Atlas of Growth and Endocrine Disorders in Children Prisca Colaco
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Growth EvaluationCHAPTER 1

Childhood is referred to as the “growing years” as growth is the hallmark of this phase of life. A child's growth is an accurate reflection of his or her general well-being and it is therefore mandatory for pediatricians to monitor the growth of children under their care. Growth faltering requires early evaluation and intervention for optimal results.
Growth charts are the basic tools of growth monitoring. Normally children follow a particular percentile line. Crossing centiles in a downward or upward direction is potentially a sign of growth disturbance and would require evaluation except in the first two to three years of life when there are shifts from the influence of factors which influence size at birth to the genetic influences on stature inherited from the child's parents. Shifts across centiles may be seen again at puberty because of differences in timing of the onset of puberty. Changes in weight or height should be investigated before a child crosses two percentile lines.
There are various growth charts available. In India, the use of the 2006 WHO Child Growth Standards (Figs 1.1 to 1.4) has been recommended from birth to five years. These have been researched from six countries, including India, and confirm that when provided with optimal conditions children under the age of five, anywhere in the world, have the same potential for growth. Breastfed infants were used as the normative model for growth and development. These charts are considered to be the gold standard for assessing the growth of young children. The growth of preterm infants can be monitored by these standards after a corrected age of 40 weeks is reached. Alternative charts are available to assess the growth of preterm infants in the neonatal intensive care unit. Measurements are plotted using corrected postnatal age for prematurity, i.e. the age of the infant from birth minus the number of weeks premature. (40 weeks – gestational age in weeks). Corrected age should be used until 2 years of age. If the child catches up before this then chronological age can be used.
The WHO Reference 2007 growth charts (Figs 1.5 and 1.6) use the original NCHS data (1977) supplemented with the WHO growth standards for the under-fives. They are recommended for monitoring the growth of children and adolescents between the ages of five and 19 years because they have been updated to address the obesity epidemic and, therefore, are considered to be closer to growth standards.2
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Fig. 1.1: WHO child growth standards: Length/height-for-age girls birth to 5 years
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Fig. 1.2: WHO child growth standards: Length/height-for-age boys birth to 5 years
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Fig. 1.3: WHO child growth standards: Weight-for-age girls birth to 5 years
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Fig. 1.4: WHO child growth standards: Weight-for-age boys birth to 5 years
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Fig. 1.5: WHO percentile: Height-for-age girls 5–19 years
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Fig. 1.6: WHO percentiles: Height-for-age boys 5–19 years
According to Khadilkar, the growth of affluent Indian children appears similar to US and UK data but the pubertal spurt appears to be less intense probably due to genetic differences.
The IAP Growth Charts 2015 for 5–18 years old Indian children (Figs 1.7 and 1.8) are based on collated national data from published studies in the last 10 years, performed on apparently healthy children and adolescents from upper and middle socioeconomic groups. Data on 33148 children (18170 males, 14978 females) from fourteen cities were used to construct the charts.
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Fig. 1.7: IAP boys: Height and weight chart 5–18 years
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Fig. 1.8: IAP girls: Height and weight chart 5–18 years
The IAP Growth Chart Committee recommends these revised growth charts for height, weight and body mass index (BMI) for assessment of growth of 5–18 years old Indian children and the use of WHO standards for growth assessment of children below 5 years of age.7
These charts have been drawn for some conditions which have characteristic growth patterns such as Turner syndrome (Fig. 1.9), Down syndrome, achondroplasia, Marfan's, Prader Willi, Williams, Cornelia de Lange and Rubinstein Taybi syndromes. These help in identifying the development of any additional problems which may develop in these children, e.g. hypothyroidism in Down syndrome. However limitations which affect the accuracy of their use include small sample size and the association of other conditions which may affect growth.
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Fig. 1.9: Growth chart for girls with Turner syndrome (TS)
Growth velocity charts (Fig. 1.10) are created from longitudinal measurements. Growth velocity is the average change in a specific anthropometric measurement over a period of time, ideally one year and no shorter than 6 months.
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Fig. 1.10: Longitudinal standards for height velocity, boys (JM Tanner, RH Whitehouse. Arch Dis Child. 1976;51:170)
The need for urgent evaluation is indicated by an abnormal growth velocity rather than just the position of the child on the growth charts. A very low single value for height velocity (3rd centile), or a height velocity persistently below the 25th centile, warrants evaluation even if the height is >3rd centile. A height velocity value consistently above the 75th centile may be related to obesity or precocious puberty.
Growth velocity charts are more sensitive indicators of small changes in growth than regular (size-attained) charts, and are more helpful when assessing changes in growth rates that are important in selected growth disorders and therapies.
Body Proportions
  • Upper to lower segment ratios (U/L): The lower body segment is the measurement of the length from the pubic symphysis to the floor; the upper body segment is the height minus the lower body segment. The U/L ratio at birth is about 1.7; at age 3 years it is 1.3; after 7 years of age, it is 1.0 with the upper body segment and lower body segment being about equal.
  • Sitting height: Sitting height is a more accurate measure of proportion. The subischial length is obtained by subtracting the sitting height from the height. Reference charts are available.
  • Arm span: The child is made to stand against a wall with arms outstretched at 90° to the torso and the distance between the tips of the middle fingers of the two hands measured. Normally the arm span is less than the height by a centimeter in children, equal in adolescents and approximately 5.0 cm more in the adult male and 1.2 cm in adult female.
Table 1.1   Comparison of Z-scores and percentiles
Exact percentile
Rounded percentile
  1. de Onis M, Garza C, Onyango AW, Martorell R eds. WHO Child Growth Standards. Acta Pediatr Supplement. 2006;450:1–101.
  1. Khadilkar VV, Khadilkar AV, Cole TJ, Sayyad MG. Crosssectional growth curves for height, weight and body mass index for affluent Indian children, 2007. Indian Pediatr. 2009;46:477–89.
  1. Khadilkar V, Yadav S, Agrawal KK, Tamboli S, Banerjee M, et al. Revised IAP growth charts for height, weight and body mass index for 5- to 18-year-old Indian children. Indian Pediatr. 2015;52:47–55.
  1. World Health Organization. WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: World Health Organization;  2006.