Growth & Puberty

ADITIAWATI
Pediatric Endocrinology
FK Unsri-RSMH Palembang
2023
 Out line
• Normal Growth and puberty
• Growth Monitoring
• I-C-P Model (Karlberg)
• Growth Disorder
• The importance of puberty
• Other variants of puberty: normal variants?
• Pubertal Disorder
GROWTH ASSESSMENT &
GROWTH DISORDERS
 PERTUMBUHAN
▪ Proses fisiologi yang khas pada anak
▪ Salah satu indikator sensitif untuk
melihat kondisi kesehatan dan
kesejahteraan anak
▪ Proses yang dinamis dengan banyak
faktor yang saling berpengaruh yang
ikut menentukan laju pertumbuhan
dari waktu ke waktu serta pencapaian
tinggi
 FAKTOR PERTUMBUHAN
Intra Uterine (Pre-natal)
1. Faktor Ibu
2. Faktor Placenta
3. Faktor Genetik
Extra Uterine (Post-natal)
1. Heredo-constitusional, Faktor GENETIK
Ras, congenital anomaly, syndrome
2. Faktor LINGKUNGAN
Nutrisi, Emosi lingkungan, exercise,
Penyakit, socio ekonomi
3. Fungsi ENDOKRIN
GH,Cortisol,Thyroid,insulin,sex
hormon
FAKTOR PERTUMBUHAN

HORMON
TETAP
PERHATIKAN
UNSUR INI

PERTUMBUHAN
hiperplasia LINGKUNGAN
GENETIK
hipertropi PSIKO-SOSIAL
deposisi matriks

NUTRISI
 2. NUTRISI
1. PENY
GENETIK KRONIS

Kekurangan Nutrisi
POTENSI TINGGI Kronik
SINDROM
GENETIK
(PTG & -MPH) Penyakit Kronik
Body height/ stature

STUNTING

Body weight
 Growth Chart
POTENSI TINGGI GENETIK (PTG/GPH)
195

190

185 PGH
180

Prediksi Tinggi pada Laki-laki: 175

170

( father’s height +13) + mother’s height ± 165

8,5 cm 160

2 155

150

Prediksi Tinggi pada perempuan: 145

Height 140
(cm) 135
(father’s height -13) + mother’s height ± 8,5 130
cm 125
2 120

115

110

105

100

95

→ Mid parental height ( MPH) 90

85
( target Height) 80
2 4 6 8 10 12 14 16 18

Age (years)
 3.
HORMON

4. LINGKUNGAN
GH,Thyroxin, Insulin,
cortisol, sex steroid, PSYCHOSOSIAL
IGF-growth factors)
Integritation of hormone systems

THE ROLE
OF
HORMONES
 2. LAJU PERTUMBUHAN
1. PERAWAKAN (Velocity)
Indikator : TB-BB-BMI-LK-LL Pada periode waktu
Konsep Statistik-Kurva ICP model
Pada satu waktu ( INFANT-CHILD-PUBRTY)

PARAMETER
PERTUMBUHAN

3. PROPORSI TUBUH
4. UMUR TULANG
Ratio segmen atas-segmen
( bone age)
bawah
Titik titik pertumbuhan
RATIO TB –RENTANG LENGAN
Umur biologis
DISMORFIK
 1.“PENGUKURAN TUNGGAL TINGGI BADAN”
Hanya akan identifikasi tinggi badan (
perawakan)
o Perawakan pendek atau perawakan tinggi
o Perawakan normal
Tidak bisa mengidenfikasi proses pertumbuhan
o Anak dengan pertumbuhan melambat (misal
:GHD, hipothiroid congenital)
o Turner Syndrome
o Acquired disorder : hypothyroidsm, coeliac disease
o Pertumbuhan yg memotong kurva garis persentil
 “Pengukuran Periodik tinggi badan”
→Bisa melihat POLA LAJU PERTUMBUHAN
•Kanalisasi
•“crossing the centiles”
•Identifikasi kecepatan pertumbuhan (misal
:GH-Thyroid defisiency)
•Pertumbuhan normal
→ Perlunya MONITORING !!!
 2. LAJU PERTUMBUHAN
( Model I-C-P dari Karlberg )
P

P
C
I

(from Tanner-Whitehouse in: Brook’s Clinical Pediatric

Endocrinology, 2005)
Catch
Up FASE BAYI -INFANT (0-2/3 tahun)
Catch *Penurunan kecepatan pertumbuhan sth intra uterine
Down
*Penambahan cepat BB dan panjang badan
*Kanalisasi (channelling) → menuju PTG
*Nutrisi , Growth Hormon, HormonThyroid

FASE ANAK-CHILD (2/3 -11 tahun)

• Kecepatan pertumbuhan konstan/ linier
• Pertumbuhan berada pada kanal genetik
• Prepubertal dip
• Tergantung pada GH dan hormon tiroid (parsial)

FASE PUBERTAS-PUBERTY
*Growth spurt / akselerasi pertumbuhan
*Tergantung pada kerja hormon seks dan GH
*Deselerasi dan berhentinya pertumbuhan
 Fase bayi –> Kanalisasi → PTG
• Catch-Up → mengejar
• Catch down → PTG

Constitutional Delay
Perawakan pendek
idiopatik
KMK ( SGA)
Fase Pubertas
GROWTH
SPURT
( SEX HORMON
& GROWTH
HORMON)

Sekuens pubertas

Juli 2008
©UKK Endokrinologi Anak & Remaja
 Kecepatan
Usia pertumbuhan
(cm/tahun) Fase pertumbuhan
Fase bayi
0-12 bulan 23-27 cm
12 – 24 bulan 10-14 cm 15%
2 - 3 tahun 8 cm
Fase anak
3 - 5 tahun 7 cm
5 tahun – 5-6 cm
menjelang
pubertas
Fase perempuan: 8-12 cm 15%
lelaki: 10-14 cm 40%
Pubertas
Untuk tetap b erada pada jalur
yang sama s elama masa
pertumbuhan →kecepatan
tumbuh ≥ persentil 25

(Valdes et al., 2018)

30%
•2 x BB lahir pada usia 4-5 bulan,
•3 x BB lahir pada usia 1th,
•4 x BB lahir pada usia 2th
•> 2 tahun: BB ↑ 2.5-3 kg per tahun - Lahir 50 cm, usia 1 tahun =75 cm, usia 4
menjelang remaja tahun =100 cm, usia 8 tahun=125cm
REFERENSI NORMAL LAJU PERTUMBUHAN

Dalam Kandungan : tercepat → 9 bulan sekitar 50 cm

luar kandungan : ada 3 fase ( Infant-Child-Puber) → adult

Fase bayi
( Lahir -3 tahun ) Fase Anak Fase Puber
Periode Emas
Pertumbuhan Pertumbuhan 8-12 cm
6 bln 1 : 15-16 cm
Tahun 1 : 23-27 cm
konstan 5-7 cm Laki : +20-24 cm
Tahun 2 : 10- 12 cm (< 4 CM : Wanita : +17-20 cm
Tahun 3 : 6-8 cm ABNORMAL )
Hormon Sex
Nutrisi Hormon Pertumbuhan Hormon Pertumbuhan
Hormon tiroid Hormon Tiroid Hormon Tiroid
Hormon pertumbuhan
3. PROPORSI TUBUH

DISMORFIK ?

Arm Span
• Rentang Lengan
Height=Arm Span ± 3½cm
TB=RL± 3½cm
•• Tinggi Duduk → Rasio
Tinggi Duduk → Rasio
Segmen
Segmen Atas/Bawah
Atas/Bawah
Lahir
Lahir: US/LS = 1.70
: US/LS (tertinggi)
= 1.70 (tertinggi)
Postpuberty: US/LS= 0.89 - 0.95
Pasca pubertas: US/LS= 0.89 - 0.95
 Short stature*
Detailed medical history and physical examination

Dysmorphism or disproportionate short Proportionate short stature without

stature dysmorphism

Turner syndrome (Girls) Down’ Systemic illnesses Malabsorption Step 1 investigations

syndrome Noonan’s syndrome Prader syndromes CBC, Albumin
Willi syndrome Russel Silver syndrome Chronic infections/ inflammatory ESR, Tuberculin test, Chest
SHOX deficiency syndromes Skeletal conditions X‐ray
dysplasias Mucopolysaccharidoses Chronic renal disease Chronic Serum creatinine Liver
Others liver disease function tests
Pseudohypoparathyroidism Serum calcium, PO4, PTH,
Rickets Radiology

Normal test results

Endocrine disorders Step 2 investigations Free
Birth weight and/or length <‐2SD
Hypothyroidism Thyroxine, TSH FSH,
Small for gestational age with failure to
Turner syndrome (Girls) Distal Karyotype Blood gas
catch up
renal tubular acidosis Celiac analysis IgA, IgA tTG
disease Basal Cortisol, LDDST
Normal test results and BA=CA Ht SDS Cushing’s syndrome
within target Ht SDS Familial short
stature
IGF deficiency syndromes Growth
hormone insufficiency/ Step 3 investigations
insensitivity IGF1, IGFBP3,
Normal test results and BA=HA<CA GH stimulation tests MRI
Similar pubertal tempo in parents pituitary
Constitutional delay in growth and
puberty Normal tests
Idiopathic short stature
 4. PENILAIAN USIA TULANG
Foto rontgen :Telapak tangan kiri

Bisa untuk prediksi tinggi akhir

(untuk >6 tahun)
Hasil : Average BA (CA = BA)
Advanced BA (CA < BA)
Retarded BA (CA > BA)
Prinsip penilaian usia tulang meliputi meliputi 2 hal penting:
1)Menilai maturitas tulang dengan memperhatikan pusat osifikasi dan
morfologinya mulai dari karpal ke arah falang distal (Fokus penilaian sesuai
tahap perkembangan)
2)Menilai fusi epifisis ke metafisis mengikuti arah dari falang distal ke karpal
(ulna dan radius)
Sanctis dkk, 2014
 MONITORING PERTUMBUHAN
• Pengukuran rutin → Deteksi pertumbuhan yang
abnormal → evaluasi dan tindak lanjut
• Tujuan monitoring pertumbuhan :
a. Mendeteksi sedini mungkin gangguan
pertumbuhan
b. Memperbaiki nutrisi dan Menurunkan resiko
dampak inadekuat nutrisi
c. Membantu edukasi
d. dan membantu kapan memutuskan merujuk
 GROWTH PARAMETERS
TO BE MONITORED SIGNIFICANCE OF GROWTH
MONITORING
• Birth‐2 years:
– Weight, length & head circumference at
birth, immunization contacts at 6, 10, 14
weeks, 9 months, 15 months & 18 months
– An additional visit at 6 months desirable 1. Monitor the growth of an
• 2‐8 years: individual and detect growth
– Height & weight 6 monthly. abnormalities
– Calculate BMI & record SMR staging in a 2. Monitor nutritional status
child beyond 6 years annually
3. Track the effects of medical or
• 9‐18 years:
nutritional interventions
– Annual assessment of height, weight, BMI &
SMR
– Growth can also be assessed at times the
child is brought for any other reason to the
physician
APA ITU MONITORING PERTUMBUHAN ?

1. Pengukuran rutin tinggi badan dan berat

badan serta lingkar kepala
2. Memploting pada kurva pertumbuhan dan
melihat pola laju pertumbuhannya
3. Saat pertumbuhan abnormal → evaluasi dan
analisa serta edukasi
4. Membantu anak menerima kondisi yang
berdampak sosial dan suport medis
 PERTUMBUHAN →KECEPATAN PERTUMBUHAN
Kapan harus diukur ?
Panjang-Tinggi-Berat badan harus diukur dan dipantau
→ MONITORING atau PEMANTAUAN
(AAP 2000) :
•< 1 tahun, saat lahir,1,2,4,6,9,12 bulan
•1-2 tahun setiap 3 bulan
•> 2-6 tahun setiap 6 bulan
•> 6 tahun-18 tahun setiap tahun

Setelah diukur → di plot ke kurva

pertumbuhan (data antropometri)
→ bisa melihat alur
Plot Pada Kurva

- Bandingkan dengan referensi

- Hitung Potensi Tinggi Genetik
- Pencatatan yg benar

Apakah Pertumbuhan NORMAL ??

Pertumbuhan Normal
•Titik-titik pertumbuhan memberikan
garis yang paralel dengan kurva
pertumbuhan. Artinya tidak ada
pemotongan lajur kurva pertumbuhan

Pertumbuhan Abnormal

•Titik-titik pertumbuhan memotong garis

pada kurva pertumbuhan, karena tidak
paralel ( kecuali pada fase bayi dan
remaja ).
4
8
Kurva pertumbuhan → PrimaKu IDAI
WEIGHT
VS
HEIGHT
 Monitoring Pertumbuhan
• Apakah anak ini mengalami
gangguan pertumbuhan?
• Apakah tinggi badan anak
ini normal?
• Apakah kaitan BB/TB pada
analisis pertumbuhan?
 Monitoring Pertumbuhan
• Apakah anak ini mengalami
gangguan pertumbuhan?
• Apakah tinggi badan anak
ini normal?
• Apakah kaitan BB/TB pada
analisis pertumbuhan?
 Perawakan ( single) Vs
pertumbuhan
(A)
( periodik)(B)

A B

• Perawakan pendek • Perawakan normal

• pertumbuhan normal • pertumbuhan terganggu

Tips &Trik
Usahakan selalu
mengukur TB-BB
secara periodik
dan catat-plot di
kurva
Yang mana yang bermasalah ?
14-15 Maret 2007
Siapa yang pendek?
©UK Endokrinologi Anak & Remaja
IDAI Jaya
 Perawakan
Pendek
• Definisi Statistik
– Normal = -2SD s/d +2SD
– Perawakan pendek=< -2SD
– Perawakan tinggi= >+2SD
• Usia
• Jenis Kelamin
• Suku/Ras

80% TB <-2SD → termasuk normal

80% TB <-3 SD → patologis

Juli 2008
©UKK Endokrinologi Anak & Remaja
 Definisi Pendek
(Standart Vs referensi)

Increasing
pathology
Height for age (cm)

dikatakan pendek jika tinggi badan

atau panjang badan menurut usia
lebih dari dua standar deviasi di
bawah median kurve standar
Short
stature
pertumbuhan anak WHO.

–4 –3 –2 – 1 2 3
1 0 SD from the
mean
4
 Perawakan Pendek
Analisis

Perlukah
dirujuk ??
Varian Atau
normal atau observasi ??
Benarkah patologis?
pendek?

• Dalam PTG • Dalam PTG

• Di bawah • Di bawah
PTG PTG
 LANGKAH –LANGKAH
→TENTUKAN…………

MODEL : I-C-P
1. Kecepatan tumbuh
2. Proporsi tubuh
Data
antropometri
Rasio
3. Potensi Tinggi Genetik
sebelumnya
segmen atas/
Monitor bawah
Data TB
orangtua 4. Dismorfik
Rentang
lengan
5. Usia Tulang
Data riwayat
pubertas
orang tua

Data tambahan
Pengukuran & BB lahir (KMK ?)
referensi BENAR
Apakah dia pendek?
Apakah dia stunting?
Potensi tinggi genetik/ mid-
parental height
Potensi tinggi genetik/ mid-
parental height
Bagaimana laju
pertumbuhannya ?
 Klasifikasi perawakan pendek
Variasi normal Patologis
▪ Familial short stature ▪ BB/TB kurang
▪ Malnutrisi
▪ Constitutional delay of ▪ Penyakit kronis
growth and puberty ▪ BB/TB meningkat
▪ GH deficiency
▪ Hipotiroid
▪ Kelebihan hormon
glukokortikoid
▪ Disproportionate
▪ Skeletal dysplasia
▪ Dismorfik
▪ Sindrom Prader Willi, Silver
SGA NO CATCH Russel, Cornelia de Lange
UP GROWTH
 PERAWAKAN PENDEK
Varian Normal Perawakan pendek Perawakan Perawakan
perawakan primer / instrinsik pendek sekunder pendek idiopatik
pendek /extrinsik
GENETIK/FAMILI • Sindrom Penyakit / Tidak dijumpai
AL kelainan kelainan
• Kelainan
CONSTITUTIONA chromosom sistemik
L DELAY OF Malnutrisi
GROWTH & • IUGR, kelainan
PUBERTY (CDGP) endokrin
• Skeletal Metabolik
dysplasia/os
teochondrop disorder
lasia Iatrogenic
(Terapi steroid,
• Storage radiasi)
disorders Psychososial
(jarang) atau emotional
 CAUSES OF SHORT STATURE “IS NICE”
I ‐ Idiopathic (Most common, constitutional delay,
familial short stature)
‐ Intrauterine (IUGR, TORCH, Fetal alcohol)
S ‐ Skeletal causes (dysplasia, osteogenesis imperfecta)
‐ Spinal defects (scoliosis, kyphosis)
N ‐ Nutritional (under nutrition)
‐ Nurturing (deprivation)
I ‐ Iatrogenic (steroids, radiation)
C ‐ Chronic disease
‐ Chromosomal (Turner, Down’s)
E‐ Endocrine (GH deficiency, hypothyroidism, cortisol >)
 Juli 2008
©UKK Endokrinologi Anak & Remaja
Allen and Cuttler, NEJM 2013
PENDEK-
KURUS
 LAJU Umur
PENDEK
TAPI TIDAK
PERTUMBUHAN tulang??
??
KURUS
 CDGP

Familial SS
 Masalah endokrin:
Delay bone age:
▪ Hipotiroid
▪ Defisiensi growth hormone
▪ Multiple pituitary hormone deficiency
▪ Delayed puberty
▪ Kelebihan kortisol (mungkin juga
tidak delay)
Advanced bone age:
▪ Pubertas prekoks
▪ CAH
 Familial Short Stature
• MPH < 3rd percentile for
reference population

• Normal tempo of puberty

• Normal height velocity

• CA=BA>HA

• Final height is < 3rd centile for

reference population but
within target range
 CONSTITUTIONAL DELAY OF
GROWTH AND PUBERTY
• Normal MPH
• Family h/o delayed puberty
• BA=HA<CA
• Normal height velocity
• Delayed puberty
• Normal final height

• A condition in which temporary short

stature occurs due to a delay in pubertal
development but normal growth velocity
• This condition is not the result of
physical abnormalities, and occurs in
individuals who are otherwise healthy.
• More common in boys
• Bone age delayed > 2years from
chronological age
• Family history of “late bloomers”
MANAGEMENT
▪CDGP is diagnosis of exlusion
▪Evaluation hormonal deficiencies, Systemic illness
or syndrome
▪Careful growth measurements at frequent interval,
often every 6 months
▪Medical treatment is not necessary
▪Short courses of sex hormones are option for
psychological distress → pediatric endocrinology
 MANAGEMENT
MANAGEMENT
Systemic diseases:
Disease directed therapy
Endocrine disorders
•Thalassemia Major: Pre Blood
Transfusion Hb: 9‐10.5 g/dl •Primary hypothyroidism:
Thyroxine
•Malnutrition: Nutrional
•GHD : Growth Hormon
rehabilitation
•Endogenous Cushing
•Nutritional rickets: Vitamin D syndrome: Tumorectomy
•Distal RTA: Shohl’s solution •Panhypopituitarism: GH,
•Celiac disease: Gluten free diet Thyroxine, sex steroids,
•Psychosocial dwarfism: Good Glucocorticoid
social environment.
INDICATIONS FOR GH THERAPY
TALL STATURE :
Height more than 97th percentile of the
•Most often constitutional
normal for age, or more than 2 SDs
above the mean height for that age,
sex and reference population

Foetal overgrowth
•Maternal diabetes mellitus
•Cerebral gigantism
•Beckwith‐Wiedemann syndrome
Childhood tall stature with adult
short stature
•Hyperthyroidism
•Precocious puberty
Postnatal overgrowth
• Familial (constitutional) tall stature
• Exogenous obesity
• Hypogonadism
• Excess GH secretion
• Marfan syndrome
• Fragile X syndrome
• Homocystinuria
• Klinefelter syndrome =XYY
APPROACH TO CHILD WITH TALL STATURE

Syndroma
???

57
MANAGEMENT OF TALL STATURE
• Reassurance of the family and the patient in constitutional
tall stature. May be oestrogen if expected final height > 3SD

• Hypogonadism: Sex steroid

• Gigantism: excision of pituitary adenoma, somatostatin

analogues, pegvisomant or radiotherapy

• CAH: glucocorticoids and mineralocorticoid replacement

• Central precocious puberty: GnRH analogues

Pediatric Endocrinology
58
 Kesimpulan
◆Kecepatan Pertumbuhan merupakan kunci utama ada
tidaknya gangguan pertumbuhan→ MONITORING/
PEMANTAUAN PERTUMBUHAN !!! → memberi
gambaran proses pertumbuhan → deteksi dini untuk
mencapai potensi tinggi genetik optimal
◆Pengukuran Antropometri mengarahkan ke diagnosis
◆Seorang anak tidak berpindah jalur pada fase anak
◆Perawakan pendek tidak selalu identik dengan gangguan
pertumbuhan dan tidak selalu terkait nutrisi
◆Hormon thyroid, Hormon pertumbuhan ,Sex Hormon,
Nutrisi berperan untuk pertumbuhan
 Investigate
immediately

97th
Investigate
immediately

50th

Clinical and lab screen

Monitor growth rate
3rd
1st
-3 SD
▪ Other variants of puberty
▪ Pubertal Disorder

PUBERTY
• normal variants ? Pathology ?
• How to recognize ?
 HORMONAL
GROWTH LH, FSH, SEX STEROID
Transition period HORMONE DHEAS
between childhood to
adult
PHYSICAL
Maturation of REPRODUCTIVE ORGAN
GROWTH SPURT
SECONDARY SEX
reproductive organs and
attainment of fertility
Termination of linear MATURE
growth FINAL HEIGHT FERTILITY
Through Estrogen
 Onset :
▪ Female : 8 -13 years old
▪ Male : 9-14 years

BASIC CHANGE
▪ Neuroendocrine : Gonadotropin, sex steroid and GH
▪ Biological/Physical : Linear growth, body composition,
Reproductive organs

Puberty is a complex
developmental
process that ends in
sexual maturity
THE ONSET OF PUBERTY
Characterized by maturation
of the hypothalamic-
pituitary-gonadal axis
▪ Physiology
▪ Morfology
▪ Behaviour
▪ 8-13 YEARS FOR GIRLS
▪ 9-14 YEARS FOR BOYS
▪ the development of
PRIMARY SEX characteristics
▪ Appearance of SECONDARY
SEX characteristics
▪ Acceleration of growth →
GROWTH SPURT
▪ Capacity for FERTILIZATION
 Pattern of gonadotropin secretin

Mini Puberty

(Adapted from Speroff L, Fritz M: Neuroendocrinology. In Speroff L, Fritz M [eds]: Clinical

Gynecologic Endocrinology and Infertility, 7th ed. Baltimore, Williams & Wilkins, 2005.)
 PUBERTY
DEVELOPMENT
Hypothalamus
GnRH

Pituitary LH/FSH Adrenal

Cortex
Ovary Testis
Folliculer Leydiq & Sertoli cell
Sex development
Development
steroid
Productions
Estrogen Testoteron Androgen

End Feminisation
Organ Direct effect on growth plate
& Indirect action by Virilisation
stimulation of GH

Sexual & Physycal maturation

Growth spurt and Cessation
 MECHANISM OF
PUBERTY AXIS

Male 2nd sex Folliculogenesis

• PENIS- Spermatogenesis Female 2nd
SCROTUM
sex :
• Facial
•BREAST
• Shoulders
•Hips
broaden
broaden
• Body-pubic
•Pubic hair
hair
• Muscle
Processes of hormone regulation in the male
and female reproductive systems
 Male Puberty Female Puberty
landmark Landmark
1. Testes enlargement 1. Breast budding
1st sign of puberty 1st sign of puberty
Thinning scrotum

2. PUBARCHE 2. PUBARCHE
6-12 month later 6-12 month later

3. Penil growth, scrotum 3. GROWTH SPURT –

pigmentation, early Tanner stage
Spermache Wet
dream : 4. MENARCHE –
(Age 12-14 yrs) 2 yrs > onset of
puberty
4. GROWTH SPURT –
late Tanner stage 5. Ovulation- Tanner 4
Spermatogenesis : 2 yrs > menarche
(tanner4)
6. Final Height -
5. Final Height –
Age 18 – 20 yrs
TANNER STAGE
Mal
e

Stage
2

Stage
3

Stage
4

Stage 5

Female: MALE

M/B, P Kappy SM ,et al. Pediatric practice

endocrinology, 2010.
Male: G, P
 GROWTH:
ATTAINMENT OF FINAL HEIGHT

▪ Rapid growth
Tanner ▪ Acceleration and
3 Growth Spurt deceleration of growth
velocity
Tanner ▪ Female : 8.5 cm/year (
2
total 20-25 cm)
▪ Male : 9.5 cm/year ( total
25-30 cm)
Puberty
▪ Sex steroid & Growth
Hormone
 What are the importance of
puberty?

BONE PSYCHOLOGICAL
FERTILITY HEIGHT HEALTH DEVELOPMENT

QUALITY OF LIFE
WHY DOES
PUBERTY
ARoot AWJ, et al. Sperling’s Pediatric endocrinology, 2014
IMPORTANT ???
 BONE HEALTH

Important to reduce the risk of At 18-19 years old:

future osteoporosis and future 95% of adult bone
mass has been
fractures achieved
 Puberty has a key role for bone development.

Skeletal mass approximately doubles at the end of adolescence.

The main determinants of pubertal gain of bone mass are
▪ the sex steroids,
▪ growth hormone and
▪ insulin-like growth factors (by their effects on bone and muscle
mass)
▪ 1,25-dihydroxyvitamin D (by stimulating calcium absorption
and retention) and muscle mass (by regulating
modelling/remodelling thresholds).
▪ Calcium intake is an additional factor influencing bone
formation.
The interactions among these factors are undefined.
The accrual of bone mass during puberty is a major determinant
of peak bone mass and, thereby, of the risk of osteoporotic
fractures during advanced age.
 Factors controlling the timing of puberty

IUGR Secule
r trend
1
3
ENVIRONMENTAL

2
2
ENVIRONMENTAL

Elona Krasniqi, The role of puberty in adolescent development, KrasniqiCakirpaloglu2020, page 2-11
Factors controlling the timing of puberty

RAS

PSYCO-
NUTRISI
SOCIAL
AWITAN
PUBERTAS

PENY.
EXERCISE
KRONIS
Interpretation of reproductive hormones before, during
and after the pubertal transition →
Identifying health and disordered puberty

Fetal Post
Mini Early- Mid Puberty Puberty
Period
Puberty Childhood

Delayed

GnRH
secretion Absent Partial
GnRH Precox

Absent
 3. ARRESTED PUBERTY :
Normal onset of puberty
Females → interrupted (STOP)
(Telarche)
4. Amenorrhoe
8 13 primer/secunder
NORMAL PUBERTY
8 9 10 11 12 13 14 15 16

1. 2.
PUBERTY
9 10 11 12 13 14 DELAYED
15 16

PRECOX NORMAL PUBERTY PUBERTY

Males
(testicular
9 14 volume
≥ 4 mL)
 VARIAN PUBERTY
Pseudopuberty

Premature Premature
Gynaecomasia
Telarche ? Adrenarche

▪ Fisiologys
▪ Patologis
▪ Varian Normal
▪ Adrenal
▪ Precox
Puberty disorder
1. Male,22 years old, Body Height
172 cm 2. Girl, 7 years old,
G1P1 ( pre puberty) M4-P3
◆ Menstruation +
◆ Breast : from age of 4 years
◆ Insecure child, Shy, often cry

◆Problem :
◆Medical aspect ◆ Problem :
◆Psikology aspect ◆ Medical aspect
◆Social Aspect ◆ Sosial aspect
◆ Psikology aspect
◆ Labile Emosion
◆ Short Stature
 3. Girl, 15 years old 4. Girl, 16 years old
Height 124 cm 158 cm, 45 kg
M1-P1-amenoorhoe M2P2- amenoorhoe primer
Retarded bone age
Osteoporosis
◆Medical aspect
▪Short stature ◆ Sosial aspect
▪What about the future? ◆Psikology aspect
▪Infertility ? ◆Labile Emosion
 6. “Girl” , 13 years, 153 cm
M1P2, “amenorhoe ’

Inferior, confused
Bullying
Worried

→ Sex Chromosom XY
5. Girl, 9 years old
M1P3
•Precocious
Pseudopuberty
•Clitoromegaly How to identify
•Short stature →assessment gender ?
Dx : CAH
Puberty Aspect :
Psikologys, Social, Medical,
Osteoorosis, short stature, fertility,
gender
 PUBERTAL DISORDER

Arrested Amenorrh Delayed

Precocious
puberty puberty ea puberty

Primary Secunder
Normal onset CDGP
of puberty —>
Central interrupted 3 months of
(STOP) amenorrhea
Pubertas Precox
( GnRH after the
Dependent) 1. No menstruation by the achievement
age of 15 year or of menarche
2. No menstruation by > 3
Perifer years after the onset of
Pubertas
puberty
Precox Hypergonadotropic
( GnRH Hypogonadotropik Hypogonadism
Inependent) Hypogonadism
 What are the importance of
puberty?

FERTILITY HEIGHT
BONE
HEALTH
PSYCHOLOGICAL
DEVELOPMENT

Risk of fractures
?
Growth
Failure and future
Short Stature osteoporosis

QUALITY OF LIFE
ARoot AWJ, et al. Sperling’s Pediatric
endocrinology, 2014
Biological Factor:
Psychological : Social Factors :
- Temprament - Traumatic life events
HPA-Axis - Personality -Academic failure, social
Hypothalamic limbic - emotional difficulty
system Physical changes Will I have normal -Bullying & conflict with
→ sexual function? peers
affect their appearance Can I grow taller ? - Abusive parents

Be aware of the
development of Psychological
puberty in children problems &
and adolescents
Psychiatric disorders

Sadock BJ et, 2015

 TREATMENT
▪ Hormonal replacement therapy
▪ Treatment of cause when possible

• Guided by underlying cause

• Can use short courses of GnRH agonist to stop puberty
or testosterone / estrogen to induce puberty
• Lifelong hormone replacement may be required in
some cases
• Referral to pediatric endocrine
• Ongoing follow up required to ensure progress through
puberty
 TAKE HOME MESSAGE

Puberty is not only for FERTILITY and FINAL HEIGHT but

also to reduce the risk for future OSTEOPOROSIS
Undetected PSYCHOLOGICAL PROBLEMS of adolescent
with endocrine disorders surely will cause great
impairment of their QUALITY OF LIFE
The key to manage children with PUBERTAL DISORDERS
are careful assessment of pubertal development and
appreciation of normal pubertal physiology

COMPREHENSIVE ASSESSMENT involving the

multidiciplinary teams are important
THANK
YOU
Wonderland Indonesia

Pulau
Garis Terluar
Titik O
Titik O- Khatulistiwa Selatan MERAU
SABANG PONTIANAK P. NDANA KE
 Short stature

Growth velocity

Normal Abnormal

Normal variant Proportional Disproportional Dysmorphic

Constitutiona
(CDGP) Chromosom
Skeletal abnormalities
BW/HT↑ BW/HT↓ Trysomi 21
Familial Dysplasias Turner

short Rickets
Endocrine: Syndromes:
stature GHD Malnutrition Prader Willi
Hypothyroid Chronic diseases Russel
Cushing Psychological Silver
Noonan etc
Pseudohypopa
rathyroid

Batubara JRL.Pertumbuhan Normal dan Gangguan Pertumbuhan Buku Ajar Endokrinologi Anak.Edisi kedua;
2017:18-49.
BODY PROPORTIONS

•Upper segment : Lower

segment ratio
•Measure lower
segment from top of
symphysis pubis to floor
•Subtract lower segment
from height to get upper
segment.

95
IMPLICATIONS OF PUBERTAL ASSESSMENT IN
SHORT STATURE
Normal Delayed
• CDGP
• Familial short
stature ( FSS) • Endocrine causes

• Skeletal dysplasia • Chronic diseases

96 1
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