dezvoltarea fizica a copiilor in pubertate

7/24/2019 dezvoltarea fizica a copiilor in pubertate

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[Assessment of physical development of children andadolescents. Part I. Infants and children up to 5 years--national reference values or WHO standards?].

[Article in Polish]Oblaciska A1,Jodkowska M, Mikiel-Kostyra K, Palczewska I

Author information

1!ak"ad Ochrony i Pro#oc$i !drowia %zieci i M"odziezyannaoblacinska&i#id#ed'l

Astract

I!"#O$%&"IO!'

(rowth and de)elo'#ent assess#ent o* in*ants and yo+n children is a )ery

i#'ortant co#'onent o* early 'ro'hylais in 'aediatric health care In .//0 the

orld 2ealth Oranization '+blished the new 3hild (rowth 4tandards *or

children +' to 5 years o* ae 6hey describe the o'ti#al 'attern o* yo+n children

de)elo'#ent

AI( O) "H* +"%$,'

1 6o co#'are the c+t-o** 'oints *or selected anthro'o#etric 'ara#eters in

children +' to 5 years between re*erence )al+es *or Polish children and 2O

3hild (rowth 4tandards . 6o atte#'t to answer the 7+estion whether the 2O

3hild (rowth 4tandards can be i#'le#ented to assess health and de)elo'#ent

in children +' to 5 years in Poland(*"HO$+'

6he di**erences *or #ean 85/th 'ercentile9 and etre#e )al+es 8:rd and ;


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[Assessment of physical development of children andadolescents. Part II. &hildren and adolescents aed /-01years--national references or WHO recommendations?].

[Article in Polish]Oblaciska A1,Jodkowska M, Mikiel-Kostyra K, Palczewska I

Author informationAstract

AI(+'

1 3o#'arison o* c+t-o** 'oints *or selected anthro'o#etric 'ara#eters in

children and adolescents between re*erence )al+es *or Polish Instit+te o* Mother

and 3hild 8IM%9 and 2O rowth

(*"HO$+'

6he acce'ted re*erence syste# were IM% re*erence )al+es and the di**erences

*or #ean 85/th9 and :rd and ;


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Growth and pubertal development inchildren and adolescents: effects of dietand physical activity1,2,3,4

1. Alan D Rogol,2. Pamela A Clark, and3. James N Roemmich

+Author Afliations

1. 1From the University o Virginia Health Sciences Center

Charlottesville.

Next Section

Abstract

The longituinal gro!th o an iniviual chil is a ynamic statement othe general health o that chil. "easurements shoul #e $erormeoten an accurately to etect alterations rom $hysiologic gro!th.Although any single $oint on the gro!th chart is not very inormative%!hen several gro!th $oints are $lotte over time% it shoul #ecomea$$arent !hether that iniviual&s gro!th is average% a variant o thenorm% or $athologic. Somatic gro!th an maturation are in'uence #yseveral actors that act ine$enently or in concert to moiy aniniviual&s genetic gro!th $otential. (inear gro!th !ithin the )rst * y

o lie generally ecelerates #ut then remains relatively constantthroughout chilhoo until the onset o the $u#ertal gro!th s$urt.+ecause o the !ie variation among iniviuals in the timing o the$u#ertal gro!th s$urt% there is a !ie range o $hysiologic variations innormal gro!th. Nutritional status an heavy exercise training are only* o the ma,or in'uences on the linear gro!th o chilren. -n the UniteStates% nutritional e)cits result rom selinuce restriction o energyinta/e. That single actor% ae to the mar/e energy ex$eniture otraining an com$etition or some s$orts% an in concert !ith the selselection o certain #oy ty$es% ma/es it ifcult to ientiy the

iniviual actors res$onsi#le or the slo! linear gro!th o someaolescent athletes% or exam$le% those !ho $arta/e in gymnastics%ance% or !restling.

Growh

adolescen de!elo"men
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growh "oenial

ahlee

n#riion

g$mnasics

wresling

n#riional dwar%sm

ahleic raining

0revious SectionNext Section

INTRODUCTION

A chil&s gro!th can #e com$are !ith that o his or her $eers #yreerring to the norm on an a$$ro$riate gro!th chart. "ore im$ortant%the longituinal measurements o a chil&s gro!th are a ynamicstatement o his or her general conition or health.

Tanner 12 has $ro$ose that chilren #e measure accurately toientiy iniviuals or grou$s o iniviuals !ithin a community !hore3uire s$ecial care% to ientiy illnesses that in'uence gro!th% or toetermine an ill chil&s res$onse to thera$y. The linear gro!th o a

chilaolescent athlete may also re'ect the ae3uacy o energyinta/e or a $articular training regimen. "easurement o gro!th mayalso #e use as an inex o the general health an nutrition o a$o$ulation or su#$o$ulation o chilren.

+y e)nition% normal $hysiologic2 gro!th encom$asses the 456 C- ora s$eci)c $o$ulation. "ost chilren an aolescents !ho have anormal gro!th $attern #ut !ho remain #elo! the lo!er *.5 $ercentilea$$roximately 7*.8 S92 are other!ise normal. The arther aniniviual&s gro!th alls #elo! the 7*.8 S9 mar/% the more li/ely he or

she is to have a conition that is /ee$ing him or her rom reaching thegenetically etermine height $otential.
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Crosssectional ata are erive rom the measurements o manychilren at various ages an are generally use to erive stanargro!th charts. Ho!ever% iniviual chilren o not necessarily gro!accoring to these stanar curves. (ongituinal gro!th charts eriverom gro!th $oints o the same chil over time more accuratelyescri#e the gro!th $attern o an iniviual. -n aolescence% there may#e 3uite large eviations rom the erive $ercentile lines% e$eningon the timing an tem$o o the $u#ertal gro!th s$urt. An average$u#ertal gro!th $attern is #uilt into the $ercentiles erive rom crosssectional ata% #ut virtually no one iniviual aheres strictly to that$attern.


GROWTH MEASUREMENTS

The gro!th o chilren shoul #e measure $erioically an accurately.T!o common evices are ae3uate or such measurements an !ereescri#e #y :ogol an (a!ton *2.Neonates and infantsSmall inaccuracies in length measurement can easily a;ect a chil&s$ercentiles on gro!th curve charts. -nants shoul #e $lace !ith theto$ o the hea against the )xe hea#oar o the measurementevice an !ith the eyeear $lane $er$enicular to the #ase o theevice &ig#re 1ro!th measurement length o an inant. :e$rinte !ith $ermissionrom reerence *.

Children and adolescents>ro!th in chilren oler than * y is measure !ith the chil staning.A iurnal variation o ?8.@ cm in height may occur in these chilren%!hose height is greatest u$on arising. Chilren shoul #e measure

!ithout shoes !hile staning against the vertical $lane to !hich themeasuring ta$e is attache. The chil&s heels% #uttoc/s% shoulers% an#ac/ o the hea shoul #e touching the !all &ig#re 2


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$lane shoul #e $er$enicular to the !all an the eet% incluing theheels% shoul #e 'at on the 'oor. ith the chil in this $osition% therightangle evice is lo!ere until it touches the to$ o the hea% anthe height is recore on the a$$ro$riate $hysical gro!th curve.

Vie! larger version= -n this $age

-n a ne! !ino!

9o!nloa as 0o!er0oint Slie

&'G(R) 2.

>ro!th measurements= height o a chil or aolescent. :e$rinte !ith$ermission rom reerence *.

An im$ortant $arameter o gro!th is height velocity% !hich can #eerive rom measurements ta/en every BD mo in inants an every E

mo in oler chilren. +ecause chilren oten have gro!th s$urts% yearlygro!th velocities are usually more accurately etermine #y ta/ingyearly measurements rather than #y annualiGing the gro!th velocityrom intervals shorter than 1 y.

>ro!th velocity in chilren has a !ie normal range% accoring to the$ercentile along !hich a chil is gro!ing. Chilren gro!ing along thethir $ercentile average 5.1 cm o gro!th $er year% !hereas thosegro!ing along the 4@th $ercentile average E.D cmIy or #oys an @.1cmIy or girls uring chilhoo to maintain gro!th along one o the

$ercentiles on the gro!th curve B2. To maintain gro!th along the 18th$ercentile or height% a chil must gro! at the D8th $ercentile orvelocity% !hereas to maintain gro!th along the 48th $ercentile orheight% a velocity at the E8th $ercentile is re3uire. This im$lies that achil !ho $ersistently gro!s at the 18th $ercentile or velocity !ill$rogressively cross $ercentiles o!n!ar on the stanar heightcurve. Some chilren have a small increase in gro!th velocity ata$$roximately E@ y migro!th s$urt2% #ut this is not a consistent)ning% an the gain in height is generally o small magnitue D2.Seasonal variations in gro!th have #een note in some chilren. (ineargro!th tens to #e greater in the s$ring than in the all% #ut !eightgain is greater in the all months. These trens em$hasiGe the nee or
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re$eate measurements uring a year to accurately assess a chil&sgro!th $attern.Growth assessment

(inear gro!th an $hysical maturation are ynamic $rocessesencom$assing molecular% cellular% somatic% an organismal changes.

Traitionally% stature has #een $rimarily use or gro!th assessment%#ut changes in #oy $ro$ortion an com$osition are also essentialelements o gro!th% es$ecially o maturation. >ro!th stanars have#een erive or several $o$ulations an $arameters !ithin a$o$ulation an are oten coi)e into a series o gro!th charts. Theollo!ing iscussion em$hasiGes the genetic% nutritional% hormonal% an$hysical activity actors that might alter the gro!th $rocess.


PHYSIOLOGIC GROWTH PATTERNS

Although any single $oint on a gro!th chart is not very inormative%!hen several gro!th $oints are $lotte over time% it #ecomes a$$arent!hether an iniviual&s gro!th is average% a variant o the norm% or$athologic gro!th ailure2. The $oint at !hich an iniviual is $laceat any given time can #e relate to the height age% or the age at !hichthat chil&s height !oul #e at the 58th $ercentile. This $oint inicatesthe mean age o chilren o that measure height in the normal

$o$ulation. The height age is etermine rom the gro!th chart #yra!ing a line $arallel to the chronologic age axis rom the chil&s$lotte $oint to the 58th $ercentile an then a $er$enicular line tothe horiGontal axis. The intersection o the latter line !ith the age axisis the height age.

>ro!th in several imensions sho!s a signi)cant amily resem#lance.Ault stature% tem$o o gro!th% timing an rate o sexual evelo$ment%s/eletal maturation% an ental evelo$ment are all signi)cantlyin'uence #y genetic actors 52 an estimates o genetic

transmissi#ility range rom D16 to @16 D2. Ault stature is #estcorrelate !ith calculations o mi$arental height the i;erence in themean ault heights o the $arents2% #ut the $olygenic moe oinheritance o height results in greater variation in the siGe o chilren#orn to $arents o is$arate heights than in chilren o $arents !ho are#oth o meium height E2. "ature height can #e $reicte on the#asis o mi$arental height. The a,uste mi$arental height targetheight2 is calculate #y aing 1B cm the i;erence #et!een the 58th$ercentiles or ault men an !omen2 to the mother&s height or #oys2or su#tracting 1B cm rom the ather&s height or girls2 an then ta/ing

the mean o the height o the samesex $arent an the a,uste heighto the o$$ositesex $arent. Aing J.5 cm a#ove an #elo! themi$arent target height !ill a$$roximate the target height range o the
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Br to 4@th $ercentile or the antici$ate ault height or that chila,uste or his or her mi$arental stature genetic $otential2. Kthermethos also exist or $reicting the ault stature o an iniviual onthe #asis o mathematical ormulations erive rom the gro!th historyo that chil or rom the attaine height an #one age o the chil ascalculate rom s$eci)c ta#les.

The overall contri#ution o hereity to ault siGe an sha$e varies !ithenvironmental circumstances% an the * continuously interactthroughout the entire gro!th $erio. Chilren !ith similar genoty$es%!ho !oul reach the same ault height uner o$timal conitions% may#e i;erentially a;ecte #y averse circumstances. Thus% theinteraction #et!een genetic ma/eu$ an the environment is com$lexan nonaitive. The genetic control o the tem$o o gro!th a$$ears to#e ine$enent o that or #oy siGe an sha$e% an environmentallyinuce changes in tem$o o not seem to signi)cantly alter ault

height or sha$e D2.0revious SectionNext Section

FACTORS INFLUENCING SOMATIC GROWTH

Somatic gro!th an maturation are in'uence #y several actors thatact ine$enently or in concert to moiy an iniviual&s genetic$otential. For exam$le% at #irth% an inant&s siGe is more e$enent onmaternal nutrition an intrauterine an $lacental actors than ongenetic ma/eu$. The correlation coefcient or ault height is only 8.*5

at #irth #ut is 8.J8 #y * y o age @2. There is also evience that not allgenes are actively ex$resse at the time o #irth% !hich $ro#a#lyaccounts or the o#servation that the correlation #et!een the siGes othe $arents an the chil is !ea/ uring the )rst year o lie #utincreases to the ault value o 8.5 #y L1J mo o age D2.9i;erences in gro!th an evelo$ment also vary as a unction o sexan ethnic origin. Sexs$eci)c $atterns in the tem$o o gro!th% thetiming o the aolescent gro!th s$urt% overall siGe% an the age os/eletal maturity are !ell /no!n% #ut i;erences #et!een the sexesare a$$arent rom the time o etal lie. At #irth% the s/eletal

maturation o emales is DE !/ more avance than that o males%an this tren continues throughout chilhoo an aolescence.>ro!th velocity is slightly slo!er in emales at #irth% #ecomes e3ual atL@ mo o age% an is then some!hat aster until age D y. Thereater%chilren o #oth sexes gro! at a$$roximately the same rate until theaolescent gro!th s$urt. Kn average% emales enter $u#erty * y earlierthan males #ut have a lesser $ea/ height velocity 4 cm com$are!ith 18.B cm2 an ault stature J% 42. Kverall siGe an rate oevelo$ment vary signi)cantly among ethnic $o$ulations. +lac/ inantsten to #e smaller at #irth #ut ex$erience an acceleration o linear

gro!th that results in greater height than in !hite chilren uring the)rst e! years o lie. S/eletal maturity in #lac/ chilren% es$eciallygirls% also tens to #e more avance an the age at $ea/ height
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velocity earlier 18% 112. +lac/ girls also ten to #e taller an heavierthan !hite girls uring $u#erty an have a tenency to!ar greater#oy mass inex an greater s/inolthic/ness measurements.Growth in the first 2 y of life>ro!th uring the )rst * y o lie is characteriGe #y a graualeceleration in #oth linear gro!th velocity an rate o !eight gain%#oth o !hich level o; at *B y o age. -t is uring this $erio thatinants exhi#it the $attern o gro!th consistent !ith their genetic#ac/grouns. T!othirs o all inants cross $ercentiles on the gro!thcurve% either u$!ar catchu$ gro!th2 or o!n!ar lago!ngro!th2 E2. Catchu$ gro!th ty$ically #egins !ithin the )rst B mo anis com$lete #y 1*1J mo% !hereas lago!n gro!th commences alittle later an may not #e com$lete until 1J*D mo E2. ith theexce$tion o $u#erty% the crossing o gro!th $ercentiles at any othertime is cause or concern an urther evaluation.

Prepubertal growth>ro!th uring chilhoo is a relatively sta#le $rocess. The inancyshits in the gro!th $attern are com$lete an the chil ollo!s thetra,ectory attaine $reviously. Until a#out the age o D y% girls gro!slightly aster than #oys an #oth sexes then average a rate o 5EcmIy an *.5 /gIy until the onset o $u#erty D2. A general rule othum# is that a chil gro!s 18 cm *5 inches2 in the )rst year o lie%hal that M1*1B cm 5 inches2 in the secon year% an then 5E cm*.5 inches2 each year until $u#erty. Assuming an average #irth lengtho 51 cm *8 inches2% an average 1yol is @E cm B8 inches2 long% a *

yol is J4 cm B5 inches2% a Dyol is 18* cm D8 inches2% an an Jyol is 1*@ cm 58 inches2.Pubertal growth0u#erty is a ynamic $erio o evelo$ment mar/e #y ra$i changesin #oy siGe% sha$e% an com$osition% all o !hich are sexuallyimor$hic. The onset o $u#erty corres$ons to a s/eletal #iological2age o L11 y in girls an 1B y in #oys 1*2. Kn average% girls enter ancom$lete each stage o $u#erty earlier than o #oys. The timing antem$o o $u#erty vary !iely% even among healthy chilren. -netermining the a$$ro$riateness o a $articular gro!th velocity% the

chil&s egree o #iological maturation must #e consiere. S/eletal or$u#ertal maturation may #e use to etermine the chil&s egree o#iological evelo$ment. The #one age is etermine as the mean othe s/eletal ages o several o the small #ones o the han an !rist.0u#ertal maturation status is #ase on the evelo$ment o #reasts an$u#ic hair in girls an o $u#ic hair an genitals in #oys. This range onormal varia#ility is ex$ane to an even greater egree #y alterationsin energy inta/e an ex$eniture. Although moerate activity isassociate !ith cariovascular #ene)ts an avora#le changes in #oycom$osition% excessive $hysical activity uring chilhoo an

aolescence may negatively a;ect gro!th an aolescentevelo$ment. S$orts that em$hasiGe strict !eight control an highenergy out$utOor exam$le% scholastic !restling% gymnastics% an
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ancingOare o $articular concern or gro!th isorers% althoughselection criteria or certain #oy ty$es ma/e selection #ias aconouning varia#le in assessing the e;ect o training on gro!th anaolescent evelo$ment. Kne must consier that some o thesechange are transient% at least in !restlers. The same mar/ers o gro!than #oy com$osition that are slo!e uring training in season2accelerate ater the season% !hich $ermits a catchu$ $rocess tocontrol gro!th an cause no $ermanent gro!th reuctions seethesection Constitutional elay o gro!th% #elo!2.Kne o the hallmar/s o $u#erty is the aolescent gro!th s$urt. As$u#erty a$$roaches% gro!th velocity slo!s to a nair $reaolescenti$2 #eore its suen acceleration uring mi$u#erty. The timing othe $u#ertal gro!th s$urt in girls is ty$ically at Tanner #reast stage Ban oes not reach the magnitue o that in #oys. >irls average a $ea/height velocity o 4 cmIy at age 1* an a total gain in height o *5 cm

uring the $u#ertal gro!th $erio 1B2. +oys% on average% attain a $ea/height velocity o 18.B cmIy * y later than girls% uring Tanner genitalstage D% an gain *J cm in height 4% 1B2. The longer uration o$re$u#ertal gro!th in #oys% com#ine !ith a greater $ea/ heightvelocity% results in an average ault height i;erence o 1B cm#et!een men an !omen. Ater a $erio o ecelerating heightvelocity% gro!th virtually ceases #ecause o e$i$hyseal usion% ty$icallyat a s/eletal age o 15 y in girls an 1@ y in #oys D2.0u#erty is also a time o signi)cant !eight gainP 586 o ault #oy!eight is gaine uring aolescence. -n #oys% $ea/ !eight velocity

occurs at a#out the same time as $ea/ height velocity an averages 4/gIy. -n girls% $ea/ !eight gain lags #ehin $ea/ height velocity #y LEmo an reaches J.B /gIy at L1*.5 y o age D2. The rate o !eight gainecelerates in a manner similar to height velocity uring the laterstages o $u#ertal evelo$ment."ar/e changes in #oy com$osition% incluing alterations in therelative $ro$ortions o !ater% muscle% at% an #one% are a hallmar/ o$u#ertal maturation an result in ty$ical emalemale i;erences.Uner the in'uence o the gonaal steroi hormones an gro!thhormone >H2% increases in #one mineral content an muscle mass

occur an the e$osition o at is maximally sexually imor$hic. Thechanges in the istri#ution o #oy at central com$are !ith$eri$heral% su#cutaneous com$are !ith visceral% an u$$er com$are!ith lo!er #oy2 results in the ty$ical anroi an gynoi $atterns oat istri#ution o the oler aolescent an ault 1D2.Uner the in'uence o testosterone% #oys have a signi)cant increase ingro!th o #one an muscle an a simultaneous loss o at in the lim#sD2. The maximal loss o at an increase in muscle mass in the u$$erarms corres$ons to the time o $ea/ height velocity. -n #oys% thesigni)cant increase in lean #oy mass excees the total gain in !eight

#ecause o the concomitant loss o ai$ose tissue. As height velocityeclines% at accumulation resumes in #oth sexes #ut is t!ice as ra$iin girls. As aults% males have 1586 o the lean #oy mass o the
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average emale an t!ice the num#er o muscle cells 152. Theincrease in s/eletal siGe an muscle mass leas to increase strengthin males. +oth anrogens an estrogens $romote e$osition o #onemineral% an Q486 o $ea/ s/eletal mass is $resent #y age 1J y inaolescents !ho have unergone normal $u#ertal evelo$ment at theusual time. -n girls% nearly onethir o total s/eletal mineral isaccumulate in the BDy $erio immeiately ater the onset o$u#erty 1E%1@2. Aolescents !ith elaye $u#erty or seconaryamenorrhea may ail to accrue #one mineral normally an havereuce #one mineral ensity as aults.9uring $u#ertal evelo$ment% interactions #et!een >H an the sexsteroi hormones are stri/ing an $ervasive. Stuies o aolescent#oys sho!e that the rising concentrations o testosterone uring$u#erty $lay a $ivotal role in augmenting s$ontaneous secretion o >Han $rouction o insulinli/e gro!th actor - ->F-2. The a#ility o

testosterone to stimulate $ituitary >H secretion% ho!ever% a$$ears to#e transient an ex$resse only $eri$u#ertallyP >H an ->F-concentrations ecrease signi)cantly uring late $u#erty an intoaulthoo% es$ite continue high concentrations o gonaal steroihormones 1J2. -n contrast !ith testosterone% estrogen moulates >Hsecretory activity in a is$arate mannerP lo! oses o estrogenstimulate ->F- $rouction through enhance >H secretion% #ut higheroses inhi#it ->F- $rouction at the he$atic level 142.


VARIATIONS OF NORMAL GROWTH

Normal variants o gro!th !ere oun in J*6 o chilren !hose heightecrease at the thir $ercentile 7* S92 #ut in only 586 o those!hose height ecrease at the )rst $ercentile 7B S92 o the mean orage *82. Assessment o s/eletal maturation is $erha$s the #estinicator o #iological age or maturity status% #ecause its evelo$ments$ans the entire $erio o gro!th. Several methos exist oretermining the ormer *1*B2. Rach uses a single raiogra$h o thelet han an !rist an ma/es com$arisons !ith chilren o normal

stature #y using an atlas an scoring system. +ecause girls are moreevelo$mentally mature than #oys at any given chronologic age%se$arate stanars exist or emales an males.Familial short stature

Kn average% chilren o smaller $arents !ill eventually attain lesserheight than chilren o taller $arents. +ecause #one age a$$roximateschronologic age% these chilren usually gro! at an a$$ro$riate rateuring chilhoo an attain sexual maturation an $u#ertal gro!ths$urt at the usual ages.

Constitutional delay of growth
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A constitutional gro!th elay is consiere to #e a elay in the tem$oo gro!th. -n this case% each calenar year is not accom$anie #y a ullyear o gro!th an s/eletal evelo$ment% so the iniviual re3uiresmore time to com$lete the gro!th $rocess. "ost o these chilren !illeventually have elaye aolescence as !ell as elaye attainment oault stature. +irth history an #irth length are generally normal% #utthe gro!th $attern shits o!n!ar to the lo!er $ercentiles% so thatthe lo!est values or gro!th velocity are o#taine at LB5 y o age.

Thereater% this $attern is characteriGe #y steay $rogression ogro!th. +ecause the #one age oes not avance 1 y or each calenaryear% it $rogressively eviates rom the chronologic age. The heightage is usually a$$roximately the same as the #one age% an i true% themature height !ill #e !ell !ithin the normal range or the a$$ro$riate$o$ulation. (i/e amilial short stature% this $attern is oten amilial% an#ecause #oth are relatively common% some chilren !ill have elements

o #oth.


NUTRITION AND GROWTH

orl!ie% the single most common cause o gro!th retaration is$overtyrelate malnutrition. -n the Unite States% nutritional gro!thretaration also /no!n as nutritional !ar)sm2 an elaye $u#ertalevelo$ment among su#ur#an u$$ermile an u$$erclass

aolescents more oten result rom selinuce restriction o nutrientenergy2 inta/e. -n aition to e;ects on overall gro!th% malnutritionseconary to avoiance o certain oos or mala#sor$tion can lea toserious isorers% such as osteo$enia% anemia% an synromes relateto e)ciencies o vitamins% minerals% essential atty acis an aminoacis% an trace elements. Nutritional status also has a signi)cantmoulating e;ect on the timing o aolescent sexual evelo$ment.Unernutrition is associate !ith later age at menarche as !ell asseconary amenorrhea2% !hereas a moerate egree o o#esity isassociate !ith early sexual maturation *D% *52. The gro!th curves or

length an !eight may at )rst #e inistinguisha#le rom those ochilren an aolescents !ith constitutional elay o gro!th seeConstitutional elay o gro!th% a#ove2 or% more rarely% rom those ochilren !ith amilial short stature.

The iagnostic criteria or nutritional gro!th ailure ollo! those o theellcome Trust classi)cation. The !eight or chronologic age is lo!%although there may oten #e a minimal e)cit in !eightorheight% asoccurs in constitutional elay o gro!th an aolescence or evenamilial short stature. Although the s$eci)c #ehaviors re3uire or the

iagnosis o anorexia nervosa or #ulimia nervosa are a#sent% there iseteriorating linear gro!th or elay in aolescent evelo$mentassociate !ith inae3uate !eight gain. -t a$$ears that a
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$reoccu$ation !ith slimness an striving or !eight control% uele #ycurrent health #elies% cause the retare gro!th. Single gro!th $ointso uner!eightorheight are not nearly as im$ortant as longituinalata% #ecause iniviuals !ith constitutional thinness may have a!eight that is Q* $ercentile lines #elo! their height.

Nutritional gro!th retaration must #e i;erentiate rom thevariations o normal gro!th note a#ove an also rom some o theorms o in'ammatory an other #o!el iseases in !hich gro!thailure% oten note #y eviation rom a $reviously e)ne length an!eight channel% may #e !ell a#ove the lo!est $ercentiles.:eha#ilitation o nutritional gro!th ailure or relie o the in'ammationmay $romote catchu$ gro!th.

The theoretical !eight% the !eight e)cit or that theoretical !eight%

an the !eightorheight e)cit shoul #e e)ne &ig#re 3


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nutritional !ar)ng. This $atient% !ith constitutional gro!th elay%sho!e a #oy !eight gain consistently along the lo!er $ercentile%!ith no eviation in gro!th. Note that there !as no #oy !eight e)citor height or or theoretical !eight #ase on $revious gro!th.:e$rinte rom reerence *E% 185% #y courtesy o "arcel 9e//er% -nc.

Chilren !ith nutritional gro!th retaration may have reache a ne!energy e3uili#rium $hase #et!een their genetically etermine gro!th$otential an the $resent energy inta/e% #ecause gro!th ecelerationis the aa$tive res$onse to su#o$timal energy inta/e. This gro!theceleration has limitsP or exam$le% energy inta/e an oten $rotein2may #e inae3uate or such a $rolonge $erio o time that energymalnutrition #ecomes evient. Acutely% su#o$timal inta/e ue to illnessor heavy exercise loa see the ollo!ing section2 may tem$orarilyelay gro!th% #ut this !ill #e ollo!e 3uic/ly #y catchu$ gro!th. This

$rocess must #e $ro$erly istinguishe rom other causes o organican nonorganic gro!th retaration.

The aa$tive res$onse is mar/e #y a ecrement in #asal an resting2meta#olic rate an a ecrease in $rotein synthesis% the latter #eing anenergyintensive $rocess. -n aition% there may #e e)ciencies inminerals% $articularly Ginc an iron% an vitamins. All may lea to aecrease in $hysical activity% !hich is an attem$t to ecrease ongoingenergy losses.


EFFECTS OF PHYSICAL ACTIVITY AND TRAINING ON

GROWTH AND ADOLESCENT DEVELOPMENT

9oes $hysical activity% s$ort training% or #oth a;ect linear gro!th an$u#ertal maturation The literature is re$lete !ith re$orts that thee;ects o athletic training on gro!th an $u#ertal evelo$ment aresalutary% eleterious% or nonexistent Mor a revie!% see"alina *@2.Ho!ever% careul a$$raisal o these re$orts oten reveals severe

methoologic aults% such as lac/ o consieration o interiniviualvariation in #iological maturity status an su#,ect selection. Certains$orts sho! avantages or the early maturer% es$ecially or males%an others% es$ecially gymnastics an ance% avor the laterevelo$ing emale. Thus% there is concern a#out the $otential e;ects otraining on the timing an $rogression tem$o2 o $u#erty cause #y$artici$ation in training an s$orts. Critical analysis !ith the #iologicalinicators o #one age or $ea/ height velocity in longituinal stuyesigns is re3uire to tease out the e;ects o such training on $u#ertalevelo$ment an ault height.

Females9elay in gro!th an sexual maturation is !ell ocumente amongcertain grou$s o elite emale athletes% most nota#ly gymnasts%
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ancers% an longistance runners *J2. The unerlying mechanisms%ho!ever% are not entirely clear% in $art #ecause o e! longituinalata in girls. Control o gro!th an age at menarche involve thecom$lex interaction o many actors% incluing the $hysical anmeta#olic emans o intensive athletic training an com$etition.-nvestigations o gro!th $arameters in aolescent emale gymnastsconsistently )n these girls to #e shorter an lighter an to have asigni)cantly lo!er $ercentage o #oy at than o agematche controlgirls or athletes $artici$ating in less strenuous s$orts% such ass!imming. >irls $artici$ating in the latter ty$es o s$orts are generallytaller an mature earlier than normal *JB12. TheintG et al *42ollo!e a cohort o aolescent gymnasts an s!immers over aninterval o *B y. Training $erios average ** hI!/ or the gymnastsan J hI!/ or the s!immers. The gymnasts ha signi)cantly lo!ergro!th velocities rom s/eletal age 111B y% sho!ing a $ea/ height

velocity o only 5.DJ 8.B* cmIy com$are !ith J.8 8.58 cmIy orthe s!immers. Kver time% height S9 scores ecrease signi)cantly inthe gymnasts !ithout a change in the ratio o chronologic age to #oneage. Conse3uently% $reicte heights o the gymnasts ecrease !ithtime% #ut those o the s!immers i not change.(inholm et al B*2 also o#serve slo!er gro!th velocities among agrou$ o aolescent emale gymnasts. These girls i not is$lay theistinct gro!th s$urt seen in the control grou$ o inactive girls% an*@6 ha ault heights that !ere less than ex$ecte #ase onmi$arental height. +ernaot an CGer!ins/i BB2 stuie * grou$s o

emale gymnasts% one age @18 y an the other age 111D y.eightorage an heightorage ecrease rom the DJth $ercentilein the younger grou$ to the *8th $ercentile in the oler gymnasts.+oy at i not i;er signi)cantly #et!een the age grou$s% an at allages the gymnasts ha signi)cantly more muscle mass or their siGethan i the control grou$.Several investigations have com$are age at menarche among emaleathletes $artici$ating in i;erent s$orts !ith that o the general$o$ulation. Claessens et al BD2 oun the meian age at menarche to#e 15.E *.1 y among a grou$ o gymnasts an 1B.* 1.* y among

the control $o$ulation. TheintG et al *42 o#serve that among a grou$o gymnasts an s!immers age 1*.@ 1.1 y% only @.D6 o thegymnasts ha ex$erience menarche% in contrast !ith 586 o the agematche s!immers. The gymnasts in this stuy% ho!ever% ha asigni)cant elay in s/eletal age 71.D* 8.44 y2% #ut the s!immersha com$ara#le chronologic an s/eletal ages. This re$ort em$hasiGethe im$ortance o the interaction #et!een somatic gro!th an sexualmaturation an the inter$retation o $hysiologically versus$athologically elaye $u#erty. +axterones et al B52 re$orte themean ages at menarche o aolescents #eing intensively traine in

gymnastics% s!imming% an tennis to #e 1D.B% 1B.B% an 1B.* y%res$ectively% !ith a $o$ulation reerence value o 1B.8 y. Signi)cantelay !as again note only among the grou$ o gymnasts. The ata or
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gymnasts are re$licate to a lesser egree in ancers an runners.S$orts such as s!imming% s$ee s/ating% an tennis a$$ear to haveminimal e;ects on gro!th or age at menarche *@% *J% B52.Although these ata suggest a relation #et!een intense athletictraining an gro!th an $u#ertal evelo$ment in emale gymnasts%they are not conclusive. -n inter$reting gro!th an evelo$ment atao athletes% a host o other varia#les% incluing the intensity o training%must also #e consiere. An iniviual&s general state o health iscritical to normal gro!th an evelo$ment% #ut this is assume inaolescents !ho meet the great $hysical emans o longtermtraining. >enetic $reis$osition also $lays an im$ortant roleP the shortstature o gymnasts is oten amilial *J2 an a $ositive correlation has#een oun #et!een menarcheal age in mothers an aughters B52.Historically% socioeconomic class an amily siGe have #een in'uentialPmenarche occurs earlier in the higher socioeconomic classes an in

amilies !ith e!er si#lings D2. 0sychologic an emotional stressorsassociate !ith yearslong training% re3uent com$etition% maintenanceo lo! #oy !eight% altere $eer relations% an emans o coachesmay also in'uence gro!th an $u#ertal timing *J2.Nutrition% es$ecially ieting #ehavior% can #e a ma,or actor orisorere gro!th% $articularly in s$orts that em$hasiGe strict !eightcontrol. Although the $rinci$le o a critical $ercentage o #oy at is nolonger consiere vali% the issue o energy #alance is crucial togro!th an evelo$ment. -nta/e o energy% as !ell as o vital nutrientssuch as calcium% !hich is necessary or #one mineral accrual% may #e

su#o$timal in athletes !ho restrict ietary inta/e uring a time oincrease meta#olic eman. Nutter BE2 oun that the esire to #ethin may in'uence ietary $atterns o emale athletes even more thano changes in exercise training.Several investigators% or exam$le% arren B@2% have stresse theim$ortance o strenuous $hysical training #eore menarche that mightcause isorere gro!th an aolescent evelo$ment. oungerchilren may #e es$ecially susce$ti#le to the energy emans ostrenuous exercise. Although similar trens e$ening on ty$e o s$ortare a$$arent% menarche is more elaye in gymnasts than in

s!immers or tennis $layers !ho #egan training at a com$ara#le age.0rior menstrual irregularity a$$ears to #e an im$ortant ris/ actor oroligomenorrhea or amenorrhea in aolescents !ho #egin training atermenarche.Alterations in gro!th an $u#ertal maturation are not common amongyoung !omen engaging in recreational exercise or in aolescents !hotrain ?15 hI!/ BJ2. The incience o oligomenorrhea or amenorrheaan seconary amenorrhea has #een cite as 18D86 among athletesan *56 among the general $o$ulation. The istinction #et!een elitean nonelite athletes is im$ortant #ecause it $ertains to training time

an intensity. Klym$ic athletes have #een sho!n to have signi)cantlylater menarche than high school% college% an clu#level athletes *@2.

The i;erent emans o various s$orts also ictate the amount o
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time s$ent in strenuous $hysical activityP gymnasts an ancers arexcee s!immers an tennis $layers in the availa#le stuies. Catchu$gro!th has #een re$orte in gymnasts !hen their training istem$orarily reuce or sto$$e B82.Ho!ever% one o the most im$ortant varia#les $erha$s the single mostim$ortant varia#le2 to ta/e into account is that o selection #ias. +oyty$es that are most successul are selecte or $articular s$orts.Several stuies have re$orte gymnasts to #e smaller than their $eersrom a young age *@% *J2. 9elaye menarche avors the continuationo s$orts such as gymnastics% !hich suggests that elite gymnasts areselecte in $art or this attri#ute. Continue $artici$ation in turn leasto more intense training an #lurring o cause an e;ect.

The im$lications o elaye menarche are irectly relevant to theaccrual o #one mineral. +ecause Q486 o the total ault #one mass isesta#lishe uring the $u#ertal years% ailure to accrue #one mineral at

a normal rate uring this time may result in $ermanent e)cits. +onemineraliGation is a com$lex $rocess in'uence #y nutrition es$eciallycalcium inta/e2% !eight#earing activity% an sex steroi hormones.Hy$oestrogenism #ecause o $u#ertal elay or seconary amenorrheacan lea to lo! #one mineral ensity es$ite ae3uate !eight#earingexercise. -n a grou$ o emale runners% (ouis et al B42 oun ecreasesin #one mineral ensity in all su#,ects !ith oligomenorrhea oramenorrhea% !hereas runners !ith regular menses ha values !ithinthe normal range. A lo! rate o #one mineral accrual has #eensuggeste as one actor contri#uting to s/eletal in,uries in gymnasts.

Males-n general% #oys !ho $artici$ate in s$orts have normal gro!th ratesan are normal or avance or their state o s/eletal an sexualmaturation *@2. The avance states o maturation in male athletesmay #e attri#ute to the $o!er an $erormance avantagesassociate !ith maturation D82.Ho!ever% or s$orts that may create an energy rain% the e;ects ongro!th an maturation remain inconclusive. Seeelt et al D12re$orte that the height velocity o elite male istance runners !ase3ual to nonrunning control su#,ects uring 1 y o training. Kther

investigations have re$orte the linear gro!th o male istancerunners to #e either slo!e or avance relative to reerence ata.Unortunately% the maturity levels o the runners% the reerence ata%or #oth !ere not given or the * ormer stuies% so e! conclusions can#e mae !ith regar to the in'uence o istance running on gro!thvelocity.

The gro!th o scholastic !restlers has also #een the concern o severalinvestigations. American !restlers #egin losing !eight to certiy orlo!er com$etitive !eight classes as young as J y o age. The !eight islost through ieting% severe exercise% ehyration% an various other

methos D*% DB2% !hich has $rouce enough concern to !arrant #oththe American College o S$orts "eicine an the American "eicalAssociation to $u#lish $osition statements calling or the limitation o
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this $ractice. -n act% several authors have s$eculate that the gro!tho $eri$u#escent !restlers may #e slo!e uring the s$orts season. Asa grou$% high school !restlers are usually shorter than average ortheir age *@2% although this too is $ro#a#ly a selselection $rocess or!restling.-n a crosssectional stuy% the gro!th $atterns o D@@ high school!restlers !ere com$are !ith those o a re$resentative sam$le oaolescent males DD2. The !restler an reerence grou$s !ere noti;erent at any age or #oy !eight% #ut the slo$e value or the gain in#oy !eight !as signi)cantly greater or the reerence sam$le. Thereerence grou$ !as signi)cantly taller than the !restlers ater age1E.D y% #ut the slo$e values or gain in height !ere not statisticallyi;erent. Slo$e values !ere also com$are or 1B otheranthro$ometric varia#les% !ith e! nota#le grou$ i;erences. Theinvestigators conclue that !restling oes not slo! gro!th an

maturation DD2. Ho!ever% the stuy i not aress !hether thegro!th rate uring the s$ort season !as slo!e an% i so% !hetherthere !as catchu$ gro!th uring the nontraining season.As ex$ecte% many investigators have re$orte reuctions in !eight%at mass% an $ercentage o #oy at uring the !restling seasonD5% DE2. Ho!ever% the atree mass is more conserveP mostinvestigators re$ort nonsigni)cant reuctions D5% DE2. Still% the atreemass oes not increase as one !oul ex$ect or normal $u#escentmales. +ecause arm an leg strength iminish D52% one might suggestthat statistically insigni)cant reuctions in these varia#les may #e

#iologically relevant. Ater the s$ort season% !restlers ex$erienceaccelerate incremental gains in !eight% at mass% an atree massD5% D@2. The $ostseason gains in !eight may #e a#ove the 44th$ercentile or age. Accelerate $ostseason gains in !eight% at mass%an atree mass suggest sottissue catchu$ gro!th in the !restlers.9uring the s$ort season% changes in anthro$ometric measures o leantissue% such as miarm girth an lean lim# crosssectional areaso#taine rom s/inol correcte girths2% also $rovie evience thates$ite heavy #outs o training% !restlers can ail to accrue lean tissueuring the s$ort season an sho! an accelerate accrual $ostseason

D52.0revious SectionNext Section

SUMMARY

A e! com$elling ata im$licate training or com$etition as causal inthe shorter stature an ecrease #oy mass o some $u#ertalathletes in s$eci)c s$orts. -t a$$ears li/ely that activities such asgymnastics an ance in girls or !restling in #oys select or those$artici$ants !ith esira#le genetic anthro$ometric traits. Ae to this

$rocess are the interactions among iminishe nutrition an theenergy rain o training. 0reliminary hormonal stuies cannotistinguish #et!een constitutionally elaye $u#erty an a synrome
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cause #y s$ort $artici$ation. Ho!ever% stuies esigne to ma/e thisistinction $ro#a#ly cannot #e one in aolescents. -nvestigations inault !omen sho! that some amenorrheic athletes have altere$ulsatile gonaotro$in release% #ut it has not yet #een $ossi#le tose$arate the e;ect o the training itsel rom nutritional an stressactors DJ2.


Footnotes

W* 0resente at the !or/sho$ :ole o 9ietary Su$$lements or0hysically Active 0eo$le% hel in +ethesa% "9% une BD% 144E.

WB Su$$orte in $art #y grant H9B*EB1 rom the National-nstitutes o Health.

WD Aress re$rint re3uests to A :ogol% -nsme -ncor$orate% J88Rast (eigh Street% :ichmon% VA *B*14 . Rmail= arogolXinsme.com.

0revious Section

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