GROWTH

MONITORING

Dr. Priti Khemka

Consultant,
Institute of Child Health
12.06.2020
1. What is growth
2. Normal growth
3. Assessment of growth
4. Which growth charts to use
5. Standards of growth
6. How to monitor growth
7. Faltering growth
 • Growth- increase in size/mass of living being
Growth vs as result of increase in size/ no of cells and/
or increase in intracellular matrix
Development
• Development- process of attainment
of functional maturity
A
GROWING
CHILD IS A
HEALTHY
CHILD
 To identify children
with growth
deviation

AIMS OF
To discuss health
GROWTH promotion
MONITORING

Reassurance of
parents about their
child’s health
FETAL GROWTH
• Upto 16 weeks- slow rate- <10 g/week
• 16-28 weeks- accelerated- 85 g/week
• 28-37 weeks- maximal rate- 200 g/week
• 37-42 weeks- 70 g/ week
 RATES OF GROWTH-Birth to 6 years

AGE WEIGHT LENGTH HC

0-3 months 30 g/day 3.5 cm/month 2 cm/month

3-6 months 20 g/day 2 cm/month 1 cm/month

6-9 months 0.5 kg/month 1.5 cm/month 0.5 cm/month
9-12 months 0.5 kg/month 1.2 cm/month 0.5 cm/month
1-3 years 2 kg/year 1 cm/month 0.25 cm/month
4-6 years 2 kg/year 5 cm/year 1 cm/year
Half of adult height attained by 2 yrs in girls and 2 ½
yrs in boys.
 5 years to puberty
• Weight -2 kgs/yr
• Head circumference-2-3 cms in the entire period
• Height- 4.5- 6 cms/yr
Puberty-
• Girls- 7-11 cms/yr
• Boys- 7-13 cms/yr
RED FLAG
• Growth velocity <4.5 cm/year
ICP model of
Karlberg
 Weight

X spring balance
Beam balance
Electronic scale

Infants nude, children minimal clothing, remove footwear

Correct zero error
Infants weight to nearest 10 g, children to nearest 100 g
TARING

Setting a temporary zero point

scale can be re-set to zero (“tared”) with the person (mother)
just weighed still on it.
While remaining on the scale, if she is given her child to hold,
the child’s weight alone appears on the scale.
SALTER WEIGHING SCALE
For growth monitoring, it is the change in weight
over a period of time which is most important, rather
than the weight itself.
More than 80% babies with IUGR show catch up
growth by 2 yrs of age
Height/length

• <2 yrs- recumbent length- Infantometer

• >2 yrs- Stadiometer
Infantometer
• baby naked
• 2 person required
• Head in the frankfurt vertical plane
Length

Stadiometer
• Socks and shoes off
• Heels, buttocks, shoulder blades, back of head touching the
wall
• Frankfurt plane parallel to the ground
Children with severe spinal deformity or cerebral
palsy who cannot stand

• Measure arm span as indicator of height

What is the best predictor of child's
final adult height?

• For girls= Father's ht+ mother's ht-13

2
• For boys= Father's ht+ mother's ht+13
2
TARGET HEIGHT & TARGET HEIGHT CENTILE
Head circumference/ OFC

• Flexible non stretchable tape

• The measuring tape should be passing:
• At the front over the supraorbital ridges and
• At the back around the occipital prominence
• Measure to nearest 0.1 cms
Newborns- measure head circumference after 36 hrs
to avoid error due to caput
Mid upper arm circumference

• To assess nutritional status of children 6 mo- 5yr

• To identify malnutrition in community settings
• When child’s age not known or weight, height cannot be
measured
GROWTH VELOCITY

Rate at which child grows over a period of time

• Single point on the growth chart is not informative
• When several points are plotted, it reflects, the progress of
growth

Growth velocity (cms)=

Present height- Initial height(cms)
Time period between 2 measurements (yrs)
When to monitor growth?

• At birth
• Immunization contacts at 6, 10, 14 weeks
• 6, 9, 15-18 months
• 18 months-5 yrs- 6 monthly
• > 5yrs- annually
• At other clinic visits
STEPS IN GROWTH MONITORING

Step 1: Determining correct age of the child

Step 2: Accurate weighing of the child
Step 3: Plotting the weight accurately on a growth chart of
appropriate gender
Step 4: Interpreting the direction of the growth curve and
recognizing if the child is growing properly
Step 5: Discussing the child’s growth and follow-up action
needed, with the mother
MOST POWERFUL TOOL IN GROWTH MONITORING IS
THE GROWTH CHART
GROWTH CHARTS

• Provide a visual record of the growth pattern of a child.

• Potent tool for diagnosing faltering growth, nutritional
problems & monitoring response to therapeutic interventions
• For parents, reassurance about children’s growth & feeding
practices
• Most children grow between 3rd to 97th centile (+/-
2 SD)
• Crossing over of 2 major centile lines is abnormal
• Any child whose growth curve is flattening or falling
needs action
GROWTH CHARTS

CDC 2000

WHO 2006

IAP 2015
Growth standards vs Growth
references

• Growth standards- show how children grow in ideal

circumstances. How children should grow.
PRESCRIPTIVE

• Growth reference-How children actually grew.

DESCRIPTIVE
GROWTH CHARTS

CDC 2000 (growth reference)

WHO 2006 (growth standards)

IAP 2015 (reference)

 1964-1994

Weight data from original 1977

Population-USA, mixed feeding

CDC 2000
Birth –20 yrs

Cross sectional data

Reference charts
 1997-2003

Primary data for 0- 5 yrs, reconstructed NCHS

data 1977 for > 5yrs

Birth to 19 yrs

WHO 2006 Multicentre (6 countries-USA, India, Ghana, Norway,

Brazil, India), healthy breast fed children

Cross sectional & longitudinal data

Growth Standards

Recommended for children<5 yrs, irrespective

of ethnicity
 Data collected more than 20 yrs back
(1988-1991)

No longer used

Birth to 18 yrs

IAP 2007
Affluent Indian population, mixed
feeding, multicentric

Cross sectional data

Reference charts
 2005-2014

5-18 yrs

Affluent Indian population,

IAP 2015 multicentric

Cross sectional data

Reference charts
WHO growth standards are considered ideal for
growth assessment in children up to 5 year age.

Beyond 5 years, genetic, nutritional & environmental

factors including timing of puberty increasingly
influence growth, hence local population derived
growth references are preferred.
 HOW TO USE GROWTH CHARTS
Use age & sex appropriate chart

Enter name, DOB, other details

All the points on the growth chart should be marked only as dots and not circles around the
dot.
Record height, weight (and HC till 3 years) and plot on the chart

At all subsequent visits join the dot up to the previous dot.

Measure the parents height. Calculate the child’s target height and plot it at 18 years. The
target range is produced by plotting two points 8 cms above and below the target height
Explain to parents

Remind parents of the time for the next measurement

What is abnormal?
• Measurements above 97th percentile/ > 2SD
• Measurements below 3rd percentile/ < 2SD
• Crossing over of 2 major centile lines
• Wt/age<-2SD underweight, <-3 SD severely
underweight
• Ht/age <-2SD stunted, <-3 SD severely stunted
• Ht/age <-2SD short stature
• Wt/ht <-2SD wasted, <-3 SD severely wasted
• BMI <2 SD underweight, >2 SD overweight, >3 SD-
obese
MOBILE/
COMPUTER
APPLICATIONS
Growth monitoring in neonates

Weight daily
Length, HC weekly

Weight loss upto 10% for term, upto 15% for preterms
Regain birth weight by 10-14 days

Weight gain 20-30 g/day or 15-20 g/kg/day

HC 0.7 cm/week
Length 1 cm/week
WHICH GROWTH CHARTS TO USE?

 For term babies- WHO growth charts

 Preterm babies-
• Intrauterine growth charts-
o Lubchenco
o Olsen
• Postnatal growth charts
o Wright
o Ehrenkranz
o Intergrowth 21st
• Fetal-infant growth charts
o Fenton 2013
 Plotting growth charts

Preterm growth charts

(Fenton, Intergrowth etc) For preterms, corrected age
upto 40 weeks, then can upto 2 yrs
switch to WHO growth chart
• Chronological age-14 weeks
Born Preterm at 28 weeks
No of weeks premature= 40-28=12 weeks
• Corrected age=14- 12= 2 weeks
 RED FLAGS
• Length/height, weight or HC <3rd percentile
or > 97th percentile
• Crossing of two major percentile lines
(upward or downward) e.g., going from above
75th percentile to below 50th percentile on
height or weight chart.
• A child below or above mid parental range
for height/length
•Micropenis
• Unilateral or bilateral undescended testis
• Ambiguous genitals
 3-9 years
• BMI over the 85th percentile at all ages.
• Rate of growth less than 5 cm/year.
• Girls with axillary, pubic hair growth or breast budding
before 8 years and boys with axillary, pubic hair growth,
genital growth or and testicular enlargement before 9
years.
• Children with craniospinal irradiation or surgery for
brain tumors.
9-18 years
• Unilateral or bilateral Gynecomastia in boys
• Hirsuitism and Menstrual irregularities in girls
• Delayed puberty that is girls with no breast budding by
14 years or no menarche by 15 years and boys with no
signs of puberty by 16 years.
Case 1
• 6 yr old boy presents with Wt 20 kgs, Height 100
cms (US 60 cms, LS 40 cms) , grossly delayed
developmental milestones & developmental age of
2 yrs. His calf muscles are quite bulky.
• How will you proceed?
• What is the most likely clinical diagnosis ?
• How will you investigate?
US 60 cms, LS 40 cms
• US:LS =1.5
BODY PROPORTION
• US:LS- 1.7 at birth, 1:1 at 10 yrs age, 0.9:1 after
adolescence

• Arm span < height at birth, equal at 10-11 yrs, then

arm span>height by 5cms in males & 1 cm in
females
• Increased US:LS -
achondroplasia, hypochondroplasia,
hypothyroidism

• Decreased US:LS- Marfan, scoliosis

• Arm span > height -Marfan, scoliosis

• Arm span< height- Achondroplasia
Case 1
• 6 yr old boy presents with Wt 20 kgs, Height 100
cms (US 60 cms, LS 40 cms) , grossly delayed
developmental milestones & developmental age of
2 yrs. His calf muscles are quite bulky.
• How will you proceed?
• What is the most likely clinical diagnosis ?
• How will you investigate?
• 6 yr old boy presents with Wt 20 kgs, Height 100
cms (US 60 cms, LS 40 cms) , grossly delayed
developmental milestones & developmental age of
2 yrs. His calf muscles are quite bulky.
• How will you proceed?
• What is the most likely clinical diagnosis ?
• How will you investigate?
• Short and obese child
• Disproportionate short stature with infantile
proportions
• Delayed milestones
D/D
• Achondroplasia, hypochondroplasia
• Hypothyroidism
• Skeletal X ray
• Thyroid hormones

CONGENITAL HYPOTHYROIDISM
 Normal variants
Constitutional
Familial/ genetic

Chronic diseases

IUGR
Proportionate
Chromosomal anomalies,
dysmorphic syndromes

SHORT Nutritional
STATURE Psychosocial

Short limbs
Achondroplasia
hypothyroidism

Disproportionate
Short trunk
Spondylo-epiphyseal dysplasia
MPS
STEPWISE APPROACH TO SHORT
STATURE
• Detailed history, clinical exam, anthropometry
• Level 1- CBP, urine, stool, Skeletal X rays for bone
age
• Level 2- thyroid profile, karyotyping
• Level 3- Coeliac serology, IGF1, IGFBP1, provocative
growth hormone testing
CASE 2
• 1 month old male infant admitted with poor
feeding, poor weight gain
• Birth weight- 3.2 kgs
• Current weight -2.5 kgs
• On formula feeds
• Dehydrated, normal systemic examination, no
dysmorphism
• Normal genitalia
Failure to Thrive
It is a description, not a diagnosis

• Weight <3rd centile

• Change in rate of growth crossing 2 major centiles
over a period of time
CAUSES
• Poor dietary intake
• Chronic illnesses
• Malabsorption
• Metabolic
• Social and emotional deprivation
DIAGNOSIS
• History
• Dietary history
• Physical exam
• Anthropometry  growth charts
• Observe parent child interaction (psychosocial
causes)
Investigations
• CBP, urine, stool
• CXR, LFT, renal function tests, electrolytes
• Na 125, K 6.1, Urea 40, Creat 0.5, mild metabolic
acidosis

• CAH suspected25OH progesterone sent

• Hyponatremia and hyperkalemia corrected
• Hydrocortisone, fludrocortisone started
How does a growth chart help
determine the diagnosis of failure to
thrive?
THANK
YOU!