by Dr. B.J.C.Perera MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician

Growth in children generally refers to physical growth that is manifested by progressive increases in height and weight. In normal children the height and weight increase in a predictable manner with very definite spurts of increase in these parameters at certain well defined periods in the life of a child. Serial recordings or plotting of these measurements over a period of time and documented in a special growth chart is extremely useful in determining whether a given child is progressing in a satisfactory manner. In Sri Lanka, the Ministry of Health provides a Child Health Development Record (CHDR), a comprehensive booklet that contains growth charts and other useful bits of information, for every baby born in this country. The cover is pink for girls and blue for boys. This booklet is issued free of charge from all institutions where babies are born.

It is often much easier to determine if one should be concerned about a child’s growth if one is aware of where he or she is on the child’s growth chart. It is not absolutely necessary for a child to be on the upper curve lines of either the weight or the height of a growth chart. What is really important is to determine how these two parameters of growth progress over a period of time. If the growth lines progress parallel to even the middle or lower lines and as long as the general directions of the growth lines are progressing upward, there is generally no cause for concern. However, if the plotted growth lines tend to go horizontally crossing the normal upward directed pre-determined lines drawn on the charts or more importantly, if the growth lines dip downward, then it calls for some action and the child needs to be assessed by a qualified doctor. This situation is referred to as growth faltering.

The best way of doing a height measurement is by having the child stand in bare feet against a wall with knees straight and hips and shoulders touching the wall. Head should be level with the eyes looking straight ahead. Using a flat object held against the top of the head and touching the wall, one could mark the height on the wall and measure it. This can also be done with a device called a "stadiometer" and is more accurate than the measuring device attached to upright scales. Children under 2 years of age should be measured lying on their backs on a flat surface with a measuring device that has adjustable ends. Each end of the measuring device should fit against the top of the head and soles of feet with legs extended. It is acceptable to see a decrease in height when switching from lying to standing measurements. This is approximately half to one inch.

Normal height growth rates vary according to age. Children during the first year of life should grow 7 to 10 inches. During the second year growth slows to an average of 5 inches. During the third year growth averages 3 inches. From age 4 years until puberty, growth should be at least 2 inches per year. Pubertal changes prompt a growth spurt of 2 to 4 inches per year for girls usually starting around 10 years. However, boys experience both puberty and this growth spurt a little bit later, usually starting by 12 years and averaging 3 to 5 inches per year. After pubertal changes are completed and bone ends fuse, very little further growth in height occurs. This last phase in late adolescence would account only for an increase of just a couple of inches.

If a child is below the 5th centile or the lowermost line of the height chart or above the 95th centile line or the uppermost line or if a child is not in the appropriate range based on his or her potential from the parents heights, one should be concerned. Such children would need further evaluation and possibly some investigations. In addition, a growth rate that has previously been following along a certain centile line and begins to move away either up or down toward another centile curve may be cause for concern as well. Typically after the age of 2 years, a child establishes a set growth pattern along one of the centile curves and follows it until growth is completed. Growing away from this percentile may signal a health problem.

It is often said that maintaining a normal growth pattern is a good indicator of a child’s overall good health. Failure to grow at least two to three inches each year can be natures early warning sign that something underlying and quite often unseen, is abnormal and needs medical evaluation. Growth is influenced by many factors such as heredity, genetic or congenital, illnesses and medications, nutrition, hormones and psychosocial environment. Measurements of growth-height and weight are a very inexpensive service that should be offered by all health care providers rendering care to children. Additionally it is also important that these be done correctly and included as a part of sick visits as well as "well child" check-ups.

Children are generally a reflection of their parents growth patterns and height. Parents who were late bloomers and experienced slow growth and late pubertal development may see the same pattern in their children. The final height these children achieve is usually normal. Parents who have short stature usually have children whose adult height potential is in the shorter range. Conversely tall parents usually have tall children. As a general rule, a child’s potential adult height ranges between the average of the parents heights toward that of the parent who is the same sex as that of the child. However, like all other things in medicine, this is not an invariable rule. Short parents can have tall children and less commonly, tall parents can have relatively shorter children.

Congenital causes for growth failure include intrauterine growth retardation before the baby is born, skeletal abnormalities and chromosome changes. Intrauterine growth retardation may result from a variety of causes such as maternal infections, smoking or exposure to second-hand smoke or alcohol and drug use while pregnant. Skeletal causes such as short limbed dwarfism result from abnormal production of new bone and cartilage. These children usually have a normal trunk with unusual trunk - limb proportions. Chromosome variations causing short stature include Turner syndrome in girls and Down syndrome in both sexes. There are a whole host of other much rarer chromosomal aberrations that are associated with short stature.

Nutritional problems too can influence growth in two ways. More commonly the problem is a poor diet with inadequate nutrients with insufficient calories or the wrong food groups. Secondly, diseases that interfere with the absorption of food from the bowel will prevent the body from using those nutrients for growth. In these cases symptoms may include nausea, vomiting, excessive gas, diarrhoea or constipation, poor weight gain or being underweight for height. After diagnosis, these problems usually improve with adequate steps being taken to deal with the problem and with proper correction of these disorders, growth will also improve.

Certain diseases which are considered chronic can reduce growth because they interfere with the body’s ability to use nutrients properly. Diseases which involve the kidneys, digestive tract, heart or lungs are examples of such conditions that may influence growth. Some medications that are used in large doses or for long periods of time may also affect growth. If one is concerned about the effects of medications given on a regular basis, one should discuss this with the physician who prescribed them.

Several hormonal disturbances can affect growth. Hormones are chemicals that are produced by certain glands of the body which exert their actions on completely different remote areas of the body. One such hormone is thyroxine. It is made by the thyroid gland located in the neck. In children, thyroxine has a major influence on the growth and development of brain and bones. It continues to regulate metabolism throughout adult life as well. Symptoms of inadequate thyroxine can include dry skin and hair, constipation, loss of energy or feeling cold in normal temperatures and quite significant failure to grow in height. If there is an inadequate amount of thyroxine made, it can easily be replaced by tablets of thyroxine.

Another hormone that is crucial for normal growth in height is the Growth Hormone. It is made by the pituitary gland located in the middle of the head at the base of the brain. Growth hormone affects glucose and fat metabolism, the production of protein to sustain new cell development and, most importantly, it stimulates bone growth at the growth plates located at the ends of the bones. Children with growth hormone deficiency usually have a dramatic slowing of growth. They may have younger looking faces than their actual age, but have normal body proportions. Diagnosis is made with blood tests and treatment is by regular injections of human growth hormone or one of its analogues. Treatment should continue until the bone growth plates fuse indicating that growth is completed. Unlike many other hormones, replacement growth hormone is very expensive.

A hormone known by the name of cortisol is made by the adrenal glands located on top of each kidney. Cortisol is an essential hormone which has effects on fat storage, glucose production and bone strength as well as aiding the body to handle the stress of illness or injury. Unlike some of the deficiency states described above, it is excessive cortisol production which stunts growth. There are also other signs that indicate excessive cortisol such as muscle wasting and weakness, weight gain, easy bruising and thinning of the skin. Treatment depends on the cause of the problem.

Growth may also be interfered with as a result of psycho-social deprivation. Children in situations where home life is disrupted or unhappy or where there is a lack of love or emotional support and those who experience severe and persistent stress do show significant growth retardation. It is also known that in such children, growth resumes when the problems are relieved and the stress is taken away.

At the other extreme of the scale, rapid and unusual gains in height or weight or both too, may indicate a problem. These need to be assessed by a qualified doctor and appropriate action instituted. It must be remembered that simple obesity which is an emerging problem in our country generally leads to a concomitant increase in height and such children are taller than their counterparts who are of normal weight. Is generally true to say that an unusually obese or fat child who is short for the age is likely to be abnormal and have a cause for the entire problem.

Children who are above the 95% in height or are growing unusually fast for their age may need to be evaluated by their physician. Most commonly, tall children come from tall families, are growing at the normal rate for age and show no signs of ill health. For those children in whom this is not the case, a physical examination and history may reveal the cause. Causes of rapid growth that may be abnormal include excessive growth hormone production, some congenital growth hormone production, some congenital genetic conditions or early puberty. Signals of these problems may include unusual body proportions, breast growth, enlargement of the genitals and axillary and pubic hair growth.