Growth monitoring

1. COPP MODULE
COMMON OFFICE PRACTICE PEDIATRIC PROBLEMS
[A MODULE OF IAP TAMILNADU STATE CHAPTER 2017]

2. TEAM
• Scientific advisors Dr P Ramachandran, Dr S Balasubramanian
• Conveners Dr S Thirumalai Kolundu, Dr Sunil Srinivasan
• Scientific Coordinator Dr A Somasundaram
• Academic coordinators Dr S Narmada, Dr R.V Dhakshayani
• Academic committee [MODERATORS]
• Dr NC Gowrishankar,
• Dr T N Manohar,
• Dr K Nedunchelian,
• Dr Rema Chandramohan,
• Dr R Somasekar,
• Dr S Thangavelu,
• Dr V V Varadarajan

3. CONTRIBUTORS
Dr RV Dhakshayani Dr A Somasundaram
Dr Giridhar Dr Somu Sivabalan
Dr Hemchand K Prasad Dr S Srinivas
Dr E Mahendar Dr P Sudhakar
Dr S Mangalabharathi Dr Sudharshana skanda
Dr Manikandan Dr B Sumathi
Dr Manikumar Dr Suresh
Dr S Narmada Dr Venkateshwaran
Dr Palaniraman Dr C Vijayabhaskar
Dr R Selvan

4. Dr.Hemchand
MBBS,MD,Fellow in Pediatric Diabete,PDCC
• Head of the Department and Consultant-in-charge,
Department of pediatric endocrinology and diabetes, Mehta
Children’s Hospital
• Trained under Dr. Vaman Khadilkar
• Speaker in International and National forums
• 12 peer reviewed publications in Pediatric endocrinology
• 76 state, national and international lectures in paediatric
endocrinology
• 26 chapters in paediatric endocrinology in various text books.

5. GROWTH MONITORING
Dr Hemchand K P
Reviewed by
Dr Thangavelu S

6. Why should a paediatrician monitor
growth of a child under his care?
• Barometer of well being in a given child.
• Important pillar of preventive care.
• Helps - reassure normalcy
• Helps - identify growth disorders, nutritional
disorders & systemic diseases, early.
Khadilkar V, Khadilkar A. Growth charts: A diagnostic tool. Indian J Endocr Metab. 2011;15(Suppl 3):S166–71.

7. What is the difference between growth
standard and reference?
Growth reference
• Descriptive chart - from a
population which is believed
to be growing under optimal
health and nutrition.
• Eg: Old IAP charts
Growth standard
• Prescriptive standard from a
population where - possible
environmental & nutritional
variables controlled
• Sole independent instrument
upon which decisions are made
• Eg: WHO Standards from
MGRS study
Vaman Khadilkar, Supriya Phanse. Growth charts from controversy to consensus. Indian J Endocrinol Metab 2012 Dec; 16 (Suppl 2): S185-S187

8. Why should all paediatricians use the same
chart and cut-offs for interpretation?
10 year old boy with height of 124 cm
10 year old boy BMI 19.1 kg/sq m
IAP 3rd percentile 123.6 – NOT SHORT CDC – short
WHO 2007 – short
Khadilkar charts – short (< 124.3 cm)
Marwah charts - short (< 125.4 cm)
CDC (20.4) – Normal
IOTF using adult 25 kg/sq m – Normal
Marwah 85th percentile – Normal
Khadilkar 75th percentile - Normal
K N Agarwal (18) – Overweight
IOTF using adult 23 kg/sq m – Overweight
Marwah 85th percentile – Overweight
WHO 2007 - Overweight

9. What are the anthropometric measures a
paediatrician should record in his office practice?
IAP growth monitoring guidelines for paediatricians in 2007.
A - Note – even if the child < 2 years can stand – prefer to use the length
Khadilkar V, Khadilkar A, Choudhury P, Agarwal A, Ugra D, Shah N. IAP Growth Monitoring Guidelines for Children from Birth to
18 Years. Indian Pediatr. 2007;44:187–97.
Age Measurement Frequency
0-2 years
2-5 years
>5 years
Length(A) weight and
head circumference
height, weight and
head circumference
height, weight, BMI
SMR (Tanners stage)
0, 6, 10 and 14 weeks, 6, 9, 15, 18
months (every vaccination visit)
every 6 months
every 6 months till 9 years and
annually there after
Every year

10. What growth charts should a paediatrician
use in office practice?
Combined IAP – WHO charts from birth to 18 years (0-5 WHO and 5-18 IAP)
are also made available for continuous growth monitoring
Onis M, Garza C, Onyango AW, Martorell R. WHO Child growth standards. Acta Pediatr. 2006;95(Suppl 450):S1–101.
Khadilkar V, Yadav S, Agarwal KK, Tamboli S, ,Banerjee M, Cherian A et al. Revised IAP growth charts for height, weight and body
mass index for 5- to 18-year-old Indian children. Indian Pediatr 2015; 52(1):47-55.
Age Chart recommended
< 5 years IAP modified WHO charts
> 5 years IAP 2015 5-18 charts

11. Why has IAP made this recommendation?
WHO 2006 standards IAP 2015 references
Nature Prescriptive Prescriptive for BMI; descriptive
for other aspects of growth
Norm Breast feeding Good nutrition and health
Statistical methods LMS method of statistics LMS method of statistics
Exclusion of obese Yes Yes
IAP 2015 references – most recent, prescriptive for BMI,
excludes obese, robust.Statistical tools – recommended by the IAP

12. WHO charts (IAP modified)
• Please enter the name and DOB
• Single page – assesses – Height/ length, weight and
head circumference
• Back side – Weight for height
• ONLY 4 LINES (4 percentiles) – for convenience
• Expressed both percentile and Z score
• Vertically – 1 dark line – 15 days
• Vertically – 1 light line – 1 week
• Horizontally – 1 line represents 1 cm or 1 kg

15. 15

16. 16

19. How should a paediatrician plot on the
growth chart?
• Enter the name, date of birth on the chart.
• Growth is marked with a dot (not circle or cross) at point of
intersection of measure (on the y-axis) and the chronological
age (on x-axis).
• Each year is divided as 12 months – NOT DECIMAL AGE.
• When you make subsequent measurements on same chart,
join the points by a line.
• Remind the parents of the next growth measurement and
explain your findings to them and reassure them.
Khadilkar V, Khadilkar A, Choudhury P, Agarwal A, Ugra D, Shah N. IAP Growth Monitoring Guidelines for Children from Birth to
18 Years. Indian Pediatr. 2007;44:187–97.

20. How To Adjust For The Family Size?
• Target Height also known as the adjusted mid
parental height is calculated as follows:
• Boy: (MHT+FHT+13)/2
• Girl: (MHT+FHT-13)/2
• This height is plotted at 18 years of age on the chart
• Target range is 6 cms below and above the target
height

21. How are the new charts more user friendly
and parent friendly?
• The IAP modified WHO charts allows one to plot –
weight, height and head circumference on a single
page and at convenient 15 day intervals.
• The weight, height (0-18) and BMI (5-18)
measurements can be plotted at 6 monthly intervals
on the 0-18 year charts.
• The BMI and weight for height charts in 0-18 charts
and 0-5 charts are colour coded – red colour
indicating obesity.

22. What is new in these current recommendations?
Previous Current
What chart should be used in a
child <5 years
WHO 2007 standards IAP modified WHO charts
What chart should be used in a
child >5 years
Old IAP charts IAP 2015 charts
Combined WHO-IAP2015 charts
Definition of short stature <3rd percentile in growth monitoring
guideline or <5th percentile on old IAP
charts
<3rd percentile on the new IAP chart
Overweight >85th percentile of BMI >23rd adult equivalent of BMI
Obesity >95th percentile of BMI >27th adult equivalent of BMI
Plotting age Decimal age On accurate months
Target range 8.5 cm above and below target height 6cm above and below target height

23. Height < 3rd percentile -
stunting
Height < 0.1st percentile –
severe stunting
Weight < 3rd percentile -
underweight
Weight < 0.1st percentile –
Severe underweight
How to recognise abnormal growth?

24. Height < 3rd percentile -
stunting
Weight < 3rd percentile –
NO INTERPRETATION

25. Weight for height < 3rd
percentile - wasting
Weight for Height < 0.1st
percentile – severe wasting
Weight for height > 99th
percentile - Obesity

26. BMI < 3rd percentile -
wasting
BMI > 23rd adult equivalent
– overweight
BMI > 27th adult equivalent
- Obesity

27. 27
< 5 years >5 years
Height Stunting
Severe stunting
< 3rd percentile
< 0.1st percentile
< 3rd percentile
-
Weight Under weight
Severe underweight
< 3rd percentile
< 0.1 percentile
-
-
BMI
(Weight for height is
< 2 years)
Wasting
Severe wasting
Overweight
Obesity
< 3rd percentile
< 0.1 percentile
>97th percentile
> 99th percentile
< 3rd percentile
-
>23rd adult equivalent
>28 adult equivalent
Crossing of 2 major
percentiles
Abnormal growth 6 month period
(infancy)
1 year period (older
child)

28. What should a paediatrician do in case of
recognition of abnormal growth?
• Check the accuracy measurement/ plotting
• Look at the trend of deviation (a single cross
sectional measure has limitations - growth does not
always follow a smooth curve)
• A line is drawn from the plotted point to the 50th
percentile and vertically downwards to touch the x-
axis
• This is the corresponding height age (HA) & weight
age (WA)
• CA (chronological age) = HA = WA – in a normal child

29. CA > HA > WA – has nutritional
deprivation or systemic disease

30. CA > WA > HA – has endocrine disease

31. WA > HA > CA – has nutritional obesity

32. WA > CA > HA – has endocrine obesity

33. HA > WA > CA – has precocious puberty

34. Abnormal growth Interpretation Disorder
CA = HA = WA
CA > HA > WA
CA > WA > HA
WA > HA > CA
WA > CA > HA
HA > WA > CA
No growth abnormality
Poor growth
Wasted more than stunted
Poor growth
Stunted more than wasted
Overgrowth
Tall and obese
Overgrowth
Short and obese
Overgrowth
Isolated tall stature
Normal child
Nutritional / systemic
Endocrine/ skeletal
disorder
Nutritional obesity
Pathological obesity
Precocious puberty
Summary of interpretation of abnormal growth

35. What is the role of bone age in growth
assessment?
• Bone age complements growth assessment.
• Speaks of the growth potential of a given child.
• Bone age should be assessed using the Tanner
whitehouse method or a Greulich pyle atlas.
• Bone age is plotted at the point of intersection of
current height (y-axis) and bone age (x-axis).
Greulich WW, Pyle SI: Radiographic atlas of skeletal development of the hand and wrist, 2nd edn. Stanford, CA: Stanford University Press, 1959.
Tanner J, Oshman D, Bahhage F, Healy M: Tanner- Whitehouse bone age reference values for North American children. J Pediatr 1997; 131:34-40.

36. How should a paediatrician assess the
growth of a LBW preterm baby?
The growth curves for preterm babies have been
developed similar to the WHO 2007 standards –
intergrowth 21st post natal standards. These standards
must be used in preterm babies will they reach term
gestational age.
Downloadable from: https://intergrowth21.tghn.org/articles/
Villar J, Giuliani F, Fenton TR, Ohuma EO, Ismail LC, Kennedy SH. INTERGROWTH-21stConsortium. INTERGROWTH-
21st very preterm size at birth reference charts. Lancet 2016;387:844-5.

37. Miscellaneous tit bits
• All girls must have their growth plotted on pink chart and boys on
the blue chart. Plotting growth on the chart for opposite sex is
unacceptable.
• Weight should not be measured more than once in 15 days and 30
days – during and beyond infancy, respectively. This is to avoid
unnecessary anxiety.
• It is preferred to interpret weight in conjunction with height and not
in an isolated perspective.
• Practical difficulty exists in plotting children < 5 years on 0-18 charts

38. Miscellaneous tit bits
• Crossing two major percentiles in 6 months and 1 year is pathological
in infancy and childhood.
• The growth charts committee recommends Weight for height to diagnose
wasting and obesity in the under 5 age group.
• The term Severe Acute Malnutrition (SAM) was defined by WHO for health
workers based on Weight for Height Z-score <-3 - should be used beyond 6
months.
• Percentiles and Z-scores are interchangeable. For uniformity and ease,
percentiles are preferable
• IAP growth charts app (for android phones) available for growth
monitoring of Indian children

39. Well child in a
paediatricians clinic
<2 years - height, weight and head circumference every vaccination visit
2-5years – height, weight and head circumference every 6 months
>5 years – height, weight, BMI and SMR (every 6 months till 9 years and
annually thereafter)
Target height in > 5 year age group
<5 years – IAP
modified WHO charts
>5 years – use combined WHO-IAP
2015 charts from 0-18 years
Height 3rd to 97th percentile
Weight 3rd to 97th percentile
BMI/ weight for height 3rd to 97th
percentile/ 23rd adult equivalent
Follow up
Calculate height age, weight
age and chronological age
CA > HA > WA – has nutritional
deprivation or systemic disease
CA > WA > HA – has endocrine disease
HA > WA > CA – has precocious puberty
WA > CA > HA – has endocrine obesity
WA > HA > CA – has nutritional obesity
No
Yes
Summary

40. THANK YOU