Recognizing and addressing atypical growth

Figure 1.  Growth charts for Abigail

Interpretation 

Abigail’s weight and length are trending downward at the same time and to a similar degree. Weight-for-length is consistent and reassuring. Her health care provider (HCP) should first confirm that dietary and medical history do not identify concerns. Familial size may help to frame expectations. Healthy children can cross growth chart percentile curves early, as they adjust to extrauterine life, and much later, when puberty timing is earlier or later than average.   

Response

Reassurance and follow-up are needed. Regular review of history and growth should continue and will likely reveal a more typical growth pattern after this child reaches her genetically determined size, which would usually occur within the first 2 years of life.

Comments:

• The interpretation of this growth pattern should be the same, regardless of where the child plots on the growth curves.
• Although this pattern violates expectations around crossing centiles, caution is needed to avoid introducing doubt concerning the child’s nutrition or overall health, which can disrupt normal feeding development as parents attempt to ‘correct’ a ‘problem’ that may not exist. Caregiver pressure to eat, or an over-emphasis on higher energy foods can lead to negative eating habits, preferences, and behaviours, as well as to unnecessary investigations and interventions, and altered relationships with both food and with parents doing the feeding^[5][6]. Such effects can be serious, persistent, and difficult to change.

Case #2: Two-year-old Dennis was born small for gestational age, with no specific reason for this being identified. He was slow to accept solids and is experiencing some developmental delays that prolong his feeding times. Figure 2 shows growth charts for Dennis^[4][7].

Figure 2.  Growth charts for Dennis

Interpretation

Dennis’s growth, while below the curve, had tracked nicely, paralleling the curve until about 9 to 15 months. Then, his weight dipped first, followed by  his length growth, and both moved gradually further away from expected curve lines. Although the last four measures on his weight-for-length chart appear to be reassuring, this pattern has resulted from sequential declines in weight and length gain. This pattern—decreasing weight gain followed by decreasing linear growth—strongly suggests a nutritional deficit.

Response

Detailed medical, nutrition and oral feeding, and social histories are required, along with nutritional biochemistry testing and a physical examination. Additional investigations will be based on the results obtained.

Comments:

• When poor growth is the manifestation of medical or nutritional compromise (or both), the resolution of underlying issues should improve growth, with attainment of a growth rate comparable to that expected for this child’s age. Individual factors will influence the timing and magnitude of catch-up.
• Some congenital or genetic conditions influence growth patterns, making the recognition of a concurrent nutritional compromise more difficult. Only after a thorough nutrition assessment and correction of deficiencies (micronutrients specifically), should a growth pattern like Dennis’s be attributed to an underlying condition. When nutritional support is introduced, careful monitoring and follow-up are needed to ensure improved function, quality of life, and the growth of lean tissue (linear growth and muscle mass) rather than disproportionate fat gain. Dietitian consultation, when available, can be invaluable to assessment and management.
• For children below (or above) the curves for whom percentiles are recorded as “<3 percentile” (or “>97 percentile”), z-scores may be helpful toward describing changes in growth. A z-score (standard deviation score) of 0 is equivalent to the 50th percentile. Values above the 50th percentile become increasingly positive, and values below the 50th percentile become increasingly negative. Z-scores can be calculated in some electronic medical records or using online applications (IOS; Android).

In the example below, a progressive decline in growth would be difficult to identify using percentiles alone. As with all growth assessments, trends are more informative than small variations.

Case #3: Ella is a happy, healthy 5-year-old who has recently started school, and her mom has noticed that she is smaller than most of her peers. Both parents say she is not a big eater, but Ella does eat a variety of healthy foods and has no concerning symptoms. Ella’s growth is depicted in Figure 3^[4][7].

Figure 3.  Growth charts for Ella

Interpretation

Growth tracked nicely along the 10th to 15th percentile, with only small fluctuations until about the age of 3 years, after which Ella’s rate of linear growth decreased. The body mass index (BMI) chart shows an increasing BMI trajectory, but this was caused by decreasing linear growth rather than accelerated weight gain. This pattern is most consistent with growth failure of hormonal etiology.

Response

Basic investigation with endocrinology referral is needed. While unlikely to be nutritional in origin, this growth pattern is also seen in rickets. A dietitian referral, when available, could help to document a comprehensive dietary analysis. A full medical history and physical examination, and complete screening bloodwork (including renal function, liver function, and bone health) are indicated.

Comments:

• Accurate measurement of linear growth in children is often challenging, but repeated measurement and z-scores help clarify evolving trends.

Case #4: Eight-year-old Ali has come for his yearly check-up, and after accurately measuring his weight and height, you observe the following on his growth records (Figure 4)^[7]:

Figure 4. Growth charts for Ali

Interpretation

Ali’s weight is accelerating relative to his height, which suggests risk for overweight and potential for associated health risks, such as type 2 diabetes and hepatic steatosis. Calculating and plotting BMI provides a clearer representation of relative weight and height gain. In this case, rising BMI is attributable to weight gain because linear growth remained steady.

Response

A careful diet and medical history, a complete physical exam, and select investigations are required to eliminate suspicion of rare but important medical causes of excessive weight gain and identify comorbidities^[8]. If history suggests high energy intake relative to needs, a more detailed exploration of underlying factors driving behaviour becomes essential. Often families are aware of healthier diet choices, but behaviour is determined by many factors. Understanding a family’s circumstances: financial constraints, time pressures, food insecurity, limited access to child care, and other social determinants of health, must predicate change (Figure 5).

Figure 5. I. Contento. Social and environmental factors that influence food choices and dietary behaviours.

Identifying excessive weight gain can open a pathway to support behaviour change and improve child (and family) life and health outcomes. An excellent evidence-based resource with case studies to assist discussions about weight concerns is available.

Comments:

• A leading challenge when addressing excessive weight gain in children is raising awareness of its importance for health. The prevalence of overweight makes it easier for parents to normalize a child’s weight gain^[9][10], and they may also feel overwhelmed by the prospect of behaviour change.
• Encouraging family and child physical activities and routines is one element of healthy lifestyle change that can be promoted alongside dietary guidance. Regular physical activity is important for long-term health.
• Skills for effective conversations using a strengths-based approach (motivational interviewing or solution-focused coaching) can be learned from a range of online training modules^[11].
• Health care providers should be aware of local resources, and connecting families with such programs is part of quality care.

Best practice points:

1. Use standardized measurement techniques and tools for measurement, and well-maintained equipment to obtain valid anthropometrics.
2. Use appropriate growth charts and correct for prematurity until children are 2 to 3 years of age. Weight-for-length (<2 years), body mass index (BMI) charts (>2 years), and z-scores aid weight status interpretation.
3. Analyze growth patterns of weight, length or height, and weight for length or BMI using as much data over time as possible. Recognize how they change relative to each other as well as the timing and magnitude of changes. If it is not clear whether or not there is a growth concern, follow-up measurements may add clarity.
4. Atypical growth patterns require further evaluation, beginning with medical, nutritional and social history, and physical examination. Consider the full causal picture: size of family members, medical history (diagnosed and potentially undiagnosed conditions), mental health, the feeding relationship, financial constraints, and lifestyle. Investigations (if needed) require individualization based on history and physical examination, to inform diagnosis and/or consequences of growth impairment.  
5. Growth assessment is a screening, rather than diagnostic process. Atypical growth patterns are not always pathological, but always require further evaluation. If medical, nutritional, or social concerns are not identified, careful follow-up without intervention is appropriate, and will often provide reassurance or clarity about etiology and concerns. Families should be encouraged to trust children’s appetites and satiety, not only to promote healthy eating but to raise concerns that may yield helpful information or an opportunity for counselling.
6. Even when clinicians are confident that a child’s growth pattern is normal, anxious family members may not be easily reassured. When explanation of normal growth patterns is not reassuring for caregivers, it is important to explore the basis of their concerns, along with regular evaluation and reassurance.
7. Under- and over-diagnosis of growth concerns and the use of stigmatizing labels (e.g., “obese”) can lead to harm. Discussions with children and families should focus on education and support, emphasizing that the purpose of investigations or interventions is to improve the health of the child, not to achieve a specific growth pattern.
8. When diet or lifestyle changes (or both) are appropriate, parents often have the necessary knowledge but encounter barriers such as tight finances, food insecurity, or lack of time. Identifying such barriers can provide opportunities for collaborative problem-solving and connection with local supportive resources.
9. Being familiar with local resources (e.g., paediatric dietitians, endocrinology clinics, weight management programs) and criteria for referral and waitlists is important for determining how best to access and use community-based services and expertise.