GROWTH ASSESSMENT

Dr. Mohan.T.ShenoyDM Resident in Endocrinology

Amrita Institute of Medical Sciences

Objectives of this study module

Why should we assess growth? What are the parameters ? How to interpret ? When to measure? Clinical implications

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.

INTRODUCTION

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

Changes in bodily proportions with age

-Cephalo-caudal (head down to toes)

- Proximodistal (center of the body to peripheral)

- General to specific

Predictable Sequence

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.

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 ;

Principles of Growth

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)

Stages of Growth and Development

Infancy Neonate

Birth to 1 month Infancy

1 month to 1 year

Early Childhood Toddler

1-3 years Preschool

3-6 years

Middle Childhood School age

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 ()

MEASUREMENT PARAMETERS

Postnatal growth patterns of normal children arewell characterized, resulting in several clinical parameters for assessment of growth.

1. Linear growth (Length/Height)2. Weight and body mass index3. Weight/Height4. Head circumference ; HC/CC ratio5. Mid arm circumference6. Body proportions (arm span and upper-to-lower segment ratio)7. Growth velocity8. Growth patterns9. Dentition10. Bone Age

Intrauterine growth charts

Calculation formulaeWeight 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 gainDoubles ( ie.. 100 cm) by 4 years6 cm / year till pubertyTriples by 12 years

Head circumference1st 3 months: 2cm/monthNext 3 months: 1cm/monthNext 6 months : 0.5 cm/month

Weight measurement

Weighing scales are of 3 types:

A) Beam balance Platform scale Beam scale/ TANSI scale

B) Spring Balance 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.

Weight categorisation/ classification

IAP Classification system

Normal: > 80% of expected Wt/Age

Grade I PEM : 71- 80 % of

expected Wt /Age

Grade II PEM : 61- 70 % of

expected Wt /Age

Grade III PEM : 51- 60 % of expected Wt

/Age

Grade IV PEM < 50 % of

expected Wt /Age

Welcome trust classification of PEM (1970)

>80% of expected weight

Normal

60 – 80% of expected weightWith edema : Kwashiorkor

Without edema : Underweight

<60% of expected weightWith edema: Marasmic kwashiorkor

Without edema : Marasmus

Other systems of classification : Gomez and Jellife’s

LENGTH/ HEIGHT

Below 2 yrs- supine length with infantometer.For older children- Harpenden

Stadiometer

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

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.

Sitting height

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

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.

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).

Cowell CT. Short Stature. In: Clinical PediatricEndocrinology, 3rd edn. Ed. Brook CGD. London,Blackwell Science, 1995; pp 136-172.

WATERLOW Classification

Waterlow Weight for Height

Classification >= 80 % < 80 %

Height for >= 90 % Normal Wasted

Age < 90 % Stunted Wasted and stunted

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 ChronicMalnutrition

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.

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 cross-sectional 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.

Weight Velocity

1st year : 6 kgPre-school: 2kg/yearSchool : 3 kg/yr till puberty

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

Head Circumference

Place the measuring tape around the largest circumference of the infant's head, across the occiput and the forehead.

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)

Chest circumference

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

Not used universally

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 100Chest circumference

Value > 28 % diagnostic

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♦At 3 years—1.3♦After 7 years—1.0

A higher upper-to-lower body segment ratio than expected may be associated with dwarfism or bone disorders.

Increase: Rickets, achondroplasia, Untreated hypothyroidismDecrease: spondyloepiphyseal dysplasia, vertebral anomalies

By about 11 years of age, adult proportions are reached

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

Individual components

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)

Percentile Rank Nutrition- Related Health Concern

Anthropometric Index Percentile Cut-off ValueNutritional 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

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 ;

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.

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.

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).

Growth should be measured and compared with statistical norms in a standard fashion on growth charts.

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)

GROWTH MONITORINGMales

Age (y)

30

34

38

42

46

50

54

58

62

66

70

74

78

Heigh

t (in)

Heigh

t (cm)

2 4 6 8 10 12 14 16 18 2070

80

90

100

110

120

130

140

150

160

170

180

190

200

0

+2

+1

-1

-2

Growth charts are visible display of child’s physical growth and development.

Also called as “road-to-health" chart. It was first designed by David Morley and was later modified by WHO.

Growth standard vs. referenceRate 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.

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 chart1 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

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.

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.

WHO growth chart: 8500 children - 6 countries

(2006)

MGRS study design

year 1 year 2 year 3

Longitudinal (0-24 months)

Cross-sectional (18-71 mo)

WHO Multicentre Growth Reference Study (2006)

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 - MGRS / reference indicators

n Attained growth• 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

n Velocity• weight• length• head circumference• arm circumference• body mass index

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.

GROWTH MONITORING

Time schedule child anthropometry

Measurement Time frame Frequency No. of visits Weight, length, head circumference

Birth Once 1 Weeks 2-8 Bi-weekly 4 3-12 months Monthly 10 14-24 months Bi-monthly 6

Arm circumference Skinfold thicknesses

3-12 months Monthly 10 14-24 months Bi-monthly 6

WHO Multicentre Growth Reference Study (2006)

Criteria for referral

(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.

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 yearsHeight 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.

Indian Pediatrics 2007; 44:187-197

IAP Growth Monitoring Guidelines for Children from Birth to 18 YearsCriteria for referral

WEIGHT AND STATURE CHARTS

Age 2 4 9 13BMI

Value 19.3 17.8 21.0 25.1

BMI Changes with Age

Example: Child’s growth tracking along 95th percentile

Body mass index for boys and girls 2-17 years.

Redesigned by Agarwal KN, Agarwal DK, Bansal AK for theIndian Academy of Pediatrics

CDC Percentile chart

BODY MASS INDEX

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

TW Method - 13 Bones

Delayed bone age

Constitutional short statureHypothyroidismCeliac diseaseGH deficiency

Better correlate with SMRPredictor of future height

Bone age

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

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

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

Dental development

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.

Growth charts for special populations:

a. Down syndrome:

b. Turner syndrome:

c. Achondroplasia:

d. Prader-Willi Syndrome

e. Silver–Russell syndrome

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.

Turner syndrome

The gray-shaded area represents the 3rd to 97th centiles for normal girls.Pubertal staging is for normal girls

Height centiles for girls with untreated Turner syndrome aged 1–20 years.

Adapted from Lyon A, Preece M, Grant D.Growth curves for girls with Turner syndrome. Arch Dis Child 1985; 60: 932–935.

Achondroplasia

Adapted from Horton W, Rotter J, Rimoin D et al. Standard growth curves for achondroplasia.

J Pediatr 1978; 93: 435–8.

Height centiles for boys with achondroplasia(mean ± 2 SD) compared with normal standard curves (dashed lines).

Data derived from 189 males.

Prader-Willi Syndrome

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.

Always Perform Sexual Maturity Rating

Sequence of maturational events

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

MALES

FEMALES

Child survival

Physical growth

Child development