Stony Brook Children’s Pediatric Primary Care Clinic Curriculum
Health Supervision I
August 2015
Some materials developed by Joseph Lopreiato MD, MPH and Jennifer Hepps MD of the National Capital
Consortium Pediatric Residency Program Bethesda, MD, adapted for use by Susan Walker, MD
Other materials developed by Susan Walker, MD
Goal: To understand recommended growth monitoring for children
Objectives:
1. Utilize growth charts to determine the initial workup of children with abnormal growth
2. Understand the differential diagnosis and plan the evaluation of a child with
microcephaly/macrocephaly
3. Know how to calculate a mid-parental target height
4. Explain the difference in physical exam findings between positional plagiocephaly and
craniosynostosis
ABP Content Specifications covered in this session:
Growth and Development:
Understand the uses and limitations of the various anthropometric techniques available to assess
growth and/or nutritional status
Linear growth and weight gain:
Use a growth chart to monitor linear growth and weight gain
Understand the utility of the body mass index
Differentiate between normal and abnormal variations in linear growth and weight gain
Differentiate between normal and abnormal growth velocity in neonates and infants
Understand the effect of chronic disease on linear growth velocity
Recognize the differences in upper body segment-to-lower body segment ratio in children
compared with that of adults
Head growth:
Differentiate between normal and abnormal variations in head shape and/or growth (eg,
craniosynostosis, plagiocephaly, microcephaly, macrocephaly)
Differentiate among the possible causes of abnormal head shape and/or growth (eg,
craniosynostosis, plagiocephaly, microcephaly, macrocephaly)
Plan the management of a patient with an abnormal head shape and/or growth (eg,
craniosynostosis, plagiocephaly, microcephaly, macrocephaly)
Pre-reading requirements (attached to this email):
1. Bright Futures recommendations for preventive health care:
This chart is useful for your well visits in clinic. For now, a brief review is sufficient. Please
note how many items are on this table- and realize what a critical service preventive pediatric
health care is!
2. Growth. Pediatrics in Review (2011) 32:9:404-406
3. Tall Stature. Pediatrics in Review (2014) 35:12:538-539
4. Abnormal Head Growth. Pediatrics in Review (2010) 31:9:382-384
5. Prevention and Management of Positional Skull Deformities in Infants. Pediatrics (2011)
128:6:1236-1241
Rules of Thumb for Growth (Adapted from Board Review Series: Pediatrics)
1. Weight loss in 1st few days—5-10% of birth weight.
2. Return to birth weight @ 7-10 days
3. Double birth weight @ 4 months
4. Triple birth weight @ 1year
5. Quadruple birth weight @ 2 years
Expected Weight Increase:
1. 20-30g/day from birth-3 months
2. 15-20g/day from 3-6 months
3. 5-10g/day from 6-12 months
4. 250g/month from 1-2 years
5. 2.3kg/year from 2 years - adolescence
What is Poor Weight Gain?
Weight gain less than:
18 grams per day from 2 weeks – 2 months
12 grams per day from 2 months – 9 months
8 grams per day from 9 months – 12 months
5 grams per day from 12 months – 18 months
Guide to Understanding Growth Charts (Adapted from www.about.com – pediatrics)
A two year old boy who is 30 pounds is at the 75th percentile for his weight. That means that he
weighs more than about 75% of boys his age. It also means that 25% of 2 year old boys weigh
more than he does.
Reading trends on the growth chart:
Growth charts are best used to follow a child's growth over time or to find a pattern of growth.
Plotting a child's weight and height at different ages and seeing if he follows a growth curve is
more important than where he is at any one time. Even if a child is at the 5th percentile for his
weight, which means that 95% of kids his age weigh more than he does, if he has always been at
the 5th percentile, then he is likely growing normally. It would be concerning and it might mean
there was a problem with his growth if he had previously been at the 50th or 75th percentile and
had now fallen down to the 5th percentile.
Quiz:
1. At what age should a child’s longitudinal growth begin to be measured as height (i.e.,
standing measurement) rather than as length (i.e., supine measurement)?
2. Calculate the predicted adult height of a 5 year old boy and a 7 year old girl (siblings) of
parents who stand 5 feet 3 inches tall (mother) and 6 feet tall (father
3. You have two 12-month well-baby-checks on your clinic schedule today. When you ask each
family if they have any concerns about their child, the parents of both babies tell you that they
are concerned about their child’s growth and would like a referral to a specialist. You review
each baby’s growth charts (see below). Do you have concerns about either or both babies? Will
you refer either baby to a specialist? If so, which specialty will you consult?
4. The following growth chart plots the head circumference of a 19 month old female with poor
weight gain and mild hypotonia. Please answer the following questions:
A. Is this head growth normal or abnormal?
B. What is your differential diagnosis?
C. How would you initially evaluate this patient?
D. If you could go back in time, when would you evaluate this patient?
5. The mother of a 10-year-old boy, whom you have been following since he was 3 years old,
complains that her son is always hungry and is gaining weight. The mother, who is overweight,
reports that the boy refuses to exercise, and that she cannot control his diet. She just read an
article in a magazine about Cushing syndrome and wonders if he could have this condition.
Of the following, the growth chart that suggests Cushing syndrome is
A. Growth chart A
B. Growth chart B
C. Growth chart C
D. Growth chart D
E. Growth chart E
6. Of the following height growth curves (see below), the one MOST likely to be associated with
familial short stature in a boy who had a birth weight of 3.3 kg is
A. Growth chart A
B. Growth chart B
C. Growth chart C
D. Growth chart D
E. Growth chart E
A
C
B
D
E
A
7. You are seeing a two month old infant in your office for his well visit. His parents are
concerned about his head shape. On exam, his head circumference plots at the 50th percentile for
age. He has some difficulty turning his head to the left. When you examine his head from
above, you note a parallelogram-shaped head, with a somewhat flattened right occiput and
anterior displacement of the right ear. What is your diagnosis, and how will you counsel the
parents? List four interventions to improve this condition.