GROWTH
Understanding normal growth patterns of childhood is important because it is an indication of the overall health of a child.
Growth is influenced by both genetics and environment.
Growth Charts
Height, weight, and head circumference are plotted on growth curves to compare the patient to the population.
Growth charts compare individual children with the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles.
Serial plotting of a patient’s growth allows the clinician to observe patterns of growth over time.
Having only one point on a growth chart is like having no point; the trend over time is what is important.
Body mass index (BMI) is plotted on growth curves for males and females from 2 to 20 years of age. BMI above 85% classifies as overweight and above 95% as obese.
Potential limitations of particular growth charts include possible development from small population sizes, ethnic differences, and whether they represent growth potential versus proper care and feeding.
Specialized charts exist for children who are premature (Babson), have Down syndrome, myelomeningocele, Prader-Willi syndrome, cerebral palsy, or Williams syndrome.
In the normal child, the greatest growth occurs in the first year of life.
Early Growth Trends
A term infant regains birth weight by 2 weeks.
During the first 3 months, a child is expected to gain 20 to 30 g/day or close to 1 kg/month.
A child doubles birth weight by the fifth month of life and triples by his or her first birthday.
Growth chart recording should be adjusted for gestational age until the infant is 2 years old.
Children with genetic short stature may have normal length and weight at birth but their growth percentiles decline within the first 2–3 years.
Appetite normally 
in the second year of life coincident with the slowing of the growth rate.
Intrauterine Factors
Carefully plotting on a growth chart is the most accurate method by which to follow a child’s physical growth.
Insulin-like growth factor (IGF) is important for fetal growth.
Growth hormone and IGF are both important for postnatal growth.
Thyroid hormone is important for central nervous system (CNS) development, but not important for fetal growth.
Fetal weight gain is greatest during the third trimester.
Teratogens, TORCH infections (toxoplasmosis, other [hepatitis B, syphilis, varicella-zoster virus], rubella, cytomegalovirus, herpes simplex virus/human immunodeficiency virus), and chromosomal abnormalities (trisomy 21, Turner syndrome) can impair fetal growth.
Teeth
By age 2½, children should have all of their primary teeth including their second molars.
Central incisors are first to erupt, between 5 and 8 months.
Second molars are last to erupt, between 20 and 30 months.
Secondary (permanent) teeth begin to erupt by age 6–7 years.
Early or late tooth eruption may be within normal limits, though it can be an indicator of a nutritional, genetic, or metabolic problem.
Delayed eruption:
Endocrine disorders (hypothyroidism).
Genetic abnormalities (Down syndrome).
SPECIFIC GROWTH PROBLEMS
Microcephaly
DEFINITION
Head circumference > 3 standard deviations below the mean for age and sex.
ETIOLOGY
Genetic (familial, isolated).
Syndromic:
Chromosomal: Trisomy 21, 13, 18.
Contiguous gene deletion: Cri-du-chat syndrome, Williams syndrome.
Single-gene defects: Cornelia de Lange syndrome, Smith-Lemli-Opitz syndrome.
Prenatal insults (radiation, alcohol, hydantoin, TORCH infections, maternal phenylketonuria [PKU] and maternal diabetes, placental blood flow).
Perinatal hypoxic-ischemic encephalopathy.
Structural malformation (eg, lissencephaly),
Measure parents’ and siblings’ head circumference to check for familial cause of microcephaly.
IMPACT
A small brain predisposes to cognitive/motor delay, mental retardation, and seizures.
Weight is affected first in FTT, followed by height and head circumference.
Macrocephaly
DEFINITION
Head circumference > 3 standard deviations above the mean.
ETIOLOGY
Familial in 50% of cases.
Hydrocephalus.
Other causes: Large brain (megalencephaly), cranioskeletal dysplasia, Sotos syndrome.
Psychosocial reasons account for most cases of FTT in the United States.
Failure to Thrive (FTT)
DEFINITION
FTT is defined as a weight below the third percentile or a fall off the growth chart by two percentiles.
Signs of FTT:
SMALL KID
Subcutaneous fat loss
Muscle atrophy
Alopecia
Lagging behind norms
Lethargy
Kwashiorkor/marasmus
Infection
Dermatitis
ETIOLOGY
Organic causes include disease of any organ system.
Nonorganic causes include abuse, neglect, and improper feeding (see Table 4-1).
SIGNS AND SYMPTOMS
Expected age norms for height and weight not met.
Hair loss.
Loss of muscle mass.
Subcutaneous fat loss.
Dermatitis.
Lethargy.
Recurrent infection.
Kwashiorkor—protein malnutrition.
Marasmus—inadequate nutrition.
DIAGNOSIS
Detailed history:
Gestation, labor, and delivery.
Neonatal problems (feeding or otherwise).
Breast-feeding mother’s diet and medications.
Types and amounts of food, who prepares and how the formula or food is prepared, who feeds.
Vomiting, diarrhea, infection.
Sick parents or siblings.
Major family life events/chronic stressors.
Travel outside the United States.
Any injuries to child.
Observation of parent-child interactions, especially at feedings, is critical for diagnosis.
Lack of weight gain after adequate caloric feedings is characteristic of nonorganic failure to thrive.
Screening tests for common causes include complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, and albumin and thyroid-stimulating hormone (TSH).
TREATMENT
If a nonorganic cause is suspected or the child is severely malnourished, hospitalization may be required.
If organic, treat the cause.
Organic versus nonorganic FTT is best distinguished by a detailed history and physical exam.
PROGNOSIS
FTT during the first year of life has a poor outcome due to the rapid growth of the brain during the first 6 months.
TABLE 4-1. Etiology of FTT
DEVELOPMENT
A child smiles spontaneously, babbles, sits without support, reaches, and feeds herself a cookie but has no pincer grasp. What is her approximate age? Think: 8–9 months (immature pincer grasp at 10 months). Fine pincer grasp of an object between the thumb and forefinger generally develops at 12 months of age.
Attainment of developmental milestones is an indicator of a child’s overall neurologic function.
Maturation of intellectual, social, and motor function should occur in a predictable manner.
It is essential that the physician recognize normal patterns in order to identify deviations.
Developmental Milestones
Each new motor, language, and social skill should be acquired during an expected age range in a child’s life.
Each new skill is built on an earlier skill, and skills are rarely skipped (see Table 4-2).
TABLE 4-2. Developmental Milestones
Neurologic Development
Myelination of the nervous system begins midgestation and continues until 2 years of age.
Myelination occurs in an orderly fashion, from head to toe (cephalocaudal).
Brain at birth weighs approximately 10% of the newborn’s body weight (adult brain, 2% of body weight).
Primitive reflexes are present after birth and diminish by 6 months (see Table 4-3).
For age adjustment between birth and 2 years, subtract the number of weeks of prematurity from the chronological age. For an 18-month-old baby who is an ex-preemie at 30 weeks, the difference from full term at 40 weeks is 10 weeks, so the corrected age is 18 months minus 10 weeks = 15½ months.
Age Adjustment for Preterm Infants
Preterm infants may differ from full-term infants with regard to development.
Age correction should be done until the child is 24 months old for children born more than 2 weeks early.
Use the corrected age when assessing developmental progress and growth.
TABLE 4-3. Primitive Reflexes
DEVELOPMENT DELAY
An 18-month-old infant brought in for temper tantrums has normal gross and fine motor skills but lacks language development and is cooperative and alert on exam. Think: Hearing loss.
Screening for hearing in the newborn nursery before discharge has resulted in earlier detection of hearing loss. Hearing impairment impacts language development. Inattention may be the initial presentation. It can also affect behavior and academic achievement.
Developmental Evaluation
12 months: No babbling and no gesture
16 months: No single word
24 months: No two-word phrase
DEFINITION
Performance significantly below average in a given skill area.
Global developmental delay: Significant delay in two or more areas of development (gross or fine motor, speech and language, cognition, social and personal, and activities of daily living).
Early detection of delay is important because brain development is most malleable in the early years of life.
At age 1 year, a child uses one word and follows a one-step command.
ETIOLOGY
Cerebral palsy.
Mental retardation.
Learning disabilities.
Hearing and vision deficits.
Autism.
Neglect.
Attention deficit/hyperactivity disorder (ADHD).
Lack of exposure.
At age 2 years, a child uses two- to three-word phrases and follows two-step commands, and others can understand half of the child’s language.
DIAGNOSIS
The Denver Development Assessment Test (Denver II) is a screening tool intended to be performed at well-child visits to identify children with developmental delay.
For children up to the age of 6 years.
Evaluates personal-social, fine motor, gross motor, and language skills.
At age 3 years, a child uses three-word sentences, and others can understand three fourths of the child’s language.
Clinical Adaptive Test (CAT)/Clinical Linguistic Auditory and Milestone Scale (CLAMS) rates problem solving, visual motor ability, and language development from birth to 36 months of age.
Early intervention is important because the younger children are treated, the better the outcome.
At age 4 years, a child should be 40 lbs. and 40 inches tall, and be able to draw a four-sided figure.
LEARNING DISABILITIES (LDs)
Present in 3–10% of children.
To make a diagnosis of learning disability, the child must have a normal
Include difficulties with reading (dyslexia), arithmetic (dyscalculia), and writing (dysgraphia).
Dyslexia is one of the most common learning disabilities.
Failure to acquire reading skills in the usual time course.
These children have excellent spoken language.
Presents with different degrees of severity.
SLEEP PATTERNS
Infants sleep 18 hours per day, with 50% rapid eye movement (REM) sleep, compared to an adult with 20% REM sleep.
By age 4 months, nighttime sleep becomes consolidated.
Two sleep stages are REM (irregular pulse and time when dreaming occurs) and non-REM (deep sleep).
Parasomnias (sleep disorders) begin near age 3 years.
Nightmares occur during REM sleep—the child awakens in distress about a dream.
Night terrors occur in non-REM sleep—the child appears awake and frightened but is not responsive, and then is amnestic about the event the next morning.
Somnambulism (sleepwalking) occurs in non-REM sleep; most common in ages 4–8 years.
Somniloquy (talking) is very common throughout life, sometimes accompanying night terrors and sleepwalking.