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1 Focused Issue of This Month Monitoring Growth in Childhood: Practical Clinical Guide In Kyung Sung, MD Department of Pediatrics, The Catholic University of Korea College of Medicine E - mail : sinky@catholic.ac.kr J Korean Med Assoc 2009; 52(3): Abstract Growth is a potent indicator of child health. The child who grows well is generally healthy, and poor growth reflects his or her ill health. Identification of poor growth acts as a useful early warning of a possible problem. Monitoring children s growth status with appropriate assessments is an important part of pediatrics, and the recognition of growth problems in children is one of the major challenges facing primary care physicians. The process of growth assessment involves measurements of height and/or weight, and sometimes also involves more specialized measurements that are plotted on standard growth charts. In order to identify pathologic growth, a careful history and physical examination should also be obtained. The purpose of this article is to provide information for primary care physicians to guide the assessment of growth in children. Tools to assist in the assessment of growth are discussed as well as normal growth patterns of children. Keywords: Child; Growth; Growth evaluation; Growth disorders 211

2 Sung IK Figure 1. Growth curve in normal children(i=1 st growth spurt, from fetal period to 2years of age; II=slow growing period, from age 2year to puberty; III=2 nd growth spurt, from puberty to age 15~16year; IV=from age 15~16 year of decreasing growth rate). Figure 2. Height velocity chart for boys and girls. The 97th, 50th, and 3rd percentile curves define the general pattern of growth during puberty. Shaded areas define velocities of children who have peak velocities at ages up to 2 standard deviations before or after the average age depicted by the percentile lines. 212

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5 Monitoring Growth in Childhood: Practical Clinical Guide Table 1. Clinical recommendations for evaluating growth of a child History and physical examination Thorough and comprehensive history and physical examination prevents unnecessary laboratory studies Plotting accurate height and weight Growth chart is an essential and basic on a growth chart tool for evaluating growth. More than 6 months of follow-up is necessary to obtain better data for assessing child s growth trends Mid-parental height (MPH)* To compare the child s current height with the genetic potential, mid-parental height should be calculated Bone age Radiology of left hand and wrist indicates bone maturation and physical maturation * MPH for boys, cm: (father s height + mother s height + 13) 2 MPH for girls, cm: (father s height + mother s height + 13) 2 215

6 Sung IK Table 2. Assessment of patient referred for short stature History Birth size, chronic illness, timing of growth problem Examination Dysmorphic features, pubertal staging Measurements Height (repeated measure growth velocity), body proportion, parent s heights Table 3. Measurements indicated for particular growth conditions Condition Concerns Measurements Age (years) Systemic conditions Linear growth, Height, Tanner staging 2~15 affecting linear growth timing of puberty Early failure to thrive Excess adiposity Weight gain Weight, fat mass Weight, length Weight, height, 0~2 2~20+ skin fold thickness, waist circumference 216

7 Monitoring Growth in Childhood: Practical Clinical Guide Table 4. Factors needed for effective growth monitoring Availability of suitable growth charts Correct measurement techniques Accurate transfer of measurements to chart Correct interpretation (requires understanding of normal and abnormal growth) Time, expertise and resources to explain measurements to parents and initiate appropriate action when necessary Access to specialist advice Figure 3. Points to consider when interpreting a weight chart. 217

8 Sung IK Table 5. Possible signs of a growth failure Child s plotted percentile changes drastically Child is plotted on the growth curve below the 3 rd percentile Consistently poor appetite and/or poor nutrition Chronic abdominal pain and/or diarrhea Marked weight loss or weight gain Delayed puberty A height very much below that predicted by the heights of both parents Other dysmorphic signs are present which can be indicative of a chromosomal disorder 218

9 Monitoring Growth in Childhood: Practical Clinical Guide Figure 4. Height-for- age curves of the four general causes of proportional short stature: postnatal onset pathologic short stature (A), constitutional growth delay (B), familial short stature (C), and prenatal onset short stature (D). 219

10 Sung IK Table 6. Endocrine PICNIC, the causes of pathological growth in children Endocrine Psychological Iatrogenic Chronic illness Nutritional Intrauterine growth retardation Chromosomal Skeletal dysplasia Hypothyroidism Growth hormone deficiency Deprivation Glucocorticoid use CNS irradiation Gastrointestinal inflammatory diseases Renal disease; chronic renal failure, renal tubular acidosis Hematological disorders Congenital heart diseases Metabolic disorders Cystic fibrosis Inadequate nutrition Unknown etiology Part of a syndrome; Russel-Silver syndrome Turner syndrome Noonan syndrome Down syndrome Prader-Willi syndrome Achondroplasia Hypochondroplasia 220

11 Monitoring Growth in Childhood: Practical Clinical Guide Table 7. Comparing constitutional growth delay with familial short stature Height Constitutional delay Short Familial short stature Short Bone age Delayed Not delayed Growth rate Slow Normal Height age Height prognosis Same as bone age Good Less than bone age Poor Table 8. Clinical features suggesting pathological cause of a growth failure Growth parameter < 3 rd percentile Abnormally short for family height History or physical examination suggesting chronic illness; weight loss > height loss Abnormal body proportions Dysmorphic features 221

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13 Monitoring Growth in Childhood: Practical Clinical Guide 11. Mascie -Taylor CG. Biosocial influences on stature: a review. J Biosoc Sci 1991; 23: Gibson AT, Carney S, Cavazzoni E, Wales JK. Neonatal and post-natal growth. Horm Res 2000; 53(s): Reiter EO, Rosenfeld RG. Normal and aberrant growth. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams textbook of endocrinology. 11 th ed. Philadelphia: Saunders, 2007: Lampl M, Veldhuis JD, Johnson ML. Saltation and stasis: a model of human growth. Science 1992; 258: Wehr TA. Effect of seasonal changes in daylength on human neuroendocrine function. Horm Res 1998; 49: Kim YT, Lee CK. eds. Child and adolescence standard growth chart. Korea Centers for Disease Control and Prevention, Korean Pediatric Society, 2007:1-60. Also available from, _page Label=HPPUNI130&rootmenuid=20010&boardid=171& boar dtype=brdtype01& boardseq= Völkl TM, Haas B, Beier C, Simm D, Dörr HG. Catch-down growth during infancy of children born small (SGA) or appropriate (AGA) for gestational age with short-statured parents. J Pediatr 2006; 148: Hokken-Koelega AC, De Ridder MA, Lemmen RJ, Den Hartog H, De Muinck Keizer-Schrama SM, Drop SL. Children born small for gestational age: do they catch up? Pediatr Res 1995; 38: Karlberg JP, Albertsson-Wikland K, Kwan EY, Lam BC, Low LC. The timing of early postnatal catch-up growth in normal, full-term infants born short for gestational age. Horm Res 1997; 48(S): Sorva R, Tolppanen EM, Lankinen S, Perheentupa J. Growth evaluation: parent and child specific height standards. Arch Dis Child 1989; 64: Nwosu BU, Lee MM. Evaluation of short and tall stature in children. Am Fam Physician 2008; 78: Blizzard RM, Johanson A. Disorders of growth In: Kappy MS, Blizzard RM, Migeon CJ, eds. Wilkins the diagnosis and treatment of endocrine disorders in childhood and adolescence. 4th ed. Springfield: Thomas, 1994: Kjellberg H, Beiring M, Albertsson Wikland K. Craniofacial morphology, dental occlusion, tooth eruption, and dental maturity in boys of short stature with or without growth hormone deficiency. Eur J Oral Sci 2000; 108; Gaethofs M, Verdonck A, Carels C, de Zegher F. Delayed dental age in boys with constitutionally delayed puberty. Eur J Orthod 1999; 21: Loevy HT, Aduss H, Rosenthal IM. Tooth eruption and craniofacial development in congenital hypothyroidism: report of case. J Am Dent Assoc 1987; 115: Cole TJ. Assessment of growth. Best Pract Res Clin Endocrinol Metab 2002; 16: Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005; 331: Fomon SJ. Reference data for assessing growth of infants. J Pediatr 1991; 119: Freeman JV, Cole TJ, Wales JKH, Cooke J. Monitoring infant weight gain: advice for practitioners. Community Pract 2006; 79: Hagenäs L, Hertel T. Skeletal dysplasia, growth hormone treatment and body proportion: comparison with other syndromic and non-syndromic short children. Horm Res 2003; 60(S): Engstrom FM, Roche AF, Mukherjee D. Differences between arm span and stature in white children. J Adolesc Health Care. 1982; 2: Lifshitz F, Botero D. Worrisome growth. In: Lifshitz F, ed. Pediatric Endocrinology. 5th ed. New York: Marcel Dekker, 2006: Keane V. Assessment of growth, In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson textbook of pediatrics. 18 th ed. Philadelphia: Saunders, 2007: Wright CM, Cheetham TD. The strengths and limitations of parental heights as a predictor of attained height. Arch Dis Child 1999; 81: Tanner JM, Goldstein H, Whitehouse RH. Standards for children s height at ages 2-9 years allowing for heights of parents. Arch Dis Child 1970; 45: Bayley N, Pinneau SR. Tables for predicting adult height from skeletal age: revised for use with the Greulich-Pyle hand standards. J Pediatr 1952; 40: Lenko HL. Prediction of adult height with various methods in Finnish children. Acta Paediatr Scand 1979; 68: Cox LA. The biology of bone maturation and ageing. Acta Paediatr 1997; 423(S): Poyrazoğlu S, Günöz H, Darendeliler F, Saka N, Bundak R, Baş F. Constitutional delay of growth and puberty: from presentation to final height. J Pediatr Endocrinol Metab 2005; 18: Tanner JM, Prader A, Habich H, Ferguson-Smith MA. Genes on the Y chromosome influencing rate of maturation in man: skeletal age studies in children with Klinefelter s (XXY) and Turner s (XO) syndromes. Lancet 1959; 274: Frasier SD. Tall stature and excessive growth syndrome. In: Lifshitz F, ed. Pediatric Endocrinology. 5th ed. New York: Marcel Dekker, 2006:

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R