Basic Approach

Education

Pediatric Physical Examination Core Curriculum Appendices

Assess the child’s growth

Complete a growth chart accurately plotting height, weight and head circumference on the CDC Growth charts of the United States.

Plotting growth measurements:

Assessing growth is a part of each pediatric encounter because this is a sensitive measure of overall health of the child. There are growth curves available for different age groups (0-36 months, 2-20 years).

Weight

Infants should be weighed naked or in a diaper only. If the weight is too high/low recheck the weight and accuracy of the scale. Fluctuations in weight influence management of children, especially those who are hospitalized.

Height

Most children younger than 2 years cannot/ will not stand by themselves so their length is measured instead of their height. There are measuring devices to assist with accurate assessment. If there is any concern about growth, measure the length at least twice.

Head circumference

The tape should encircle the most prominent portions of the head. For increased accuracy, measure three times. It is easy to make small changes in the measurements accidentally. Do not start your examination by obtaining this measurements b/c the infant may start crying!

BMI

BMI should be calculated in all children and followed in addition to height and weight. To calculate BMI:

Wt (kg)/ stature (cm) / stature (cm) x 10,000

Or Wt (lb) / stature (in) / stature (in) x 703

Special situations

Premature infants: the growth of premature infants is typically “corrected” for their premature birth. Although special growth charts are available, many pediatricians plot the current weight at the “chronological” age and then subtract the months/weeks of prematurity (e.g. if the child was born at 30 weeks they subtract 10 weeks) and plot the growth parameters at the “corrected” age. Plotting the corrected age usually continues until age 2 years.

Other populations: there are special growth charts available to plot the growth for children with Down syndrome, Turner syndrome and achondroplasia

Assess the child’s development
Use a comment developmental screening instrument such as the Denver II or Ages and Stages questionnaire. You should practice doing this during your pediatrics/family medicine clerkships

Tips for doing a developmental assessment:

Ask open-ended questions about each area of development outlined on the Denver II
Know 1-2 items in each category that you can ask initially, and then follow up any concerns (yours or the parents) by asking more specific questions from the Denver or other screening tool.
You will get information about the child’s development by history and your own personal observation

Know

Be alert to the possibility of a problem when the head circumference is at one extreme or the other
Sequential measurements of growth are sensitive measures of overall health.
Alteration in the rate of growth “crossing percentiles” should alert you to possible underlying problems.
Typical weight gain: 20-30 grams/day in the newborn period
Typical height velocity:
- In children 5 years –puberty, normal growth velocity is = 5 cm; < 5 cm/year should be investigated; <4 cm is pathologic
Patterns of growth:
- Growth hormone deficiency (high weight to height ratio)
- Chronic disease (e.g. inflammatory bowel disease…low weight to height ratio)
Constitutional growth delay (normal weight to height ratio)

Developmental delays identified on tools used in clinician’s office are “red flags” and warrant further, more formal investigation.