Assessment of Growth and

the abnormalities

S. Yudha Patria
Div. Endocrinology, Dept Child Health
Faculty of Medicine, Universitas Gadjah Mada
INTRO

What is physical GROWTH and DEVELOPMENT ?

Who will be growth & develop in human?
When will human growth & development occur ?
What measurement is as determinant for growth ?
How do we meassure ?
What standard is used?
The abnormalities
• GROWTH:
increase in size of the body dimension, parts, or
tissues toward maturity

• DEVELOPMENT:
changes human body of attaining mature state →
- differentiation
- (be) functions
- maturation
- adaptation
Growth & Development

• Basic science of child health

• Major determinants of child health-illness
• React & refer to adjust genetic-environment
interaction factors in human body
• Not the same processes, but interrelated
The Phases in Child G&D

Prenatal:
embryonic-, middle fetal-, late fetal-

Infancy:
neonatal, infant, late infancy

Childhood:
preschool year, school year

Adolescence:
prepuberty, puberty, post-puberty
The Phases of Growth
1. Pre-natal
2. Infant
3. Childhood
4. Puberty/ adolescence
 Prenatal – Fetal growth
The growth and development is influenced by
placenta, as source of
- nutrition
- growth factor (GHvar, hPL, CRH, etc)

fetal genetic (chromosome), and endocrine (thyroid, insulin, IGF2)

maternal condition

→At the end of 2nd trimester 10 cm/month, max weight gain at

3rd trimester
 Infant growth
(0-2 yo)

Extension of fetal growth

Nutrition dependent
Thyroid dependent
GH independent

→ Growth velocity 25 cm/ year, and growth decrement

Childhood Growth
(2-8/12 yo)
Endocrine dependent
- GH dependent (pulsatile, act on epiphyseal cartilage cells
→ GH – IGF1 axis)

- Orexigenix
hormones (Ghrelin)
- Thyroxine, Vit D (+ Calcium)
Nutrition adequacy

→ Growth velocity 5 – 6 cm/year (growth decrement)

Pubertal and Adolescent Growth
(8/12- 15/18 yo)

GH pulsatile dependent

Sex steroid dependent

→Peak growth velocity 10-12 cm/yr than finish of growth

(growth increment until final height)
Decrement and
Increment of
Growth Phases
Other factors
→ influent all phases

• Diseases (chronic, systemic)

• Psychogenic stress
• Familial genetic
As a doctor, you may need to answer…

Doctor, do you think

my son is too short?
Is he growing fine?
Or…

Am I too skinny?
Too fat?
Sometimes… It is easy to answer
However,
most of the
time… it is not
You must do….

Growth measurement and

analyze
What is physical GROWTH and DEVELOPMENT ?
Who will be growth & developed ?
When will growth & development occur ?
What measurement is as determinant for growth ?
How do we meassure ?
What standard is used?
Anthropometric measurement

Body weight (mostly)

Body length / height (important fo linier growth)
Head circumference
Mid-upper arm circumference
BMI (important parameter)
Growth velocity
Body proportion
Weight / height ratio
Other measurements (do when needed)
• Skin-fold thickness
• Waist circumference
• Waist-to-hip ratio
• Sitting height
• Arm span
• Bi-acromial diameter
• Bi-iliac (bicristal) diameter, etc.
Normal distribution curve
Normal distribution
 Hz/age

WHO charts
H/age

CDC charts
Specific Universal Growth Charts
 SpecificUniversal Growth Charts

Growth Charts for Down Syndrome Growth Charts for Marfan Syndrome
Height Velocity

Simm & Wether, 2005

Normal Growth Velocity

• Prenatal : 1,2 – 1,5 cm/wk

• Infant : 23 -28 cm / yr
• Childhood : 5 – 6,5 cm/yr
• Puberty : 8 – 10 cm/yr (girls)
9 – 12 cm/yr (boys)
U / L Ratio

Rose, et al. 2005

Z-scores or standard deviation scores (SD- scores):
Indicates how far a measurement is (less or more) form the
median/ average (mean), 95% of the time it is within 2SDs

Less Higher
than normal than
normal normal
Sita, 5 mo
Prita

Be careful of
Genetic
Channeling
Am I too skinny or fatty?

Weight in relation to stature or length

Indicator: weight for length/ height (WLZ or WHZ),
and
BMI for age (BMIZ)

BMI= body mass index

Weight (kg)/ squared height (m2)
Who is heavier?
Weight-for-age
• Sometimes, we can only measure weight so
we can only get indicator weight-for-age
• However, a child can be heavy because he/
she is tall (tall and skinny) or fatty (fatty and
short)
• This indicator is not ideal for assessing growth
and nutritional status, it can only be used for
screening
Interpretation causes of abnormal
growth and nutritional status
WHO interpretation table
Possible Cause of Growth Abnormalities

• Nutrition
• Chronical diseases
• Endocrine
• Psychological
• Genetics
Length/ height for age

• z-score > +2: too tall → beware of endocrine or

genetic abnormalities (Marfan syndrome, Kleine-
felter syndrome, precoccious puberty, GH secreting
tumor, etc)
Length/ height for age …

Z-score < -2: too short

Stunted: chronic undernutrition/ poor-health
Genetic or endocrine causes of short stature:
- BB/TB N or and proportional:
hypothyroidism, GH deficiency, familial short stature,
constitutional delay of growth and puberty (CGDP)

- BB/TB N or and disproportional:

achondroplasia, etc
Weight for length/ height or BMI for age

• Z-score < -2: wasted

• Acute undernutrition:
• Marasmus
• Marasmic-kwashiorkor
• Kwashiorkor
marasmus
• the appearance of skin and bones due to loss of
muscle and fatty tissue.
• The child’s face looks like an old man following loss
of facial subcutaneous fat, but the eyes may be
alert.
• The ribs are easily seen.
• There may be folds of skin on the buttocks and
thighs that make it look as if the child is wearing
baggy pants.
marasmus
 Kwashiorkor
• The child’s muscles are wasted, but the wasting may not be
apparent due to generalized edema (swelling from excess fluid in
the tissues).
• The child is withdrawn, irritable, obviously ill and will not eat.
• The face is round (because of edema) and
 Kwashiorkor…

• The hair is thin, sparse and sometimes discolored

• The skin has symmetrical discolored patches where the
skin later cracks and peels off
• A child with kwashiorkor will usually be underweight,
but the edema may mask the true weight
kwashiorkor
kwashiorkor
Marasmic-
kwashiorkor
 Weight for length/ height or BMI for age

Z-score > +2: overweight or

obese
Riskesdas 2013
Riskesdas 2013
Riskesdas, 2013
Male Body Height
Female Body Height
 Suggested Readings

• Valadian & Porter. Physical growth and development – from

conception to maturity
• Moshang,T. Pediatric endocrinology- requisites in pediatrics
• WHO, CDC Growth standard Charts