Constitutional Delay of Growth and Puberty: A Guide for

Constitutional Delay of Growth and Puberty: A Guide for Parents and Patients

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CHILD GROWTH FOUNDATION

BSPED

THE CHILD GROWTH FOUNDATION Registered Charity No. 1172807

21 Malvern Drive Walmley Sutton Coldfield B76 1PZ Telephone: +44 (0)20 8995 0257 Email: info@

GROWTH AND GROWTH DISORDERS ? SERIES NO: 10 (THIRD EDITION, SEPTEMBER 2000).

Written by Dr Richard Stanhope (Gt. Ormond Street/Middlesex Hospital, London) and Mrs Vreli Fry (Child Growth Foundation)

CGF INFORMATION BOOKLETS The following are also available:

No. Title

1. Growth and Growth Disorders 2. Growth Hormone Deficiency

(Puberty and the Growth Hormone Deficient Child now incorporated in 2 above) 4. Premature Sexual Maturation 5. Emergency Information Pack for Children with Cortisol and GH

Deficiencies and those Experiencing Recurrent Hypoglycaemia 6. Congenital Adrenal Hyperplasia 7. Growth Hormone Deficiency in Adults 8. Turner Syndrome 9. The Turner Woman 10. Constitutional Delay of Growth & Puberty 11. Multiple Pituitary Hormone Deficiency 12. Diabetes Insipidus 13. Craniopharyngioma 14. Intrauterine Growth Retardation 15. Thyroid Disorders

? These booklets are supported through an unrestricted educational grant from Serono Ltd., Bedfont Cross, Stanwell Road, Feltham, Middlesex TW14 8NX, UK. Tel. 020 8818 7200

CONTENTS

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The Timing of Puberty

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The Harmony of Puberty

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Growth during Puberty

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Bone Age

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The Pubertal Growth Spurt

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Growth Hormone Secretion during Puberty

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Other Diagnoses which should be Excluded:

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Gonadotrophin Deficiency

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Gonadal Failure

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Turner Syndrome

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Bone Dysplasia

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Growth Hormone Deficiency

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Psychological Effects

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School and Social Concerns

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Treatment of Constitutional Delay

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Girls

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Boys

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Other Treatments

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Gonadotrophin Deficiency or Constitutional Delay?

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A Patient's Story

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Questions and Answers

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Additional Information

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Bullying

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Age Identification

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Clothes and Shoes

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Summary

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INTRODUCTION

Constitutional delay of growth & puberty is a condition in which temporary short stature occurs along with delayed pubertal development in otherwise healthy teenagers. It is more accurate though to describe it as a delay of puberty and growth as it is the delayed puberty which causes the delay in growth. Other terms which are used to describe this condition may include constitutional delay, short/delay, growth delay or even just delay. They all mean the same thing.

Constitutional delay of growth and puberty is a common condition which is seen more in boys than in girls. It is probably the most common condition seen by specialists at growth clinics. Constitutional delay can produce extreme anxiety, particularly in boys, often because of short stature in comparison with friends of the same age and the apparent lack of genital development. Reassurance that the changes of puberty will soon begin is often all that is required, but some children may also need medical help in order to advance the timing of puberty and the subsequent growth spurt.

Constitutional delay of growth is not a medical disorder, but a temporary condition. If treatment is necessary for an individual child, it must be emphasised that they are normal, and it is only that their "body clock" for puberty has just started later than in their friends.

THE TIMING OF PUBERTY

Puberty is the process of the body maturing into adulthood, with the appearance of secondary sexual characteristics and the development of the ovaries or testes, eventually resulting in the ability to have children. The physical characteristics of puberty include breast development in girls, enlargement of the penis and the growth of testes in boys, as well as pubic hair and underarm hair in both sexes. Development of the testes in boys can be easily assessed through simple examination in the clinic to establish the stage of puberty they have reached by the size of the testes. The doctor will assess the size of the testes by comparing them to a set of standard beads called an orchidometer. The equivalent assessment of the ovaries in girls cannot be done in the clinic and may require the simple technique of using an ultrasound scan to assess the maturity of the ovaries.

The average age for the onset of puberty in boys is 12 years and in girls 11/2 years. Surprisingly, the age difference between boys and girls starting puberty is only half a year, although it is often thought to be much more. In girls, the start of breast development, which is an early event in their puberty, happens at the same time as the growth spurt. In boys, the pubertal changes involving the growth of the testes and penis are less socially obvious and the growth spurt, being a relatively late event, happens mid-way during the

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physical changes. The comparatively late start of the growth spurt in boys explains why the difficulties associated with pubertal delay are more common in boys than girls. It may be entirely normal for a boy to enter puberty at 14 years of age and not experience a growth spurt until 17 years, by which time he would be considerably shorter than his peers, and may be experiencing social problems.

The onset of puberty in boys and girls is triggered by the increase in gonadotrophin releasing hormone [GnRH] secretion from the hypothalamus which stimulates the pituitary gland. The pituitary gland then releases the two gonadotrophins -- Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) -- which stimulate the testes or ovaries to develop. This process starts much earlier in childhood than is normally appreciated. There are various glands and hormones that are involved in this process of puberty, which continues as sexual maturation in adult life. [Figure 1, overleaf]

When there are no physical signs of puberty by 14 years in a girl and 141/2 years in a boy then investigations should be carried out to find the cause, and treatment commenced. There is no benefit in waiting many years for the spontaneous onset of puberty in a child with the expected diagnosis of constitutional delay. Such a course of action is unnecessary and may produce considerable psychological difficulties.

THE HARMONY OF PUBERTY

The events of puberty have a characteristic pattern in the timing of their appearance. This pattern should remain the same even if the start of puberty is either delayed or early. By this we mean that the development of breasts or genitalia and the appearance of pubic hair always occur in a fixed order. In addition, the spontaneous growth spurt occurs at a particular stage of either breast development in girls or size of genitalia in boys. Even though the age at which puberty starts may vary considerably between individuals, the same pattern of normal puberty is retained. Indeed, the absence of this normal pattern points to a hormonal abnormality. This pattern will allow your specialist to determine whether your child's late puberty is a characteristically normal process of delay or whether there is a hormone abnormality which needs investigation. Keeping this normal pattern of the appearance of secondary sexual characteristics, and the timing of the growth spurt, is the most significant feature of constitutional delay and is the key to the diagnosis.

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