基于初潮时骨龄预测女童初潮后身高剩余生长潜力的横断面调查

doi:10.3969/j.issn.1673-5501.2021.02.004

摘要/Abstract

摘要： 背景初潮是女童进入青春发育后期的重要标志,也是身高干预的最后一个机会窗口期,且初潮受多种因素影响、个体差异很大。正确认识和掌握女童初潮后的生长规律和特点,可为临床实践中不同初潮年龄女童的终身高评估和干预决策的制定提供参考依据。目的通过分析女童初潮时年龄、骨龄和体格发育特征,探讨初潮后预测终身高(PAH)的临床评估方法。设计横断面调查。方法回顾性收集2008至2018年于首都儿科研究所附属儿童医院(我院)生长发育门诊就诊、有女童月经初潮时间、体格测量数据、骨龄X片的病例。排除初潮时间与就诊时间间隔≥3个月的病例、病历诊断中有明确的影响儿童生长发育的疾病、病历诊断中有明确病因引起的继发性中枢性性早熟或外周性性早熟和既往使用过生长激素或促性腺激素释放激素抑制剂药物的病例。按事先定义的方法计算实际年龄、骨龄、身高的标准差分值(HtSDS)、PAH和预测生长潜力、骨龄HtSDS(HtSDS_BA)和女童遗传身高,3名儿童保健科医生从纸质或电子病历中按照纳入和排除标准筛选病历、提取数据和判断,单人录入至Epidata数据库。以初潮年龄每1岁为段分组,以初潮时骨龄每0.5岁为段分组。主要结局指标 初潮骨龄、PAH和预测生长潜力。结果 ① 694例女童的初潮年龄8.5~13.2(10.7±1.1)岁,初潮时骨龄12.4~12.8(12.4±0.6)岁。②初潮年龄越小的女童,骨龄提前越多,HtSDS也越高。例如,8~岁组骨龄提前(3.8±0.5)岁,HtSDS为2.6±1.3;13~岁组骨龄落后(0.7±0.7)岁,HtSDS为-1.05±0.59。骨龄校正后不同初潮年龄组的平均HtSDS_BA为-1.17~-0.68,组间差异较小。③初潮后的预测生长潜力为(7.3±2.6)cm,生长潜力仅与初潮时的骨龄高度负相关(r=-0.960,P<0.001),骨龄从11.0~岁组到13.0~岁组,平均生长潜力从12.7 cm降至4.0 cm(F=1 194.393,P<0.001)。④本研究获得PAH计算公式[0.868×身高(cm)-3.754×骨龄(岁)+73.677],拟合优度R²=0.992,据此计算预期达到不同终身高的女童初潮时身高应达到的临界值。例如,女童初潮时骨龄为12岁,PAH达到150 cm则初潮时身高应＞139.8 cm,PAH达到160 cm初潮时身高应＞151.3 cm。结论女童初潮时骨龄相对稳定,骨龄是反映身体成熟度和预测月经来潮的可靠指标,也是预测初潮后生长潜力的关键指标。

关键词: 初潮, 骨龄, 身高, 生长潜力

Abstract: Background Menarche is an important sign for girls to enter the late stage of puberty, and it is also the last opportunity for girls' height intervention. As menarche is affected by many factors and has great individual differences, correcting understanding and mastering the growth pretention and characteristics of girls at menarche can provide reference for the final height evaluation and intervention of girls with different menarche age in clinical practice.Objective To analyze the age, bone age (BA) and physical development characteristics of girls at menarche to explore the clinical evaluation method of predicting final height (PAH) after menarche.DesignCross-sectional survey.Methods We retrospectively collected the data of girls with menarche time, physical measurement and X-ray of bone age who visited the Department of Growth and Development of Children's Hospital Affiliated to Capital Institute of Pediatrics from 2008 to 2018. We excluded the cases with the interval between menarche time and visit time longer than 3 months, with clear diseases affecting children's growth and development, with clear etiology causing secondary central precocious puberty or peripheral precocious puberty, and those previously treated by growth hormone or Gonadotropin-Releasing hormone inhibitors. According to the inclusion and exclusion criteria above, three professional pediatricians screened medical records in paper or in electronic forms, extracted and chose data, and finally entered all selected data into Epidata database by a single person. The chronological age, bone age, HtSDS, HtSDS_BA, predicted final height (PAH) and predicted growth potential were calculated according to the pre-defined methods. The menarche age was divided by interval of 1 year, and the BA at menarche was divided by interval of 0.5 year.Main outcome measures BA at menarche, PAH and predicted growth potential.Results a. MA of 694 girls was 10.7±1.1 years and BA at menarche was 12.4±0.6 years. The average MA of different groups varied from 8.5 to 13.2 years, but the BA at menarche was stable, ranging from 12.4 to 12.8 years. b. The BA at menarche was closely related to their growth level. The youngest MA group had the most advanced BA and highest HtSDS. For example, the BA of 8-year-old MA group was 3.8±0.5 years advanced and their HtSDS was 2.60±1.32 while the BA of 13-year-old MA group was 0.7±0.7 years behind, and their HtSDS was -1.05±0.59. However, the average HtSDS_BA of different MA groups ranged from -1.17 to -0.68, with few differences between groups. c. The PAH-Ht of girls after menarche was 7.3±2.6 cm which was highly negatively correlated with BA at menarche (r=-0.960, P<0.001). The average PAH-Ht of girls decreased from 12.7 cm to 4.0 cm when the BA at menarche increased from 11.0 to 13.0 years (F=1,194.393, P<0.001). d. According to the formula of PAH we derived from this study (R²=0.992), we can calculate the cut-off point of height at menarche in accordance with different PAH. When the BA at menarche is 12 years, for example, the height at menarche should be higher than 139.8 cm with PAH higher than 150 cm, and the height at menarche should be higher than 151.3 cm with PAH higher than 160 cm.Conclusion The BA of girls at menarche is relatively stable. BA is a reliable index to predict menstruation and evaluate the growth level of girls. For girls after menarche, BA can also accurately predict their growth potential.

Key words: Menarche, Bone age, Height, Growth potential

武华红, 李阳, 郭佳运, 李辉. 基于初潮时骨龄预测女童初潮后身高剩余生长潜力的横断面调查[J]. 中国循证儿科杂志, 2021, 16(2): 99-103.

WU Huahong, LI Yang, GUO Jiayun, LI Hui. Prediction on residual growth potential of girls after menarche by bone age at menarche: A cross-sectional study[J]. Chinese Journal of Evidence-Based Pediatrics, 2021, 16(2): 99-103.

参考文献

[1] SAID-MOHAMED R, PRIORESCHI A, NYATI L H, et al. Rural-urban variations in age at menarche, adult height, leg-length and abdominal adiposity in black South African women in transitioning South Africa. Ann Hum Biol, 2018, 45(2): 123-132.
[2] IBITOYE M, CHOI C, TAI H, et al. Early menarche: A systematic review of its effect on sexual and reproductive health in low- and middle-income countries. PLoS One, 2017, 12(6): e0178884.
[3] LI S, WANG X, ZHAO Y, et al. Combined therapy with GnRH analogue and growth hormone increases adult height in children with short stature and normal pubertal onset. Endocrine, 2020, 69(3): 615-624.
[4] LAZAR L, LEVY S, ORON T, et al. The beneficial effect of combined GH/GnRHa therapy in increasing adult height outcome in children with ISS. J Clin Endocrinol Metab, 2019,104(8): 3287-3295.
[5] WANG Z, DANG S, XING Y, et al. Correlation of body mass index levels with menarche in adolescent girls in Shaanxi, China: a cross sectional study. BMC Womens Health, 2016, 16: 61.
[6] 中华医学会儿科学分会内分泌遗传代谢学组青春发育调查研究协作组. 中国九大城市女孩第二性征发育和初潮年龄调查. 中华内分泌代谢杂志, 2010, 26(8): 669-675.
[7] 李辉, 季成叶, 宗心南, 等. 中国0~18岁儿童、青少年身高、体重的标准化生长曲线. 中华儿科杂志, 2009, 47(7): 487-492.
[8] 王春林, 梁黎, 留佩宁, 等. 促性腺激素释放激素类似物联合重组人生长激素对中枢性性早熟女童身高的影响. 中国当代儿科杂志, 2014, 16(1): 25-30.
[9] TANNER J M, GOLDSTEIN H, WHITEHOUES RH. Standards for children's height at ages 2-9 years allowing for height of parent. Arch Dis Child, 1970, 45(244): 755-762.
[10] 刘丽艳, 刘宝林. 早发月经初潮女生的手腕骨发育特征. 中国学校卫生, 2008, 29(10): 886-887.
[11] 刘宝林, 张慧颖, 孙健, 等. 女性不同初潮年龄的手腕骨发育特征. 中国公共卫生学报, 1996, 1: 56-58.
[12] TANNER J M, WHITEHOUSE R H. Standards for subcutaneous fat in British children. Percentiles for thickness of skinfolds over triceps and below scapula. Br Med J, 1962, 1(5276): 446-450.
[13] DENG Y, LIANG J, ZONG Y, et al. Timing of sperarche and menarche among urban students in Guangzhou, China: trends from 2005 to 2012 and association with Obesity. Sci Rep, 2018, 8(1): 263-270.
[14] DURDA-MASNY M, HANCT, CZAPLA Z, et al. BMI at menarche and timing of growth spurt and puberty in Polish girls - longitudinal study. Anthropol Anz, 2019, 76(1): 37-47.
[15] 张迪, 程颖, 白春玉. 月经初潮年龄与骨龄和形态指标关系的研究. 中国学校卫生, 2000, 21(4): 300-301.
[16] 季成叶, 吕姿之, 叶恭绍. 骨龄及其它发育指标与月经初潮关系的研究. 中华医学杂志, 1982, 62(9): 528-530.
[17] MOLINARI L, GASSER T, LARGO R. A comparison of skeletal maturity and growth. Ann Hum Biol, 2013, 40(4): 333-340.
[18] GHAEMI N, GHAHRAMAN M, NOROOZI ASL S, et al. Novel DNA variation of GPR54 gene in familial central precocious puberty. Ital J Pediatr, 2019, 45(1): 10.
[19] 高海涛, 李阳, 李辉. 不同营养状况下儿童青少年骨龄发育提前或落后的风险分析. 中国循证儿科杂志, 2020, 15(2): 114-117.
[20] SINGLETON A, PATOIS E, PEDRON G, et al. Increment in height of the upper segment and bi-iliac diameter after menarche in young girls. Longitudinal study of 40 adolescents. Arch Fr Pediatr, 1975, 32(9): 859-869.
[21] CASTILHO SD, SAITO MI, BARROS FILHO ADE A. Post-menarcheal growth in a cohort of Brazilian girls. Arq Bras Endocrinol Metabol, 2005, 49(6): 971-977.
[22] TANNER JM, WHITEHOUSE RH, MARSHALL WA, et al. Prediction of adult height from height, bone age, and occurrence of menarche, at ages 4 to 16 with allowance for midparent height. Arch Dis Child, 1975, 50(1): 14-26.
[23] TANNER JM, LANDT KW, CAMERON N, et al. Prediction of adult height from height and bone age in childhood. A new system of equations (TW Mark II) based on a sample including very tall and very short children. Arch Dis Child, 1983, 58(10): 767-776.