Growth and development

The processes of growth and development are governed by many factors, including the inherent capacity of tissues for growth and differentiation, the hormonal influence of the endocrine system, and the stimulatory signals from the nervous system. In the amount of time from the 10th to the 20th week of pregnancy, the fetus grows 12.7 cm (5 inches) in length. This phenomenal growth rate slows dramatically as birth approaches.

Birth weight is an important marker of nutrition during gestation and an important predictor of growth following birth. Low birth weight is common among infants of mothers whose family histories include low birth weight, and it may also be an indication of premature birth or of poor intrauterine nourishment. Rapid growth occurs during infancy and then slows until the onset of puberty, when it increases strikingly for several years. The pubertal growth spurt lasts 2 to 3 years, and it is accompanied by the appearance of secondary sexual characteristics. The pubertal growth spurt is associated with both an increase in nocturnal secretion of growth hormone and an increase in serum concentrations of sex steroids. The growth potential of a child can be estimated with moderate accuracy from measurements of the child’s height and the heights of the parents and from measurements of the child’s skeletal, or bone, age.

Accurate estimates of bone age in children can be made from X-rays of the hands and wrists. These X-rays reveal the extent of maturation of the epiphyses (growth centres) of bones, which allows the bone age of the child being examined to be compared with the bone age of healthy children of the same chronological age. In children with endocrine disorders, bone age may not correlate closely with chronological age. For example, bone age is delayed in children with growth hormone deficiency and accelerated in children with growth hormone-producing tumours. Hyperthyroidism, even when it occurs in the developing embryo, is associated with an increase in bone age, whereas hypothyroidism is associated with a decrease in bone age. Children with Cushing syndrome not only have osteoporosis but also have delayed growth and bone age. Excess production of androgens or estrogens in childhood is associated with an increase in growth rate and an acceleration of epiphyseal maturation so that bone age is advanced. The excess production of androgens and estrogens ultimately causes premature closure of the epiphyses and short stature. Deficiency of androgens and estrogens during crucial periods of growth in childhood leads to a delay in epiphyseal maturation (retarded bone age), and, consequently, in adulthood affected individuals have long arms and long legs and a normal trunk (eunuchoid habitus, or height that is equal to or less than arm span).

Endocrine-related developmental disorders

There are a number of growth and developmental disorders that arise from aberrant sexual differentiation during embryonic development. Many of these disorders result from abnormalities in the number of sex chromosomes. Humans possess a total of 46 chromosomes, two of which are sex chromosomes, designated X and Y. Individuals with two X chromosomes (XX) are female, and individuals with one X chromosome and one Y chromosome (XY) are male. Examples of conditions that affect sex chromosomes, and hence growth and development, include Klinefelter syndrome (47,XXY, 48,XXYY, 48,XXXY, 49,XXXYY, and 49,XXXXY), Turner syndrome (45,X, 46,XX, 45,X, and 47,XXX), and hermaphroditism (46,XX).

Ectopic hormone and polyglandular disorders

There are several syndromes of hormone hypersecretion that are caused by the unregulated production of hormones, usually by tumours. Ectopic hormone production involves the synthesis and secretion of peptide or protein hormones by benign or malignant tumours of tissues that do not normally synthesize and secrete the particular hormone. The hormone that is most commonly produced ectopically is adrenocorticotropic hormone (ACTH), resulting in ectopic Cushing syndrome. This syndrome occurs most often in patients with small-cell carcinomas of the lung (SCLC), but it can occur in patients with carcinoid tumours (benign or malignant tumours that secrete hormonelike substances such as serotonin), islet-cell tumours of the pancreas, and carcinomas of many other organs. Many patients with ectopic corticotropin production have the symptoms and signs of Cushing syndrome, as well as intense pigmentation, caused by hypersecretion of ACTH, and severe depletion of potassium (hypokalemia), caused by the mineralocorticoid action of high serum cortisol concentrations. Treatment ordinarily involves surgical removal or drug-induced destruction of the tumour. However, in cases in which the tumour cannot be removed or its function reduced, adrenalectomy (removal of the adrenal glands) or treatment with a drug such as ketoconazole, an antifungal drug that inhibits adrenal steroid synthesis, may be more effective.

Ectopic hormone production can result in numerous abnormal hormone-related physiological conditions, including hypercalcemia (increased serum calcium concentrations), hyponatremia (decreased serum sodium concentrations), hypoglycemia (decreased blood sugar concentrations), and acromegaly (excess production of growth hormone). Tumour-induced hormone production (or production of hormonelike substances) can cause many of these conditions. For example, hypercalcemia can be caused by tumour production of parathyroid-hormone-related protein (structurally similar to parathormone) or, rarely, by tumour production of parathormone, 1,25-dihydroxyvitamin D₃ (the active form of vitamin D in animal tissues; sometimes called calcitriol, or 1,25-dihydroxycholecalciferol), or interleukins (mediators of immune response). Hypercalcemia can also be caused by the invasion and destruction of bone tissue by a tumour. Hyponatremia can occur as a result of vasopressin (antidiuretic hormone) secretion, usually by small-cell carcinomas of the lung, and hypoglycemia may be caused by tumour production of insulin-like growth factors or, very rarely, insulin. Acromegaly is caused by tumour production of growth hormone or, very rarely, tumour production of growth hormone-releasing hormone (GHRH). Treatment is aimed at removing the offending tumour, reducing the size or activity of the tumour, or mitigating the effects of the hormone that is produced in excess.

Production of thyrotropin, luteinizing hormone, and follicle-stimulating hormone by nonpituitary tumours does not occur. Similarly, the production of steroid or thyroid hormones by tumours of tissues that do not normally produce these hormones does not occur. This may be because these hormones have a high degree of structural complexity, with multiple rings, chains of amino acids, and carbohydrate molecules, and the production of these hormones is dependent upon genes expressed by the tumour that are required to produce the multiple enzymes involved in hormone synthesis. The placental hormone known as human chorionic gonadotropin, which is structurally similar to luteinizing hormone and has similar biological properties, is produced by tumours of cells of embryonic origin, such as hepatoblastomas and chorionic tumours (e.g., hydatidiform moles and choriocarcinomas), and is occasionally produced by other tumours. The clinical effects of excess chorionic gonadotropin production include precocious pubertal development in children, ovarian hyperstimulation in women, and estrogen excess in men. Chorionic tumours that produce very large amounts of chorionic gonadotropin can cause hyperthyroidism, since this hormone also has weak thyroid-stimulating activity.

There also are several genetic disorders characterized by hormone-producing tumours of several endocrine glands. In these disorders, known as multiple endocrine neoplasia (MEN), affected patients have germ line mutations (heritable mutations that are incorporated into all of the cells of the body) in genes that predispose them to endocrine gland hyperplasia (an abnormal increase in the number of cells in the gland) and tumour development. The tumours may occur in more than one endocrine gland and may appear simultaneously or at varying times in the course of the disease. The embryonic origin of the cells of the endocrine glands that are involved may also be different. In addition, there exist multiple endocrine deficiency disorders (polyglandular autoimmune syndrome), in which affected persons have deficiencies of multiple endocrine glands caused by autoimmune destruction of the glands. Multiple endocrine deficiency disorders result in multiple hormonal deficiencies and are suspected to be caused by underlying heritable genetic mutations.