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Journal of the Anatomical Society of India

Bone Age Based Linear Growth and Weight of Under Privileged North west Indian Children Compared with their Well-Off North west Indian Peers

Author(s): G. Pathmanathan, P. Raghavan

Vol. 55, No. 2 (2006-07 - 2006-12)

G. Pathmanathan(1), P. Raghavan(2)
(1)Panjab University, Chandigarh , (2)Australian National University, Canberra

Abstract:

The Radius, Ulna and the Short Bone Age (RUS BA, TW2 System) based linear growth – Stature, Sitting Height, Subischial Leg Length and Weight of under privileged NW Indian children (445B and 342G) were compared with their well-off peers.

Contrary to the normal observations that it is the females who withstand the adverse conditions better, in the present study, compared to the well-off children, the linear dimensions of the under privileged girls showed lesser attained means at each Bone Age. Surprisingly, the boys’ means were more or less on par till adolescence; thence the difference sets in leading to lesser adult values in the undernourished group. This may probably be due to the operating social factors in this part of the world where male child is preferred and favoured. Unlike the Chronological Age based typical distance growth curves in the RUS BA based distance linear growth curves the boys showed larger means throughout. In weight both the sexes of the economically weaker section were more or less on par. However these children were much lighter compared to their well-off Bone Age peers.

Key Words: Bone Age, linear Growth and weight, under privilesed children, North West Children

Introduction:

Apart from its clinical application, the information inherent in the progress of skeletal maturity necessitates its incorporation as an important research criterion in understanding the variations in human growth and development. Thus, as it is for clinicians, it is also an equally important research tool for physical anthropologists particularly the human auxologists in augmenting the knowledge of discrete patterns of maturation displayed by various populations and the unequivocal role played by the genetic factors that control the scenario of maturation.

Besides this is the only scale of maturation that covers the entire period of childhood through adolescence. Unlike that of sexual maturation the maturity milestones are same in both the sexes. A substantial number of earlier reports on the time of appearance of ossification centres and a few others on the fusion of the same with the respective mataphyses in Indian children gave very limited information in understanding the progress of skeletal maturation during the intervening period (Eveleth &Tanner 1976, Prakash & Cameron 1981). This intervening period commences from the time of appearance of the ossification centres of the epiphyses and its final phase, i.e., ossification of the epiphyseal cartilaginous plates leading to their functional destruction and their ultimate fusion with the metaphyses/emergence of adult characteristic configurations in certain bones (round bones) is completed by the end of puberty. It is during this period that the skeleton progresses towards maturity and the characteristic adult form gradually becomes apparent.

It is the most important phase for understanding the rate and pattern of skeletal maturation, the underlying factors influencing them that eventually lead to human morphological variations. Despite the modern techniques to appraise this information, it has not been possible to use them widely in the Indian subcontinent except for a few reports (Maniar et al. 1974a, Maniar et al.1974b, Prakash & Bala 1979, Prakash & Cameron 1981, Prakash & Sharma 1985) which have employed modern techniques to estimate attained mean bone ages of young Indian children belonging to different socioeconomic levels.

The Status of growth of children is better related with the rate of skeletal maturation. Thus it is the tempo of the maturation of the skeleton that determines the comparative status of physical growth of a child (Tanner et al. 1983, Tanner 1978a, b, Takai 1981). Therefore, in research, various clinical situations and to assure the worried parents it is important to interpret child growth in terms of Skeletal Age rather than Chronological Age alone. Besides, Calendar age may not be known especially in rural and tribal populations. From earlier studies it became clear that the welloff NW Indian children run faster on the road to maturity compared to the Standards i.e., their British counterparts.

In the present study we present the differences in Physical growth (The General Body Dimensions) of the under privileged NW Indian school going children at various skeletal maturity age points compared to their well-off Bone Age peers.


Fig. 1: Attained means of height

Fig. 2: Sitting height

Fig. 3: Subischial leg length

Fig.4: Weight of the underprivileged NW Indian
children based on their RUS Bone Age
(TW2 System).

Subjects and methods

This study was conducted in Chandigarh, NW India.

Sample

a. The Underprivilegd

The sample consists of 445B and 342G belonging to the under privileged section of the Chandigarh population. They were contacted in Government primary and high schools of Chandigarh. The parents were interviewed to know whether the children suffered from any chronic illness or any illness that lasted more than two weeks and required prolonged treatment during the past 6-12 months prior to the examination. By and large the families were large with more than two children and the parents were mostly illiterate or studied up to the primary school level. They were either daily wage earners, Class IV employees working in any Government/private organizations, houses etc., and few of them were doing their own petty business.

b. The well-off

The details of the well-off children can be had from Pathmanathan & Prakash (1991b).

Auxological Anthropometry

Height and Sitting height were taken by a single measurer (GP) using the Harpenden range of instruments – The Stadiometer and the Sitting Height Table (Holtain Ltd., Crymmych, Pembrokeshire, Wales, Great Britain) in the Auxological Laboratory, Department of Anthropology, Panjab University, Chandigarh. All these measurements were taken in the morning and the subjects were requested to wear minimum possible clothes. Slight upward pressure was applied beneath the mastoid process as described in Cameron (1986) to minimize the diurnal variations in these measurements. Weight was measured with the help of a AVERY beam balance to the nearest .5gm.GP’s reliability in taking these measurements was high (Table 1a.).

Table 1a. Replicability of the Anthropometric measurements

Measurements Within Measurer Smeas
Stature 0.20±.01
Sitting Height 0.22±.02
Weight 0.11±.11

A radiographer took the left hand wrist radiographs of these subjects on the same day. The positioning of the left hand and the anode film distance were kept strictly as per instructions of Tanner et al.1983 for assessing the Skeletal Maturity in the TW2 System. Cassettes with intensifying screens were used.

Rating

The rating technique was practiced by GP for sufficiently long time on about 50 radiographs belonging to different chronological age categories. Radiographs were shuffled and picked up at random for rating.

Thirty-five films from a different collection were rated by GP twice after an interval of about two months. The ratings of these films done by Dr. Noel Cameron of Institute of Child Health, London were also available for comparison. The reliability of the Skeletal Maturity ratings ‘within’ and ‘between’ raters is presented in Table 1b.

Table 1b: Replicability/Comparability of the Skeletal Maturity

Ratings
Bone Maturity rater
Smeas ‘within’
rater
Smeas ‘between’
Scores
RUS 8.5 9.0

Results

The attained means and standard deviations based on Radius, Ulna and the Short Bone Age of the General Body Dimensions i.e., Height, Sitting Height, Subischial Leg Length (Height – Sitting height) and Weight for the under privileged NW Indian children from Chandigarh are given in Table 2. The same are displayed in Figs. 1- 4.

It becomes clear that the underprivileged boys are larger at every bone age point compared to their female counterparts especially in the linear measurements. Even though both the sexes are closer to each other at the younger bone ages they depart from each other from about 8 years RUS BA onwards. Thus towards the end of the maturity scale the boys become much larger. The Figures also show a trend in flattening of the curves in boys (fitted according to eye approximation) whilst the girls fail to show the same. However the attained means of Weight show a somewhat different pattern. Here both the sexes are closer to each other till about 12 years RUS BA. There after the girls and boys show almost similar means till the formers’ full bone maturity i.e. 16 years RUS BA.

Discussion

During the pilot survey it was felt that the parents/ guardians of the underprivileged children were not very clear about the dates of birth of their wards. Some of them claimed that the Date(s) of Birth of their children were written on the walls of their houses, trees of their courtyards even on the base of the kitchen utensils which very many times got distorted or illegible during the course of time. And in numerous occasions the parents did not even know which date belongs to which child. Most of the parents related the Dates of Birth (DOB) of their children with the events that occurred in the lives of the popular local figures – politicians, film stars and prominent sportspersons i.e. mainly cricketers and a sizable number even recalled the DOBs of their wards with relationship to the release of popular movies. Even though matching of seasons/events at the time of birth of the child to help them come closer to the actual date, this may not yield the desired results. Thus the CA based attained means might even lead to spurious results. Therefore the authors decided to base the Attained Means of the General Body Dimensions of the under privileged NW Indian children on their RUS Bone Age and compare them with the same of their well-off NW Indian age peers.

Maturation of the Skeleton – the change of the cartilaginous and membranous skeletal frame of a fetus to the fully ossified bones of an adult except at the areas of articulation – takes place throughout childhood and adolescence. This process i.e., the gradual molding of the cartilaginous model into bony one, called Osteogenesis by deposition and resorption, is the prime cause for the size increment. Under normal circumstances Physical Growth and Skeletal Maturation proceed together. They “start together and must stop together” (Acheson 1954). Therefore when the proliferative cartilage has metamorphosed into the bony tissue “the faculty for physiologic growth has gone forever”. Thus osteogenesis, “is a growth process but on the contrary is exclusive of growth” (Acheson & Hewitt 1954, Acheson 1957).

Assessment of the Skeletal Maturation to estimate the extant of abnormality and also treating the same in various clinical situations is important. It is also important to assess the normal variations that lead to Morphological Variations. Therefore, in Human Auxology it is an equally important tool for the Auxologist as it is for the clinicians to study and understand the underlying genetic and environmental factors that control the various stages of maturation and ultimately, the process of Growth.

In this study an important point that comes to the fore front is the Bone Age range between the two samples i.e. the well-off and that of the under privileged. Both the samples were collected from the schools of the same locale, from the lowest class to the highest class of the schools. This means that the samples were supposed to be chronologically similar. However, The RUS Bone Age of these samples varies considerably. The well-off children ranged in their Mean Bone Age between 6 and 18 years, while the underprivileged sample ranged between 4 and 18 years in their Bone Age. Besides this, the flattening of the growth curves of the General Body Dimensions in the well-off children shows that the chronologically similar (i.e., between 6 and 16 year old children) samples there were many well-off children who have reached full bone maturity even before 16 years CA and thus the adult value in physical growth. Whereas in the underprivileged sample who were supposed to be between 6 and 16 years chronologically, their Bone age ranged between 4 and 18 years. They reach their adult value later than their well–off counterparts (Figs. 5-12). The distribution of the percentage frequency in these two samples (Figs. 13 and 14) shows that the frequency of the well-off group is more during the adolescence while the frequency of the fully matured children are more in the under nourished group.

This means that the chronological age of these economically weaker children are not very reliable. On investigation with the school authorities and the class teachers, it became clear that many of the under privileged children repeat many classes due to many reasons such as poor performance mainly stems from poor attendance, lack of interest in studies, unable to buy the required books on time, lending a helping hand to the parents in house hold chorus, in doing petty jobs etc. This again confirms the point that chronologically these two samples of well off and the under privileged NW Indian age peers cannot be matched.

When compared to the well-off age peers the under privileged children show lesser attained means at every bone age points which is clearly displayed by the girls (Figs.5 – 12). Among the boys, The undernourished group is very close to that of the well-off boys rather more or less on par till about 14 years RUS BA. There after the differences in the attained means step in. As a result, the well – off boys end up at a mean height of 168cm. as adults, whereas the deprived children end up somewhere between 165 -168cm.

Similarly, the attained means of the girls show that they depart from each other from 11 years onwards and the well-off girls end up at 155 cm. as adults whence their age peers from deprived society end up around 148cm. as adults i.e., at 16 years RUS BA.

In Sitting Height the boys of both the sample lie close to each other. In fact both the samples share the same attained mean values from 9 -11 years and at 15 years RUS BA as well from where the well–off means depart to flatten out at about 88cm. whereas the unprivileged lag behind by about a couple of centimeters. The Sitting Height attained means in girls again show a similar pattern as that of the Height. The adult value in the well-off girls is reached 82cm. while the means of the 16 years RUS BA underprivileged girls remain around 80cm.

The Subischial Leg Length also shows a similar trend as that of Sitting Height in the boys as well as in the girls. The Undernourished children are lighter indeed much lighter compared to their well-off age peers. These become more pronounced around 7 years BA onwards. Skeletal Maturity is affected by various factors that are genetic and environmental in origin. That is the genetically determined pattern of Skeletal Maturity can also be altered by environmental factors as well. Climate is a factor that can alter the pattern of Skeletal Maturation (Weiner 1964) and eventually the physical Growth for, it is not uncommon to see poor nutrition, low temperature and hypoxia lead to delayed maturity in high altitudes (Eveleth 1986).

Our earlier studies of Skeletal Maturation of the well-to-do NW Indian children displayed that the Indian children are way ahead in their Skeletal Maturity compared to the Tanner et al (1975) Standards except towards the end of the maturational periods where they become on par with the British children. The well-off Indian boys are advanced by about one year and their female counterparts by about two years compared to their English peers (Pathmanathan and Raghavan communicated to Homo)

The actual ‘genetic potential’ of a child/population cannot be assessed without controlling the nutrition, parasitic load, etc. It is a well-accepted fact that illness or starvation even for a shorter duration of time or in milder forms are known to affect the growth in height permanently i.e., bring about stunting (Tanner 1976, Cutting et al. 1987, Prakash et al. 1988). And the final adult height of a child ‘growing under favourable’ conditions depends on heredity (Tanner et al 1975).

Normally adverse circumstances are known to affect the boys more than the girls (Tanner et al. 1983), but our earlier study also showed that the attained means of the General body dimensions, Triceps and Subscapular Skinfold thicknesses of the deprived boys were very close and indeed more or less on par at certain Bone age points till about 14 years RUS BA to those of well-off boys. In their study on Chronological Age based height and weight of deprived NW Indian school children Prakash and Sharma (1985) also supports this point. This is mainly due to the operative cultural factors in this part of the world where the preference and adoration of the male child is the norm.

Even though growth and Skeletal Maturation are two different processes, in normal circumstances these two proceed together so that in the end of Skeletal Maturity when the epiphysio-diaphysial union takes place, the scope for further linear growth also ceases. But in adverse conditions these two processes may not proceed hand in hand and may depart from each other. If timely corrective measures are not carried out the damages that are effected such as stunting remain permanently.

Under nourishment – low protein and calcium intake lead to retardation in Bone Maturity and eventually the physical growth (Jones & Dean 1956, Masse’ & Hunt 1963, Himes et al. 1975, Blanco et al. 1972). Whatever the extrinsic factors that affect the growth and maturational processes affect boys and girls differently.

Table 2. General Body Dimensions of Under Privileged NW Indian children based on their RUS Bone Age.

Bone Age
Gp.(Yrs.)
Median Bone
Age (Yrs.)
Stature
(Cm.)
Sitting Height
(Cm.)
Subischial Leg
Length (Cm.)
Weight
(Kg.)
  Mean SD Mean SD Mean SD Mean SD Mean SD
4 4.03 .29 101.33 6.25 57.34 2.76 43.99 5.55 15.75 1.54
5 4.94 .34 107.89* 8.59 59.84 2.39 48.05 6.64 17.02 1.65
6 6.12 .29 109.77* 6.44 60.70 2.49 49.50 5.11 17.78 1.51
7 6.99 .31 115.56 4.74 62.63 2.44 52.73 3.53 18.90 1.99
8 7.93 .30 121.29 7.28 64.28 3.17 57.01 4.91 21.19 4.45
9 9.01 .30 125.51 9.60 66.28 4.73 59.26 6.24 22.71 5.12
10 10.04 .28 127.76 8.59 67.57 4.04 59.91 5.21 23.75 4.10
11 10.90 .25 132.48* 9.80 68.82 5.27 63.66 6.17 25.97 4.38
12 11.97 .27 135.32 7.72 70.20 3.67 65.21 5.40 26.64 4.62
13 12.88 .27 140.95* 8.64 72.91 3.76 68.04 5.80 29.86 5.35
14 14.11 .46 143.73* 8.80 75.35 4.48 68.12 5.00 34.30 6.67
15 14.99 .23 146.79 4.76 76.89 3.12 69.90 2.99 33.60 4.28
16 15.91 .14 151.47 5.93 80.01 3.10 71.46 3.96 40.74 6.49
Boys
4 4.10 .31 104.44 7.85 58.05 3.45 46.36 6.18 16.52 2.32
5 5.15 .27 110.27 10.03 60.98 4.46 49.29 6.07 17.63 3.92
6 5.98 .32 118.42 9.52 63.56 3.88 54.82 7.01 19.62 3.25
7 7.04 .30 120.34 5.24 65.01 2.50 55.27 3.24 20.65 2.29
8 7.90 .29 126.33 6.44 67.19 2.90 59.09 3.93 22.89 3.13
9 8.92 .26 133.33 7.14 69.75 2.95 63.58 4.74 25.90 3.90
10 10.01 .30 135.30 5.61 70.73 2.97 64.59 3.68 26.28 3.30
11 10.99 .31 140.24 9.53 72.63 5.13 67.61 5.37 28.92 5.54
12 12.02 .27 140.52 5.44 72.66 2.49 67.81 3.81 28.97 3.00
13 12.86 .26 147.1 98.00 75.92 4.22 71.27 4.30 32.15 4.56
14 14.04 .29 154.95 6.20 78.01 5.77 76.94 5.76 37.78 6.19
15 15.12 .34 158.18 4.23 81.92 1.42 76.2 63.14 41.31 5.48
16 16.15 .24 160.95 3.69 83.62 2.17 77.32 1.94 43.62 4.00
17 17.04 .35 158.19 9.77 83.66 5.52 74.63 4.54 43.45 7.06
18 18.17 .14 165.51 6.63 86.01 3.94 79.51 3.63 47.51 7.81

P<0.05 between sexes.


Fig. 5-8 Attained means of Stalure (Fig.5, Fig.6), Sitting height (Fig.7, Fig.8), of the underprivileged NW Indian boys and girls based on their RUS Bone Age (TW2 System) compared with their Well-off counterparts.

Fig. 9-12: Attained means of Subischial Leg Length, (Fig.9, Fig.10), Weight (Fig. 11, Fig 12) of the underprivileged NW Indian boys and girls based on their RUS Bone Age (TW2 System) compared with their Well-off counterparts.

Fig. 13 & 14: Frequency distribution in each RUS Bone Age (TW2 System) group of underprivileged NW Indian boys (Fig. 13) and girls (Fig. 14) compared with their Well-off counterparts.

Acknowledgements

We are thankful to Prof. S. Prakash (retd.), Department of Anthropology, Panjab University, for his constructive criticisms and valuable suggestions.

I am also grateful to the Principals, Staff and the students of Govt. High School, Sector 11, Chandigarh, Govt. High School, Sector 38, (DMC), Chandigarh, Sarvitkari Senior Secondary School, Sector 15, Chandigarh.

References:

  1. Acheson RM (1954). A method of assessing skeletal maturity from radiographs. A. J. Anat. (Lond). 88: 498- 508.
  2. Acheson RM.(1957). The Oxford method of assessing skeletal maturity. Clin. Orthop. 10: 19-39.
  3. Acheson RM (1966). Maturation of the skeleton. In Frank Falkner (ed) Human Development, Philadelphia W. B. Saunders.
  4. Acheson RM & Hewitt D (1954). Oxford child health survey: Stature and Skeletal Maturation in the preschool child. Brit. J. prev. soc. Med. 8: 59–65.
  5. Blanco RA Acheson RM. Canosa C Salomon JB (1972). Retardation in appearance of ossification centres in deprived Guatemalan children. Hum. Biol. 44: 525–536.
  6. Cameron N (1986). The methods of Auxological Anthropometry. In Frank Falkner and J. M. Tanner (eds) Human Growth, Vol. 3. Plenum, New Yor 2nd edition, 3–43.
  7. Cutting WAM, Elton RA Campbell JL, Minton EJ, Spreng JM (1987). Stunting in African children. Arch. Dis. Child. 62:508–509.
  8. Eveleth PB(1986). Population differences in growth. Environmental and Genetic Factors. In Frank Falkner and J. M. Tanner (eds). Human Growth, Vol. 3. Plenum, New York. 2nd edition, 221–240.
  9. Eveleth PB & Tanner JM (1976). Worldwide variation in human growth Cambridge University Press, Great Britain.
  10. Frisancho AR, Garn SM, Ascoli W (1970). Childhood retardation resulting in reduction of adult body size due to lesser adolescent skeletal delay. Amer.J. Phys. Anthrop.33:325–336.
  11. Greulich WW& Pyle SI (1959). Radiographic atlas of skeletal development of the hand and wrist. Stanford University Press , California. 2nd edition
  12. Hauspie RC Das SR Preece MA, Tanner JM (1980). A longitudinal study of the growth in height of boys and girls of West Bengal (India) aged six months to 20 years. Ann. Hum. Biol. 7:429–441.
  13. Himes JH Martorell R Klein RE (1975). Patterns of cortical bone growth in moderately malnourished preschool children. Hum. Biol. 47:337–350.
  14. Jones DRM. & DeanRFA (1956). The effects of kwashiorkor on the development of bones of the hand. J. Trop. Pediat 2:51–68.
  15. Maniar BM Seervai MH Kapur PL (1974a). A study of ossification centres in the hand and wrist of Indian children. Ind. Pediat. 11:203–211.
  16. Maniar BM Kapur PL Seervai MH (1974b). Effect of malnutrition of bones hand in children. Ind. Pediat. 11:213–226.
  17. Masse’G & Hunt EE Jr. (1963). Skeletal maturation in hand and wrist in West African children. Hum.Biol. 35:3– 25.
  18. Prakash S & Bala K (1979). Skeletal maturation in deprived pre-school children of Chandigarh. Ind. J. Med. Res. 70:242–251.
  19. Prakash S & Cameron N (1981). Skeletal Maturity of well-off children in Chandigarh, North India. Ann. Hum. Biol. 8:175-180.
  20. Prakash S & Sharma S (1985). Skeletal maturity of Punjabi pre-school children. Ind. J. Phys. Anthrop. & Hum. Genet. 11:1-8.
  21. Prakash S, Singh G & Chhibber SR (1988). Growth and Nutritional Status of anganwadi children in Morni hills (Haryana). In M. C.Vaidya (ed). Recent Advances in Anatomy. Macmillan, New Delhi ,128–130.
  22. Takai S (1981). Sexual dimorphism in somatic growth viewed from the skeletal maturation, Igaku Kenkyu. Acta Medica. 51:225–237.
  23. Tanner JM (1976). Population differences in body size, shape and growth rate: A 1976 view. Arch. Dis. Child. 51:1–2.
  24. Tanner JM (1978a). Foetus into man. Open Books, London.
  25. Tanner JM (1978b). Education and physical growth. Implications of the study of children’s growth for educational theory and practice. Hodder and Stoughton, London.
  26. Tanner JM Whitehouse RH Marshall WA Healy MJR Goldstein H (1975). Assessment of skeletal maturity and prediction of adult height. (TW2 Method). Academic Press, London.
  27. Tanner JM. Whitehouse RH Cameron N Marshall WA Healy MJR Goldstein H (1983). Assessment of skeletal maturity and prediction of adult height. Academic Press, London. 2nd edition.
  28. Weiner JS (1964). Human Ecology. In Human Biology, an introduction to human evolution, variation and growth. W. A. Harrison, J. S. Weiner, J. M. Tanner and N. A. Barnicot (eds). Oxford University Press. 401– 508.
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