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
TETAP
PERHATIKAN
UNSUR INI
2. NUTRISI
1. PENY
GENETIK KRONIS
Kekurangan Nutrisi
POTENSI TINGGI Kronik
SINDROM
GENETIK
(PTG & -MPH) Penyakit Kronik
Body height/
stature
STUNTING
Body
weight
POTENSI TINGGI GENETIK (PTG/GPH)
PGH
Prediksi Tinggi pada Laki-laki:
4. LINGKUNGAN
GH,Thyroxin, Insulin,
cortisol, sex steroid, PSYCHOSOSIAL
IGF-growth factors)
Integritation of hormone systems
THE ROLE
OF
HORMONES
1. PERAWAKAN
Pendek vs “Normal” vs Tinggi
1.“PENGUKURAN TUNGGAL TINGGI BADAN”
Hanya akan identifikasi tinggi badan (
perawakan)
oPerawakan pendek atau perawakan tinggi
oPerawakan normal
Tidak bisa mengidenfikasi proses pertumbuhan
oAnak dengan pertumbuhan melambat (misal :GHD,
hipothiroid congenital)
oTurner Syndrome
oAcquired disorder : hypothyroidsm, coeliac disease
oPertumbuhan 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
• 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%
Pubertas lelaki: 10-14 cm 40%
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
Pertumbuhan Normal
•Titik-titik pertumbuhan memberikan garis
yang paralel dengan kurva pertumbuhan.
Artinya tidak ada pemotongan lajur kurva
pertumbuhan
Pertumbuhan Abnormal
A B
Tips &Trik
Usahakan selalu
mengukur TB-BB
secara periodik
dan catat-plot di
kurva
Yang mana yang bermasalah ?
14-15 Maret 2007
Siapa©UK
yang pendek?
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
Increasing
pathology
Height for age (cm)
–4 –3 –2 –1 0 1 2 3 4
SD from the
mean
Perawakan Pendek
Analisis
MODEL : I-C-P
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/FAMILIA • Sindrom •Penyakit / Tidak dijumpai
L kelainan kelainan
• Kelainan
•CONSTITUTIONAL chromosom sistemik
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-KU
RUS
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
• CA=BA>HA
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
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
97t
h
50t
h
Clinical and lab
screen
3rd
Monitor growth
1st
rate
-3
SD
▪ Other variants of puberty
▪ Pubertal Disorder
PUBERTY
•normal variants ? Pathology ?
•How to recognize ?
e r ty Intro
Pub o f duct
i m e ion
At g e
cha n
Transition period
between childhood to
adult
Maturation of
reproductive organs and
attainment of fertility
Termination of linear
growth
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
▪ Physiology
▪ Morfology
▪ Behaviour
Puberty is a complex
developmental
process that ends in
▪ 8-13 YEARS FOR GIRLS
sexual maturity
▪ 9-14 YEARS FOR BOYS
THE ONSET OF PUBERTY
▪ the development of
PRIMARY SEX characteristics
▪ Appearance of SECONDARY
SEX characteristics
Characterized by maturation
of the
▪ Acceleration of growth 🡪
hypothalamic-pituitary-gon GROWTH SPURT
adal axis ▪ Capacity for FERTILIZATION
Pattern of gonadotropin secretin
Mini Puberty
End Feminisation
Organ Direct effect on growth plate
& Indirect action by Virilisation
stimulation of GH
2. PUBARCHE 2. PUBARCHE
6-12 month later 6-12 month later
Stage 2
Stage 3
Stage 4
Stage 5
Female: MALE
BONE PSYCHOLOGICAL
FERTILITY HEIGHT HEALTH DEVELOPMENT
QUALITY OF LIFE
WHY DOES
PUBERTY ARoot AWJ, et al. Sperling’s Pediatric endocrinology, 2014
IMPORTANT ???
BONE HEALTH
IUGR Seculer
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
AWITAN
PUBERTAS
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
e s
Cas
◆Problem : ◆Problem :
◆Medical aspect
◆Medical aspect
◆ Sosial aspect
◆Psikology aspect ◆Psikology aspect
◆Social Aspect ◆Labile Emosion
◆Short Stature
as e s
C
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
Primary Secunder
Normal onset CDGP
of puberty —>
Central interrupted 3 months of
(STOP) amenorrhea
Pubertas Precox
( GnRH after the
1. No menstruation by the
Dependent) achievement
age of 15 year or of menarche
2. No menstruation by > 3
Perifer
Pubertas years after the onset of
Precox puberty 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
Be aware of the
development of
puberty in
children and
adolescents
Pulau
Garis Terluar
Titik O
Titik O- Khatulistiwa Selatan MERAU
SABANG PONTIANAK P. NDANA KE
Short stature
Growth velocity
Normal Abnormal
Batubara JRL.Pertumbuhan Normal dan Gangguan Pertumbuhan Buku Ajar Endokrinologi Anak.Edisi kedua;
2017:18-49.
BODY PROPORTIONS
95
IMPLICATIONS OF PUBERTAL ASSESSMENT IN
SHORT STATURE
Normal Delayed
•CDGP
•Familial short stature (
FSS) •Endocrine causes
96 1
8