BASIC PEDIATRICS Hormonal Factors

• The interaction and balance of many hormones are important for

1.2 GROWTH – AUGUST 2021 growth to occur
• Growth and puberty are dependent on the interaction of:
o GH, IGF-1, sex steroids
INTRODUCTION
• Thyroid hormones affect the growth of skeletal and other body
DEFINITION
tissues
• It is a process by which a living being or any of its parts increases in
the physical size and mass either by multiplication or by enlargement
Environmental Factors
of component cells.
• Modifiable factors
• It is measured quantitatively. (Ex: kg, cm)
• The timing and consistency of these factors are very important
SIGNIFICANCE
determinants of growth
• Knowing normal values in growth, normal growth patterns and • Can be categorized as Prenatal vs. Postnatal
variance is very important for physicians (esp. pediatricians) to: o Environmental factors have a significant role in influencing the
o Detect pathologic deviations early growth and brain development of the developing fetus in utero
o Prevent the unnecessary evaluation of children with acceptable • PRENATAL
normal variations in growth o Intrauterine infections have been strongly associated with
• Normal growth is a reflection of overall health and nutritional status intrauterine growth restriction
of a child o Exposure of the fetus to alcohol in utero leads to physical
o Important indicator for a person’s health, the adequacy of diet, deformities and growth retardation once the fetus is born (fetal
wellness, and general well-being alcohol syndrome)
o The growth status of infants and children may be indicators for • POSTNATAL
the health and socioeconomic development of the family and o Nutrition, Infection, and Neurotoxins
the communities to which they belong o Chronic illnesses and parasitic infestations also have been
implicated in a decrease of linear growth
PHASES OF GROWTH o Socioeconomic Factors
FETAL GROWTH § Poverty influences growth significantly as children from
• Fastest growth phase, with maternal, placental, fetal, and poorer families are often smaller than their age-matched
environmental factors playing key roles peers
• Factors that inhibit fetal growth may have long-lasting effects, as o Cultural Factors
seen in children with intrauterine growth retardation § Affect feeding habits and child-breeding habits/practices,
and significantly affect growth
INFANTILE GROWTH
• Particularly sensitive to nutrition as well as congenital conditions PATTERNS OF GROWTH
• Genetic height gradually becomes influential • Normal human growth is PULSATILE
o Periods of rapid growth (growth
CHILDHOOD GROWTH spurts) are separated by periods of
• Height percentile channel is fairly consistent in otherwise healthy no measurable growth
children. o Growth spurts usually occur twice in
• Most steady and predictable the child
§ 1st growth spurt: within the
ADOLESCENT GROWTH first 2 years of life
• Associated with a decrease in growth velocity prior to the onset of § 2nd growth spurt: prepubertal
puberty period
o Deceleration tends to be more pronounced in males • The progression of growth is interpreted within the context of the
• TESTOSTERONE & ESTROGEN are the primary drivers of growth and genetic potential for particular child
enhance growth hormone secretion, thereby facilitating pubertal • Newborns
growth acceleration. o Average birthweight of Filipino children = 3000g (3kg)
• GIRLS – growth acceleration during Tanner Stage 3 for breast o Average length = 50cm
development o Head circumference = 32-37cm
• BOYS – acceleration occurs during Tanner Stage 4 for pubic hair • Growth Rate
development o Individual growth rates vary greatly, but
o Boys achieve greater height velocities than girls during puberty. in children, rapid growth rate occurs in the
o Boys grow approximately 2 years longer than girls. first few years of life, slows down, then
pick up again when the child enters the
FACTORS AFFECTING GROWTH pre-pubertal stage
Genetics • Changes in the Proportion and Body Shape from Fetal to Adult Life
• Parental characteristics may be transmitted from parents to their o Changes are secondary to skeletal growth
offspring o Head becomes smaller compared to the rest of the body as the
o Ex: height, head size, general physique child grows older
• Certain chromosomal abnormalities, metabolic and congenital
endocrine disorders may also adversely affect growth potential

Gender
• Normally, boys are heavier and taller than girls in the early years of
life (before girls have their growth spurt)
• Girls enter the pre-pubertal growth spurt earlier than boys
• Once the boys experience their pre-pubertal growth spurt, they catch
up and become taller and heavier again

Race/Ethnicity
• Caucasian children are heavier and taller than their Asian
counterparts

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 SYSTEMIC GROWTH Computation of Expected Weight
• Skeletal Growth o <6 Months Old
o Continues until the fusion of the epiphyses § Weight in grams = age in months x 600 + birth weight
of the long bones occurs o 6-12 Months
§ Occurs earlier in females (14 years) § Weight in grams = age in months x 500 + birth weight
§ Occurs in males at 17 years o If birth weight is not given, assume that it is 3000g (3kg) for
• Genital Tissues Filipinos
o Grow slowly before puberty
o Double in size during adolescence when Mnemonics: Rapid Computation
they mature and become functional At birth 3.4 kg
• Lymphatic Tissues 𝐴𝑔𝑒 𝑖𝑛 𝑚𝑜𝑛𝑡ℎ𝑠 + 9
o Small, but well-developed at birth 3-12 months
2
o Reach adult dimensions by 6 years of age 1-6 years old Age in years x 2 +8
o Peaks about 10-12 years after which it decreases in size 𝐴𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠 𝑥 5 − 5
• CNS 7-12 years old
2
o Brain continues to grow dramatically after birth
o Myelination of the cerebrum is completed by 2 years of age Changes in Weight at Different Ages
o Brain growth continues until 1—12 years old
At 4-5 months 2x birth weight
• Dental
o Mineralization At 1 year 3x birth weight
§ Begins as early as the 2nd trimester and continues through At 2 years 4x birth weight
3 yr of age for the primary teeth and 25 yr of age for the At 3 years 5x birth weight
secondary (permanent) teeth. At 5 years 6x birth weight
§ Begins at the crown and progresses toward the root.
o Eruption At 7 years 7x birth weight
§ Usually occurs at 6 months of age – mandibular central At 10 years 10x birth weight
incisors (first teeth to erupt)
§ Eruption of permanent teeth begins at 6 years of age and Weight Gain
completed around 18 years of age Newborn-3 months old 30g/day
o Exfoliation 4-6 months old 20g/day
§ Begins at 6 years until 12 years old
§ Causes of early exfoliation include hypophosphatasia, 7-12 months old 10g/day
histiocytosis X, cyclic neutropenia, leukemia, trauma, and
idiopathic factors. • Neonates may lose up to 10% of their birth weight in the first few
days of life, but regain it after 10-14 days
GROWTH MEASUREMENTS • Children are expected to gain 2kg/year between 2 years and puberty
WEIGHT • A pre-pubertal child whose weight velocity is <1kg/year should be
• Simple reproducible growth parameter monitored closely for progressive nutritional deficits
• Can serve as an index for acute nutritional depletion o Pediatricians must be inquisitive about the diet composition of
• Process of Weighing the children (Are they picky eaters? Do they receive enough
o Infants should be weighed on an Infant Scale or Tared Weighing supplements for their age? Etc.)
Scale
§ Under 2 years old or cannot stand
§ Must be weighed naked (only with diaper)
o Tared Weighing Scale
o Older children can be made to stand in the middle of a platform
scale
§ Over 2 years old (can stand alone)

Weighing a child using a taring scale

If the child is less than 2 years old, do tared weighing.
• To turn on the scale, cover the solar panel for a second. When the
number 0.0 appears, the scale is ready.
• The mother will remove her shoes and step on the scale to be weighed
first alone. Have someone else hold the undressed baby wrapped in a
blanket.
• Ask the mother to stand in the middle of the scale, feet slightly apart (on
the footprints, if marked), and to remain still. The mother’s clothing must
not cover the display or the solar panel. Remind her to stay on the scale
even after her weight appears, until the baby has been weighed in her
arms.
• With the mother still on the scale and her weight displayed, tare the
scale by covering the solar panel for a second. The scale is tared when
it displays a figure of a mother and baby and the number 0.0.
• Hand the undressed baby to the mother and ask her to remain still.
• The baby’s weight will appear on the display (shown to the nearest 0.1
kg). Record this weight.

Note: If a mother is very heavy (e.g. more than 100 kg) and the baby’s
weight is relatively low (e.g. less than 2.5 kg), the baby’s weight may not
register on the scale. In such cases, have a lighter person hold the baby
on the scale.

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LENGTH • A pre-pubertal child whose height velocity <5cm/year should be
• Reliable criterion of growth as it is not affected by excess fat or fluid monitored closely (just like for weight gain)
o Reflects growth failure and chronic undernutrition especially in
early childhood Normal Variants
• Recumbent Length • Familial short stature
o Measurement of choice for infants from birth to 24 months • Delayed (constitutional) growth
§ Within this age, growth measurement is affected by • Both variants have normal growth velocity
normal lordosis Feature Familial Stature Constitutional Delay
o Place the infant in a supine position on an infantometer as the Parent’s Stature Small (one or both) Average
parent/assistant holds the infant’s head against the headboard Parent’s Puberty Usual Timing Delayed
and the legs are held straight, flat against the foot board Birth Length Normal Normal
• Height Growth (0-2yrs) Normal Normal to Slow
o Children above 3 years old are able to stand and use standing Growth (puberty) Normal Slow
height Bone Age Normal Delayed
§ Not affected by normal lordosis anymore
Timing of Puberty Normal Delayed
o The child must stand erect with their backs against the
Puberty Growth Rate Lower range of
stadiometer, and the occiput, upper back, buttocks, and heels Diminished
normal
should be against the backboard of the device
Adult Height short Normal

Predicted Height
• Projected Height
o Determined by extrapolating the child’s growth along the
current channel to the 18- to 20-year mark
• Mid-parental Height
𝐹𝐻 − 13𝑐𝑚 + 𝑀𝐻
Average Length/Height Girls
2
At birth 50cm 𝑀𝐻 + 13𝑐𝑚 + 𝐹𝐻
At 1 year 75cm Boys
2
MH = mother’s height; FH = father’s height
Total Average Gains in Length During the First Year o 13cm represents the height difference
When summed up, it equals 25cm, which the expected gain in length between men and women
during the first year o For both girls and boys, there is ±8.5cm on
Birth-3 months 9cm (3cm/month) the other side of this calculated value (target
4-6 months 8cm (2.6cm/month) height), which represents the 3rd to 97th
percentiles for anticipated adult height
7-9 months 5cm (1.6cm/month)
10-12 months 3cm (1cm/month)

Formula for Computing Height 2 Years and Above

o Height in cm = age in years x 5 + 80
HEAD CIRCUMFERENCE
Other Mnemonics for Height • At birth = 35cm
At 1 year 1 ½ x birth length o Can be at the range of 32-37cm
At 2 years ½ mature height o Usually is 0.4-0.8in (1-2cm) larger than the chest circumference
at birth
At 3 years 3 ft tall
• Should be monitored routinely during the first 3 years of life
At 4 years 2x birth length o Reflects the status of brain growth and might be the first
At 13 years 3x birth length indicator of disturbances of the skull
• Head Circumference/Occipital Frontal Circumference is measured
over the most prominent part of the occiput and just above the
supraorbital ridges

Growth in Head Circumference Per Month

0-3 months 2cm
4-6 months 1cm
7-12 months 0.5cm
1-3 years 0.25cm
4-6 years 1 cm/yr

CHEST CIRCUMFERENCE
• Not routinely taken, but can be useful:
o For comparison against the circumference of the head
o If one suspects a problem with either the head or chest size

Comparison to Head Circumference

Birth-5 months HC ≥ 2cm CC
6 months-2 years HC = CC
> 2 years HC < CC
• Chest circumference is greater than head circumference after 2 years
of age as the organs in the chest grow more rapidly than the brain
at this time

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BMI (BODY MASS INDEX) TRICEPS SKINFOLD THICKNESS
• Measured in children after 2 years of age • Provides another index of nutritional status of an individual
• Valid predictor of adiposity • Can be correlated with body fat content
• Best clinical standard for defining obesity • Procedure is similar to MUAC
!"#$%& ()$)
• 𝐵𝑀𝐼 = o The child’s right arm must be in a relaxed position
!
%"#$%& (+)
o The measurement should be taken at the half-way point
• BMI Table
between the acromion and the elbow
o The triceps skin fold is lifted using the thumb and index finger,
and is measured with the caliber
o Measurement is read at the nearest mm

GROWTH CHARTS
USE
• To determine the child’s growth percentiles, the weight and length
(or height) should be plotted on the appropriate growth chart at each
well-child visit and as indicated at interval visits
o Also performed during immunization days
• Used to assess if:
o The child is having a normal growth pattern
o Their weight/height is appropriate for their age
• WHO CGS chart is used for infants up to 5 years of age
o These charts were designed to be used internationally
https://www.londondoctorsclinic.co.uk/wp-content/uploads/2018/06/screen-shot-2016-10-19-at-141402.png regardless of the race/genetics/SES
• CDC/NCHS charts are used for children from 5-19 years of age
BMI-FOR-AGE

Weight-for-Age
• Weight in kg vs. Age in years
• Z-scores are located on the
right side
o 0: normal
o < -2: underweight
o < -3: severely
underweight

Length-for-Age
• Length in cm vs. Age in years
• Z-scores are located on the
MID UPPER ARM CIRCUMFERENCE right side
• Measurement of thinness o > +3: very tall
• Proper Procedure (endocrinologic problems)
o Remove the clothing of the o 0: normal
child to expose the arm o < -2: stunted
o Locate the tip of the o < -3: severely stunted
shoulder and the elbow
and get the midpoint
o Measure the circumference Head Circumference-for-Age
at the midpoint • Assesses if the child has micro-
o Read the measurement to or macrocephaly
the nearest 0.1cm
• MUAC Tape (Mid Upper Arm
Circumference Tape)
o Red < 11.15cm (severe
acute malnutrition)
o Yellow 11.5-12.5cm
(moderate acute
malnutrition)
o Green > 12.5cm (well- Weight-for-Length
nourished) • Weight in kg vs. height in cm
• Z-scores are located on the
right side
o > +3: obese
o > +2: overweight
o > +1: risk of being
overweight
o < -2: wasted
o < -3: severely wasted
• Rapid evaluation to detect children who have severe acute
malnutrition
o The government has platforms for these children to catch up
(ex: feeding programs)

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SPECIAL GROWTH CHARTS ABNORMAL PATTERNS OF GROWTH
• There are special growth charts for children with special conditions SIGNIFICANCE
o Turner Syndrome • Growth can be slowed or accelerated by a variety of conditions
o Down Syndrome • Changes in growth may be the first sign of a pathologic condition
o Williams Syndrome o Ex: inflammatory bowel disease, hypercortisolism, thyroid
o Achondroplasia dysfunction
o Prematurity
EXAMPLES
• Poor weight gain
• Obesity
• Short stature
• Tall stature
• Microcephaly and macrocephaly

Turner Syndrome Down Syndrome

Williams Syndrome Achondroplasia

Prematurity

• Used for premature infants

o The corrected age should be used
§ If not, the infant could appear to be growing sub-
optimally
o Premature infants have catch-up growth
o Corrections for Gestational Age:
§ Weight can catch up to 24 months of age (2 years)
§ Stature up to 40 months of age
§ HC up to 18 months of age
• Issues:
o Developed from a very small sample size of patients
o Nutritional status of the children in the sample was not
assessed
• American Academy of Pediatrics recommended using the WHO and
CDC standard growth charts instead of the special growth charts.
o It is the expectation that each child grow at his or her own
potential, even if it is below the normal growth curves using
the WHO and CDC growth charts.
o It is acceptable for a child to grow at slower rates if they are
consistently tracking along a satisfactory curve as determined
by the clinician.

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