A comprehensive approach from Pediatric Endocrine viewpoint.

1. GROWTH ASSESSMENT
Dr. Mohan.T.Shenoy
DM Resident in Endocrinology
Amrita Institute of Medical Sciences

2. Objectives of this study module





Why should we assess growth?
What are the parameters ?
How to interpret ?
When to measure?
Clinical implications

3. INTRODUCTION

Growth and development are sometimes used interchangeably.

Growth is defined as net increase in the size or mass of tissues. It is largely due
to multiplication of cells,increase in the intracellular substance (quantitative )

Development is defined as maturation of functions and acquisition of skills.
(qualitative growth)



Early childhood : Cognitive growth and development difficult to differentiate from
neurologic and behavioural maturation.
Later childhood, it can be measured by communicative skills and cognitive abilities
influenced by the physical, emotional and social environment.
Myelination of the nervous system and denotes acquistion of a variety of
competences for optimal functioning of the individual.

4. The ICP growth model for height for boys
(Karlberg, 1989)

5. Changes in bodily proportions with age
Predictable Sequence
-Cephalo-caudal (head down to toes)
- Proximodistal (center of the body to peripheral)
- General to specific

6. Principles of Growth
1. Continous process from conception onward
Orderly - definite time limits for growth. Any time lost during a
rapid growth period may prevent catch-up growth.
2. Unique for each individual - genetic and environment factors
3. Growth is governed by complex chain of hormonal interactions. The
growth in the first year is mainly controlled by inherent potential of
the cells and later by several factors (environmental and genetic).
4. First 3 years of life, curvilinear pattern ; Later it is linear.

7. Principles of Growth

5. Growth spurts occur in late foetal period ; pubertal period.
It is a dynamic process




Phase I – Hyperplasia
Phase II - Hyperplasia + Hypertrophy
Phase III - Hypertrophy alone
Phase IV – Maturity
•
6. Growth does not follow normal distribution curve.
•
7. Each stage of G&D is affected by the preceding types of
development ;

8. Differential growth
•
Each child grows in his/her own
unique way.
•
Not all body parts grow in the same
rate at the same time

CNS : Neuronal division essentially
complete by 1 year,

Bone, Muscle, and Fat cells continue
to divide until later in childhood.

Other - Skin, gastrointestinal
epithelial cells, and liver retain the
capacity for hyperplasia throughout
life.
•
Don’t progress at the same rate
(↑ periods of GR in early childhood
and adolescents & ↓ periods of GR in
middle childhood)

9. Stages of Growth and Development

Infancy

Neonate


Birth to 1 month

Toddler


1-3 years
Preschool

3-6 years
School age


1 month to 1 year
Early Childhood
Middle Childhood

Infancy



6 to 10 years (Girls)
6 to 12 years (Boys)

Late Childhood (Adolescent)

Prepubescent : 10-12 yrs () 12-14 yrs ()

Pubescent : 12- 14 yrs(ƒ); 14-16 yrs ()

Post Pubescent : 14 -18 yrs(ƒ); 16- 20 yrs ()

10. MEASUREMENT PARAMETERS
Postnatal growth patterns of normal children are
well characterized, resulting in several clinical
parameters for assessment of growth.
1. Linear growth (Length/Height)
2. Weight and body mass index
3. Weight/Height
4. Head circumference ; HC/CC ratio
5. Mid arm circumference
6. Body proportions (arm span and upper-to-lower segment ratio)
7. Growth velocity
8. Growth patterns
9. Dentition
10. Bone Age

11. Intrauterine growth charts

13. Calculation formulae
Weight gain
•Newborn1st 3 months - 200 gm/ week
•Next 3 months – 150 gm/ week
•Next 6 months – 100 gm/ week
•Doubles by 4 months; Triples by 1 year
•Quadruples by 2 years;
•Thereafter 2kg /yr added on till 6 years
•Threafter 3 kg/yr added till puberty
Length gain
Doubles ( ie.. 100 cm) by 4 years
6 cm / year till puberty
Triples by 12 years
Head circumference
1st 3 months: 2cm/month
Next 3 months: 1cm/month
Next 6 months : 0.5 cm/month

14. Weight
measurement

Weighing scales are of 3 types:

A) Beam balance



B) Spring Balance



Platform scale
Beam scale/ TANSI scale
Salters weighing scale
Bathroom scale
C) Electronic scale
Measure to the nearest 10 gm for infants and 100 gm for children. Weighing together with mother.

15. Weight categorisation/ classification
IAP Classification system
Normal:
> 80% of
expected
Wt/Age
Grade IV PEM
< 50 % of
expected Wt
/Age
Grade II PEM :
61- 70 % of
expected Wt /Age
Grade I PEM :
71- 80 % of
expected Wt
/Age
Grade III PEM
: 51- 60 % of
expected Wt
/Age

16. Welcome trust classification of PEM (1970)
>80% of expected weight
Normal
60 – 80% of expected weight
With edema : Kwashiorkor
Without edema : Underweight
<60% of expected weight
With edema: Marasmic kwashiorkor
Without edema : Marasmus
Other systems of classification : Gomez and Jellife’s

17. LENGTH/ HEIGHT
Below 2 yrs- supine length with infantometer.
For older children- Harpenden
Stadiometer

19. Prerequisites

Without footwear

Heels & back touching
the wall

Looking straight ahead
in frankfurt plane.

Gentle but firm
pressure upwards
applied to the
mastoids from
underneath

Record to last 0.1cm

20. Sitting height
Equipment:
sitting base of a known height (e.g., 50 cm x 40 cm x 30 cm) and a wall-mounted stadiometer
Technique:
The child is placed as erect as possible with buttocks, shoulders, and head in contact with
backboard of the stadiometer. Total height is measured. The height of the sitting surface is then
subtracted from the total height.
Plotting and Interpretation:
The measurement can be plotted on the CDC charts for stature-for-age.
Even if measurements fall below the 5th percentile, they establish a growth pattern over time.

21. Height measurements






Iliac Height (IH)
The distance between the summit of the iliac crest and the floor.
Subischial Leg Length (SLL)
The difference between stature and sitting height.
It assumes that in a seated position the proximal landmark corresponds to
the hip joint, which is very difficult to locate.
Useful to measure upper to lower body proportions

23. Calculation of Target Height and Target Height Centile
Measure the parent’s heights and
make a note of their heights on the
chart.
Calculate the child’s target height (TH)
and plot it at 18 years and mark it
with an arrow on the growth chart.
Cowell CT. Short Stature. In: Clinical Pediatric
Endocrinology, 3rd edn. Ed. Brook CGD. London,
Blackwell Science, 1995; pp 136-172.
This represents the child’s projected
height and the target range is
produced by plotting two points
7.5 cms above and below for a boy
and 6 cm above and below for a girl
(representing the 10th and the 90th
centile for that child).

24. WATERLOW Classification
Weight
Waterlow
>= 80 %
Classification
Height for
>= 90 %
Normal
Age
< 90 %
Stunted
for
Height
< 80 %
Wasted
Wasted and stunted

25. WHO Classification
Wt/ Age
Ht/ Age
Wt/Ht
Intepretation
Normal
Normal
Normal
Normal
Decreased
Normal
Decreased
Acute Malnutrition
Decreased
Decreased
Normal
Chronic Malnutrition
Decreased
Decreased
Decreased
Acute on Chronic
Malnutrition

26. GROWTH VELOCITY

The most critical factor in evaluating
the growth is determining
GROWTH VELOCITY.

Observation of child’s height pattern
in the form of “CROSSING
PERCENTILE LINES” on a linear
growth curve is the simplest method
of observing abnormal growth
velocity.

Atleast 3 measurements with
preferably 6 months interval in
between is necessary to comment
on growth pattern.

27. Growth patterns **

From the end of infancy until puberty begins, growth normally proceeds along a
channel that closely corresponds to a given height-attained percentile on crosssectional growth standards. A child normally establishes this channel by 2 to 3 years
age, although, on rare occasions, a gradual drift by as many as 40 percentile positions in
height attained may occur over a period of several years in normal children.

The velocity of growth (cm per year) actually decelerates slightly during this period
and averages about 6 cm per year in midchildhood.However, normal children cross
height-velocity percentiles to maintain their height channel.

A growth velocity that is consistently along the third percentile will lead to a
subnormal height. The growth channel seems to be genetically determined. Children
grow as if to reach a genetically predetermined height.

This target height, which represents the child’s genetic potential, can be
approximated by calculating the MPH.

28. Weight Velocity
1st year : 6 kg
Pre-school: 2kg/year
School : 3 kg/yr till puberty

29. Growth velocity

Sequential height measurements
and can be plotted on growth
velocity charts.

A minimum interval of 6 months is
needed for meaningful assessments
of growth velocity

30. Head Circumference
Brain growth is rapid during infancy and it is
unaffected by mild to moderate degree of
malnutrition
Should not be measured within 24 hrs after birth
Bony land marks – superior orbital ridge (ant),
external occipital protuberance (post)
Place the measuring tape around the largest circumference of the infant's head, across the occiput
and the forehead.

31. Chest circumference
Not used universally
Useful measurement for comparison with the head circumference
when a problem is suspected with either the head size or chest size.
Wrap the measuring tape around the infant's chest ideally taken at
xiphisternum / substernal notch just below the nipple line, midway
between inspiration and expiration firmly but not tight enough to
cause an indentation of the skin. read to the nearest 0.5 cm

32. Internipple distance

Trunk physical parameter as in special situations

Internipple distance calculated by using Sliding callipers with
child at rest and at end of expiration.

Internipple Index = Internipple distance X 100
Chest circumference
Value > 28 % diagnostic

33. Upper-to-Lower Segment Ratio
The upper-to-lower segment ratio is calculated when a child's body may have
inappropriate proportions between the head and trunk to the extremities.
Measure the lower body segment (distance from the symphysis pubis to the floor
when a child stands).
Calculate the upper body segment by subtracting the lower body
segment from the total height. Then divide the upper body segment by
the lower body segment to calculate the ratio.
Expected ratios by age are
♦ At birth—1.7
Increase: Rickets, achondroplasia, Untreated hypothyroidism
♦ At 3 years—1.3
Decrease: spondyloepiphyseal dysplasia, vertebral anomalies
♦ After 7 years—1.0
By about 11 years of age, adult proportions are reached
A higher upper-to-lower body segment ratio than expected may be associated
with dwarfism or bone disorders.

34. Individual components

Arm length – Acromion to tip of 3rd finger with arm in full
extension and parallel to the body.

Upper segment of arm – Acromion to Olecranon with elbow
bent at 90º

Foream / Lower segment of arm – Olecranon process to distal
end of styloid process of radius with elbow bent at 90º

Hand length – Distal wrist crease to tip of 3rd finger

Palm length – Distal wrist crease to prox. Crease of 3rd finger

35. Skeletal dysplasia

Rhizomelia (Upper arm / Proximal shortening)

Mesomelia (Forearm / Middle shortening)

Acromelia (Palm &Fingers / Distal shortening)
Acromesomelia (Forearm, Palm, fingers /Middle & distal)
Micromelia (Whole upper limb shortening)



38. Percentile Rank Nutrition- Related Health Concern
Anthropometric Index
Percentile Cut-off Value
Nutritional Status
Indicator
BMI-for-Age
≥ 95th
Obese
BMI-for-Age
≥ 85th and < 95th
Overweight
Weight-for-Length
< 5th
Underweight
Head Circumference-for-Age
< 5th and > 95th
Developmental Problems
Growth parameters and their interpretation for the World Health Organization
charts

39. Age independent Anthropometric
indicators

Labile tissues like subcutaneous fat and muscle are
more reduced in malnutrition than skeleton

Bangle test: If a bangle of 4 cm Internal diameter crosses elbow
Shakir’s tape: Plastic tape with color zones – Red if < 12.5 cm
Quac stick : Rod with markings for Height and Arm circumference.
Nabarrow’s thinness chart : Graphic chart for Wt/Ht




MAC:HC (Kanawati) ratio: 0.28- 0.314 : Mild ; <0.249 : Severe
MAC : Height ratio : Normal if >0.32 ; Severe malnutrition if <0.29

Ponderal index : Weight (in kg)/ length 3 (in cm) x 100 ;

Normal if >2.5 ; Symmetrical IUGR 2.0 -2.5 ; Asymmetric IUGR < 2.0

Dughadale ratio : Weight (in kg)/ height
1.6 ;
Normal if >0.79 ;

40. Mid Upper arm circumference
(MUAC)
Steps of MUAC measurement
Ask the mother to remove any clothing that covers the
child’s arm. If possible the child should stand erect and
sideways to the measurer.
Estimate the mid-point of the left arm.
Straighten the child’s arm and wrap the tape around at the
mid-point. Make sure that the numbers are right side up. Make
sure the tape is flat around the skin.
Inspect the tension of the tape on the child’s arm. Make sure
the tape has the proper tension and is not too tight or too
loose. Repeat any step as necessary.
When the tape is in the correct position and correct tension
on the arm, read and call out the measurement to the nearest
0.1 cm.
Immediately record the measurement.

41. Skinfold thickness
Skinfold thickness by age and sex, as
measured by Harpenden skinfold calipers
over triceps and under scapula.
The lines shown are the 50th percentiles
for British children. Scale is in millimeters
on the left side and logarithmic
transformation units on the right side.
Usually gives a better estimate of adiposity,
although considerable experience is needed
for accuracy, and variability in fat
distribution may confound the
measurement.

42. Waist circumference and waist-hip ratio:

Both waist circumference (WC) and waist-hip ratio are
indicators of visceral fat or abdominal obesity in children and
adolescents age 2–19 years.

Increased visceral adiposity measured by WC increases the risk
of obesity-related morbidity and mortality.

WC should be measured at the highest point of the iliac crest
when the individual is standing and at minimal respiration.

Waist-hip ratio is calculated as a ratio of waist circumference
(cm) and hip circumference (cm).

43. Males
200
78
+2
190
0
170
-1
Height (cm)
Growth should be measured and compared
statistical norms in a standard fashion on
70
66
-2
160

74
+1
180
62
with
150
140
58
54
growth charts.
130
50
120
46
110
Growth charts are visible display of child’s physical growth
and development.
42
100
38
90
34
80
30
70
2
4
6
8
10 12
Age (y)
14
16
18
20
Also called as “road-to-health" chart. It was first designed by
David Morley and was later modified by WHO.

Growth is assessed by plotting accurate measurements on growth charts and
comparing each set of measurements with previous measurements obtained at
health maintenance visits or at other visits if there is a concern over the child's
growth pattern.

Serial measurements more useful than single measurements to detect deviations
from a particular child's growth pattern even if the value remains within statistically
defined normal limits (percentiles)
Height (in)
GROWTH MONITORING

44. Growth standard vs. reference
Rate of growth of children is one of the finest indicators of the health of a
community. Growth monitoring followed by suitable action prevents illness,
malnutrition and even death. It provides reassurance about child’s health and prevents
parental anxiety.
A growth reference simply describes the growth of a sample of individuals,
whereas a standard describes the growth of a healthy population and suggests an
aspirational model.
WHO growth charts are growth standards. A reference is representative of the
existing growth pattern of children and allows us to study the secular trends in height,
weight and obesity.
On community and national level it helps identify children at risk of morbidity and
mortality. It thus helps in implementation of national programmes for nutritional and
medical interventions like supplementary feeding, foods to vulnerable group,
underprivileged school children, etc. It is also a method to evaluate programs for
improving child health and nutrition and can form the basis for policy making.

45. Z-score

It is another way of expressing a child’s height in comparison
with the mean for child’s age.
Child’s Height- Mean Height for age in the reference chart
1 SD of height for that age in the reference data
The resultant value is a number without units.
Advantage: Children of different ages and gender can be compared

46. GROWTH CHARTS AND REFERENCE DATA
 Ideally constructed growth charts depict the longitudinal growth of a
cohort of children from birth to maturity. Many logistic difficulties as it
would entail a prolonged study.
 50th percentile of Harvard Standards (1970s) is considered 100% for
Indian children. If a child is at 5th percentile it means 5% children of that
age have less weight or growing less fast than this child.
Many international reference standards NCHS (US National centre
for Health Statistics, Boston) have been obtained from cross-sectional or
semi-longitudinal studies ; Pubertal spurt gets blunted in these charts.
Separate reference standards for different ethnic groups derived from
studying growth of children living in an optimal environment with
adequate nutrition.

47. BACKGROUND

The ICMR undertook a nationwide cross sectional study during 1956-1965
to establish indian referance charts. Irrelevant now as they were done on
lower socio-economic class.

Indian context Multicenter study : Agarwal et al. (1992,1994); Khadilkar et al.
(2009); Marwaha et al. (2011)

The growth charts compiled by Agarwal et al were based on affluent
urban children from all major zones of India measured 1989-1991. The data
is now 20 years old.

WHO recommends that each country should update its growth references
every decade and hence new growth references were produced in 2009.

Khadilkar et al have published the growth charts on affluent children 5-18
years and have also compared the growth of 2-5 years old indian children
with the new WHO growth charts. These are the most modern national
growth references available now at present.

48. WHO growth chart:
8500 children - 6 countries
(2006)

49. MGRS study design
Longitudinal (0-24 months)
year 1
year 2
year 3
Cross-sectional (18-71 mo)
After the age of 5 years, the WHO extended the MGRS chart till 18 yrs by appending
NCHS data and extrapolating the MGRS percentile lines.
Many countries choose to use WHO charts only for toddlers {upto 2 yrs in USA}
[upto 4 yrs in UK] and their own national charts for older children.
WHO Multicentre Growth Reference Study (2006)

50. WHO - MGRS / reference indicators
n
Attained growth
•
•
•
•
•
•
•
•
n
weight-for-age
length/height-for-age
weight-for-length/height
head circumference-for-age
mid-upper arm circumference-for-age
triceps skinfold-for-age
subscapular skinfold-for-age
body mass index-for-age
Velocity
• weight
• length
• head circumference
• arm circumference
• body mass index

51. GROWTH MONITORING

Deviations in growth patterns may be nonspecific or may be important
indicators of serious and chronic medical disorders.

An accurate measurement of length/height, weight, and head circumference
should be obtained at every health supervision visit.

52. Time schedule child anthropometry
Frequency No. of visits
Once
1
4
Bi-weekly
Monthly
10
Bi-monthly
6
Measurement
Weight, length, head
circumference
Time frame
Birth
Weeks 2-8
3-12 months
14-24 months
Arm circumference
Skinfold thicknesses
3-12 months Monthly
14-24 months Bi-monthly
10
6
WHO Multicentre Growth Reference Study (2006)

53. Criteria for referral
Indian Pediatrics 2007; 44:187-197
IAP Growth Monitoring Guidelines for Children from Birth to 18 Years
(i) First three years
† Length/height, weight or head circumference below 3rd percentile or above 97th percentile
on growth chart.
† 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
† Weight loss or lack of weight gain for a month in the first 6 months.
† Absence of weight gain for 2-3 months from 6-12 months of age.
† Micropenis.
† Unilateral or bilateral undescended testis.
† Ambiguous genitals.
(ii) Three to nine years
» Length/Height below 3rd percentile or above 97th percentile on growth chart.
» Crossing of two major percentile lines (upward or downward)
» A child below or above mid parental range for height .
» BMI over the 85th percentile at all ages.
» Rate of growth less than 5 cm/year.

54. Criteria for referral
Indian Pediatrics 2007; 44:187-197
IAP Growth Monitoring Guidelines for Children from Birth to 18 Years
(ii) Three to nine years (Continued)
»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.
»Micropenis.
(iii) Nine to eighteen years
Height below 3rd percentile or above 97th percentile on growth chart.
Crossing of two major percentile lines (upward or downward)
A child below or above mid parental range for height.
BMI over the 85th percentile at all ages.
Arrest at the same stage of puberty for more than 2 years.
Micropenis.
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.

60. WEIGHT AND STATURE CHARTS

62. BMI Changes with Age
Age
BMI
Value
2
4
9
13
19.3 17.8 21.0 25.1
Example: Child’s growth tracking along 95th percentile

63. Body mass index for boys and girls 2-17 years.
Redesigned by Agarwal KN, Agarwal DK, Bansal AK for the
Indian Academy of Pediatrics

64. CDC Percentile chart

65. BODY MASS INDEX

75. G & P Method
Patient’s film is
compared with the
standard of the
same sex and
nearest age
It is next
compared with
adjacent standard,
both older and
younger to get the
closest match

76. TW Method - 13 Bones

77. Bone age
Better correlate with SMR
Predictor of future height
Delayed bone age
Constitutional short stature
Hypothyroidism
Celiac disease
GH deficiency

78. Bone age: an
algorithm for boys
Unnikrishnan AG, Kumar H, Jayakumar RV.
Bone age in a minute: a simple algorithm.
Amrita J Med 2006; 2:39-41

79. Bone age: an
algorithm for girls
Unnikrishnan AG, Kumar H, Jayakumar RV.
Bone age in a minute: a simple algorithm.
Amrita J Med 2006; 2:39-41

80. CAVEATS TO INFORMATION IN BONE AGE
Subjectivity: Interobserver variation
Normal children radiographs comparability ; Non-applicability to spl.
context- skeletal dysplasias, genetic causes .
BAYLEY-PINNEAU and RWT (Roche,Wainer,Thissen)
CHARTS

81. Dental development

82. Dental development

Dental development includes mineralization, eruption, and exfoliation.

Initial mineralization begins as early as the second trimester (mean age
for central incisors, 14 wk) and continues through 3 yr of age for the
primary (deciduous) teeth and 25 yr of age for the permanent teeth.

Mineralization begins at the crown and progresses toward the root.

Eruption begins with the central incisors and progresses laterally.

Exfoliation begins at about 6 yr of age and continues through 12 yr of
age. Eruption of the permanent teeth may follow exfoliation
immediately or may lag by 4-5 mo. The timing of dental development is
poorly correlated with other processes of growth and maturation.

83. Growth charts for special populations:

a. Down syndrome:

b. Turner syndrome:

c. Achondroplasia:

d. Prader-Willi Syndrome

e. Silver–Russell syndrome

84. Down syndrome
Height and weight centiles for boys with trisomy 21
syndrome aged 2–18 years. The gray-shaded areas
represent the comparable values for the 3rd to 97th
centiles for normal children.
Adapted from Cronk C, Crocker A,Peuschel S et al.
Growth charts for children with Down syndrome.
Pediatrics 1988; 81: 102–10.

85. Turner
syndrome
Height centiles for girls with untreated Turner
syndrome aged 1–20 years.
The gray-shaded area
represents the 3rd to
97th centiles for
normal girls.
Pubertal staging is for
normal girls
Adapted from Lyon A, Preece M, Grant D.
Growth curves for girls with Turner syndrome. Arch Dis Child 1985; 60: 932–935.

86. Achondroplasia
Height centiles for boys
with achondroplasia
(mean ± 2 SD) compared
with normal standard
curves (dashed lines).
Data derived
from 189 males.
Adapted from Horton W, Rotter J, Rimoin D et al.
Standard growth curves for achondroplasia.
J Pediatr 1978; 93: 435–8.

87. Prader-Willi Syndrome

88. Silver–Russell syndrome
Height centiles for boys with Silver–Russell
syndrome .The grayshaded area indicates
normal boys ±2 standard deviations (SD).
Adapted from Wollman H, Kirchner T, Enders H
et al. Growth and symptoms in Silver–Russell
syndrome: review on the basis of 386 patients.
Eur J Pediatr 1995; 154: 958–68.

90. Always Perform Sexual Maturity
Rating

93. Sequence of maturational events
MALES
FEMALES
Adapted from Marshall WA,Tanner JM:Variations in the pattern of pubertal changes
in boys. Arch Dis Child 1970;45:13

95. Child survival
Physical growth
Child development