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WardSpace

Pediatrics

Growth

The chart is a reasoning tool: place the point yourself, view the trajectory, say what you notice, interpret the trend. The centile framework is the WHO Child Growth Standards from birth to five years, for weight, length and head circumference; the children are teaching cases plotted on it.

Measure

  • Weight naked on a calibrated scale under 2; length lying under 2, height standing after; head circumference at every visit under 2
  • Plot every measurement, and plot it on the right chart: WHO under 2 (the standard for how breastfed children should grow), the WHO-based national charts after
  • Correct for prematurity until 2 years (weight and length) and 18 months (head circumference)
  • Body mass index for age from 2 years; a single BMI centile means little, a trajectory means a lot

Read

  • The trajectory matters more than the position: crossing two major centile lines in either direction is the trigger to ask why
  • Weight falls first with intake and absorption problems; length falls with time and with endocrine causes; head circumference falling with both is severe or prenatal
  • Compare the child with the parents: mid-parental height explains most short children
  • Rapid upward crossing of weight centiles without length is the beginning of obesity; a head crossing upward with the body tracking is imaged

Faltering growth

  • Faltering growth (failure to thrive) is a description, not a diagnosis: weight falling across two centile lines or below the 2nd, sustained
  • Most of it is intake: feeding difficulty, dilute formula, milk excess, grazing, food insecurity, neglect
  • Then absorption and loss: celiac disease, cystic fibrosis, cow's milk protein allergy, chronic diarrhea
  • Then demand: congenital heart disease, chronic lung disease, chronic infection, hyperthyroidism, malignancy
  • The feeding observation and the 24-hour recall find more than the screening bloods do

Trajectory 1 of 6

Crossing centiles downward

BoyWeight-for-ageZoom

Place it first: the latest measurement is 8.1 kg at 12 months. Tap the chart where it lands.

03691215182124051015age, monthsweight, kg3rd15th50th85th97th0 months: 3.4 kg3 months: 6.3 kg6 months: 7.6 kg9 months: 8 kg (solids started late, mostly purees)
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.
AgeweightCentileNote
0 mo3.4 kg54th · z +0.1
3 mo6.3 kg46th · z -0.1
6 mo7.6 kg35th · z -0.4
9 mo8.0 kg16th · z -1.0solids started late, mostly purees
12 mo8.1 kgplace it

A boy born at term, 3.4 kg, breastfed, seen at 12 months for 'not gaining like he used to'. Length has stayed near the median.

What does the trajectory show, and where does the history point?

Trajectory 2 of 6

Tracking low, in proportion

GirlWeight-for-ageZoom

Place it first: the latest measurement is 8.6 kg at 18 months. Tap the chart where it lands.

03691215182124051015age, monthsweight, kg3rd15th50th85th97th0 months: 2.7 kg3 months: 4.9 kg6 months: 6.2 kg9 months: 6.9 kg12 months: 7.5 kg
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.
AgeweightCentileNote
0 mo2.7 kg11th · z -1.2
3 mo4.9 kg8th · z -1.4
6 mo6.2 kg9th · z -1.4
9 mo6.9 kg7th · z -1.5
12 mo7.5 kg7th · z -1.5
18 mo8.6 kgplace it

A girl, born at 39 weeks, 2.7 kg. Both parents are under 160 cm. Seen at 18 months because a relative 'thinks she looks small'.

How do you read this chart?

Trajectory 3 of 6

The acute drop

BoyWeight-for-ageZoom

Place it first: the latest measurement is 8.2 kg at 9 months. Tap the chart where it lands.

02468101202468101214age, monthsweight, kg3rd15th50th85th97th3 months: 6.4 kg6 months: 8 kg8.5 months: 8.9 kg (two weeks ago, well)
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.
AgeweightCentileNote
3 mo6.4 kg52th · z +0.0
6 mo8.0 kg53th · z +0.1
8.5 mo8.9 kg56th · z +0.1two weeks ago, well
9 mo8.2 kgplace it

A boy of 9 months with three days of vomiting and diarrhea. His last weight two weeks ago was 8.9 kg.

What is the last point telling you?

Connected

TopicSodium and water

Trajectory 4 of 6

Crossing centiles upward

BoyWeight-for-ageZoom

Place it first: the latest measurement is 21.4 kg at 48 months. Tap the chart where it lands.

2427303336394245485154576051015202530age, monthsweight, kg3rd15th50th85th97th24 months: 12.2 kg30 months: 14 kg36 months: 16.2 kg42 months: 18.5 kg (started nursery; juice at every meal)
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.
AgeweightCentileNote
24 mo12.2 kg52th · z +0.0
30 mo14.0 kg67th · z +0.4
36 mo16.2 kg84th · z +1.0
42 mo18.5 kg93th · z +1.5started nursery; juice at every meal
48 mo21.4 kgplace it

A boy seen at 4 years for a school-entry check. He was on the median at 2. His height has stayed on the 50th centile throughout. He drinks three cups of juice a day and has a screen in his bedroom.

How do you read this trajectory, and what does it call for?

Trajectory 5 of 6

The length line falls

GirlLength/height-for-ageZoom

Place it first: the latest measurement is 86.8 cm at 36 months. Tap the chart where it lands.

1215182124273033363942454860708090100110120age, monthslength, cm3rd15th50th85th97th12 months: 74.5 cm18 months: 80.5 cm24 months: 84.5 cm30 months: 86 cm (constipation began)
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.
AgelengthCentileNote
12 mo74.5 cm58th · z +0.2
18 mo80.5 cm47th · z -0.1
24 mo84.5 cm28th · z -0.6
30 mo86.0 cm9th · z -1.3constipation began
36 mo86.8 cmplace it

A girl of 3 years brought because 'she is the smallest in her class'. Her weight has stayed near the 50th centile. She is constipated, tires easily, and her skin is dry. Both parents are of average height.

What is the pattern, and what does it point to?

Trajectory 6 of 6

The head crosses upward

BoyHead circumference-for-ageZoom

Place it first: the latest measurement is 46.2 cm at 6 months. Tap the chart where it lands.

02468101225303540455055age, monthshead circumference, cm3rd15th50th85th97th0 months: 34.5 cm2 months: 39.6 cm4 months: 43.4 cm
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.
Agehead circumferenceCentileNote
0 mo34.5 cm51th · z +0.0
2 mo39.6 cm66th · z +0.4
4 mo43.4 cm93th · z +1.5
6 mo46.2 cmplace it

A boy of 6 months at a routine check. He is feeding well, smiling, rolling, and his weight and length are on the 50th centile. His head circumference has been plotted at each visit.

What do the head measurements show?

Place any child

The growth calculator

Sex, age, and one measurement: the chart draws the point and reads the centile and z-score from the WHO tables. Use it to see how far a measurement can move before it crosses a line.

49th centile · z -0.03

about the 49th centile (z -0.0), within the expected band. The WHO median at 9 months is 8.23 kg.

A single point is a position, not a diagnosis. The trajectory across visits is what the chart is for. Teaching tool; not for assessing a real child.

03691215182124051015age, monthsweight, kg3rd15th50th85th97th9 months: 8.2 kg
Centile framework: WHO Child Growth Standards 2006 (weight-for-age, length/height-for-age, head circumference-for-age), birth to 60 months, LMS parameters and the 3rd, 15th, 50th, 85th and 97th percentiles from the WHO expanded tables. Teaching use; the plotted children are fictitious and the chart is not for assessing a real child.

Quick fire

Normal or not?

Normal for age?

0/0 · 6 items

4 daysNewborn finding

Weight 6 percent below birth weight, breastfeeding, wetting diapers