Growth

•Growth is a continuum that involves changes in

body size and form, changes in physiologic
function, and biologic maturation

•A corresponding increase in cell size and

number; no true normal, rather an “average” (50th
percentile) plus or minus two standard deviations
Body Mass Index (BMI)
= weight (kg) / height (m)2

For children, BMI is age and gender

specific;
so BMI-for- age is the measure used in
growth chart
Anthropometric Index Percentile Cut-off Value Nutritional Status
Indicator

BMI-for-Age ≥ 95th Overweight

Weight-for-Length > 95th

BMI-for-Age ≥ 85th and < 95th At Risk of Overweight

BMI-for-Age
Weight-for-Length < 5th Underweight

Stature/Length-for-Age < 5th Short Stature

Head Circumference- for-Age < 5th and > 95th Developmental Problems
 35 35
95th
95th
30 30
50th
25
Weight (kg)

5th
25
20 50th

BMI
15 20 5th
10
15
5
0 10
80 90 100 110 120 130 24 72 120 168 216
Stature (cm) Age (months)
For Children, BMI Changes with Age
BMI BMI

Example: 95th Percentile

Boys: 2 to 20 years Tracking

Age BMI

2 yrs 19.3
4 yrs 17.8
9 yrs 21.0
13 yrs 25.1

BMI BMI
Can you see risk?

• This boy is 3 years, 3 weeks old.

• Is his BMI-for-age

- >85th to <95th percentile: at risk for

overweight?
Plotted BMI-for-Age
BMI BMI Measurements:
Boys: 2 to 20 years Age=3 y 3 wks
Height=100.8 cm
(39.7 in)
Weight=18.6 kg
(41 lb)
BMI=18.3
BMI-for-age=
>95th percentile
overweight
BMI BMI
Can you see
risk?
• This girl is 4 years, 4 weeks old.
• Is her BMI-for-age

- >85th to <95th percentile: at risk for

overweight?
Plotted BMI-for-Age
Measurements:
BMI BMI

Girls: 2 to 20 years Age= 4 y 4 wks

Height=106.4 cm
(41.9 in)
Weight=15.7 kg
(34.5 lb)
BMI=13.9
BMI-for-age=
10th percentile
Normal
BMI BMI
Can you see risk?

• This girl is 4 years old.

• Is her BMI-for-age

- >85th to <95th percentile: at risk for

overweight?
Plotted BMI-for-Age
BMI BMI
Measurements: Age=4 y
Girls: 2 to 20 years Height=99.2 cm
(39.2 in)
Weight=17.55 kg
(38.6 lb)
BMI=17.8
BMI-for-age= between
90th –95th percentile
At
risk for overweight
BMI BMI
Summary of Using BMI-for-Age

• BMI-for-age is the recommended method

for screening overweight and underweight
• For children, BMI is age and gender
specific; for adults there are fixed cut
points
• Accurate and periodic measurements are
important elements of any anthropometric
screening
 Obtain accurate weight and
height measurements
 Select the appropriate growth
chart
 Record the data
 Calculate BMI
 Plot measurements
 Interpret plotted
measurements
Short stature
Measurement that falls below the 3rd – 5th
percentile for height is the short stature

Risk factors/etiology:
•Pathologic (postnatal onset)
•Constitutional growth delay
•Familial short stature
•Prenatal onset short stature (IUGR)
Presentation:
Pathologic :
Starts with the patient in the normal range for
height
Over time, starts falling off the height curve,
crossing percentiles
Constitutional:
Starts with the patient in the normal range for
height
Over time, normal final adult height is reached ,
but the growth spurt and puberty are delayed
Causes of short stature
A. Genetic-familial short stature 
B. Constitutional growth delay 
C. Endocrine disturbances 
  1. Growth hormone deficiency
  2. Hypothyroidism
  3. Excess cortisol—Cushing disease and Cushing
syndrome (including iatrogenic causes)
  4. Precocious puberty
  5. Diabetes mellitus (poorly controlled)
  6. Pseudohypoparathyroidism
  7. Rickets
Causes of short stature (contd…)
D. Intrauterine growth restriction 
  1. Intrinsic fetal abnormalities—chromosomal disorders
  2. Syndromes (eg, Noonan )
  3. Congenital infections
  4. Placental abnormalities
  5. Maternal abnormalities
    a. Hypertension/toxemia
    b. Drug use
    c. Malnutrition
Causes of short stature (contd…)
E. Inborn errors of metabolism 
  1. Mucopolysaccharidosis
  2. Other storage diseases
F. Intrinsic diseases of bone 
  1. Defects of growth of tubular bones or spine (eg,
achondroplasia)
  2. Disorganized development of cartilage and fibrous
components of the skeleton (eg, multiple cartilaginous
exostoses, fibrous dysplasia with skin pigmentation)
Causes of short stature (contd…)
G. Short stature associated with chromosomal
defects 
  1. Autosomal (eg, Down syndrome, Prader-Willi
syndrome)
  2. Sex chromosomal (eg, Turner syndrome-XO)
H. Chronic systemic diseases, congenital defects,
and cancers (eg, chronic infection and infestation, IBD,
hepatic disease, CVS disease, hematologic disease, CNS
disease, pulmonary disease, renal disease, malnutrition,
cancers, collagen vascular disease) 
I. Psychosocial short stature (deprivation
dwarfism) 
Familial:
Stays parallel to the growth curve
Strong family history of short stature

Prenatal short stature:

Parallel to the growth curve but much more
marked
Diagnostic tests
•Growth chart
•Physical exam
•Karyotype (Turner syndrome)
•X-ray (left hand and wrist ) for bone age

Treatment:
•Correction of the underlying disease state
•Growth hormone in selected cases
D/D:
Work-up for short stature
•Familial: A normal variant,
•Exogenous obesity
•Endocrine: growth hormone excess (gigantism,
acromegaly)
•Androgen excess (tall as children but short as
adults)
•Hyperthyroidism
•Genetic syndromes metabolic disorders:
homocystinuria, cerebral gigantism , Beckwith-
Wiedemann, Weaver-Smith, and Klinefelter
syndrome
A. Constitutional (familial) 
B. Exogenous obesity
C. Endocrine causes 
  1. Growth hormone excess (pituitary
gigantism)
  2. Precocious puberty
  3. Hypogonadism
D. Nonendocrine causes 
  1. Klinefelter syndrome
  2. XYY males
  3. Marfan syndrome
  4. Cerebral gigantism (Soto syndrome)
Homocystinuria:
•Autosomal recessive
•Incidence 1:200,000
•Marfanoid appearance
•mental retardation or psychiatric illness

Cerebral gigantism (Sotos syndrome)

•Large for gestational age,
•Mental retardation
•Mild hydrocephalus
Growth velocity:
Yearly increments of growth; should follow a
growth curve

Chronologic age (CA): Actual age

Bone age (BA): X-ray of left hand and wrist

Ideal : CA= BA with normal growth velocity

CA> BA
•With normal growth velocity: constitutional delay
•With abnormal growth velocity: chronic systemic
disease endocrine disorders
CA = BA
•With normal growth velocity: genetic short stature
•With abnormal growth velocity: genetic, chromosomal,
syndrome
CA< BA
•With normal growth velocity: obesity
•With abnormal growth velocity: precocious puberty,
congenital adrenal hyperplasia (CAH) , hyperthyroidism
Failure to thrive is the failure to gain weight or
deceleration of weight growth

Risk Factors/ etiology:

•Malnutrition (starvation, deprivation, abuse)
•Malabsorption (from infection, celiac disease,
cystic fibrosis, disaccharidase deficiency, protein-
losing enteropathy)
•Allergies
•Immune deficiency states
•Chronic disease
 Presentation:
Growth charts
•In infants, birth weight is doubled by 4-5 months
of age and tripled by 1 year
•Patients may show little subcutaneous fat,
muscle wasting, rashes , poor tone, weak cry
Diagnostic tests:
•Hospitalization for documentation of caloric
intake and weight gain
•CBC, urinalysis, LFT, serum protein
•Sweat chloride
•A generalized, excessive over-accumulation of
fat
•May result from an increase in number or size of
adipocytes

Risk factors/ etiology:

•Parental obesity and family inactivity
•Feeding babies as a generic response to any
crying
•Too much fruit juice in the first year of life
•Some syndromes
Presentation:
•Tall stature may sometimes be seen
•Boys may present with increased adipose
tissue in the mammary area
•Abdominal striae
•A large pubic fat
•Puberty may come early
•Associated obesity of the proximal extremities
common
Diagnostic tests:
Body mass index (BMI) > 95% for age/sex or
> 30 in adolescents

Treatment
Exercise and a balanced diet
Complications:
•Increased risk for becoming obese adults
•Cardiovascular (HTN, increased cholesterol)
•Hyperinsulinism
•Slipped capital femoral epiphysis
•Sleep apnea

D/D:
•Endocrine causes (Cushing, hypothyroidism,
Prader-Willi)
•Genetic causes (Turner, Laurence-Moon-Biedl)