Constitutional delay of growth and puberty is one of the most common causes of delayed bone age (10). Precocious puberty and statural growth - Oxford Academic A table of possible causes of abnormal stature and the expected bone age associated with each condition is provided below. 29. New technology for bone age determination includes computer-automated readings and assessments obtained from alternative imaging modalities. This means a child tends to be shorter than average and to enter puberty later than average, while growing at a normal rate. Eur J Pediatr. chronological and bone age for each sex and age group, the equality of the mean for each age was compared (Student's t-test for paired The issue here is the size of the standard deviation (SD) of the difference between bone age and chronological age, which is 15 months or more. ( p =0.67). (2005) 154:312. X-ray exam: bone age study. Bone age should be compared with chronologic age to help narrow the differential diagnosis of short or tall stature. The BayleyPinneau method uses a series of tables that are indexed according to gender, chronological age, and skeletal age. Although several body areas have been studied over the years in order to define a standardized and universal method (3, 6), the wrist and knee areas represent the gold standard procedures (3, 7). GreulichPyle distinguished two standard templates: 31 and 27 radiographic images, in male and female individuals, respectively, which illustrate different phases of bone maturation between 0 and 18 or 19 years, respectively. In order to achieve a greater accuracy and diagnostic reproducibility, it is important that bone age determination has the lowest intra- and interoperator variability. 2015;24(4):143-152. doi:10.1297/cpe.24.143. Table 2 includes normal growth velocity by age.1,9. London: Academic Press (1983). [1 2 3]The two major methods of BA assessment used commonly are i . As a child grows the epiphyses become calcified and appear on x-rays, as do the carpal and tarsal bones of the hands and feet, separated on x-rays by a layer of invisible cartilage where most of the growth is occurring. Thus, some authors suggest that, whenever possible, the same method should be used, favoring TW2 method if possible (93). 78. A numerical value is then assigned to each stage with specific differences between gender. (2015) 16:2015. The bone age (also called the skeletal age) is measured in years. 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). Meet the Board: Vivian P. Hernandez-Trujillo, MD, FAAP, FAAAAI, FACAAI. Degree of a person's skeletal development, Evaluation of the bones of the hand and wrist. doi: 10.1109/TMI.2008.926067, 132. Nemours Kids Health. CT Analysis Demonstrates That Cochlear Height Does Not Change with Age Conventionally, this clinical condition is defined by the presence of delayed bone age (at least 2 SD) compared to chronological age associated with short stature, a delay in both pubertal maturation, as well as in the achievement of adult height, compared to peers. For the Fels method, the prediction of adult height is calculated with the RocheWainerThissen formula. (1988) 77:15460. doi: 10.1002/ibd.22979, 31. These tables have been formulated on bone age assessment according to the standards of Greulich and Pyle. (2012) 216:200 e14. Fishman LS. Briers PJ, Hoorweg J, Stanfield JP. (1987) 14:35765. Heyman R, Guggenbuhl P, Corbel A, Bridoux-Henno L, Tourtelier Y, Balencon-Morival M, et al. Herman TE, Crawford JD, Cleveland RH, Kushner DC. 71. Bone health in children with inflammatory bowel disease: adjusting for bone age. (10), adult height may be overestimated in constitutional delay, and at the same time, it may be underestimated in idiopathic short stature. Common causes of tall stature include familial tall stature, obesity, Klinefelter syndrome, Marfan syndrome, and precocious puberty. doi: 10.1002/ajpa.1330180309, 81. CG has organized the material. doi: 10.1159/000053086, 49. Bone age assessment: automated techniques coming of age? Evaluation of Short and Tall Stature in Children | AAFP 73. (2005) 35:42933. Correlation of bone age, dental age, and chronological age in survivors of childhood acute lymphoblastic leukaemia. (1998) 75:4929. Multiple regression equations for predicting the adult height of boys and girls from height and bone age at ages 4 and upwards are presented. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. BA/CA, bone age divided by chronological age. MATERIALS AND METHODS: We measured CH on coronal CT scans of the temporal bone of 422 ears scanned from 2001 to 2007 in 211 patients, 1 month to 23 years of age. Tanner-Whitehouse method of assessing skeletal maturity: problems and common errors. doi: 10.1016/j.jflm.2013.11.011, 98. Wong SC, Smyth A, McNeill E, Galloway PJ, Hassan K, McGrogan P, et al. Tanner JM. However, bone age itself cannot be considered the only absolute and incontrovertible datum to define the chronological age (6879); therefore, limits and accuracy of this examination in predicting chronological age, especially in relation to different ethnic groups and underlying diseases, need to be considered. Several endocrine diseases might induce changes in bone age (10). doi: 10.1056/NEJMra021561, 54. 9:580314. doi: 10.3389/fped.2021.580314. The mean bone age is advanced over chronological age by 3 years and results in decreased predicted adult height (-5 to -11 cm compared to target height). Underweight in a child with short stature suggests a systemic illness or malnutrition, whereas overweight suggests an endocrine disorder.2,21, Different causes of short stature tend to fall within identifiable growth patterns, and a review of a child's growth curve and bone age should guide further evaluation. PDF Research Article Reliability of the Greulich & Pyle Method for Bone Age The BoneXpert method for automated determination of skeletal maturity. Although the Khamis-Roche method is considered an accurate predictor, it is not as accurate as methods using the bone age. The chronological age (CA) is the child's actual age, based on birth date. Endocr Rev. Table 1. Evaluation of two methods of bone age assessment in peripubertal In fact, if a simple comparison is made, it is likely inadequate when the proximal and distal bones vary in maturation, sometimes by several years. These data distinguish these patients from patients with familial short stature, in whom bone age corresponds approximately to chronological age (1114). doi: 10.1111/j.1651-2227.2011.02476.x, 74. 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. This lack of precision impacts on the value of bone age as evidence . These look white on the X-ray image. There is a chart for males and another for females with possible bone ages ranging from 1 month to 5 years. Benso L, Vannelli S, Pastorin L, Angius P, Milani S. Main problems associated with bone age and maturity evaluation. doi: 10.1002/ajhb.1310010206, 126. Introduction. doi: 10.1111/j.1651-2227.1988.tb10615.x, 46. doi: 10.1016/j.forsciint.2011.09.022, 101. Cushing's syndrome in children and adolescents. Frontiers | Evaluation of Bone Age in Children: A Mini-Review Soudack M, Ben-Shlush A, Jacobson J, Raviv-Zilka L, Eshed I, Hamiel O. 110. (1996) 167:13958. [3] However, most pediatric radiologists still use the Greulich and Pyle technique for estimating bone age in infancy. Horm Res. Acta Radiol. Furthermore, the image was digitized and transformed into a series of mathematical coefficients produced mostly from standard image of the left hand and wrist X-rays. (2015) 24:14352. As sex steroid levels rise during puberty, bone maturation accelerates. They can be seen on an X-ray because they're softer and contain less mineral, making them appear darker on an X-ray image than the rest of the bone. Ann Hum Biol. Braz Oral Res. 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. Forensic Sci Int. Lodish MB, Gourgari E, Sinaii N, Hill S, Libuit L, Mastroyannis S, et al. Puberty timing plays a big role in growth, too. Arch Dis Child. (1994) 331:62936. Therefore, the complete characterization of the main methods and procedure available and particularly of all their advantages and disadvantages need to be known in order to properly utilized this information for all its medical and non-medical main fields of application. Int Clin Psychopharmacol. [7][8][16], The two most common techniques for estimating bone age are based on a posterior-anterior x-ray of a patient's left hand, fingers, and wrist. (2014) 23:2734. doi: 10.1136/bjsports-2015-094623, 67. It may take more than four years for a preterm infant who is born small for gestational age to attain a normal height.24, Recombinant growth hormone is approved for a variety of conditions that cause short stature, including Turner syndrome, chronic renal failure, Prader-Willi syndrome, small for gestational age, Noonan syndrome, short stature homeobox-containing gene deficiency, and idiopathic short stature. Front. Several smartphone applications have been developed to facilitate the use of vertebral methods such as Easy Age. J Pediatr Endocrinol. Int J Legal Med. (1998) 49:3740. They do this by taking a single X-ray of the left wrist, hand, and fingers. Projected height can be estimated by projecting the current growth curve to adulthood in children with normal bone age, or by using a bone age atlas in those with delayed bone age.. doi: 10.1111/jpc.13114, 75. [] 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. Horm Res. Ann Hum Biol. Zachmann M, Sobradillo B. Bayley-Pinneau, Roche-Wainer-Thissen, and Tanner height predictions in normal children and in patients with various pathologic conditions. Schmidt S, Nitz I, Schulz R, Schmeling A. Applicability of the skeletal age determination method of Tanner and Whitehouse for forensic age diagnostics. (2006) 22:110. (2014) 16:424. doi: 10.1186/s13075-014-0424-1, 34. Moradi M, Sirous M, Morovatti P. The reliability of skeletal age determination in an Iranian sample using Greulich and Pyle method. Mentzel HJ, Vilser C, Eulenstein M, Schwartz T, Vogt S, Bottcher J, et al. They add length and width to the bone. doi: 10.1111/j.1651-2227.1984.tb09966.x, 15. 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. Van Rijn RR, Thodberg HH. (2013) 58:1149. The growth hormone insulin-like growth factor 1 axis in children and adolescents with inflammatory bowel disease and growth retardation. In addition, studies have shown that, in some bones, ossification typically begins at birth, while in others, it typically begins between 14 and 17 years of life. The long-term effects of protein energy malnutrition in early childhood on bone age, bone cortical thickness and height. Role of thyroid hormones in skeletal development and bone maintenance. Available online at: http://www.unhcr.org/publications/legal/3d4f91cf4/guidelines-policies-procedures-dealing-unaccompanied-children-seeking-asylum.html. [4] Other uses of bone age measurements include assisting in the diagnosis of medical conditions affecting children, such as constitutional growth delay, precocious puberty, thyroid dysfunction, growth hormone deficiency, and other causes of abnormally short or tall stature. Pak J Med Sci. (1993) 147:132933. Different population groups mature at different speeds. Bone age is measured in years and assigned by a trained radiologist or endocrinologist by comparing the childs measurements with existing standards. J Adolesc Health Care. Pediatr Endocrinol Rev. [24] Since most of the ossification centers counted using this technique appear early in life, this method is only valid for measuring bone age up to around 5 years of age. The GreulichPyle tables can be applied in subjects belonging to Australia and the Middle East (108110) but not to African or Asian populations (106, 111, 112). (2014) 164:8016. The bone age at onset of puberty was 11.0 1.5 years. This test is usually ordered by pediatricians or pediatric endocrinologists. Table 5 lists the indications for referral.2,6,22. These are based on longitudinal data from 116 boys and 95 girls of the Harpenden Growth Study and the London group of the . Table 3. . Patel PS, Chaudhary AR, Dudhia BB, Bhatia PV, Soni NC, Jani YV. 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. 69. A healthy body mass index for age (BMI/A) is considered to be between 18.5 to 24.9kg/height/height. Bone age assessments can provide pediatricians with a rough estimate of when a child will enter puberty, Kutney stated. The use of bone age in clinical practice - part 1. [24] This technique was created to avoid errors in estimating bone age though to arise from focusing on only one area of the body. Arq Bras Endocrinol Metabol. Received: 05 July 2020; Accepted: 08 January 2021; Published: 12 March 2021. Is the Greulich and Pyle atlas applicable to all ethnicities? Several authors have proposed different algorithms for predicting adult height. doi: 10.1016/j.jpeds.2008.08.018, 137. doi: 10.1111/j.1556-4029.2012.02294.x. [1][6], Estimating the bone age of a living child is typically performed by comparing images of their bones to images of models of the average skeleton for a given age and sex acquired from healthy children and compiled in an atlas. For this reason, pediatricians should evaluate patients on the bases of all the available knowledge about the child, particularly their personal growth history. [3] If a patient's x-ray is found to be very close in appearance to two contiguous images in the atlas, then an average of the chronological ages in the atlas may be used as the patient's bone age, although some evaluators choose to interpolate the closest age while others report a range of possible bone ages. Soegiharto BM, Cunningham SJ, Moles DR. Skeletal maturation in Indonesian and white children assessed with hand-wrist and cervical vertebrae methods. Huda W, Gkanatsios NA. Cambridge. doi: 10.1016/j.ajodo.2006.07.037, 99. Speiser PW, White PC. (2010) 13:35560. Bone age - Wikipedia A number of factors can help determine your body age. Tamminga RY, Zweens M, Kamps W, Drayer N. Longitudinal study of bone age in acute lymphoblastic leukaemia. doi: 10.1210/er.2015-1106, 20. Consequently, when a naturally short child has an advanced bone age, it stunts their growth at an early age leaving them even shorter than they would have been. TW2 and TW3 bone ages: time to change? A projected height that differs from the midparental height by more than 10 cm suggests a possible pathologic condition. Am J Hum Biol. In fact, the bone maturation process lasts longer in male than in female individuals (8385), and the moment of closure of the epiphyseal region occurs is roughly 2 years earlier in girls than in boys. 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. These methods differ according to the technique of the procedure and particularly to peculiar advantages and disadvantages (Table 1). The main aspects of these differences are summarized in Table 1 focused on variability, time of execution, radiation risk, and standardization. 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. (1991) 10:61620. 112. doi: 10.1007/BF02171555, 116. Vaska AI, Benson J, Eliott JA, Williams J. doi: 10.1159/000184848. It is important to highlight that all the available methods might be carefully used in the daily clinical approach in order to avoid unreliable expectation in children and parents. 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. Effective dose and energy imparted in diagnostic radiology. Martin DD, Wit JM, Hochberg Z, Savendahl L, van Rijn RR, Fricke O, et al. (2008) 18:21723. If bone age reading is performed with the TannerWhitehouse method, there are some equations proposed by Tanner to calculate growth prognosis (10, 122, 123). Pediatrics. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. Those with an advanced bone age typically hit a growth spurt early on but stop growing at an earlier age. See permissionsforcopyrightquestions and/or permission requests. The long bones of the leg comprise nearly half of adult height. (2007) 51:5003. There are also exceptions with people who have a delayed bone age (bone age is younger than chronological age) due to being a late bloomer (someone starting puberty and hitting PHV later than average), being a late bloomer with delayed puberty, or having another condition. The following are generally documented (84, 97105): a delay in bone age in Middle-Eastern men and Iranian men and in Southeast Asian children (Indonesian and Indian men and women) and Asian-American men; an advanced age in Afro-American children (more in female than in male) and in Middle Eastern female children (Iranian girls); no variation is documented for Italian, Korean, and Scottish children and in Pakistani girls. Means and standard deviations of weight, height, chronological age, SA, P-TW3 and P-KR were determined by group 1 and 2 (model and validation groups) and by sex, for all 497 (group 1 = 252; group . J Pediatr. Tanner J, Oshman D, Bahhage F, Healy M. Tanner-Whitehouse bone age reference values for North American children. Pediatr Endocrinol Rev. Ann Hum Biol. doi: 10.1007/s00247-008-1090-8, 131. FCa has written the first draft of the manuscript. In terms of height growth and height growth related to bone age, average females stop growing taller two years earlier than average males. Below the 5 th percentile or from below-1.96SD reported as thinness or leanness. High-dose sex steroids have been used to promote growth plate closure, but use has decreased over the past 20 years because of adverse effects.28 Surgical destruction of the growth plates has also been performed, but this procedure is controversial. Children do not mature at exactly the same time. These characteristics are mainly documented in large cartilaginous centers, such as the head of the femur, head of humerus, and the tarsal navicular bone and are known as stippled epiphyseal dysgenesis. (2014) 12:2005. The bone mineral density (BMD) of the lumbar spine (L1-L4) was measured by dual energy x-ray absorptiometry (Hologic QDR 1000) in 135 healthy caucasian children, aged 1-15 yr, and values were correlated with age, height, weight, body surface, bone age, pubertal status, calcium intake, vitamin D supplementation, and serum bone gla protein. Albanese A, Stanhope R. Predictive factors in the determination of final height in boys with constitutional delay of growth and puberty. Herman-Giddens ME. Statistical Confirmation of a Method of US Determination of Bone Age Coefficients used in the RWT method are tabulated to 14 years of age for girls and 16 years of age for boys (138). Overall results indicated that use of the GP atlas underestimated Botswana female age by 0.64 years, while age for males was underestimated by 0.50 years. A delayed bone age is common in malnourished conditions associated with chronic diseases such as intestinal inflammatory chronic diseases, celiac disease, and cystic fibrosis (2629). [Paternal height (cm) 13 cm + maternal height (cm)] 2, [Paternal height (in) 5 in + maternal height (in)] 2, [Paternal height (cm) + 13 cm + maternal height (cm)] 2, [Paternal height (in) + 5 in + maternal height (in)] 2, Constitutional delay of growth and puberty, Normal growth velocity, history of delayed puberty in parents, History and physical examination, bone age, Short parents, projected height consistent with midparental height, normal growth velocity, Midparental height, growth velocity, bone age; consider targeted laboratory evaluation, Height < 2 standard deviations below the mean for age with no identified pathology, normal growth velocity and bone age, Abdominal pain, malabsorption, anemia; short stature may be the only symptom, Tissue transglutaminase and total immunoglobulin A measurements; consider referral for endoscopy and biopsy, History of renal disease, poor weight gain, Abdominal pain, bloody stool, poor weight gain, Erythrocyte sedimentation rate and C-reactive protein measurements, referral for endoscopy and biopsy, Short limbs; long, narrow trunk; large head with prominent forehead, History of head trauma or cranial irradiation, central nervous system infection, IGF-1 and IGFBP-3 measurements, referral for growth hormone stimulation, other pituitary function tests, Hypoglycemia, birth length may be normal, height and bone age progressively delayed; jaundice, microphallus, midline craniofacial abnormalities, IGF-1 and IGFBP-3 measurements; referral for growth hormone stimulation, magnetic resonance imaging, other pituitary function tests, Mental retardation if not identified early, Newborn screening, thyroid-stimulating hormone and free thyroxine (T4) measurements, Born small for gestational age, normal height not achieved by 2 to 4 years of age, Focused laboratory testing to evaluate organic causes, consider referral to pediatric endocrinologist, History of poor nutrition, weight loss precedes height loss, Short stature, webbed neck, characteristic facies, short metacarpals, broad chest with widely spaced nipples, hyperconvex fingernails and toenails; may be normal appearing; decreased growth velocity and delayed puberty, Follicle-stimulating hormone, karyotyping, Erythrocyte sedimentation rate, C-reactive protein, Thyroid-stimulating hormone, free thyroxine (T4), Tissue transglutaminase and total immunoglobulin A, Serum luteinizing hormone, follicle-stimulating hormone, testosterone, Children with intrauterine growth retardation who do not catch up to the growth curve by 2 years of age, Height more than 3 standard deviations below the mean for age, No onset of puberty by 14 years of age for boys or 13 years of age for girls, Projected height more than 2 standard deviations (10 cm [4 in]) below the midparental height, Bone age more than 2 standard deviations below chronologic age, Diagnosis of conditions approved for recombinant growth hormone therapy, Family history of early puberty, bone age greater than chronologic age, Projected height within 5 cm (2 in) of midparental height, bone age greater than chronologic age, normal growth velocity after catch-up growth, Rapid childhood growth, goiter, tachycardia, hypertension, diarrhea, fine tremor, exophthalmos, Thyroid-stimulating hormone and free thyroxine (T4) measurements, Body mass index greater than the 95th percentile, slightly early onset of puberty, modest overgrowth/tall stature, minimally advanced bone age, Pituitary gigantism (excess growth hormone), Coarse facial features, mandibular prominence, broad root of nose, broad hands and feet, excessive sweating, hypertension, glucose intolerance, Measurement of insulinlike growth factor 1 and insulinlike growth factor binding protein 3, brain/pituitary magnetic resonance imaging, glucose suppression test, Girls: breast development before 8 years of age, Measurements of luteinizing hormone, follicle-stimulating hormone, estradiol, and testosterone, Boys: testicular enlargement (> 3 mL) before 9 years of age, Measurement of 17-hydroxyprogesterone, human chorionic gonadotropin, dehydroepiandrosterone, estradiol, and testosterone; bone age, Macrocephaly, macroglossia, ear pits, renal abnormality, omphalocele, umbilical hernia, hepatosplenomegaly, Insulin and glucose measurements, advanced bone age, karyotyping, renal ultrasonography, echocardiography, Marfan-like habitus, developmental delay, inferior subluxation of lens, Homocysteine and methionine measurements, dilated eye examination, Delayed puberty; infertility; small, firm testes; gynecomastia; high-pitched voice; learning disability, Measurements of luteinizing hormone, follicle-stimulating hormone, and testosterone; karyotyping, Increased arm span, thin extremities, superior subluxation of lens, hypotonia, kyphoscoliosis, cardiac valvular deformities, aortic root dilation, Clinical diagnosis using Ghent criteria, testing for, Large, protruding ears; long face; high-arched palate; hyperextensible fingers; pes planus; soft skin; macro-orchidism, Clinical suspicion based on dysmorphic features, testing for, Large head; long, thin face; broad forehead; prominent, narrow jaw; downward slanting palpebral fissures; feeding difficulties from birth; facial flushing; hypotonia, Clinical suspicion based on dysmorphic features, renal ultrasonography, echocardiography, advanced bone age, Small chin, broad forehead, hypertelorism, long philtrum, camptodactyly, Clinical suspicion based on dysmorphic features, renal ultrasonography, brain magnetic resonance imaging, advanced bone age (from birth).