was small, the findings indicate that the children's 'uncoiled' height would be greater than average.

Fibromuscular dysplasia of renal arteries: an important cause of renovascular hypertension in children

Fibromuscular dysplasia of renal arteries was the cause of hypertension in four consecutive children with renal artery stenosis. Two were asymptomatic, the third had had hypertension for seven years but had not been treated, and the fourth, a 9-month-old infant, presented with cardiac failure. Heart enlargement and left ventricular hypertrophy were present in all. Rapid sequence urograms demonstrated a smaller kidney and delayed appearance and disappearance of the contrast medium on the affected side in all. Angiograms showed left RAS in all. Peripheral plasma renin activity was elevated in only three of the four patients. Antihypertensive and diuretic drugs were not very effective therapeutically. Ischemia of the ipsilateral kidney probably prevented normal growth and led to shrinkage of the kidney in one patient. Following nephrectomy the BP has remained normal without any therapy for 24 to 64 months. With normalization of BP, accelerated growth ensued, the cardiomegaly regressed and the hypertensive retinopathy resolved. These patients demonstrate that: (1) FMD is an important cause of RAS. (2) the well-known radiologic feature of FMD, the beaded appearance, is usually not seen in children. (3) control of BP leads to normalization of linear growth, usually impaired in severe hypertension, and (4) target organ complications such as cardiomegaly, LVH, and hypertensive retinopathy are reversible in one to 10 months.

TSH and PRL response to thyrotrophin-releasing hormone in children with chronic renal failure undergoing haemodialysis

Eight children (aged between 8 1/2 and 15 1/2 years) with chronic renal failure receiving intermittent haemodialysis, and 2 children with renal transplants were studied. The response of TSH and prolactin (PRL), and basal T4 and T3 values was measured. Basal TSH was normal, and rose only slightly after TRH stimulation. Plasma T4 and T3 were below normal levels in 6 children. Mean basal PRL was raised and could not be stimulated by TRH. This study demonstrates the involvement of the hypothalamus and pituitary in chronic renal disease. The cause of the abnormal secretion of TSH and PRL in chronic renal failure is discussed in the light of clinical importance.

Monthly changes in the gain and loss of growth in weight of children living in Guatemala

Monthly increments of weight growth for a sample of 246 Guatemala City private school children are analyzed for the presence of a seasonal pattern in rates of growth. Neither a seasonal pattern nor any other periodic rhythm is found. It is observed that a significantly greater number of children aged 5.0 to 6.9 years experience their minimum annual growth rate during the dry season, with up to 60% of them losing or not gaining weight in any one month. Patterns of diet, exercise and disease cannot explain this trend. A possible association between minimum weight growth and maximum growth in height is discussed.

A longitudinal study of the changing pattern in Aboriginal infants' growth 1966--76

Comparison of some longitudinal data on infant weight in two samples of Australian Aborigines indicates changes in infant growth between 1966 and 1976 which suggest that at the time when the child comes off the breast, weight gain slows. This faltering of weight gain is often followed by a partial catch-up, but the resultant weight for age at 1 year corresponds with a lower British centile than the child was at just before weaning.

Growth characteristics of preschool Aboriginal children

Cox, J. W. (1979). Aust. Paediatr. J., 15, 10–15. Growth characteristics of preschool Aboriginal children. Many Australian Aborigines appear small for age when they start attending school. The growth records of over 500 Aboriginal children born since 1970 and living on five Aboriginal communities in Cape York, Queensland are analysed. For the first two to three months of life, the Aborigines appear to have similar measurements for weight and head circumference as British children. Growth retardation occurring at 3 to 12 months of age is partially compensated by a “catch‐up” spurt during the following 1–2 years. This does not fully compensate for the check during the critical period of head growth and the resultant mean head circumference remains below the British average.

It seems that the small head circumference and light weight, characteristic of the Aboriginal school child is primarily attributable to growth failure and is not a racial characteristic.

Rheumatoid arthritis and growth retardation in children: treatment with human growth hormone

Twenty patients with rheumatoid arthritis or Still's disease associated with growth failure were treated with human growth hormone, 7.5 to 17 U/m2 body surface per week. Five patients did not respond with better growth. In the remainder the mean growth rate increased from 1.9 cm/year (range: 0 to 3.3) to 6.2 cm/year (range: 3.6 to 12) over 5 to 7 months. Twelve patients treated for longer periods increased their mean growth rate from 2.6 cm/year (range: 0.7 to 5.7) to 6.3 cm/year (range: 2.4 to 9.7) and continued to grow during a second year of treatment. Growth velocity decreased in 6 patients when the hGH therapy was discontinued. The causes for this improvement in growth are possibly multifactorial: the growth rate is depressed by the severity of the disease and high-dose glucocorticoid therapy. Increases of growth rate occurred during improvements in the disease, reduction of steroid medication, as a result of therapy with human growth hormone, and because of puberty in some patients. Human growth hormone seemed to improve the underlying condition of four of the patients but had no influence on the disease in the remaining children.

Abnormal gonadothrophin secretion in children with chronic renal failure

LH and FSH response to intravenous injection of GnRH was evaluated in a group of patients with chronic renal failure on intermittent haemodialysis and in two children with successful renal transplant. Basal plasma LH was elevated in children with chronic renal failure as compared to control, and significantly increased following GnRH injection in most of the children. Basal plasma FSH was higher than in the control group, and slightly increased after GnRH. These data suggest an abnormal response to GnRH in chronic renal failure and an involvement of hypothalamus and pituitary in chronic renal disease. The role of abnormal gonadotrophin secretion in growth retardation and pubertal delay of these children is still not well understood.

Effect of supplementary feeding on infant growth in an aboriginal family

The weight charts for the six infants of a 20-year-old Aboriginal woman are examined. They all show satisfactory growth whilst being exclusively breast-fed, yet all demonstrate growth failure following the introduction of supplementary feeding. The double benefits of optimal infant growth and delay in the next conception derived from exclusive breast-feeding indicate its desirability for women in these circumstances. The problems associated with supplementary feeding and the non-utilization of family planning methods are demonstrated in the low maternal age at first pregnancy, the lack of adequate family spacing during the mother's teenage years, excessive family size and the impaired growth rate of the children.

Sexual dimorphism in the growth of the cranium

The major sexual dimorphisms in body size appear at puberty but, by then, 95% of the growth of the cranium is completed. As sexual dimorphism in the cranium is as great as for other parts of the body, this suggests that it must appear at an earlier age, and that cranium/body size ratios for the two sexes will vary during growth. Results from a longitudinal study of Montreal children are used to investigate this phenomenon. The effect is expressed quantitatively by proportional growth and growth velocity curves, based on the final size of boys, which show that the dimorphism indeed makes an early appearance. The data are also analyzed on an age scale relative to the ages of peak growth velocity in stature, derived from the individual growth curves. This shows that although there is a minor pubertal spurt in growth for the external cranial dimensions of boys, it contributes relatively little to the final dimorphism in cranial size. To summarize this aspect of growth, an index of cephalization is calculated: head length X head width/stature. Cross-sectional standards for the change of the mean index with age show a linear decline for boys and girls until puberty, with a constant difference between them. After puberty, the index becomes equal in the two sexes. Individual development curves for the index are however not linear.

Growth impairment in children treated for brain tumours

Growth and growth hormone (GH) secretion were studied in 14 children with brain tumours before radiation and chemotherapy and at various time intervals afterwards. The peak GH response to hypoglycaemia was normal in all patients before radiation. In 6 patients the peak GH response was impaired 1 year after radiation, and in a seventh it was normal at 1 year but impaired 2 years after radiation. In 12 of 13 patients the growth velocity during the first year of chemotherapy was below the 3rd centile, although none of these had an initial standing height below the 3rd centile. Thus it appears that poor growth in such children occurs irrespective of whether radiation-induced GH deficiency develops. The cause of this impaired growth is unknown.

Dialysis and renal transplantation of children in Europe, 1975

The number of new paediatric patients accepted for treatment by regular dialysis and transplantation increased more slowly than in previous years. Survival in children above 10 years appeared to be better with all modes of therapy than in younger children. The only improvement in survival noted among the different treatments was in patient and graft survival of living donor transplants. A quarter of all children transferred to home dialysis were less than 10 years of age. Nephronophthisis and Henoch-Schönlein nephritis emerged as major primary renal diseases. In 1975 the proportion of retransplants in children rose and living donor grafts from fathers were more common than from mothers. Evening dialysis was practised more frequently in both hospital and home dialysis and rehabilitation in these patients seemed to be better than for those dialysed at other times. Renal osteodystrophy was present in at least half of all children dialysed for more than 1 year. The degree of grouth retardation was affected by sex, chronological age and the primary renal disease. Body height on dialysis and after transplantation progressively reduced in the majority of children. Growth seemed to be more impaired in boys than in girls on dialysis. Bone age advanced faster than height age especially in girls. The pubertal growth spurt was usually delayed and depressed on long-term dialysis and the development of genitalia and pubic hair as well as menarche was retarded.

Genital in relation to somatic maturation

Before relating somatic growth and maturation to genital maturation, we should present a concept of growth that is sometimes a little difficult to conceive. The most important basis in studying human growth is the fact that it is a continuum, and does not start at birth, but at conception. This continuum rarely moves at a constant speed. We are so used to thinking in terms of size attained: the average measure of head circumference at 3 months of age in health, for example. Yet to consider growth as movement leads us to think in terms of velocity; that is, how fast, or slowly, is an individual child growing.

Time of onset of sperm production in boys

Puberty is defined in the Oxford English Dictionary as the state or condition of having become functionally capable of procreating offspring, suggesting that it is a discrete event that occurs at a particular point in time. Whilst it is easy to determine the age at puberty in animals from the time of completion of spermatogenesis in the male, or the first ovulation in the female, these are particularly difficult criteria to evaluate in our own species. Thus human puberty is generally described in terms of a sequence of changes in secondary sexual characteristics occurring over an extended period of time, and these have been reviewed in detail by Marshall & Tanner (1974).

Current controversies in childhood obesity

The conclusions that one can state with assurance are remarkably few. Adiposity in children is best monitored clinically by the measurement of skin-fold thickness. The likelihood that obesity will progress from infancy to childhood to adult life is still questionable and may be more important in the individual child than as a significant cause of adult obesity. Behavioral and social factors pedominate in etiology, yet biologic factors, including genetic, are also involved. Behavioral and social factors are critical in the significance of obesity to the individual. Although there are definite disease hazards, they appear to be predominantly confined to the very obese. The best treatment appears to be prophylaxis, again heavily involving behavioral and social factors as well as the wide-spread distribution of sound nutritional information. When prophylaxis fails, the behavioral modification approach to therapy currently holds the greatest promise.

Growth as a monitor of nutritional status

1. Methods of monitoring growth of individuals in a population, and average growth in height and other measurements of populations or subpopulations must be distinguished. 2. Individual monitoring of nutritional status should be by growth velocity charts, for height, chiefly, and weight, if interpreted correctly. Growth velocity may be reduced by psychological stress; it monitors a total micro-ecological situation, not just a nutritional one. 3. Population monitoring requires defined and repeated samples. The secular trend and the differences in height for age and in age at menarche related to occupational class and number of siblings reflect nutritional differences, but only as part of the same micro-ecology. Height for age and weight-for-height-irrespective-of-age have been recommended as monitors, especially for populations in developing countries. The latter poses methodological problems and is probably only legitimate between the ages of 1-0 and 9-9 years.