The Final Phase of Growth in Stature - GGH Journal

Alex
F. Roche, M.D., Ph.D., D.Sc.
Fels Professor
Department of Pediatrics
Wright State University School of
Medicine
Dayton, Ohio
Editor's Note
The dilemma of prognosticating
how much growth may yet occur
after certain milestones of growth
are met often frustrates the clinician.
A second dilemma of when
to stop growth hormone, anavar,
estrogen, or other treatment for
growth follows from the first. In
this article, Dr. Roche addresses
these questions and provides
some answers. For example,
growth in stature ceases in males
and females at median ages of
21.2 :i: 2.5 years and 17.3 :i: 2.5
years, respectively. Children often
grow an extra centimeter or
slightly more after their growth
velocity has decreased to < 1. 0
cm during the previous year; the
later the occurrence of peak
height velocity, the later menarche
occurs, and subsequent
growth in stature after late menarche
is less than that in girls
with earlier menarche. The
reader will find that the abstract
entitled, "New Concepts of the
Growth Spurt of Puberty, " which
appeared in the previous issue of
Growth, Genetics, and Hormones
(Volume 5, Number 3) will supplement
the reading of this
article.
Robert M. Blizzard, M.D.
Knowledge of the "normal" range
of growth after particular ages and
pubescent events may assist the
clinical management of older children
with unusual statures. Serial
studies are needed to determinethe
distributions of these growth
increments. Partly because the
protocols for almost all growth
studies cease at 18 years, and
partly because marked attrition of
the sample population after 17
years is common, there are few
reported data concerning the final
phase of growth in stature for normal
children and almost none for
children with pathologic conditions.
The following account summarizes
some of the findings from the
Fels Longitudinal Study in 19721
and presents further analyses of
the larger database that is now
available from this study. In 1972,
data were analyzed for 192 participants
aged 28 years or more at
their most recent examinations.
Data are now available for 520 par-ticipants,
inter-observer difference for stature
measurements from 12 to 18years
was 0.16 cm (SO 0.15 cm).
represent the lack of change during
early adulthood. The age at
with serial stature measurements
which the fit was maximal for the
extending to at least 20years. two functions combined was ac-
Many of the Fels participants
cepted as the age at which growth
are siblings or offspring of in stature ceased. The median
older participants, and the inclusion
ages were 21.2 years for males
of related individuals theo-
and 17.3 years for females, with
retically could introduce bias. ranges of about 5 years from the
However, the differences between
sex-specific analyses in which all
the available data were included
10th to the 90th percentiles.1 This
sex difference in the timing of cessation
is greater than that for peak
and those in which only one participant
height velocity (PHV) and pre-
per family was included, are sumably results from sex-associ-
inconsequential. The participants ated differences in growth patterns
involved in the present analyses
during the final phase of
were born between 1929 and growth.
1968, but there are no secular Some authors3 consider adult
trends in these data. Although
there was no strict sampling design,
distribution statistics for Fels
statures are similar to those from
national U.S. surveys.
At the time of enrollment, the
families of the participants lived in
southwestern Ohio. These families
were generally of middle socioeconomic
status, with distributions
of education and occupation that
matched those from national samples,
except that the lowest group
was slightly underrepresented
among those born after 1939. All
the children were white and
healthy.
Stature was measured with a
wooden stadiometer until 1971,
when a Holtain stadiometer was
introduced. Both instruments were
calibrated monthly, and the procedures
used to measure stature
match current recommendations.2
All measurements were made by
two anthropometrists working independently
who repeated their
measurements when they differed
by more than 1.0 cm. The mean
Cessation of Growth in Stature
It is difficult to determine when
growth in stature ceases. In earlier
analyses, 1 a pair of mathematical
functions was fitted to the serial
data for individuals; the second
function was a horizontal line to
stature to be reached when an annual
growth increment is less than
1.0 cm, but the median increases
in stature after such an increment
exceed 1 cm in each sex.1 The
data in Table 1 and other findings4
show that the total median for
growth in stature, after an annual
increment

1.5 cm for males and 1.0 cm for
females.1 The final phase of
growth in stature probably reflects
elongation in the vertebral column.
Increments after Peak Height
Velocity (PHV) and Menarche
The distributions of the total increments
after PHV are slightly larger
for boys than for girls, with large
differences between the 10th and
90th percentile levels in each sex
(Table 2). These sex-associated
differences are particularly large
for the first year after PHV. The
annual increments decrease rapidly
after PHV, with almost as much
growth in the first year as in the
second to fifth years combined.
The data for annual increments
after PHV do not add up to the total
increments, because the groups
for the annual increments differ
across intervals. It is noteworthy
that at least 10% of the boys and of
the girls had increments greater
than 1.0 cm even from 4 to 5 years
after PHV.
The median total stature increment
after menarche was 7.4 cm
with a 10th to 90th percentile range
from 4.3 to 10.6 cm. These findings
are in agreement with reports of
growth from menarche to the end
of school attendance or to 18.25
years.6.? The median increments
during the first year after menarche
exceeded the sum of the
median annual increments over
the next 4 years.
Relationships to the Timing of
PHV and Menarche
The later the occurrence of PHV
and menarche, the lesser the
growth in stature after these
events 1,4,8,9 (Figure), After PHV,
there was considerably more
growth in boys than in girls for
groups matched in age at PHV, but
the ranges from the 5th to the 95th
percentiles and the slopes of the
regressions were almost identical
in each sex, The increments in
boys from 14 to 17 years are also
negatively related to stature at 14
years,10
Clinical Applications
The preceding data may serve as
guides to the potential for growth in
stature, depending on the patient's
maturational status. This information
therefore may assist decisions
about the initiation or
cessation of therapy. Such decisions
will be influenced as well by
the presence and nature of any
pathological condition and by the
attitude of the patient and the patient's
family.
More complex procedures utilize
regression equations to pre-
dict adult stature from childhood
variables.3.11,12 These require assessments
of skeletal age and,therefor
cannot be used after
maturation of the hand-wrist is
complete. Prediction methods
based on regression are likely to
be misleading when applied to
children with chronic diseases that
affect growth, with large overpredictions
more likely than underpredictions.
The Bayley-
Pinneau method13 is the best current
procedure for predicting the
adult statures of children with diseases;
but even with this method,
the prediction errors are large.12
The present data should be applicable
to healthy children, including
those with statures or maturational
levels unusual for their
chronological ages.
In making decisions regarding
the cessation of growth-promotingtherapy,
clinicians may utilize the
distributions of age at which
growth in stature ceases. 1 This
approach is limited in value, how-

Girls
~ 35
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~ 25-;
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.-15.c:i
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c'.5 5
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-J
~ 35
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:J~
...25
C'ij
c
.-15.Coi
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:"...",~
~ 35
E~
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5 25
"cQrn
~
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-5 T"I,,'~~' .,. -' -5 I ' , .,. ,j,.;,..' I', -' -5 -., ., ., ., ., ' ,'I
10 11 12 13 14 15 16 17 10 11 12 13 14 15 16 17 10 11 12 13 14 15 16 17
Age at PH V (years) Age at PH V (years) Age of Menarche (years)
Figure Selected percentiles for the remaining growth in stature (cm) after peak height velocity (PHV) and menarche in
relation to the ages at which these events occur. The interrupted portion of the 5th percentile for growth in stature after
menarche represents values that are less than zero. These are unacceptable biologically but are found in actual data due
to measurement errors.
ever, because growth is very slow
prior to cessation, and a decision
made on this basis would commonly
prolong therapy beyond t-Pie
age at which it is effective. The
present data for expected growth
after particular maturational
events may offer a more useful
alternative for basing clinical
judgments. In the absence of an
effective stature prediction
method for children with diseases,
it is recommended that surveillance
and treatment continue until
about 3 years after PHV or 2 years
after menarche. The later these
events occur, the shorter the following
period during which treatment
or surveillance should be
continued.
Research Applications
Another major potential application
of these data is in study
design. If the planned statistical
analyses relate to differences in
stature increments between experimental
and control groups, the
present data could assist a power
analysis of the sample sizes required.
They could also indicate
the necessary duration of the
study relative to age and maturity
levels. If the study is to extend until
growth in stature is complete in
90% of the group, data collection
must continue until about age 23.5
years in males and 21.1 years in
females.1
Conclusion
The data discussed here describe
late growth in normal children. Presumably,
late growth occurs as
well in children with chronic diseases,
although the magnitude of
such changes is likely to be different.
Application of these data
therefore would require adjustment
for the altered rate of growth
produced by many diseases. There
is, however, insufficient evidence
on which to base these adjustments,
and further studies are required
to provide such support.
References
1. Roche AF, Davila GH. Pediatrics 1972;
50:874-80.
2. Lohman TG et ai, eds. Anthropometric
Standardization Reference Manual.
Human Kinetic Publishers, Inc.,
Champaign, Illinois, 1988.
3. Tanner JM. Assessment of skeletal
maturity and prediction of adult height
(TW2 method). Academic Press,
London, 1975.
4. Lenko HL. Acta Paediatr Scand 1979;
68:85-92.
5. Garn SM et al. Am J Phys Anthropol
1961 ;19:365-72.
6. Fried RI, Smith EE. J Pediatr 1962;
61:562-5.
7. Roy MP et al. In: C.R. Xiiie Reunion des
Equipes Chargees des Etudes sur la
Croissance et Ie Developpement de
l'Enfant Normal. Paris, 1974,39-41.
8. Hulanicka 8, Kotlarz K. Ann Hum BioI
1983;10:429-34.
9. Lindgren G. Ann Hum BioI 1978; 5:
253-67.
10. Gallagher JR, Seltzer CC. Pediatrics
1961 ;27:984.9.
11. Roche AF et al. Monogr Paediatr
1975;3:1-114.
12. Roche AF. Acta Medica Auxologica
1984; 16:5-28.
13. BayleyN. Pinneau SR. JPediatr1952;
40:423-441.
Growth, Genetics, and Hormones
is published under an educational
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