This document provides information on defining and interpreting various growth parameters in children, including low birth weight, prematurity, weight formulas, normal heights and head circumferences at different ages, mid-parental height calculation, and causes of growth retardation. It also discusses evaluating a child with short stature, including anthropometry, bone age assessment, differential diagnosis, and initial investigations. Key areas of focus are nutritional status, endocrine and systemic illnesses, skeletal dysplasias, and familial or constitutional growth patterns.

1. Define Low Birth Weight?

2. Define Prematurity?

3. Define Prematurity?
Terminology

4. Simple weight calculation
2-12 years = [Age (years)+3]x5 /2
7-12 years = Age(years)x3
 2

5. Weight - formula
3 – 12 months = age in months + 9
2
1 – 6 years = age (yr) x 2 + 8
7 – 12 years = age (yr) x 7 – 5
2

6. Weight gain
Newborn
10% of birth weight is lost initially
Regain birth weight by 10 days
200 gm / week – 1st three months (30g/day)
150 gm / week – 2nd three months (20g/day)
100 gm / week – next 6 months (15g/day)

8. Normal – Height
At birth – 50 cm
3 months – 60 cm
9 months – 70 cm
1 year – 75 cm
2 years – 90 cm
4 ½ years – 100 cm
Till 10 years – 5 cm / year

10. Weight/ Height
A value below 90.5% indicates malnutrition
Value >120% indicates over wt or obesity

11. GROWTH VELOCITY
Rate at which the child grows over a period
of time

12. Growth Velocity - Boys

13. Growth Velocity - Girls

14. Body Proportion
Upper segment/Lower segment ratio
At birth- 1.7:1
3yrs - 1.3:1
10-12yrs - 1:1

15. Arm span
Tips of middle fingers when the arms are
stretched out
It is equal to height at 10 yrs
In earlier years it is 1-2cms less than ht/length
After 12yrs it is 1-2cm>height

16. Arm span
Abnormally large span-
Klinefelter’s syndrome
Coarctation of aorta
Marfan’s syndrome

17. Head Circumference
• Brain growth is rapid during infancy and it is unaffected by
mild to moderate degree of malnutrition
• Should not be measured with in 24 hrs after birth
• Boney land marks – superior orbital ridge (ant), occipital
protuberance (post)

18. Normal head circumference
Birth – 35 cm
3 months – 40 cm
12 months – 45 cm
2 years – 48 cm
12 years – 52 cm
2 cm / month in 1st 3 months
1 cm / month in next 3 months
0.5 cm / month in 6 months

19. Chest circumference
At the level of nipple in a plane at right angle to the spine. Measured
the mid respiration
At birth HC is more than CC (by about 2.5cm)
By 6 to 12 months HC=CC
At 1st yr CC > HC (larger by 2.5cm).
At 5yrs CC >HC (by 5cm)
In PEM CC may continue to be less than HC

20. Mid arm circumference
Age independent criteria
Mid point between acromian process and olecranon
1 – 5 years : Arm Circumference fairly constant
>13.5 cm - Normal
12.5 – 13.5 cm : moderate malnutrition
<12.5 cm : severe malnutrition

21. MAC - Shakir’s Tape
It is a plastic tape with colored zone –
green, yellow & red
eindicateseverema12.5cm
Yellow indicates moderate malnutrition
(12.5-13.5cm)
reendica13.5cm

22. Mid parental height
• MPH for boys = (paternal height + maternal height + 13) /2
•
• MPH for girls = (paternal height + maternal height – 13) /2

23. Length / Height
• < 2 years – recumbent length using infantometer
• > 2 years – standing height – Stadeometer
Formula : 2 – 12 yrs = age in years x 6 + 77 (in cm)
• In girls at 2yrs - half of adult height is attained.
• In boys at 2 ½ yrs - half of adult height is attained

24. • What are the common causes of growth retardation in a child
Dept of Pediatrics, AFMC

25. Growth Retardation
• Physiological
• Familial
• Constitutional
• Pathological
• Undernutrition
• Chronic Systemic illnesses
- Renal : RTA, CRF, Steroid dependent Nephrotic
- Cardiopulmonary : CHD, Asthma, CF
- GI & Hepatic : Malabsorption , Chr Liver Disease
- Chronic infections, JRA
• Endocrinological
- GHD, Hypothyroidism,Cushings syndrome,pseudohypoparathyroidism
• Psychosocial
• Skeletal Dysplasias
• Genetic Syndromes
Dept of Pediatrics, AFMC

26. • Can you apply the term Failure to thrive for this patient
• Descriptive term for < 5 yr
• Organic or Non organic(80%)

27. • How do you define short stature
• Ht below 3rd centile or more than 2 standard deviations below the
mean ht for that age and sex according to population standard

28. Salient Points in History
• Well till 5 - 6 yrs of age
• Behavior changes
• Constipation
• Puffiness of face and swelling hands and feet
• Dry skin
• 2 yrs younger sister is taller than her
• History of delayed dentition
Dept of Pediatrics, AFMC

29. • What are the common dentition problems in children
• Delayed eruption
- Hypothyroidism
- Hypoparathyroidism
- familial
- Idiopathic
• Early Exfoliation
- Histiocytosis
- Leukemia
- cyclic neutropenia

30. Differential Diagnosis
• Familial
• Constitutional
• Nutritional
• Endocrinological
• Chromosomal
• Renal
Dept of Pediatrics, AFMC

31. • How do we differentiate between Familial and Constitutional delay in
growth?
Dept of Pediatrics, AFMC

32. Feature Constitutional Familial
Height Short Short
Height Velocity Normal Normal
Family history Delayed puberty short stature
Bone Age < CA Normal
Puberty Delayed Normal
Final Ht Normal Low
(normal TH)
Dept of Pediatrics, AFMC

33. Anthropometry
• Weight- 22.9 kg (52% of 50th centile)
• Height- 113 cm (<3rd centile)
• US/LS = 1.1
• Arm span- 112 cms
• Weight for height – 19 kg
• Height age corresponds – 6 yrs
• Weight age corresponds – 8 yrs
• Wt age > Ht age
• MPH – 149.5 cm
33
Dept of Pediatrics, AFMC

34. 34
Dept of Pediatrics, AFMC

35. • What are the latest recommendations on growth charts
• < 5 yrs – WHO
• > 5 yrs – modified Agarwal charts / IAP

36. • What is Growth velocity

37. • What are the conclusions derived from US LS ratio
• Decreased US LS ratio
- spondyloepiphyseal dysplasias
- vertebral anomalies
• Increased US LS ratio
- rickets
- Congenital hypothyroidism
- achondroplasia

38. • How do we calculate Mid Parental Height
• Boys – mothers ht + father’s ht
------------------------------ + 6.5
2
Girls – mother’s ht + father’s ht
------------------------------ - 6.5
2

39. • What is the interpretation of wt for ht in children with short stature
• Decreased wt for ht
- malnutrition, chronic illnesses
• Increased wt for ht with short stature
- Endocrinopathies
- Syndromes
- Skeletal dysplasias

40. • How do we plot target ht on the growth chart

41. Indian Pediatrics 2007; 44:187-197

42. Investigations
• How do you investigate a child with short stature
• Level 1 inv
- CBC
- Bone Age
- Urinalysis (ME,pH,osmolality)
- Blood – urea,creat,ABG,Ca,PO4,ALP, Proteins,LFT,BSL
• Level 2 inv
- Thyroid Function
- Karyotype
• Level 3
- Celiac serology
- IGF 1 , GH stimulation tests

43. Bone Age
Dept of Pediatrics, AFMC 43

44. • What are the radiographs that you will prefer to assess bone age at
- < 1 yr
- 1 – 12 yrs
- > 12 yrs

45. Investigations in short stature
Ref:Dr Swati Joshi, Pediatric on call,2007

46. • Interpretation of anthropometry?

47. WHO Charts

48. On Examination
• Frontal bossing +
• Depressed nasal bridge
• Epicanthal fold +
• No pallor,LNE,pedal
oedema,jaundice,clubbing,cya
nosis
• Dentition- 20
• AF- closed

49. • Summary?

50. D/D
• Short stature
• Renal cause
• CKD
• Primary tubulopathy
• Malabsorption
• Celiac disease
• Hypothyroidism

51. Question?
• Causes of short stature in renal disease?

52. Causes of short stature in renal disease
• Poor nutrition
• Metabolic acidosis
• Osteodystrophy (rickets)
• Anemia
• Decreased IGF level
• Hypothyroidism
• Proteinuria

53. Who is Short?
• If child is below 3rd percentile
• But target height is also below 3rd percentile
• HEREDITORY SHORT STATURE
• REASSURANCE

54. Who is Short ?
• If child above 3rd percentile with target height
percentile above it
• Observe after initial screening
• Quarterly height measurement for height velocity
• It should be > 4 cm/year

55. Who is Short ?
• If child below 3rd percentile with target height
percentile above it
• height velocity < 4 cm/year
• Then he/she is short

56. What Next ?
Look at the child
• Whether upper body and lower body is proportionate or
disproportionate
• Disproportionate
• Skeletal Causes
• Proportionate
• Systemic or Endocrinal causes

57. Upper/Lower Ratio
• Normal
• 1.7 at Birth ,1.3 by 4 year, 1.0 by 7 years
• Increased Ratio
• Skeletal Dysplasia
• Turner’s Syndrome
• Cretinism
• X-Linked Hypophosphatemic Rickets
• Decreased Ratio
• Mucopolysaccharidosis
• Spondylo-epiphyseal dysplasia

60. What Next ?
Again look at the child
• Whether child is mentally retarded
or normal
• If Mentally Retarded
• Chromosomal Abnormality
• Genetic Syndrome’s
• Cretinism

61. Then ?
Calculate BMI
• If Low : Systemic Illness
: Anorexia Nervosa
• If Normal : Endocrinal
DICTIM: All obese children are taller than counterparts,
and if Short indicate endocrinal disease

62. Then What ?
Measure
• Chronological Age
• Height Age
• Weight Age
• Bone Age

63. Height Age
Weight Age

64. Bone Age Estimation
• X-Ray left hand with wrist
• Scoring system of each of 20 individual hand bones
(Tanner-Whitehouse Method, TW2), a technique that has
been adapted for computerized assessment
• BA is a better predictor pubertal milestones than CA

66. Possibilities
• BA = HA = CA
• Normally growing child
• BA = HA < CA
• Delayed Growth (Constitutional)
• BA = CA < HA
• Hereditory Short Stature
• Intrinsic Short Stature (Genetic)
• BA < HA < CA
• Delayed/Attenuated Growth (Pathological)

67. Dysmorphic Features
• Epicanthal fold
• Hypertelorism
• Auricular Malformation
• Facial Asymmetry
• Teeth Dysplasia
• Webbing of Neck
• Polydactyly
• Abnormal Crease of Palm
• Nail abnormality

68. Hypertelorism
Clinodactyly

69. Short 4th Metacarpel
Short 4th Metatarsal

70. Intrinsic Short Stature
• Single Gene Defects
• Down’s Syndrome
• Turner’s Syndrome
• Mucopolysaccharidosis
• Polygenetic or Unknown
• Prader Willi Syndrome
• Noonan’s Syndrome
• Progeria
• Silver Russell Syndrome

71. Idiopathic Short Stature
• Short Stature otherwise Healthy child
• Exclusion of Other causes
• Bone age within 2 SD of CA
• Normal GH Response to test
• For Treatment
• HA < 2.25 SD for age and sex
• Open Epiphyses
• Unable to achieve normal height with current Height
velocity

72. Further Evaluation
• Referral to Endocrinologist
• T3, T4, TSH
• IGF-1, IGF-BP3
• GH Stimulation
• Cortisol Evaluation
if Cushing’s syndrome is suspected

73. Diagnosis of growth failure
IGF 1 & BP3
IGF deficiency
ruled out
Normal
GH testing
Low
Increased basal
and stimulated
GH insensitivity
Peak < 10
Pit/ Hypothalamic
Peak 10 - 40
Functional

74. TREATMENT
• Growth Hormone Therapy
• GHD
• Adult Growth Hormone Deficiency
• Chronic Renal Failure
• Turner’s Syndrome
• Prader Willi Syndrome
• Idiopathic Short Stature
• IUGR

75. Follow Up
• 6-12 monthly
• Clinical evaluation
• Assessment of side effects
• IGF-1 levels
• Lipid Profile
• Fasting B Glucose
• BMD if initial was abnormal

76. SIDE EFFECTS
• Malignancy
• Benign Intracranial Hypertension
• Slipped Epiphysial Disc
• Fluid Retention
• Increase in naevi
• Gynaecomastia
• IGT & DM (Aggravation of Retinopathy)
• Predisposition of hypothyroidism & ACTH
deficiency

77. Confirmation of GHD: IGF-I
• Polypeptide, synthesized by liver and also locally in peripheral tissue
• Locally synthesized IGF-I – 20% of serum level
• Mediates growth promoting actions of GH
• Single sample for estimation
• Assay – difficult as extraction step is required
Williams text book of Endocrinology, 10th Ed

78. Factors affecting IGF-I levels
• Age
• Nutrition
• Genetic factors, ethnicity
• GH
• Insulin, cortisol, thyroxine, estrogen, androgen
• Catabolic state
• IGFBP
Williams text book of Endocrinology, 10th Ed

79. Indications and Goals of GHD Rx
• Patients with proven GHD - treated with GH as soon as possible
• Primary objectives of the therapy of GHD are:
- Normalization of height during childhood
- Attainment of normal adult height and genetic potential!!

80. GH Dosing
• O.025-0.035mg/kg daily subcutaneously in the evening
• 0.17 – 0.35 mg/kg/week (Summary statement, GH Research
Society 2000)
• Few studies – 0.3 mg/kg/wk better result than 0.17 mg/kg/wk (GH-IGF Res
1998)

81. Duration of GH therapy
• Improvements in linear growth have been almost the sole indication for the
use of GH in pediatric practice.
• Treatment is initiated as soon as possible once
• GH should be continued until the attainment of final height.
• Final Ht - slowing of growth to an annualized HV of <1 cm/yr or fusion of the
long bone epiphyses.
• Ideally – life long