A delay or advance in bone age is most commonly associated with normal variability in growth, but significant deviations between bone age and biological age may indicate an underlying medical condition that requires treatment. The inability to be applied in children younger than 6 years or to perfectly match (equal to 100%) the images or to weigh the differences between bone structures (short and long) represents the main disadvantages of the procedure. The . doi: 10.1016/B978-0-323-04883-5.50052-0, 43. (2016) 170:16370. Bone age is measured in years and assigned by a trained radiologist or endocrinologist by comparing the childs measurements with existing standards. http://www.who.int/childgrowth/standards/en/. J Pediatr. FCa, CG, AM, and FCh have contributed to the conception and the design of the manuscript. Table 5 lists the indications for referral.2,6,22. Childrens bones have areas of new bone growth called growth plates at both ends. Rofo. Constitutional Delay of Growth and Puberty. Doctors assign a childs bone age based on which standard X-ray images in the atlas most closely match how the child's bones look on the X-ray. (2016) 52:5238. Midparental height growth velocity should be calculated to evaluate a child's growth vs. potential height. The numbers of participants with data from each age are presented in Figure 1 and in a footnote to the Table. Bone age assessment: a large scale comparison of the Greulich and Pyle, and Tanner and Whitehouse (TW2) methods. By two years of age, growth hormone plays a predominant role. 3. This process is characterized by a predictable sequence of development and progression of ossification centers. Speiser PW. doi: 10.1016/0197-0070(87)90048-9, 84. This method has the advantage of eliminating the need for additional radiographic exposure in cases where the vertebrae have already been recorded on a lateral cephalometric radiographic. Kim JR, Lee YS, Yu J. (1973) 83:2336. 68. Apart from the ability to assess the chronological age of a person, the evaluation of growth remaining in a person can be extremely beneficial to a clinician in different circumstances, as previously discussed. The choice of the left hand depends on the fact that, at the time of sampling, the left hand was the less frequently impaired (at that time, many boys used to work in factories, and they could have suffered accidents at work). This was followed by a comparison between the skeletal age estimates and the chronological ages of the patients. (2007) 92:3712. Available from: Constitutional delay in growth and development, "Infant bone age estimation based on fibular shaft length: model development and clinical validation", "Bone age assessment practices in infants and older children among Society for Pediatric Radiology members", "Bone age: assessment methods and clinical applications", "Is the use of the cervical vertebrae maturation method justified to determine skeletal age? Bone age should be compared with chronologic age to help narrow the differential diagnosis of short or tall stature. (2016) 31:939. Your body age is a measure of how healthy and typical your physical condition is compared to what is expected for your chronological age. doi: 10.1093/ajcn/36.3.527, 27. Ranjitkar S, Lin NH, Macdonald R, Taylor JA, Townsend GC. Stature and skeletal maturation of two cohorts of Australian children and young adults over the past two decades. Lodish MB, Gourgari E, Sinaii N, Hill S, Libuit L, Mastroyannis S, et al. Bone growth assessments can be useful when it comes to gauging growth rates, especially when it comes to understanding1: Pediatricians can look to a childs parents for some of this information, but more specialized assessments can help, particularly if there is a concern for any disorders or conditions that may affect growth, development, or bone health. Mentzel HJ, Vilser C, Eulenstein M, Schwartz T, Vogt S, Bottcher J, et al. Constitutional advancement of growth in tall children is the equivalent of constitutional delay of growth and puberty in short children.1,19,20 Children with constitutional advancement of growth have accelerated growth until two to four years of age and then track parallel to the growth curve. FCa has written the first draft of the manuscript. Thodberg HH. Hand Bone Age. Pediatr Endocrinol Rev. In 1991, Pietka et al. AJR Am J Roentgenol. During growth, biological maturity is defined by several parameters, including the characterization of skeletal maturity, sexual maturity, dental elements eruption, menarche, spermarche, deepening of the voice, growth spurt, and the achievement of 95% of the adult height (13). Sopher AB, Jean AM, Zwany SK, Winston DM, Pomeranz CB, Bell JJ, et al. (1987) 8:4708. Assessing the skeletal maturity of the hand-wrist: FELS method. [29] A girl has reached 99% of her adult height at a bone age of 15 years and has a small amount of height growth left from this point on. Constitutional delay of growth and puberty is one of the most common causes of delayed bone age (10). defects in bone mineralization process (commonly found in osteochondrodysplasia). Dickerman Z, Loewinger J, Laron Z. This condition may be congenital or acquired, and has an incidence of one in 3,000 to 9,000 children.13 A history of head trauma, central nervous system infection, birth trauma, or cranial irradiation may suggest an acquired cause of growth hormone deficiency. Am J Roentgenol Radium Ther Nucl Med. Forensic Sci Int. A child whose growth is initially normal but then falls progressively further off the growth curve may have growth hormone deficiency. (2006) 29:2416; discussion 8690. J Paediatr Child Health. To note, usually the first ossification center to appear is in the contest of Capitate and Hamate at the second month in females and around the fourth month in males. Although most children with short or tall stature do not have a pathologic condition, extremes of height, especially beyond three standard deviations, require further workup. Moreover, weight gain and obesity are one of the most important causes of pediatric advanced bone age; the mechanisms underlying these alterations are not fully clarified, although insulin resistance and hormonal factors produced by adipose tissue might play an important role (50, 51). 1996;45:5355. Martin DD, Wit JM, Hochberg Z, Savendahl L, van Rijn RR, Fricke O, et al. These look white on the X-ray image. High intake of phytoestrogens and precocious thelarche: case report with a possible correlation. Bone age is the degree of a person's skeletal development. J Clin Endocrinol Metab. The X-ray image is black and white. Ontell FK, Ivanovic M, Ablin DS, Barlow TW. After puberty, all carpals, metacarpals, and phalanges are completely developed, their physes are closed, and the assessment of skeletal maturity is based on the degree of epiphyseal fusion of the ulna and radius (8082). In these normal boys, the chronological age at onset of puberty was 11.4 0.8 years (mean S.D.). Comparison of dental maturity in children of different ethnic origins: international maturity curves for clinicians. Variability in the order of ossification of the bony centers of the hand and wrist. doi: 10.4103/0975-1475.176956, 76. [5][9] The first atlas published in 1898 by John Poland consisted of x-ray images of the left hand and wrist. Beunen G, Lefevre J, Ostyn M, Renson R, Simons J, Van Gerven D. Skeletal maturity in Belgian youths assessed by the Tanner-Whitehouse method (TW2). Therefore, carpal bones are not ossified at birth, and this process typically advances from the center of ossification (80). Over the years, practitioners have tried to assess bone age by ultrasound. The long bones include the femurs, tibias, and fibulas of the lower limb, the humeri, radii, and ulnas of the upper limb (arm + forearm), and the phalanges of the fingers and toes. (2005) 35:42933. doi: 10.1016/j.jflm.2013.11.011, 98. Powell SG, Frydenberg M, Thomsen PH. (2005) 154:312. (1990) 65:110912. Although aromatase inhibitors have been used in children with idiopathic short stature, long-term effectiveness and safety data are not available.27. [1][2], Bone age acts as a surrogate for physiological development because growth and maturation of the skeletal system depend on the presence of hormones like growth hormone, sex steroids (e.g., estrogen and testosterone), and thyroxine. In premature babies, there is often a delayed skeletal maturation (49). The long bones of the leg comprise nearly half of adult height. (2012) 216:200 e14. Buckwalter JA, Einhorn TA, Simon SR. Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System. Manzoor Mughal A, Hassan N, Ahmed A. Dense body parts, such as bones, block the passage of the X-ray beam through the body. Performing bone age assessments can assist clinicians in diagnosing central precocious puberty. Khan K, Elayappen AS. Assessment of the carpals, metacarpals, and phalanges are used to find the closest match in the atlas; the chronological age of the patient in the atlas becomes the bone age assigned to the patient under review. This method is very simple and fast, needing roughly 1.4 min for the evaluation (10, 107), thus explaining why it is preferred by 76% of pediatric endocrinologists and radiologists (10). doi: 10.1016/j.ajodo.2006.07.037, 99. In addition, subjects with long-lasting and untreated growth hormone (GH) deficiency have a delay in bone maturation. basis of physical characteristics such as height, weight and general body shape and a comparison of the results with growth curves [9,20]. Das S, Ghosh R, Chowdhuri S. A novel approach to estimate age and sex from mri measurement of liver dimensions in an Indian (Bengali) Population A pilot study. Chronological age vs. bone age in 169 children with Cystic Fibrosis Dots under the line represented a delay in bone age. Rosemont, IL: American Academy of Orthopaedic Surgeons (2000). [3][21], Images in the Greulich and Pyle atlas came from healthy white boys and girls enrolled in the Brush Foundation Study for Human Growth and Development between the years 1931 and 1942. (1996) 167:13958. Acta Paediatr Scand. Ahmed ML, Warner JT. 29. 4. Thereafter, the pisiform and the sesamoid become recognizable. A systematic search has been performed in PubMed to identify randomized controlled trials (RCTs), meta-analyses, and retrospective and prospective studies of different methods to evaluate bone age, focusing on strengths and weaknesses of each procedure. Over the years, numerous standardized methods have been developed to evaluate a skeletal maturity score for the hand and wrist radiographs (3, 5, 9092). The height age (HA) refers to the CA at which a child's height would be at the 50th percentile for age and sex. doi: 10.1136/adc.68.5.677, 37. Multiple regression equations for predicting the adult height of boys and girls from height and bone age at ages 4 and upwards are presented. 7. For a child with average puberty timing, Kutney said pediatricians should expect the child to follow the height percentile consistent with their final adult height. Schmidt S, Nitz I, Schulz R, Schmeling A. Applicability of the skeletal age determination method of Tanner and Whitehouse for forensic age diagnostics. BMD increased with age in children of both sexes (r = 0 . In particular, bone age is more advanced in female than in male individuals with the same chronological age. Interleukin-6 release by cultured peripheral blood mononuclear cells inversely correlates with height velocity, bone age, insulin-like growth factor-I, and insulin-like growth factor binding protein-3 serum levels in children with perinatal HIV-1 infection. doi: 10.1210/jc.2006-1645, 13. Although this method is very accurate and allows doctors to estimate children's bone age even when they are <1 year old, the Fels method is too complex, thus minimizing its daily use. [7][8] Features of bone development assessed in determining bone age include the presence of bones (have certain bones ossified yet), the size and shape of bones, the amount of mineralization (also called ossification), and the degree of fusion between the epiphyses and metaphyses. Evaluation for pathologic etiologies is guided by history and physical examination findings. Cox LA. (2003) 349:77688. Although the Khamis-Roche method is considered an accurate predictor, it is not as accurate as methods using the bone age. (1990) 149:3147. 135. doi: 10.2214/ajr.167.6.8956565, 97. Most infants with the congenital form are normal size at birth, but may have episodes of hypoglycemia or prolonged jaundice. Patil ST, Parchand MP, Meshram MM, Kamdi NY. A distance of 76 cm from the box tube is recommend. A longitudinal study. doi: 10.1515/jpem-2015-0234, 38. If bone age reading is performed with the TannerWhitehouse method, there are some equations proposed by Tanner to calculate growth prognosis (10, 122, 123). If findings from the initial evaluation do not suggest a diagnosis, laboratory testing may be performed (Table 4).1,3,13,14,16,19,20 A retrospective study found that a complete laboratory evaluation of an asymptomatic child with idiopathic short stature is low yield and expensive. Am J Orthod Dentofacial Orthop. 104. Horm Res. doi: 10.1016/S0022-3476(97)90000-7, 8. J Adolesc Health Care. Common normal variants of short stature are familial short stature, constitutional delay of growth and puberty, and idiopathic short stature. The Royal Children's Hospital Melbourne, Immigrant Health Service. [3] In certain instances, abnormal growth conditions may be treated with supplemental hormone therapy. (2003) 23:2942. (2013) 106:3415. In Sweden, many asylum applications in 2016 were made by lone refugee children, thus requiring novel proposed guidelines. Bone age represents a common index utilized in pediatric radiology and endocrinology departments worldwide for the definition of skeletal maturity for medical and non-medical purpose. Children with short stature and no identified cause and children with certain other identifiable causes of short stature should be referred to a pediatric endocrinologist. (2008) 134:21726. doi: 10.1210/jc.82.5.1603, 86. Intestinal inflammatory chronic conditions. Insulinlike growth factor has been used in children with insulinlike growth factor deficiency. [39] Liver weight increases with age and is different between males and females. (2015) 9:50. doi: 10.1186/s13034-015-0082-3, 45. JAMA Pediatr. 106. Int J Legal Med. (1987) 14:35765. Children with familial short stature or idiopathic short stature have a bone age equivalent to their chronologic age, and children with constitutional delay of growth and puberty or endocrine disorders have a bone age that is less than their chronologic age. (2011) 76:19. An appraisal of Greulich-Pyle Atlas for skeletal age assessment in Pakistan. During late puberty, the fusion of the epiphyses to the metaphyses in the long bones of the hand tends to occur in a characteristic pattern: (3) fusion of the proximal phalanges, and. Table 6 includes the differential diagnosis of tall stature. (2000) 12:6105. Short stature is defined as a height more than two standard deviations below the mean for age (less than the 3rd percentile). Constitutional delay of growth and pubertal development. Bone age should be compared with chronologic age to narrow the differential diagnosis of short stature.5,10,11 The traditional method compares a plain radiograph of the left wrist and hand to a database of norms, although various methods are now available.1012 Children with normal variations of growth may have advanced or delayed bone age, but a bone age that is more than two standard deviations from the mean for age is likely due to a pathologic condition. doi: 10.1159/000329372, 11. Moreover, the score based on 20 bone segments was abolished, and the reference values and the graphs were modified and based on data obtained from native North American children. N Engl J Med. As well, hypophyseal alterations secondary to malformation, tumor, or infiltrative pathologies may also be associated with bone age delay consequently to a secondary GH deficiency or hypothyroidism. Br J Radiol. doi: 10.1046/j.1365-2265.2003.01905.x, 50. [28], For the average person with average puberty, the bone age would match the person's chronological age. Braz Oral Res. Tanner JM, Gibbons RD. Most children will achieve a final height within 4 inches of the mid-parental height estimate, she said. This may be inherited. The bone age study can help evaluate how fast or slowly a child's skeleton is maturing, which can help doctors diagnose conditions that slow down or speed up physical growth and development. doi: 10.3109/03014460.2015.1032349, PubMed Abstract | CrossRef Full Text | Google Scholar, 2. Dysmorphic characteristics suggest a genetic disorder, whereas midline defects suggest an abnormality of the growth hormone axis. Discussion. The effect of chronic childhood malnutrition on pubertal growth and development. The Knee Joint as a Biological Indicator", "Rate of Appearance of Ossification Centers from Birth to the Age of Five Years", "Use of cervical vertebral dimensions for assessment of children growth", "Management of the Child Born Small for Gestational Age through to Adulthood: A Consensus Statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society", "2 to 20 years: Girls Stature-for-age and Weight-for-age percentiles", "2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles", "Physical Development, Ages 11 to 14 Years", "Bone age and onset of puberty in normal boys", "Overgrowth SyndromesEvaluation, Diagnosis, and Management", "An approach to constitutional delay of growth and puberty", http://www.jfsmonline.com/text.asp?2019/5/4/177/272723. When a child experiences earlier than normal puberty timing, the child would be expected to follow a height percentile above their final adult height percentile. [1][2][21], The Tanner-Whitehouse (TW) technique of estimating bone is a "single-bone method" based on an x-ray image of a patient's left hand and wrist. Moreover, even when there is a good correlation between predicted and actual adult height, there is a wide individual variation, with almost 30% of adults differing by more than 5.0 cm from the BP predicted height (141). A child with GHD may have a bone age that is much less than his/her chronological age. Images of hand and wrist x-rays in four female subjects compatible with physiological skeletal maturation in different ages: A (4 years), B (8 years), C (12 years), D (16 years). 78. These methods differ according to the technique of the procedure and particularly to peculiar advantages and disadvantages (Table 1). doi: 10.1007/s00247-019-04435-z. Pediatr Res. doi: 10.1111/j.1365-263X.2007.00892.x, 39. Condo R, Costacurta M, Maturo P, Docimo R. The dental age in the child with coeliac disease. Radiograph Atlas of Skeletal Development of the Hand and Wrist. Because the bone age of a child with endocrine diseases will progressively fall behind chronologic age, calculating bone age every 12 months might be useful to differentiate constitutional delay of growth from endocrine diseases.1, Children with endocrine disorders, such as growth hormone deficiency, hypothyroidism, or glucocorticoid excess, have normal to increased weight, whereas children with systemic disease tend to have decreased height and weight.2,21. Available online at: http://www.unhcr.org/publications/legal/3d4f91cf4/guidelines-policies-procedures-dealing-unaccompanied-children-seeking-asylum.html. The TannerWhitehouse method was developed in 1,930 using data obtained in European children (3, 113). Bone age is delayed if it is below this threshold (blue area), and advanced if it is above this threshold (green area). Philadelphia, PA: Mosby (2008). Fortes EM, Malerba MI, Luchini PD, Sugawara EK, Sumodjo L, Ribeiro Neto LM, et al. Data described in the TW3 method show a progression of bone age typically between 10 and 12 years compared to that reported in the TW2 method; in particular, TW3 estimates of bone age are younger than TW2 especially in children with idiopathic short stature and constitutional delay in growth and puberty. Oxford University Press (2011). When the bone age reaches 16 years in females and 18 years in males, growth in height is over, and they have reached their full adult height. Regardless of the method used, an appropriate and standardized hand positioning procedure and radiographic image acquisition are required in order to better describe the skeletal maturation. Clin Pediatr Endocrinol. (1989) 1:493494. Most children will have a projected adult height within 10 cm (4 in), or two standard deviations, of their midparental height. This test is usually ordered by pediatricians or pediatric endocrinologists. Wong SC, Smyth A, McNeill E, Galloway PJ, Hassan K, McGrogan P, et al. (2005) 19:20915. 1. In this study of prepubertal children with and without obesity and/or PA, obesity was highly associated with BA advancement. Images provided by The Nemours Foundation, iStock, Getty Images, Veer, Shutterstock, and Clipart.com. Herman TE, Crawford JD, Cleveland RH, Kushner DC. In clinical trials, the most common adverse reactions involved the implant site and included discomfort, bruising, soreness, pain . Reference standards for this method were published in 1950 and 1960; however, from these initial publications, several studies have shown a shift toward an earlier bone maturation process in the general population worldwide (16). Growth in atopic eczema. J Obstet Gynaecol Res. Most children with short stature have normal variants such as familial short stature, constitutional delay of growth and puberty, or idiopathic short stature. [5] For example, a patient's bone age may be less than their chronological age suggesting a delay in growth as may be caused by a growth hormone deficiency. This evaluation is more detailed than a simple comparison and takes into consideration a detailed analysis of structural characteristics of different bones with the assignment of a score to each element (3, 113, 114). The next version (TW3) takes into consideration only RUS bones, and it can be used through a software. The use of bone age in clinical practice - part 1. BMJ Case Rep. (2015) 2015:bcr2015212216. doi: 10.1080/03014460500087725, 119. Among these, three methods were the most representative and used worldwide: The GreulichPyle method, the TannerWhitehouse, and the Fels method. Holderbaum RM, Veeck EB, Oliveira HW, Silva CL, Fernandes A. [2][5], To assign a bone age to the patient under review, a radiologist compares the patient's hand and wrist x-ray to images in the Greulich and Pyle atlas. A newborn's size and growth are a result of the intrauterine environment, and growth hormone does not play a major role. The presence of hypogonadism with the consequent lack of circulating estrogens, androgens, and other pubertal hormones may cause an important delay in bone maturation during pubertal period (2025). Because children grow in spurts, two measurements at least three to six months apart, and preferably six to 12 months apart, are needed to accurately determine growth velocity.4. 2019;29(6):2910-2923. doi:10.1007/s00330-018-5792-5. doi: 10.1097/YIC.0000000000000109, 44. Handbook of Growth and Growth Monitoring in Health and Disease. These are based on longitudinal data from 116 boys and 95 girls of the Harpenden Growth Study and the London group of the . Fishman LS. In our opinion, this method could be useful also to obtain information about: defects in condrogenesis and/or osteogenesis (commonly found in hypochondroplasia); irregularity of metaphyseal regions and enlargement of the metaphyseal region of the ulna and of the radius (commonly found in subjects with rickets or metaphyseal chondrodysplasias); shortening of the fourth metacarpus, triangularization of radius distal epiphysis, pyramidalization of carpus distal line, or translucency of radius (commonly found in LeriWeil and Turner Syndrome); shortening of the fourth and fifth metacarpus (commonly found in pseudohypoparathyroidism); Harris lines (expression of a temporary arrest of long bones growth); and. Am J Clin Nutr. (2001) 50:6248. Further, there can be moderate levels of variability in the bone ages assigned to the same patient by different assessors. However, this system has some limits that must be considered, in particular, the absence of carpal bones evaluation, the opposition of local administrations to install the software, and the higher cost compared to available methods (GP and TW) (134). Basel; Freiburg; Paris; London; New York, NY; New Delhi; Bangkok; Singapore; Tokyo; Sydney, NSW: Karger Publishers (2002) doi: 10.1159/isbn.978-3-318-00778-7. Ann Hum Biol. 22. The Fels method was developed by Roche through a longitudinal study, based on a total of 13,823 serial X-rays of the left hand and wrist. 134. These tables have been formulated on bone age assessment according to the standards of Greulich and Pyle. These images were performed in 355 male and 322 female children born between 1928 and 1974, from the first month of life up to the age of 22 years (124). [] The other applications of BA include height prediction and estimation of age in children seeking asylum in other countries and in competitive sports where chronological age (CA) may be unknown. Although several bones have been studied to better define bone age, the hand and wrist X-rays are the most used images. (1960) 18:21930. According to a recent study, the BoneXpert method is affected by obesity to a lesser extent than the GreulichPyle method. Patel PS, Chaudhary AR, Dudhia BB, Bhatia PV, Soni NC, Jani YV. 2 SDs), a range of 5 years. (2014) 238:8390. Contemporary Pediatrics sat down with one of our newest editorial advisory board members: Vivian P. Hernandez-Trujillo, MD, FAAP, FAAAAI, FACAAI to discuss what led to her career in medicine and what she thinks the future holds for pediatrics. New growth references for assessment of stature and skeletal maturation in Australians.
