(Received May 10; revision accepted for publication July 13, 1972.)
This work was supported by contract 72-2735 and grants HD04660 and HD04629 from the National Institutes of Health, Bethesda, Maryland.
ADDRESS FOR REPRINTS: (A.F.R.) The Fels Research Institute, 800 Livermore Street, Yellow Springs,
Ohio 45387.
PEDIATRICs, Vol. 50, No. 6, December 1972
874
LATE ADOLESCENT
GROWTH
IN STATURE
Alex F. Roche, M.D., Ph.D., D.Sc., and
Gail H.
Davila, BA.From the Fels Research Institute, Yellow Springs, Ohio
ABSTRACT. Information is lacking concerning the ages at which children cease to grow in stature and the increment in stature after particular chronolog-ical ages or maturational events. This information would assist the management of children receiving therapy that may alter potentials for growth in stature and would be useful in developing new methods for estimating adult stature from child-hood parameters.
The data were obtained from 194 children mea-sured serially from birth to at least 22 years of age.
Piecewise regressions provided estimates of the
ages at which adult statures were reached and of adult stature levels. Growth in stature ceased at
median ages of 21.2 years (boys) and 17.3 years
(girls). The median stature increments, from 18 years to the cessation of growth in stature, were very small in the girls but were about 1.0 cm in the boys. The median stature increments after the femur or the tibia became mature, until growth in stature ceased, were close to 1.0 cm in each sex.
These results demonstrate the variability of growth in children. Some retain considerable po-tentials for growth in stature after 18 years of age, after the femur or tibia has become mature or after intervals of one or two years during which stature
increments are small. PedIatrics, 50:874, 1972,
STATURE, LATE ADOLESCENT GROWTH, MENARCHE.
M
OST analyses of the age at which adultstature is reached and of stature
in-crements after adolescence have been
based on cross-sectional means, although
such data cannot provide information about
individuals. The present data show that
some individuals grow considerably in
stat-ure after 18 years of age and after the
fe-mur and tibia are mature. This study
con-cerns the ages at which individuals ceased
to grow in stature and the total increments (all age intervals combined) in their
stat-ures after particular chronological age or
maturity levels. This information is of value
in the management of children receiving
therapy that may alter their potentials for
growth in stature. Furthermore, it should
assist the preparation of more reliable
methods for estimating adult statures from
childhood parameters and, thus, improve
the care of those children whose present
statures are deviant.
Clements’ analyzed statures to 18.5 years (boys) or 17.0 years (girls) in English
chil-dren of upper socioeconomic levels. After
assuming that growth in stature had ceased
when the increment was less than 3 inch
during either 8 months (boys) or 12
months (girls), he concluded that this
oc-curred at mean ages of 17.8 years in boys
(SD, 0.83 years) and 16.2 years in girls
(SD, 1.13 years). These data were
inade-quate because, by his own criteria, 43% of
the children were still growing at the time of their last measurements. Anderson et al.2
re-ported mean increments, from 17 to 18
years, of 0.9 cm (SD 1.05 cm) in boys and
zero mean increments in girls. Others3’4
have reported mean increments of less than
0.5 cm in boys after 20 years and girls after
18 years. Mean positive increments from 20
to 28.9 years in each sex and a very small
mean increment (0.09 cm) from 29 to 37.9
years in men but not women were found by
B#{252}chi.5There were mean decreases during later intervals in each sex. The mean stature
increments after 20 years were
approxi-raately 0.7 cm for the men and 0.5 cm for
the women. These findings of B#{252}chiare in
general agreement with those of von
Ver-schuere and Miall et al.
*SA = skeletal age.
TABLE I
CENTILES FOR AcEs (YEARS) OF AchIEvING GROWTH AND DEVELOPMENT LANDMARKS
Boys Girl8
N 10 50 90 N 10 50 90
PIIV 78 12.2 13.7 14.7 64 10.2 11.7 13.2
Menarche . . . . . . . . . . . . 90 11.5 12.8 14.5
Annual increment
<1.0cm 101 16.5 17.5 19.0 91 14.3 15.5 17.0
Four successive six-monthly increments
<0.5cm 101 18.3 19.5 20.0 91 16.0 1.5 20.0
in individuals, the relative influence of mea-suring errors increases, making it
impossi-ble to determine precisely when growth in
stature ceases. This problem is particularly
grave if the data cover a brief age range or
if they were collected at wide intervals in
individuals. Partly due to these difficulties,
and for operational purposes, some have
defined the age when growth in stature
ceases as 17 or 18 years5’#{176}or the completion of skeletal maturation.8’1#{176} Others have
made less acceptable decisions. For
exam-ple, a value extrapolated over about two
years has been used as “observed adult stat-ure.”11
MATERIAL AND METHODS
The present data were derived from
Southern Ohio white children (103 boys; 91
girls) in The Fels Longitudinal Sample.
Their recumbent lengths or statures were
measured serially froni 1 month to at least 22 years of age and, in some cases, to ages
exceeding 40 years. Data recorded after 28
years were not used in the present
statisti-cal analysis but they were used to check
some of the findings. The measurements
were made at visits scheduled five times in
the first year and then six-monthly except
after 18 years when they were biennial. The
statures were measured to the nearest 0.1
cm by two independent observers using a
fixed anthroporneter. The greater of the two
measurements was recorded unless the
dif-ference between them exceeded 1.0 cm. On
the few occasions when this occurred the
children were remeasured. In 420 pairs of
measurements in children aged 14 years or
more, the mean interobserver difference
was 0.3cm (SD, 0.15 cm).
These statures were used to obtain
six-monthly increments; the midpoint of the
in-TABLE II
CENTILES FOR AGES AT \\HICH ADULT STATURE \AS REACHED IN 50 Boys AND 45 GIRLS
Boys Girls
10 50 90 10 50 90
Chronological Age (yr) 18.4 21.2 23.5 15.8 17.3 21 .1
YearsafterPHV 4.4 7.8 10.3 4.6 6.0 9.8
Years after menarche . .. . . . . . . ‘3.8 4.8 6 .7
Years after SA* 13 years 4.8 8. 1 10.9 . . . . . . .
TABLE III
CENTILES FOR TOTAL INCREMENTS (cm) IN STATURE AFrER GROWTH AND DEVELOPMENTAL LANDMARKS
To Level of 0-degree Polynomial
To Last Stalure (up to 8 years)
N 10 50 90 N 10 .50 90
16 Years-boys 50 1.2 2.4 &O 103 1.2 2.8 7.2
16 Years-girls 45 0.0 0.9 2.3 91 -0.1 1.1 2.7
18 Years-boys 50 -0.2 0.8 1.9 103 -0.3 0.8 2.3
18 Years-girls 45 -0.3 0.2 1.2 91 -0.4 0.6 1.4
Annual increment <1.0 cm-boys 50 0.0 1.2 2.5 101 -0.2 1.0 2.4
Annual increment <1.0cm-girls 45 0.4 1.2 2.4 91 0.5 1.5 3.0
Foursix-monthly increments <0.5cm-boys 50 -0.2 0.4 1.8 101 -0.3 0.4 1.7
Foursix-monthly increments <0.5cm-girls 45 -0.2 0.3 1.2 91 -0.3 0.5 1.5
terval with the largest increment was
re-corded as the age of peak height velocity
(PHV). When two successive increments
were equally the largest, the midpoint of
this combined interval was recorded as
PHV. In none of these children were two
nonsuccessive increments equally the
larg-est. An age of PHV was not recorded if
more than one successive scheduled visit
was missed between 9 and 17 years.
Con-sideration was given to combining
succes-sive six-monthly increments to annual
incre-ments thus eliminating seasonal effects.
This was not done because PHV would be
determined with less reliability which was
not justified by the small seasonal variations
in increments in a subset of the children.
Furthermore, PHV should be considered
the midpoint of the largest increment
re-gardless of the factors, seasonal or
other-wise, that are responsible.
Age at menarche was obtained by
six-monthly
inquiry
at appropriate ages.Recti-linear interpolations were made to obtain
stature at PHV or at menarche because, in
general, these occurred between scheduled
visits. The ages at which the distal end of
the femur and the proximal end of the tibia
became mature were recorded as those of
the first radiographs in which the
corre-sponding epiphyseal lines were completely
obliterated. Children were excluded from
this part of the study if the interval
be-tween this radiograph and the immediately
preceding radiograph of the knee was
greater than 1.7 years. Missing data were
not interpolated to obtain statures at the
ages these bones became mature. The mean
TABLE IV
CENTILES FOR TOTAL INCREMENTS (cm) IN STATURE As’rES GROWTH AND DEVELOPMENTAL LANDMARKS
To Level of 0-d egree Polynomial To Last .Statur e (up to 8 years)
N 10 50 90 N 10 50 .90
PHV-boys 50 12.1 17.9 24.3 78 11.6 17.8 28.7
PHV-girls 44 10.8 16.4 22.8 63 10.8 15.8 22.3
Menarche 44 5.8 7.9 10.7 90 4.3 7.4 10.6
Femurmature-boys 20 0.7 1.5 2.2 31 0.6 1.4 2.7
Femurmature-girls 15 -0.2 0.8 1.7 35 0.3 1.0 2.0
Tibiamature-boys 21 0.4 1.5 2.0 38 0.3 1.2 2.3
*01 IN YEAtS
Fic. 1. Graphs of stature against age for two girls differing markedly in age at menarche. The girl with menarche at 11.6 years (No. 255) grew much more after menarche and for a longer period than the girl with menarche at
15.2 years (No. 261).
ages at which PHV and menarche occurred
were similar to those in other healthy Ameri-can childrenll (Table I). Skeletal age was recorded as the mean of the bone-specffic skeletal ages of the left hand-wrist. These
were obtained using the Greulich-Pyle
at-las.’
Applying the method of Mellits14’15 two
polynomial lines were fitted to all available
stature data between the age of PHV and
28 years for each individual. A 2-degree
polynomial was fitted to the earlier data
and a 0-degree polynomial was fitted to the
latter data. Piecewise regressions were
cal-culated to locate the junction between
ear-lier and later data subsets at which the
goodness of fit was maximized for the two
lines (2-degree polynomial; 0-degree
poly-nomial) considered together. This was
ac-cepted as the age at which the individual
reached his adult stature. When the chosen
junction was placed so that there was only
one later datum point, the individual was
excluded from the study unless data
re-corded for stature and recumbent length
af-ter 28 years justified acceptance of this
junction as the age of achieving adult stat-ure. Nine boys but no girls were excluded for this reason. The level of each 0-degree
polynomial (horizontal straight line) was
accepted as the adult stature for each
indi-vidual. The piecewise regression method
provided very reliable estimates of the lev-els of adult stature attained but less reliable
estimates of the ages at which this
oc-curred. In some individuals, the goodness of
fit for the two polynomial lines combined varied only slightly between some junctions. Furthermore, after 18 years, the data points
were at two-year intervals. Consequently, it
was impossible to determine, precisely and
reliably, the age at which adult stature was reached.
RESULTS
In some serial growth studies, data collec-tion is terminated for individual children
when one annual increment in stature is
less than 1.0 cm. This policy is based on the belief that little or no increase in stature occurs after this time. Annual increments in
stature, whether commencing at birthdays
or half birthdays, were reviewed to identify
the earliest annual interval during which
each child grew less than 1.0 cm. The
me-dian ages at the latter ends of these
inter-vals were 17.5 years in the boys and 15.5
years in the girls (Table I). In each sex, the
range from the 10th to the 90th centile was
about 2.5 years. In other serial growth stud-ies, data collection stops when a child first
has four successive six-monthly stature
in-crements that are each less than 0.5 cm. In
the present children, the median ages at the latter ends of these two-year intervals were 19.5 years in the boys and 18.5 years in the
those at which adult stature was reached in
the girls but not the boys. Presumably,
more girls than boys reached their adult
statures during the first two-year period in
which four successive six-monthly
incre-ments were each less than 0.5 cm.
The children studied reached their adult
statures at median ages of 21.2 years
(boys) and 17.3 years (girls) (Table II).
It was expected that these ages would tend
to be later in boys than in girls but it was not anticipated that the sex-associated
dif-ference between these medians would be so
large. There was a wide range in each sex
with growth continuing in 10% of the boys
until 23.5 years and in 10% of the girls until 21.1 years.
Growth in stature tended to continue
longer after PHV in the boys than in the
girls, with wide ranges in each sex. The
centiles for these intervals were similar,
within each sex, to those for the intervals
between the attainment of skeletal age 13
years (boys) or 11 years (girls) and the
ages at which adult stature was reached.
After menarche, growth in stature
contin-ued for almost five years at the 50th centile level and for 6.7 years at the 90th centile level.
Centiles have been calculated for total
increments in stature (sun#{238}of all
six-monthly increments) after particular
land-marks of growth and development (Table
III). The centiles were similar whether
adult stature was considered as the level of the 0-degree polynomial or the last stature
recorded between 22 and 28 years. The
mean differences between these two
esti-mates of adult stature were small (boys:
mean, 0.04 cm; SD, 0.4 cm; girls: mean, 0.2
cm; SD, 0.4 cm) with the last stature
tend-ing to be slightly greater. Despite the
smaller sample size, the level of the
0-de-gree polynomial is preferred because it was
derived from more than one datum point
and, consequently, would be affected less
by measurement error. Predictably, growth
in stature after 16 or 18 years was greater in
boys than in girls. From the viewpoint of
either stature prediction or growth study
design, it is important to note that 10% of
these children grew at least 1.9 cm (boys)
or 1.2 cm (girls) after 18 years of age. The
negative total increments after 18 years at
the 10th centile levels reflect technical
er-rors of measurement involving posture and
other factors. These errors would have
in-creased the range of the distribution of
in-crements lowering the 10th centile levels
and raising the 90th centile levels. It is
rea-sonable to assume that the errors were ran-dom in direction and had little effect on the 50th centiles (medians).
The centiles for further growth in stature,
after the first annual increment of less than
1 cm, were similar in each sex. The medians
for these increments were at least 1 cm and
the 90th centiles exceeded 2 cm. After the
first four successive six-monthly increments
that were each less than 0.5 cm, the median
total increments were small in each sex.
However, the 90th centile levels for total
increments exceeded 1 cm in each sex, even
after this two-year period.
The centiles for growth in stature after
PHV were greater in the boys than in the
girls (Table IV) but the ranges from the
10th to the 90th centiles were similar in
each sex. The increases in stature after PHV
were large with median values that
ex-ceeded 15 cm in both the boys and the girls. Growth in stature after inenarche differed
markedly between the girls studied but was
considerable even at the 10th centile level.
The total stature increments (sum of all
six-monthly increments) after menarche
were associated with the age at which
menarche occurred (n = 96; r = 0.51;
p < .0005). This highly significant relation-ship is illustrated in Figure 1.
Centiles were calculated also for total
in-crements in stature after the distal end of
the femur or the proximal end of the tibia
had become mature. Due to the small
sam-ple sizes for this part of the study, the 10th
and 90th centiles are unreliable, but they
were similar within each sex, for further
the tibia had become mature. There was a
tendency to more growth in the boys than
in the girls after either of these maturity levels had been reached.
DISCUSSION
The use of piecewise regressions to
deter-mine the age at which adult stature was
reached and the level of adult stature
at-tained in each individual appears
appropri-ate. The ages and levels obtained from
these statistical analyses were found to be
acceptable when checked against the raw
data for each individual. Furthermore, the
almost zero mean differences between adult
statures obtained from the levels of the
0-degree polynomials and the last statures re-corded before 28 years affirm the validity of the method used.
The median values from the present
study direct attention to sex-associated
dif-ferences in the form of late adolescent
growth curves for stature. The girls reached
PHV about two years earlier than the boys
but were about four years younger than the
boys when they reached their adult
stat-ures. The first annual increment of less than
1.0 cm occurred two years earlier in the
girls than the boys but the first series of
four successive six-monthly increments,
each less than 0.5 cm, occurred only one
year earlier in the girls than the boys.
Ap-parently, the rate of growth in stature
de-celerated more rapidly in the girls than the
boys soon after PHV but there was a lesser
sex-associated difference in the rates of final deceleration to zero increments.
Haskel and Bflchi5 reported mean
in-crements in stature for girls after 18 and 20
years, respectively. These findings are not
in conflict with the present conclusion that
the girls reached their adult statures at a
median age of 17.3 years. There was a wide
range of these ages with the 90th centile for this age at 21.1 years. This is consistent with the occurrence of positive mean incre-ments after 20 years. The findings
concern-ing growth in stature after menarche are in
general agreement with those of Fried and
Smithl6 who studied a large sample until
the end of attendance at secondary school.
In the children studied during the present
investigation, there was a slight tendency to
greater growth in stature in the boys than
the girls after either the femur or the tibia
had become mature. Presumably, this late
phase of growth in stature reflects
elon-gation of the trunk and involves increases
in the heights of vertebral bodies rather
than intervertebral disks.17
The total increments in stature (sum of
all six-monthly increments) were too large, particularly at the 90th centile level, to al-low acceptance of views that, for practical
purposes, growth in stature has ceased at 18
years, at the first annual increment that is less than 1.0 cm or when the femur or tibia has become mature.8’#{176}’18 The operating
cri-terion that growth in stature has ceased
when four successive six-monthly
incre-ments are each less than 0.5 cm is prefera-ble to the others considered, except in girls. Their growth in stature after this two-year
interval is similar to their growth after 18
years. The piecewise regression method
re-quires data extending beyond the age after
growth in stature ceases. Consequently, it is
not recommended for determining when
data collection should cease for an
individ-ual.
Late adolescent growth in stature is
im-portant in the management of children
re-ceiving therapy intended to alter potentials
for growth in stature. The findings indicate
the ages after which such therapy is likely to be ineffective. In addition, they are rele-vant to the provision of a reliable method
for the estimation of adult stature using
childhood parameters. The current tables
used for this purpose estimate stature at 17
or 18 years.8 This differs substantially from adult stature in some girls and most boys.
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Acknowledgment
