Normal growth
Dr fatholahpour pediatric endocrinologist
Kordestan university of medical science
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Agenda
INTRODUCTION
Phases of growth
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating
Short Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
INTRODUCTION

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Normal growth is the progression of
changes in height and weight that are
compatible with established standards for a
given population
Understanding the normal patterns of
growth can prevent the unnecessary
evaluation of children with acceptable
normal variations in growth.
INTRODUCTION

Most healthy infants and children grow in a
predictable fashion, following a typical
pattern of progression in weight, length, and
head circumference
Agenda
INTRODUCTION
Phases of growth
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating Short
Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
Phases of growth
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Infantile
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Childhood
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pubertal
Phases of growth
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The infantile phase is characterized by
rapid but decelerating growth during the first
two years of life
Phases of growth
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The childhood phase is characterized
by growth at a relatively constant
velocity of 5 to 7 cm per year
Normal Growth velocities at different ages
Age
Average Growth
Velocity / Year
1st year
25cm
2nd year
3rd & 4th year
5 years- till onset of puberty
12-13cm
6-7 cm
5cm/year
The Growth Velocity may fall to as low as 4cm/year just
before the pubertal spurt
NORMAL PUBERTAL GROWTH
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Pubertal growth accounts for
approximately 20 percent of final adult height
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The pubertal growth spurt is immediately
preceded by a decrease in height velocity
NORMAL PUBERTAL GROWTH
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The pubertal growth spurt
in girls:
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Tanner stage II and III

23 to 28 cm during puberty

average peak height velocity of 9 cm/year
NORMAL PUBERTAL GROWTH
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The pubertal growth spurt in boys :
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
Tanner stage III and IV
18 to 24 months after the spurt in girls
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26 to 28 cm during puberty
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average peak height velocity of 10.3 cm per year
The later onset, longer duration, and increased
velocity of the pubertal growth spurt in boys
accounts for their taller stature (an average of 12
to 13 cm greater than that of girls
Typical Pattern of Growth Rate
Through Adolescence
Normal Growth
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The linear growth of normal infants (up to 8 months) may
move to higher or lower percentile due to physiologic shift
from intrauterine influences to the child’s inherent growth
potential
A child’s growth curve follows along the same channel or
percentile from 2-9 years of age
Crossing channels during puberty may be due to differential
onset & extent of the pubertal growth spurt
Thus, excepting infancy, subnormal growth velocity is the
hallmark of postnatal pathologic Short Stature
Agenda
INTRODUCTION
Phases of growth
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating Short
Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
EVALUATION OF GROWTH
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The history :
The weight, length, and head circumference at
birth
 Developmental history
 Family history, including parental heights,
parental growth patterns, and timing of
pubertal onset in parents
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The physical examination :

measurements of weight, length, and head
circumference
EVALUATION OF GROWTH
 Measurements of length:
In children younger than two years:
child supine on a horizontal rule that has a movable plate
perpendicular to the feet and a stationary plate at the head.
The older child :
 standing position, preferably with a stadiometer
The child's heels should be placed against the wall
 with the ankles together; the knees and spine should be in a
straight line
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The height of an individual child should be measured at the same time
of day (eg, morning or afternoon) at each visit if possible since the
measurement may be greater in the morning than at the end of the day
Agenda
INTRODUCTION
Normal Growth velocities
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating Short
Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
STANDARD GROWTH CURVES
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Weight, height, and head circumference
should be plotted on the appropriate
respective growth curve at each well-child
visit and as indicated at interval visits
The accurate charting of growth may prevent
the unnecessary evaluation of a child who
has a normal pattern of growth.
Z-score
Z- score
Exact percentile
Rounded percentile
o
50th
50th
-1
15.9
15th
-2
2.3
3th
-3
0.1
1th
Z-Score
Z-score
Exact percentile
Rounded percentile
0
50th
50th
+1
84.1
85th
+2
97.7
97th
+#
99.9
99th
Agenda
INTRODUCTION
Normal Growth velocities
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating
Short Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
Important terminologies & facts while evaluating
Short Stature
Mid-parental height (MPH):
The child’s probable inherited growth potential can be
estimated by mid-parental height percentile.
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MPH range for boys = (mother’s height+13cm)+ father’s height + 8cm
2
MPH range for girls = Mother’s height + (father’s height- 13cm) + 8cm
2
The 13 cm represents the average difference in height of
men and women
Important terminologies & facts while evaluating
Short Stature
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PREDICTION OF ADULT STATURE
Important terminologies & facts while evaluating
Short Stature
Height Age - The age at which the patient’s height is at
the 50th percentile.
Bone age - Refers to the age at which the skeletal
maturation shown in patient’s radiographs is normally
attained.
Greulich Pyle charts are the most commonly used
method, which examines the epiphyseal maturation of
the hand & wrist.
Important terminologies & facts while
evaluating Short Stature
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Growth velocity / Height velocity :
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Observation of a child’s height over a period of time
or height velocity is the most important aspect of
assessment of Short Stature
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Determination of height velocity requires at least
6 months of observation.
Important terminologies & facts while evaluating
Short Stature
Standard Deviation Scores:
 (SDS)= (x-X)/SD
 x: Child height
 X: Mean height
 SD: Standard deviation for the child sex and
age;0.3-50/2
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Weight-for-height
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A weight-for-height:
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between the 5th and 95th percentile normal variation
less than the 5th percentile: undernutrition
greater than the 95th percentile : obesity
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The weight-for-height typically is normal in children who
have constitutional growth delay or familial short stature
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Children with endocrine disorders, such as Cushing's
syndrome, growth hormone deficiency, and
hypothyroidism are usually overweight-for-height.
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Upper segment/lower segment ratio
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The lower segment is measured from the top of the
symphysis pubis to the plantar surface of the foot
The upper segment is calculated by subtracting the lower
segment from the child's height
Normal ratios are as follows:
Birth – 1.7
3 years – 1.33
5 years – 1.19
10 years – 1.0
The US/LS ratio is abnormal in children who have skeletal
dysplasia, rickets, Turner syndrome, and Marfan syndrome
Agenda
INTRODUCTION
Normal Growth velocities
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating
Short Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
RADIOLOGIC EVALUATION OF GROWTH
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The bone age is the most important lab test in the
evaluation of growth
Bone age : comparing the epiphyses or shapes of
bones on a radiograph with standards for a given
age
The left hand and wrist typically are used
Radiographs of the knee may provide additional
information in infants and adolescents
The Greulich and Pyle atlas of radiographs
of the left hand and wrist is the standard
RADIOLOGIC EVALUATION OF GROWTH
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A bone age that is more or less than two
standard deviations from the mean is
considered abnormal
One standard deviation is approximately 10
percent of the child's chronologic age
Bone age is delayed in children with
constitutional growth delay, hypothyroidism,
GH deficiency, or chronic disease,
particularly gastrointestinal disease.
Agenda
INTRODUCTION
Normal Growth velocities
EVALUATION OF GROWTH
STANDARD GROWTH CURVES
Important terminologies & facts while evaluating
Short Stature
RADIOLOGIC EVALUATION OF GROWTH
VARIANTS OF NORMAL GROWTH
VARIANTS OF NORMAL GROWTH
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The most common causes of short stature
beyond the first year or two of life :

familial (genetic, intrinsic) short stature

delayed (constitutional) growth
Normal variant of Short Stature
Familial short stature (FSS)
 A child who has FSS is short for general population
but is normal for the family pedigree.
 The birth length tends to be small.
 The child’s projected adult height falls within the mid
parental height range.
 The bone age & growth velocity are normal.
 Growth proceeds along a channel below but parallel to
the 3rd percentile curve.
 The final height of such a child will be short.
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Normal variant of Short Stature
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Constitutional growth delay (CGD)
Typically, the child, is a normal looking who is
described as a ‘late bloomer’.
There is often a family history of father being short
as a child & experiencing a late pubertal spurt.
The bone age is delayed & corresponds to the
height age.
The birth length is normal but typically slows down
to fall below 5th percentile in the first three years of
life.
Although puberty is delayed, the final adult
height and sexual development are normal.