Growth and Development

• Caloric intake


  May be inadequate because of increased caloric needs
• Children with chronic illnesses

  • May require a significantly higher caloric intake to sustain growth
• Rules of Thumb for Growth

  • Weight loss in first few days: 5-10% of birthweight
  • Return to birthweight: 7-10 days of age
  • Double birthweight: 4-5 months
  • Triple birthweight: 1 year
  • Daily weight gain: 20-30 g for first 3-4 months, 15-20 g for rest of the first year
• Growth Measurements


  • Average length: 20 in. at birth, 30 in. at 1 year
  • At age 4 years, the average child is double birth length or 40 in.
  • Average head circumference: 35 cm at birth (13.5 in.)
  • Head circumference increases: 1 cm per month for first year (2 cm per month for first 3 months, then slower)
• An increasing weight percentile in the face of a falling height percentile suggests hypothyroidism
• Head circumference may be disproportionately large when there is familial megalocephaly, hydrocephalus, or merely catch-up growth in a neurologically normal premature infant
• A child is considered microcephalic if the head circumference is less than the third percentile, even if length and weight measurements also are proportionately low
• Serial measurements of head circumference are crucial during infancy, a period of rapid brain development, and should be plotted regularly until the child is 2 years of age
• Any suspicion of abnormal growth warrants at least a close follow-up, further evaluation, or both
• Specific Growth Patterns Requiring Further Evaluation

  • Weight, length, head circumference all <5th percentile
  • Discrepant percentiles (e.g. leg length 5th, weight 50th, head circumference 50th)
• Representative diagnoses to consider

  • Familial short stature
  • Constitutional short stature
  • Intrauterine insult
  • Genetic abnormality
  • Normal variant (familial or constitutional)
  • Endocrine growth failure
  • Caloric insufficiency
• Further evaluation

  • Midparental heights
  • Evaluation of pubertal development
  • Examination of prenatal records
  • Chromosome analysis
  • Thyroid hormone
  • Growth factors, growth hormone testing
• The most common reasons for deviant measurements are technical (ie., faulty equipment and human errors)
• Repeating a deviant measurement is the first step
• Separate growth charts are available and should be used for very low birthweight infants (weight 1,500 g) and for those with Turner syndrome, Down syndrome, achondroplasia, and various other dysmorphology syndromes
• Newborns' heads are significantly larger in proportion to the rest of their body. This difference gradually disappears
• Certain growth disturbances result in characteristic changes in the proportional sizes of the trunk, extremities, and head
• Children, in general, follow their parents' growth pattern, although there are many exceptions
• Midparental height calculation for a girl

  Paternal height (inches) + Maternal height (inches) / 2
• Midparental height calculation for a boy

  Paternal height (inches) + Maternal height (inches) / 2 + 2.5
• Actual growth depends on too many variables to make an accurate prediction from midparental height determination for every child
• The growth pattern of a child with low weight, length, and head circumference is commonly associated with familial short stature
• A child who, by age, is preadolescent or adolescent and who starts puberty later than others may have the normal variant called constitutional short stature
• An evaluation for primary amenorrhea should be considered for any female adolescent who has not reached menarche by 15 years or has not done so within 3 years of thelarche (beginning of breast development)
• Lack of breast development by age 13 years also should be evaluated
• Many children assume a lower percentile between 6 and 18 months of age until they match their genetic programming; then they grow along new, lower percentiles
• Infants born small for gestational age, or prematurely, ingest more breast milk or formula and, unless there are complications that require extra calories, usually exhibit catch-up growth in the first 6 months
• Many psychosocial risk factors that may have led to being born small or early may contribute to nonorganic failure to thrive
• Infants who recover from being low birthweight or premature have an increased risk of developing childhood obesity
• Growth of the nervous system is most rapid in the first 2 years, correlating with increasing physical, emotional, behavioral, and cognitive development
• There is again rapid change during adolescence
• Osseous maturation (bone age)


  Determined from radiographs on the basis of the number and size of calcified epiphyseal centers; the size, shape, density, and sharpness of outline of the ends of bones, and the distance separating the epiphyseal center from the zone of provisional calification
• Observation of any asymmetric movement or altered muscle tone and function may indicate a significant central nervous system abnormality or a nerve palsy resulting from the delivery and requires further evaluation
• Important reflexes to assess during the newborn period

  • Moro reflex
  • Rooting reflex
  • Sucking reflex
  • Asymmetric tonic neck reflex
• A delay in the expected disappearance of the reflexes may also warrant an evaluation of the central nervous system
• With the development of gross motor skills, the infant is first able to control his or her posture, then proximal musculature, and, last, distal musculature
• Evaluation of vision and ocular movements is important to prevent the serious outcome of strabismus
• The cover test and light reflex should be performed at early health maintenance visits; interventions after age 2 decrease the chance of preserving binocular vision or normal visual acuity
• Older school-age children who begin to participate in competitive sports should have a comprehensive sports history and physical examination, including a careful evaluation of the cardiovascular system
• Any history of heart disease or a murmur must be referred for evaluation by a pediatric cardiologist