2.pediatric growth

2016 YSMU AFTER M. HERATSI, DEPARTMENT OF PEDIATRICS №1
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Growth
COMPETENCIES
You must…
Know Be able to Appreciate
• When a child՚s growth is of concern
• How to diagnose the common and important
conditions responsible for poor growth in
infants and children, and the principles of
managing them
• The causes of poor weight gain in young
children and babies
• How to advise a child who is suffering from
obesity
• Plot measures on a growth chart
• Weigh and measure a baby and
child accurately and correct for
prematurity
• Calculate BMI
• The stress and anxiety of having a
child with weight faltering (FTT),
especially if there are eating difficulties

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Growth is the progressive increase in the size of a child or parts of a child.
The assessment of growth is very helpful in finding out the state of health and nutrition of a child.
Continuous normal growth and development indicate a good state of health and nutrition of a child.
Abnormal growth or growth failure is a sign of disease. Hence, measurement of growth is an essential
component of the physical examination.
Factors affecting growth and development
Each child’s path or pattern of growth and development is determined by genetic and environmental
factors. The genetic factors determine the potential and limitations of growth. If favourable, the
environmental factors, such as adequate nutrition, facilitate the achievement of the genetic potential of
growth. Unfavourable factors, acting singly or in combination, slow or stop growth. Some of the
unfavourable factors are malnutrition, infections, congenital malformations, hormonal disturbances,
disability, lack of emotional support, lack of play, and lack of language training. To promote optimum
growth, these environmental factors can be removed or minimized. Once they are removed, there follows a
period of catch up growth. During this period the growth rate is greater than normal. This growth rate
continues until the previous growth pattern is reached. Then the growth rate is reduced to the normal rate
determined by the individual’s genetic factors. A child genetically determined to be tall grows slightly
more rapidly than a child genetically determined to be short.
Phases of human growth
Growth phase Growth rate Main determinants of growth
1 Fetal phase - the fastest period of growth,
accounting for about 30% of
eventual height
- Mother’s size and nutrition
- Placental circulation and nutrient supply
2 Infancy
phase
- the fastest period of postnatal
growth, accounting for about 15%
of eventual height
- Adequate nutrition
- Normal thyroid function
* An inadequate rate of weight gain during this
period is called ‘failure to thrive’.
3 Childhood
phase
- a slow, steady but prolonged
period of growth that contributes
40% of final height
- Hormones: growth hormone (GH), thyroxine
and insulin
4 Pubertal
growth spurt
- occurs from the onset of puberty
to fusion of the epiphyses. This
adds 15% to final height
- Growth hormone and sex hormones
(androgens and oestrogens)
* The same sex hormones cause fusion of the
epiphyseal growth plates and a cessation of growth.
If puberty is early, which is not uncommon in girls,
the final height is reduced because of early fusion
of the epiphyses.

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Sex differences in growth
 Growth sprut starts in early puberty but
maximal velocity does not occur untill
middle puberty.
 Puberty begins 2 years later in males than
in females. The growth spurt can last 2 to
3 years, but occurs earlier in females, and
their peak height velocity (PHV) is less,
so their adult height is usually shorter
than males.
 The peak height velocity occurs at a mean
of 13.5 years in boys and 11.5 years in
girls. The weight gain follows the height
gain a few months later.
 Adult males are taller than females as
they have a longer childhood growth
phase, their peak height velocity is higher
and their growth ceases later.
Endocrine regulation of growth
Growth hormone (GH) exerts the major influence on
postnatal growth. GH stimulates the synthesis from
the liver and a number of other organs of insulin-like
growth factors (IGF-1 and IGF-2), which share a
degree of structural homology with proinsulin and
may exert weak insulinlike effects. IGF-1 is thought
to be a major regulator of GH action. It circulates
bound to IGF binding protein-3 (IGFBP-3), whose
concentrations are also regulated by GH. This
complex associates with another GH-dependent
glycoprotein known as acid-labile subunit, the
combination forming a ternary complex.
Fig. The growth hormone/IGF-1 axis. Cytokines act on (1) appetite
centres in the brain affecting appetite and calorie intake; (2) growth
hormone signal transduction in the hepatocyte; (3) proteolysis of
IGFBP-3; (4) IGF-1 expression in the growth plate; (5) proliferation of
growth plate chondrocytes.

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Genetic mutations associated with pituitary hormone deficiencies
• PROP1 gene – the most common, autosomal recessive inheritance, associated with deficiencies of GH (growth
hormone), TSH (thyroid-stimulating hormone), LH (luteinizing hormone), FSH (follicle-stimulating hormone),
ACTH (adrenocorticotrophic hormone) and prolactin.
• POU1F1 (previously known as PIT1) – autosomal dominant or recessive, causes deficiencies of GH, prolactin and
the β-subunit of TSH.
• HESX1 – autosomal dominant or recessive, is expressed in the oral ectoderm that gives rise to Rathke’s pouch,
causes GH deficiency in association with septo-optic dysplasia.
• LHX3 and LHX4 – regulate the proliferation and differentiation of pituitary specific cell lineages, associated with
combined pituitary hormone deficiencies.
Major parameters of physical growth. Anthropometry
1. Body weight
 Weigh babies naked (a wet nappy could change
their weight significantly)
 Weigh older children in only their underwear
 Make sure that the scales you are using have been
properly calibrated
2. Length/height Length
 If a child is less than 2 years old you should measure
their length insteadof their height.
 You need a special piece of equipment and two
people in order to do this properly
 This can be really tricky to do well and often best to
have an experienced person help you if length needs
to be measured
Height
 From 2 years onwards you can measure a child’s
height
 Measure the child’s height with no shoes on
 Make sure that their knees and heels are flat against
the wall or back of the measuring frame
 Use a proper standing frame to measure the child’s
height
 Lift slightly at the child’s head to encourage them to
stand straight but make sure they keep their feet flat
on the floor
Before 2 years of age

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3. Calculation of body mass index (BMI)
— is accepted as best clinical indicator for measure
of under- and overweight
3. Head circumference
 Use a tape measure which is not stretchy! Most units have
disposable paper versions
 Measure around most prominent part of the occiput to the most
prominent part of the forehead
 Take the tape off and reposition to take three measurements
 Record the largest of the three measurements as the head
circumference
4. Dentition
The normal sequence of primary tooth eruption The normal sequence of permanent tooth eruption
5. Bone age
The bone age of a child indicates his/her level of biological and structural maturity better than the
chronological age calculated from the date of birth. Radiography of the hand & wrist is the commonest
modality used to calculate bone age (see "The musculoskeletal system").
6. Mid upper arm circumference (MUAC)
MUAC is the circumference of the left upper arm, measured at the mid-
point between the tip of the shoulder and the tip of the elbow (olecranon
process and the acromium). In children, MUAC is useful for the assessment
of nutritional status. For children aged 6 to 60 months, values below the
cut-offs of 125 mm and 115 mm are used to define moderate and severe
acute malnutrition, respectively (WHO).

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7. Body proportions
Proportionality can be assessed by
measuring the lower body segment, defined
as the length from the symphysis pubis to
the floor, and the upper body segment,
defined as the height minus the lower body
segment. The ratio of upper body segment
divided by lower body segment (U/L ratio)
equals approximately 1.7 at birth, 1.3 at 3 yr
of age, and 1.0 after 7 yr of age. Higher U/L
ratios are characteristic of short-limb
dwarfism or bone disorders such as rickets.
As stature and weight increase, the individual's proportions also change,
from the relatively large head and small torso and limbs of the neonate,
to the adult's relatively small head and long torso and limbs.
CASE
STUDY
A mother brings in her 7-day-old, full-term newborn with concerns that the infant’s
current weight is 10% less than birth weight. What is the next step?
Average growth measurements of normal children
 Newborn infants can lose up to 10% of their birth weight soon after birth, which is due to loss of
extracellular water. The infant should stop losing weight by 5 to 7 days and regain birth weight by 10 to
14 days.
 The average infant doubles their birth weight by 5 to 6 months of age and triples their birth weight by
12 months. Birth height increases 50% by 1 year, doubles by 4 years, and triples by 13 years.
Age Weight Length/height Head circumference
Birth 3 kg 50 cm 35 cm
6 Months 7.0 kg
1 year 10.0 kg 75 cm 46 cm
2 years 12.0 kg
3 years 14.0 kg
4 years 16.0 kg 100 cm
5 years 18.0 kg 50 cm

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CENTILE CHARTS AND ASSESSING GROWTH
There is ample evidence that the growth (height and weight) of well-fed, healthy children from different ethnic
backgrounds and different continents is remarkably similar, at least up to six years of age.
The most powerful tool in growth assessment is the growth chart.
Growth in children is typically assessed by plotting a child’s measurement and age on a gender-specific growth curve.
Growth curves allow clinicians to compare a child’s measurements with those of other children of the same age and
to evaluate patterns in an individual child’s growth if measurements from multiple points in time are plotted on the
same curve.
There are two standard forms commonly used:
- the Centers for Disease Control and Prevention (CDC) charts published in 2000 based on data from multiple
national cross-sectional studies including both healthy children and those with medical problem; the charts consist of
seven centile lines (3rd, 10th, 25th , 50th 75th, 97th).
- the World Health Organization (WHO) charts published in 2006 based on a prospective longitudinal study of
healthy, breastfed children on six continents; the charts consist of five centile lines (3rd, 15th, 50th, 85th, 97th).
Growth
indicators
The growth measurements are presented in five standard charts:
- Length/height-for-age
- Weight-for-age
- Weight-for-length/height
- Body mass index-for-age (BMI, kg/m2)
- Head circumference
Gender Girls – pink charts Boys – blue charts
 Because centile charts are usually used to assess a parameter over time, they are normally presented graphically. The
parameter is shown on the y axis and the age on the x-axis.
 Each chart is composed of five or seven percentile curves, representing the distribution of weight, length, stature, or head
circumference values at each age.
 The percentile curve indicates the percentage of children at a given age on the x-axis whose measured value falls below the
corresponding value on the y-axis.
 By definition, the 50th percentile is the median. It is also termed the standard value.
 The weight-for-height charts are constructed in an analogous fashion, with length or stature in place of age on the x-axis.
 Centile charts show the position of a measured parameter within a statistical distribution. They do not show if that
parameter is normal or abnormal. They merely show how it compares with that measurement in other individuals. If a
parameter such as height is on the 3rd centile, this means that for every 100 children of that age, 3% would be expected to
be shorter and 97% - taller. On the 97th centile, 97% would be shorter and 3% - taller.
 Specialized charts have also been developed for children with various conditions, including Down, Turner, and Klinefelter
syndromes and achondroplasia.

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Growth
monitoring
Centile charts are very useful for assessing growth velocity over time.
 Growth velocity varies during childhood and adolescence, being the fastest during the first year of life,
approximately 25 cm. The rate of growth then decreases, averaging 5 cm/year after age 6 until puberty.
 Child is genetically programmed to stay on one to two growth curves after age 2 yrs and any deviation
should prompt further assessment of growth abnormalities.
 Height percentile at 2 years of age correlates with final adult height percentile.
Final height and target height
Final height is the height reached after the completion of puberty and is estimated to be achieved when
growth velocity has slowed to <2.0cm/year. This can be confirmed by finding epiphyseal fusion of the small
bones of the hand and wrist on assessing the bone age X-ray.
Final height is largely genetically determined. A target height range can be estimated in each individual
from their parent’s heights, first calculating the mid-parental height (MPH).This is calculated using:
MPH (boys) = [(Mother’s height (cm) + Father’s height (cm))/2] + 6.5cm
MPH (girls) = [(Mother’s height (cm) + Father’s height (cm))/2] – 6.5cm
Target height range = MPH ± 10cm

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Use of Z -scores in anthropometry
Z-scores (also known as standard deviation scores, or ‘SD’ scores) are a measure of the distance between the
child’s value and the expected value of the reference population.
SDS (Z-score) = (observed value - median reference value) / z-score of the reference population
Z-scores allow more precision in describing
anthropometric status than does the
customary placement “near” or “below” a
certain percentile curve. For example, the
phrase “below the 3rd percentile” does not
distinguish between a child just below this
point (whose z-score may be -2.1) from one
with severe growth faltering (whose z-score
may be -3.5 or lower)
Fig. Comparison of per-centiles vs. standard deviation or z-scores.
Two SDs below (or above) the mean corresponds to the 3rd (or
97th) percentile.
Expressing anthropometric measures in terms of z-scores is recommended by the World Health
Organization (WHO), especially when describing groups of subjects.
There are CDC computer programs that calculate anthropometric data such as weight for height for age and
weight for height (http://www.cdc.gov/growthcharts/computer_programs.htm); these are expressed as
percentiles, z-scores, and percentage of the median without making recourse to plotting points by hand.
Software for palm-based computers is also available.
1.A newborn presents with weight, length, and head circumference significantly below age-matched norms. What is the
most likely cause?
2. A newborn presents with weight and length below average and head circumference within normal limits. What are some
possible causes?
3. A newborn presents with weight significantly below average with sparing of the height and head circumference. What
are some possible causes?
4. A 1-year-old boy is failing to meet expected norms for weight and height and is noted to have loss of subcutaneous fat,
loss of muscle mass, edema, distended abdomen, and hair loss. These signs are a characteristic of which condition?

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Growth Disorders
I knew a little elfman once
Down where the lilies blow.
I asked him why he was so small,
And why he didn’t grow
He slightly frowned, and with his eyes
He looked me through and through:
‘ I ’ m quite as big for me, ’ he said,
‘ As you are big for you. ’
John Kendrick Bangs
(1862 – 1922)
ASSESSING GROWTH DISORDERS BY CENTILE CHARTS
Growth disorder Parameters
1. Body weight
changes
Underweight
weight-for-age,
weight-for length/height,
BMI-for-age
<3rd centile
Overweight >85th centile
Obesity >97th centile
2. Length/height
changes
Short stature (stunted growth) length-for-age,
height-for-age
<3rd centile
Tall stature >97th centile
3. Head
circumference
changes
Microcephaly
head circumference
<3rd centile
Macrocephaly >97th centile
ASSESSING GROWTH DISORDERS BY Z-SCORES
Z-score
Growth indicators
Length/height
for-age
Weight-for age
Weight-for
length/height
BMI-for-age
Above 3 Very tall A child whose weight-for-age falls in
this range may have a growth problem,
but this is better assessed from weight-
for-length/height or BMI-for-age.
Obese Obese
Above 2 Overweight Overweight
Above 1
Possible risk of
overweight
Possible risk of
overweight
0 (median)
Below -1
Below -2 Stunted Underweight Wasted Wasted
Below -3 Severily stunted Severily underweight Severily wasted Severily wasted

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Failure to thrive (FTT) or faltering growth
This applies to a young child who is not growing well, usually for weight gain.
In practice, this means:
 weight is below the 3rd or 5th percentile for age on more than one
consecutive occasion
 weight drops down two major percentile lines*
 weight is less than 80% of the ideal weight for age
 a child who is below the 3rd or 5th percentile on the weight-for-length
curve
 body mass index (BMI) for age less than the 3rd or 5th percentile
 weight velocity less than the 3rd or 5th percentile
* Unfortunately, no standard uniform approach exists to identify reliably each child who has FTT solely by
use of growth curves. Based on strong research evidence, infants and young children may cross major
percentile lines on growth curves during a normal course of growth.
Mei and associates described shifts in growth curves during the first 60 months of age in a cohort of 10,844 children. Between birth
and 6 months of age, 39% of healthy children crossed two major percentile lines (up or down) on the weight-for-age curve, as did 6%
to 15% of children between 6 and 24 months of age. Similar shifts occurred with the length-for-age curve. Strikingly, on the weight-
for-height curve, 62% of children between birth and 6 months and 20% to 27% of children between 6 and 24 months crossed two
major percentile lines.
Therefore, documentation of weights or lengths falling off of growth channels is not, by itself, proof of
FTT.
FTT is a physical sign of undernutrition, NOT a diagnosis!
In nutritional insufficiency, weight is generally the first to be affected, and the weight for height is low.
But with prolonged duration of malnourishment, length and head circumference may also adversely be
affected. The head circumference declines only in severe FTT.
Nutritional insufficiency must be differentiated from congenital, constitutional, familial, and endocrine
causes of decreased linear growth. In the latter cases, the length declines first or at the same time as the
weight; weight for height is normal or elevated.
Major causes of undernutrition
Illness-related Non-illness-related
 Malabsorbtive diseases, e.g., celiac disease, cystic fibrosis
 Congenital heart defects (CHD)
 Gastroesophageal reflux disease (GERD)
 Neurologic disorders
 Metabolic disease
 Poverty and neglect are important
issues to consider in the evaluation
of a child with failure to thrive.

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Overweight and obesity
Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health.
Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight
and obesity in adults. It is defined as a person's weight in kilograms divided by the square of his height in
meters (kg/m2).
WHO defines overweight and obesity as follows:
OVERWEIGHT OBESITY
For adults BMI greater than or equal to 25 BMI greater than or equal to 30
For children under 5
years of age
Weight-for-height greater than 2 standard
deviations above WHO Child Growth
Standards median
Weight-for-height greater than 3 standard deviations
above the WHO Child Growth Standards median
For children aged
between 5–19 years:
BMI-for-age greater than 1 standard
deviation above the WHO Growth
Reference median
BMI-for-age greater than 2 standard deviation above
the WHO Growth Reference median
High BMI correlates with excess body fat in all age groups and in both genders, with the exception of
persons with very high muscle mass (e.g., "body builders").

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Key facts
 Worldwide obesity has more than doubled since 1980.
 In 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 600 million
were obese.
 39% of adults aged 18 years and over were overweight in 2014, and 13% were obese.
 Most of the world's population live in countries where overweight and obesity kills more people than
underweight. Once considered a high-income country problem, overweight and obesity are now on the
rise in low- and middle-income countries, particularly in urban settings.
 41 million children under the age of 5 were overweight or obese in 2014.
 Obesity is preventable.
Common health consequences of overweight and obesity
Raised BMI is a major risk factor for noncommunicable diseases such as:
 cardiovascular diseases (mainly heart disease and stroke), which were the leading cause of death in
2012;
 diabetes;
 musculoskeletal disorders (especially osteoarthritis – a highly disabling degenerative disease of the
joints);
 some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon).
The risk for these noncommunicable diseases increases, with increases in BMI.
Childhood obesity is associated with a higher chance of obesity, premature death and disability in
adulthood. But in addition to increased future risks, obese children experience breathing difficulties,
increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance and
psychological effects.
Short stature (stunted growth)
Because height is a continuous variable, the definition of “short” involves a selected cutoff; a height that is
more than 2 standard deviations (SD) below the mean for age and sex is the most commonly accepted
threshold.
MAJOR CATEGORIES OF CAUSES OF SHORT STATURE
Normal growth variants Abnormal growth variants
Bone age = Chronologic age Familial short stature Genetic syndromes associated
with short stature
Bone age < Chronologic age Constitutional delay of
growth and puberty
Chronic illness
Nutritional deficiencies
Endocrine disorders

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Normal variants of short stature
Familial short stature (FSS) Constitutional delay of growth and puberty (CDGP)
 The child’s pattern of growth is consistent
with that of his/her parents (and often
siblings, too).
 The child’s growth velocity is usually normal,
so that the growth curve is low, but parallel to
the normal lines. As skeletal growth is not
delayed, the bone age should be within the
normal range (BA=CA).
 The predicted adult height is in keeping with
midparental target height.
 In the absence of a family history of delayed
puberty, the timing of puberty is usually
average.
 Delayed puberty - the absence of pubertal
development by 14 years of age in females and
15 years in males.
 Pubertal growth spurt is also delayed, and these
children continue to grow at the prepubertal
rate of 4 to 6 cm/year while their peers’ height
velocity increases, resulting in a gap between
the heights of children with CDGP and the
heights of age-matched peers — a transient
relative short stature.
These children usually have a normal birth length, begin
to cross height percentiles early in life, and settle in the
lower percentiles by the age of 2 years. Between the ages
of 2 years and the onset of puberty in their peers, the
children’s height velocity usually places them along the
lower margins of the growth curve (around or sometimes
below the 5th to 10th percentile). Then, as their peers
begin the pubertal growth spurt and the growth curve
slope increases, the children with CDGP commonly fall
further below the fifth percentile.

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Pathologic variants of short stature
Endocrine disorders  Hypothyroidism (congenital/autoimmune thyroiditis)
 Growth hormone deficiency (possibly secondary craniopharyngioma
affecting pituitary),
 Corticosteroid excess = Cushing syndrome (usually iatrogenic)
 Pseudohypoparathyroidism
Intrauterine growth
retardation (IUGR)
33% of infants with severe IUGR/extremely premature infants remain short.
Nutritional/chronic
illness
Relatively common cause; children short and underweight secondary to
malnutrition from insufficient food intake, unbalanced diets or anorexia
associated with a underlying chronic disease (coeliac disease, Crohn.s disease,
chronic renal failure, cystic fibrosis, congestive cardiac failure and chronic
hypoxia).
Psychological Emotional deprivation/neglect
Chromosomal disorders Trisomy 21, Turner syndrome (45XO), Noonan syndrome …
Disproportion  Skeletal dysplasias (e.g., achondroplasia, chondrodystrophy)
 Mucopolysaccharidoses
Growth hormone deficiency Albright hereditary osteodystrophy
Growth hormone deficiency that appears during
the first year of life is associated with
hypoglycemia; after the age of 5 years, it is
associated with short stature.
A type of pseudohypoparathyroidism, is characterized by short
stature, obesity, developmental delay, and brachydactyly, specifically
a shortening of the fourth and fifth metacarpals.

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Turner syndrome (45XO) Chondrodystrophy Pituitary dwarfism
Detailed evaluation for short stature warranted when:
• Severe height deficit (<1st percentile for age)
• Abnormally slow growth rate (<10th percentile for bone age)
• Predicted height is significantly different from midparental height
• Body proportions are abnormal
Extensive laboratory tests are generally not indicated unless the growth velocity is abnormally low.
Laboratory testing may include any or all of the following: complete blood count, urinalysis, chemistry
panel, sedimentation rate, thyroxine, thyroid-stimulating hormone, insulin-like growth factor-1 (IGF-1),
and IGF-binding protein-3 (IGFBP-3).
 Depending on the ethnic background of the child or the clinical history, testing might also be done for
celiac disease, inflammatory bowel disease, renal tubular acidosis, or other occult conditions.
 Random growth hormone levels are of little value because they are generally low in the daytime, even
in children of average height.
 IGF-1 mediates the anabolic effects of growth hormone, and levels correlate well with growth hormone
status. However, IGF-1 can also be low in nonendocrine conditions (e.g., malnutrition, liver disease).
 IGFBP-3, which is the major binding protein for IGF-1 in serum, is also regulated by growth hormone.
IGFBP-3 levels generally indicate growth hormone status and are less affected by nutritional factors
than IGF-1. Most endocrinologists now use IGF-1 and IGFBP-3 as their initial screening tests for
growth hormone deficiency.

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Tall stature
• Tall stature is defined as height beyond 97th. percentile (i.e., over 2 standard deviations) of mean for age
and sex.
• Bone age ≥ Chronologic age
− Normal growth variant: familial tall stature, obesity
− Abnormal growth variant: genetic syndromes, endocrine disorders, CNS lesions
Children who are growing above the 97th percentile should be examined carefully for signs of precocious
puberty or adrenal androgen excess.
1. Most children have familial tall stature. Occasionally, girls in early adolescence who have familial tall
stature may request treatment to reduce final adult stature. High-dose estrogen may induce premature
epiphyseal fusion and reduce final height.
2. Rare causes of tall stature are:
 GH excess (causing acromegaly and gigantism)
 Marfan syndrome
 Homocystinuria
 Klinefelter syndrome (XXY)
 Beckwith-Wiedemann syndrome
 Cerebral gigantism (Sotos syndrome)
 Fragile X syndrome
etc.
Klinefelter syndrome (XXY) Facial appearance of patient with cerebral gigantism
(Sotos syndrome)
Excess GH secretion

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Abnormal head growth
Normal head circumferences (HC) in term infants range from 32 to 38 cm. Head circumference is an
important indicator of brain development and should be monitored over time, especially if a fontanel closes
early. Bright Futures recommendations state that head circumference measurements should be obtained at
each health supervision visit from birth to 24 months of age, but the Centers for Disease Control and
Prevention growth charts extend to 36 months.
 Abnormalities in Head Size
Microcephaly Macrocephaly
HC > 2 standard deviations
(SDs) below the mean for age or
roughly less than the 2nd
percentile
HC > 2 SD above the mean for age
on the standard curve or greater
than the 98th percentile
In the newborn, this generally reflects abnormal
growth due to genetic, infectious, or teratogenic
forces. It is often, but not always, associated with
developmental delay.
Normal genetic variants may also occur (e.g. in
pygmies and dwarfs).
It is important to determine HC of both parents in
order to interpret this finding. A common etiology
is benign familial macrocephaly. However, one
must also consider the possibility of pathologic
conditions such as hydrocephalus, intracranial
cysts, arteriovenous malformation.
 Abnormalities in Head Shape due to Craniosynostosis
Craniosynostosis is the premature fusion of one or more cranial sutures, typically resulting in an abnormal
head shape.
Scaphocephaly: Brachycephaly: Plagiocephaly: Trigonocephaly:
Condition in which the head
is elongated from front to
back in the sagittal plane;
most normal skulls are
scaphocephalic
Condition in which head
shape is shortened from
front to back along the
sagittal plane; the skull is
rounder than normal
shape is asymmetric in the
sagittal or coronal planes; can
result from asymmetry in
suture closure or from
asymmetry of brain growth
shape is triangular due to
premature fusion of the
metopic suture

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Growth Charts Quiz
Test your ability to identify growth charts. They are all Girls: Birth to 36 Month CDC US Growth Charts.
Which of the following explanations is the most likely description of the growth charts below?
a) Normal catch up growth pattern
b) Constitutional short stature
c) Overweight due to excessive cereal mixed with
the formula
d) Benign familial megalocephaly
e) Environmental failure to thrive
f) Growth hormone deficiency
g) Hydrocephalus
h) Normal breast fed baby
3 4
1 2

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ANSWERS
1. c
2. b
3. f
4. h
5. e
6. g
7. a
8. d
5 6
7 8

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ANSWERS TO QUESTIONS on page 9
1. An intrauterine insult or genetic abnormality is most likely responsible when multiple growth
parameters are below average at birth.
2. Likely causes include constitutional growth delay, genetic short stature, or endocrine causes of growth
failure.
3. Likely causes include insufficient caloric intake or a hypermetabolic state.
4. This child is presenting with failure to thrive (FTT), defined as weight, height, or head circumference
below the third to fifth percentile, falling off the growth curve by crossing two major percentiles, or weight
less than 80% of ideal body weight for age. It is not a diagnosis; it is a sign of an underlying organic or non-
organic disorder.
REFERENCE
1. World Health Organization. WHO child growth standards: length/height-for-age, weight-for-age, weight-for-height and body mass index-for-age:
Methods and development. Geneva, Switzerland: World Health Organization; 2006. Available at http://www.who.int/childgrowth/pub-
lications/technical_report_pub/en/index.html. Accessed June 1, 2010.
2. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 2002;246:1–190.
3. Jaffe A.C., 2011. Failure to thrive: current clinical concepts. Pediatr. Rev. 2011;32;100-108
4. Mei Z, Grummer-Strawn LM, Thompson D, Dietz WH. Shifts in percentiles of growth during early childhood: analysis of longitudinal data from the
California Child Health and Development Study. Pediatrics. 2004;113:e617–e627
5. Olsen EM, Petersen J, Skovgaard AM, Weile B, Jørgensen T, Wright CM. Failure to thrive: the prevalence and concurrence of anthropometric criteria
in a general infant population. Arch Dis Child. 2007;92(2):109-114.
6. Failure to thrive. Criteria for determining disability in infants and children summary. Evidence report/technology assessment: number 72. AHRQ
publication no. 03-E019. Rockville, Md.: Agency for Healthcare Research and Quality; March 2003.
http://www.ahrq.gov/clinic/epcsums/fthrivesum.htm. Accessed January 6, 2010.

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