Growth Charts Interpretation DrMajdi

Growth charts are used to compare the child's height, weight, and head size against children of the same age.
In this presentation, we will identify the most important pattern of pathological abnormal head circumference, failure to thrive, short statures and tall statures.

1. 1
Practical Guide to
Growth Charts
Interpretation
Dr. Majdi N. Al-Jasim
SBFM, ABFM
Consultant Family Medicine

3. OBJECTIVES
Dr. Majdi
AlJasim
1.Tounderstanddifferentcomponentsthatcreatethegrowthchart.
2.Todefinethenormalcurvebasedongrowthvelocity.
3.Tobeabletoidentifypathognomonicfeatureofpathologicvsnormalcurves:
Macrocephalyandmicrocephaly
Failuretothrive
Shortstature
Tallstature

5. Growthchartsarenotintendedtobeusedasa
solediagnosticinstrument.Instead,growth
chartsaretoolsthatcontributetoformingan
overallclinicalimpressionforthechildbeing
measured.
Growthchartsareusedtocomparethe
child'sheight,weight,andheadsize
againstchildrenofthesameage.
Growthchartsconsistofaseriesof
percentilecurvesthatillustratethe
distributionofselectedbody
measurementsinchildren.
Dr. Majdi
AlJasim
OVERVIEW

6. Dr. Majdi
AlJasim
Growth parameters
Length
Weight
Head
circumference
Birth –2 years
Height
Weight
Body mass
index
2 years –20
years

7. Dr. Majdi
AlJasim
Measurements
Height:
Is used in children from 2 years to 20 years.
Height is measured while standing.
Head circumference:
Is used in children from birth to 2 years.
Normal term newborn HC: 32 to 38 cm.
Length:
Is used in children from birth to 2 years.
Length is measured in the recumbent position.
Weight:
Pan scale or hanging-spring scale (up to 25 Kg).
Stand-on scale: if able to stand unsupported.

8. Dr. Majdi
AlJasim
Normal expected growth
Length/height:
Average at birth is 50cm.
Doubled by the age of 4 years.
Tripled by the age of 13 years.
Weight:
Normal weight at birth is 2.5 –4 Kg.
Doubled by the age 6 months.
Tripled by the age of 1 year.
Quadrupled by the age of 2 years.
If age < 12 months
Weight (kg) = [Age (mo) + 9] ÷2
If age ≥ 1 year
Weight (kg) = [Age (yr) ×2] + 8
Head circumference (HC):
Normal HC at birth is 32 –38 cm.
On average, it increases by 1 cm per
month in the first year of life.
It increases by 2 cm per year between
1 to 3 years of age.
It increases by 1 cm per year between
3 to 5 years of age

9. CDC recommends that health care providers
Use the WHO growth charts for infants and children 0 to 2 years
of age.
Use the CDC growth charts for children ages 2 to 20 years.
Dr. Majdi
AlJasim
GROWTH CHART RECOMMENDATION

10. Dr. Majdi
AlJasim
RECOMMENDED CUT-OFFS
WHO Growth Charts -Birth to 24 months
2 505 10 25 75 989590
< 2%
Low weight to
length
> 98%
High weight to
length
2% –98%
HEALTHY WEIGHT

11. Dr. Majdi
AlJasim
RECOMMENDED CUT-OFFS
CDC Growth Charts -2 to 20 years
5 5010 25 75 9585
5% –< 85%
HEALTHY WEIGHT
85% -< 95%
Overweight
≥ 95%
Obese
< 5%
Under-
weight

12. Dr. Majdi
AlJasim
RECOMMENDED CUT-OFFS
Important
Sinceeachnationhas
itsowncharacteristics,
usegrowthchartfor
agethatisapprovedin
yourcountry,whatever
thecut-pointis.

13. Dr. Majdi
AlJasim
COMPONENTS OF GROWTH CHART
Measured parameter (like weight here)
Child chronological age
98
th
75
th
50
th
25
th
2
nd
Percentiles/Centiles
1
2
3
4
5
6
7
8
9
10
Kg
1 2 3 4 5 6 7 8 9 101112months
❶
❷
❹
❸
1 standard deviation(1SD)
“The measured space between centiles”
❺

14. Dr. Majdi
AlJasim
PERCENTILES/CENTILES
Apercentileshowstherelativepositionofthechild'sBMI,weight,orheight
amongchildrenofthesamesexandage.
Example:
Aboyatthe25
th
percentileforweightmeansifwetook100normalboysand
measuretheirweight,thisboywillbeat25
th
positioncomparedtoother.
3
rd
5
th
7
th
10
th
25
th
50
th
75
th
85
th
90
th
95
th
97
th

15. Dr. Majdi
AlJasim
How to get started
1.Take measurements.
2.Select appropriate growth charts for age and gender.
3.Record and plot on growth charts.
4.Interpret growth indicators.
5.Evaluating the growth curve.

16. Normal characteristics of growth chart:
1.Growth velocity line is in between the upper and lower normal centile limit.
2.Growth velocity line is in parallel with adjacent centiles.
3.If there is deviation, it should NOT cross any other centile line “less than 1SD”.
Dr. Majdi
AlJasim
Normal curve
98
th
75
th
50
th
25
th
2
nd
●
●
●
●
●
●

17. What is wrong with the following growth charts?
Dr. Majdi
AlJasim
Normal curve
98
th
75
th
50
th
25
th
2
nd
●
●
●
●
●
PARALLEL
98
th
75
th
50
th
25
th
2
nd
●
●
●
●
●
NOT IN-BETWEEN
NOT PARALLEL
IN-BETWEEN
CROSSING = 0 CROSSING = 3 (CHRONIC)

18. What is wrong with the following growth charts?
Dr. Majdi
AlJasim
Normal curve
98
th
75
th
50
th
25
th
2
nd
●
●
● ● ●
●
●
98
th
75
th
50
th
25
th
2
nd
●
● ●
●
●
●
NOT PARALLEL
IN-BETWEEN
NOT PARALLEL
IN-BETWEEN
CROSSING = 2 (CHORONIC) CROSSING = 1 (ACUTE)

19. Macrocephalyand
microcephaly

20. Dr. Majdi
AlJasim
Macrocephaly: Overview
Macrocephalyisdefinedasheadcircumferencegreaterthantwostandarddeviations
abovethemean(i.e.crossing≥2centiles)orgreaterthanthe97
th
centilefora
givenageandsex.
Itcanbepresentedatbirthorlaterduringdevelopment.
Causes:
Itcouldbebenignwithoutanyneurologicalmanifestationsincaselikefamilialmacrocephaly.
Othercausescanbeduetoincreasedbrainparenchyma(megalencephaly),orincreasedblood,thickened
bone,orincreasedintracranialpressure(ICP)duetoincreasedCSForspaceoccupyinglesion.

21. Dr. Majdi
AlJasim
Macrocephaly: curve characteristics
Curvecharacteristics:
HCcurvecrossed≥2centiles(>2SD)
[bluearrows]abovethemean.
HCcurvepassesabovethe97
th
centile.
●
●
●
●
●
●
●
● ●

22. Dr. Majdi
AlJasim
Macrocephaly: workup
Referral

23. Dr. Majdi
AlJasim
Microcephaly: Overview
Microcephalyisdefinedasheadcircumferencegreaterthantwostandarddeviations
belowthemean(i.e.crossing≥2centiles)orlesserthanthe3
rd
centileforagiven
ageandsex.
Itiscommonlycongenital,butitcanhappenlaterwithstuntedheadgrowth.
Itisassociatedwithbraindevelopmentabnormalities.

24. Dr. Majdi
AlJasim
Microcephaly: curve characteristics
●
●
●
●
●
●
●
●●●
Thecurveliesbelowthe3
rd
centileThecurvecrosses≥2centiles(>2SD)
[bluearrows]bellowthemean

25. Dr. Majdi
AlJasim
Microcephaly: workup
Referral

26. Failure to thrive

27. Dr. Majdi
AlJasim
Overview
Failuretothrive(FTT)isanabnormalpatternofweightgaindefinedbythelackof
sufficientusablenutritionanddocumentedbyinadequateweightgainovertime.
About 80% of cases,
the cause is non-
organic(incorrect
formula preparation,
poor feeding habits,
neglect, poverty
…etc.)

28. Dr. Majdi
AlJasim
Case approach
Dietary history:
Duration of mealtime.
Type of food.
Amount of intake.
Formula mixing technique.
Pre and perinatal history:
Low birth weight.
Intra-uterine growth retardation.
Prenatal exposures (drugs, smoking,
alcohol)
Medical history:
Chronic disease of any type.
Food allergy.
Gastroesophageal reflux.
Frequent recurrent illness and infection.
Social and family history:
Family economic status.
Stressors.
Family history of FTT.
Mental illnesses.

29. Dr. Majdi
AlJasim
Case approach
Finding Potential Underlying Causes
Dysmorphic appearance Genetic abnormality, undiagnosed syndrome
Edema Renal, liver disease
Hair color/texture changeZinc deficiency
Heart murmur Anatomic cardiac defect
Hepatomegaly Infection, chronic illness, malnutrition
Mental status change Cerebral palsy, poor social bonding
Poor parent-child interactionDepression, social stress
Rash, skin changes, bruisingHuman immunodeficiency virus infection, cow's milk allergy, abuse
Respiratory compromiseCystic fibrosis
Wasting Cerebral palsy, cancer

30. Dr. Majdi
AlJasim
Growth velocity line CROSSES only 1 centile line when there is deviation from
normal growth.
Growth velocity line CROSSES2 or more centile lineswhen there is deviation from
normal growth. FTT lies in this category.
Acute
events
Chronic
events
The weight curve will be affected beforeheight curve.
Tips for interpretation

31. Dr. Majdi
AlJasim
Acute and chronic events
98
th
75
th
50
th
25
th
2
nd
1
2
3
4
5
6
7
8
9
10
Kg
1 2 3 4 5 6 7 8 9 101112months
10
th
5
th
90
th
95
th
●
●
●
●
●
●
●
●
●
●
ACUTE EVENT
Thelinecrossesonly1centileline.
Thechildhadseveregastroenteritis.

32. Dr. Majdi
AlJasim
Acute and chronic events
98
th
75
th
50
th
25
th
2
nd
1
2
3
4
5
6
7
8
9
10
Kg
1 2 3 4 5 6 7 8 9 101112months
10
th
5
th
90
th
95
th
●
●
●
●
● ● ● ● ● ●
CHRONIC EVENT (FTT)
Thelinecrosses≥2centilelines.
Thechildhasceliacdisease.

33. Dr. Majdi
AlJasim
FTT curve characteristics
The weight will be affected beforeheight.
The curve is depressed crossing ≥ 2 centiles.
Curve characteristic
Here in this chart, the weight curve is affected
before height curve (red line), and the curve is
depressed crossing 4 centiles (blue arrows) 
chronic event FTT case

34. Dr. Majdi
AlJasim
Workup
No standard set of laboratory tests is recommended for FTT
The following is reasonable initial workup:
CBC.
Urinalysis.
Electrolytes.
Thyroid function test.
Tissue transglutaminase IgA (IgA-tTG) as a screening for celiac disease.
SpecifictestingforcertaindiseaseslikeCysticfibrosis,food
allergies,HIV,TBmaybeindicateddependingonthepresentation.

35. Dr. Majdi
AlJasim
Management
Non-organic causes:
Multidisciplinary approach: primary care physician, dietitian, psychologist, social work.
Nutritional:educate about age-appropriate foods, calorie boosting, mealtime schedules;
goal to reach 90-110% ideal body weight, correct nutritional deficiencies.
Behavioral:positive reinforcement, mealtime environment.
Organic causes:
Treat the underling causes.

36. Dr. Majdi
AlJasim
Referral
1.Outpatient treatment failure.
2.Psychosocial factors that put the child's safety at risk.
3.Serious underlying illness or medical problem.
4.Severe malnutrition or dehydration.

37. Scenario
A 12-months-old boy presenting with vomiting that
began 2 months ago but had become more forceful
and persistent over the past 2 weeks.
In addition, he was reported to be losing weight
over the past 2 months.
Review of systems is negative for fever, diarrhea, and
rash. Diet is appropriate for an 12-month-old. Family
history is noncontributory
How are you going to proceed?
Dr. Majdi
AlJasim

38. Scenario
Theweightisaffectedbeforeheight(red
line),andthecurvecrossedatleast4
centiles(blackarrows)chroniccase
FTTcase
Dr. Majdi
AlJasim
MostlikelydiagnosisischronicGERD

39. Short stature

40. Dr. Majdi
AlJasim
Overview
Shortstatureisdefinedasaheightmorethantwostandarddeviationsbelowthe
meanforage,orlessthanthe3rdpercentile.
Historyandphysicalexaminationfindingsshouldguidefurther
evaluationforpathologiccausesofshortandtallstature.
Mid-parentalheightgrowthvelocityshouldbecalculatedto
evaluateachild'sgrowthvs.potentialheight.
Boneageshouldbecomparedwithchronologicagetohelpnarrow
thedifferentialdiagnosisofshortortallstature.

41. Dr. Majdi
AlJasim
Mid-parental and projected height
Estimated mid-parental height:
Is an equation based way to find out the most likely the final height of the child when they are 20 years
old. This method will not take on account the skeletal maturity!!
Formula (boys):
??????????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ????????????&#3627408474;+&#3627408474;????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ????????????&#3627408474;+13??????&#3627408474;
2
Formula (girls):
??????????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ????????????&#3627408474;+&#3627408474;????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ????????????&#3627408474;−13??????&#3627408474;
2
Estimated projected height (potential height, final height or target height):
A rough estimate of the child's projected height by extrapolating the child's growth along his or her own
height percentile to the corresponding 20-year point.

42. Dr. Majdi
AlJasim
Mid-parental and projected height
Theprojectedpotentialheightshould
bewithin±10cm(±2SD)rangeof
calculatedmid-parentalheight.
Normal for
the family
●
●
●
●
A
●
B
PointArepresentscurrentchildheightcentile(10
th
here).
PointBistheestimatedprojectedheight,obtainedby
extrapolatingfollowingthechildcurrentcentile(10
th
centile
here)till20yearsoldendpoint(same10
th
centile).
Theprojectedheighthereis168cm.
Themeasuredfatherheightis175cm
Themeasuredmotherheightis160cm
Thecalculatedmid-parentalheight=174cmforboys
Thenormaldeviationforthefamilyis±10cm.Sothefuture
boy’sheightwillfallanywherebetween164cmand184cm.
Sincetheprojectedheightfromthegraphis168cm,itiswithin
the164cmto184cmrange,sothisisconsiderednormal.
Example #1:

43. Dr. Majdi
AlJasim
Mid-parental and projected height
●
●
●
●
A
●
B
PointArepresentscurrentchildheightcentile(5
th
here).
PointBistheestimatedprojectedheightonthesame5
th
centileatage20-yearold.
Theprojectedheighthereis165cm.
Themeasuredfatherheightis180cm
Themeasuredmotherheightis165cm
Thecalculatedmid-parentalheight=179cmforboys
Thenormaldeviationforthefamilyis±10cm.Sothefuture
boy’sheightwillfallanywherebetween169cmand189cm.
Theprojectedheighthereis165cm,itDOESNOTfallbetween
169cmto189cmrange,thissuggestsapossiblepathologic
condition.
Example #2:

44. Dr. Majdi
AlJasim
Mid-parental and projected height
●
●
●
●
A
PointArepresentscurrentchildheightcentile(5
th
here).
TheheightcurveisNOTparalleltoothercentiles.
Themeasuredfatherheightis180cm
Themeasuredmotherheightis165cm
Thecalculatedmid-parentalheight=179cmforboys
Thenormaldeviationforthefamilyis±10cm.Sothefuture
boy’sheightwillfallanywherebetween169cmand189cm.
TheprojectedheightherecanNOTbeplotbecauseofun-
parallelcurve.Thissuggestsapossiblepathologiccondition.
Example #3:
●
●

45. Dr. Majdi
AlJasim
Bone age
A method of comparing a plain radiograph of the left wrist and hand to a database of norms.
Bone age should be compared with chronologic age to narrow the differential diagnosis of short stature.
Normal appearance x-ray
of 5 years old child
Normal appearance x-ray
of 7 years old child
Normal appearance x-ray
of 9 years old child

46. Dr. Majdi
AlJasim
Short stature evaluation algorithm
Short child
Is the height curve
parallel to other centiles?NO YES
Do Bone age
BA=CABA<CA BA=CABA<CA
Hormonal or
chronic disease
Chromosomal
disorder
Constitutional
short stature
Familial short
stature
BA: Bone ageCA: Chronological age
Projected height is withinmid-parental
height range
Projected height can NOTbe plot because
the curve is not parallel

47. Important
If the height curve is parallelBUTthe projected height is
BELLOWmid-parental height range, you should do at least:
BOYS: Hormonal assay (priority), then karyotyping.
GIRLS: Karyotyping (priority), then hormonal assay.
Short stature evaluation
The height curve will be affected beforeor at the same timeof weight curve.
Dr. Majdi
AlJasim

48. SHORT CHILD #1
Bassamisa12yearoldboywhohasalwaysbeenshorter
thanhispeers.Hismotheris149cmandhisfatheris169
cm.Hismotherhadmenarcheatage15years,andhis
fatherhadlatepubertaldevelopment.
His physical examination is unremarkable, with pubertal
development Tanner I.
Mid-parental height is 165.5 cm, projected potential
height is 164 cm and bone age is delayed.
How are you going to proceed?
Dr. Majdi
AlJasim

49. SHORT CHILD #1
Themeasuredfatherheightis169cm
Themeasuredmotherheightis149cm
Projectedheightis164cm
Mid-parentalheightis165.5cm
Theacceptedrangeis(155.5–175.5)
Theprojectedheightiswithintherange
Boneageisdelayed
Thecurveisparalleltoothercentiles
Dr. Majdi
AlJasim

50. Dr. Majdi
AlJasim
SHORT CHILD #1
Short child
Is the height curve
parallel to other centiles?NO YES
Do Bone age
BA=CABA<CA BA=CABA<CA
Hormonal or
chronic disease
Chromosomal
disorder
Constitutional
short stature
Familial short
stature
BA: Bone ageCA: Chronological age
Projected height is withinmid-parental
height range
Projected height can NOTbe plot because
the curve is not parallel

51. Dr. Majdi
AlJasim
Constitutional short stature
Characterizedby:
Familyhistoryofsimilarpattern.
Delayedpuberty.
Delayedbone age.
Normal predicted adult height in context of family pattern.
No organic or emotional cause of growth failure.
Eventually they will grow to their destined height normally (late bloomers)
More common in boys.
Management:Reassurance.

52. SHORT CHILD #2
Continuethecase…
Afterfewyears,Bassamcameforassessmentashismotheris
concernedthatheisnotgainingappropriateheightinthepast2
years.
Lookingathisfile,hismid-parentalheightis165.5cmand
expectedpotentialprojectedheightis164cmandboneageis
delayed.
Thefollowingishiscurrentgrowthchart:
Dr. Majdi
AlJasim

53. SHORT CHILD #2
ProjectedheightCANNOTbeobtained
now
Mid-parentalheightis165.5cm
Boneageisdelayed
ThecurvenowISNOTparalleltoother
centiles
●
●
●
●
●
●
Dr. Majdi
AlJasim

54. Dr. Majdi
AlJasim
SHORT CHILD #2
Referral
Short child
Is the height curve
parallel to other centiles?NO YES
Do Bone age
BA=CABA<CA BA=CABA<CA
Hormonal or
chronic disease
Chromosomal
disorder
Constitutional
short stature
Familial short
stature
BA: Bone ageCA: Chronological age
Projected height is withinmid-parental
height range
Projected height can NOTbe plot because
the curve is not parallel

55. Dr. Majdi
AlJasim
The following is reasonable initial workup:
CBC: anemia, evidence of chronic illness.
ESR: IBD, other chronic illness.
Biochemistry and electrolytes: Renal disease (renal tubular acidosis)
Thyroid function test:TSH, if ↑ then free T4 (hypothyroidism).
24hr urine collection for urinary free cortisol: screeningfor Cushing syndrome.
Tissue transglutaminase IgA (IgA-tTG): screening for celiac disease.
Insulin-like growth factor 1 (IGF-1) and Insulin-like growth factor-binding protein 3 (IGFBP-3): screening
for growth hormone deficiency.
SHORT CHILD #2

56. SHORT CHILD #2
Continuethecase…
ReferralfeedbackofBassamfrompediatricendocrinologist
showedunremarkableresultsandsuggestedtofollowthe
caseasthisiscouldbealatebloomercase(constitutional
shortstature).
Athis19
th
yearbirthday,Bassamcamewiththefollowing
growthchart:
Dr. Majdi
AlJasim

57. SHORT CHILD #2
Bassam’sheightstartstocatch-up
Atageof19-yearold,hisheightis
168cmwhichiswithintherangeof
calculatedmid-parentalheight(155.5–
175.5)
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●
●●●
●
●
●
●
●
●
Dr. Majdi
AlJasim

58. SHORT CHILD #2
Dr. Majdi
AlJasim
Typical look of constitutional
short stature curve
(Bone age < chronological age)
In constitutional short stature the bone age is
delayed usuallyby 1 or 2 years.
TIP

59. SHORT CHILD #2
Dr. Majdi
AlJasim
Typical look of hormonal or
chronic disease short stature curve
(Bone age < chronological age)
In hormonal or chronic disease short stature
the bone age is delayed usually by > 2 years.
TIP

60. SHORT CHILD #3
Jawharais 11 year old girl who always been “short for her
age”. Her mother is 152 cm, her father is 165 cm.
Her physical exam is normal and her breasts are Tanner II,
pubic hair is Tanner II.
Bone age is normal for her age.
How are you going to proceed?
Dr. Majdi
AlJasim

61. SHORT CHILD #3
Themeasuredfatherheightis165cm
Themeasuredmotherheightis152cm
Projectedheightis152cm
Mid-parentalheightis152cm
Theacceptedrangeis(142–162)
Theprojectedheightiswithintherange
Boneageisnormalforage
Thecurveisparalleltoothercentiles
Dr. Majdi
AlJasim
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Thegirlcalculatedmid-parentalheight=
??????????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ??????+&#3627408474;????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ??????−13
2
165+152−13
2
=152??????&#3627408474;
●
●
●
●
●
Potential
height

62. Dr. Majdi
AlJasim
SHORT CHILD #3
Short child
Is the height curve
parallel to other centiles?NO YES
Do Bone age
BA=CABA<CA BA=CABA<CA
Hormonal or
chronic disease
Chromosomal
disorder
Constitutional
short stature
Familial short
stature
BA: Bone ageCA: Chronological age
Projected height is withinmid-parental
height range
Projected height can NOTbe plot because
the curve is not parallel

63. Dr. Majdi
AlJasim
Familial short stature
Characterizedby:
Family History of short stature.
Birth weight > 2.5 kg.
Height < lowest percentile for chronological age.
Growth curve parallel but at or below the lowest percentile.
Predicted adult height < lowest percentile.
No organic or emotional cause of growth failure.
Normalannual growth rate and bone age.
Normalpubertal onset.
Management:Reassurance.

64. SHORT CHILD #3
Dr. Majdi
AlJasim
Typical look of familial
short stature curve
(Bone age = chronological age)

65. SHORT CHILD #4
Sara is an 11 year old girl with short stature and history of recurrent otitis media.
Her mother is 162 cm and her father is 175 cm.
Her physical exam is remarkable for:
Multiple nevi, low posterior hairline, webbed neck, widely spaced nipples,
and increased carrying angle.
Her breast and pubic hair development are Tanner I.
Her bone age is appropriate for her age.
How are you going to proceed?
Dr. Majdi
AlJasim

66. SHORT CHILD #4
Themeasuredfatherheightis175cm
Themeasuredmotherheightis162cm
ProjectedheightCANNOTbeobtained
Mid-parentalheightis162cm
Boneageisnormalforage
ThecurveisNOTparalleltoothercentiles
Dr. Majdi
AlJasim
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Thegirlcalculatedmid-parentalheight=
??????????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ??????+&#3627408474;????????????????????????&#3627408475;??????&#3627408473;ℎ??????????????????ℎ??????−13
2
175+162−13
2
=162??????&#3627408474;
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67. Dr. Majdi
AlJasim
SHORT CHILD #4
Short child
Is the height curve
parallel to other centiles?NO YES
Do Bone age
BA=CABA<CA BA=CABA<CA
Hormonal or
chronic disease
Chromosomal
disorder
Constitutional
short stature
Familial short
stature
BA: Bone ageCA: Chronological age
Projected height is withinmid-parental
height range
Projected height can NOTbe plot because
the curve is not parallel
Referral

68. Dr. Majdi
AlJasim
Chromosomal disorders short stature
Themostcommoncausesare:
Turner syndrome (as in this case scenario).
Down syndrome.
Prader-Willi syndrome.
Noonan syndrome.
Investigation: Karyotype and genetic mutation analysis.
Growth chart consideration: Replot the measurements on the
specialized growth chart for the syndrome.

69. Dr. Majdi
AlJasim
Chromosomal disorders short stature

70. SHORT CHILD #4
Dr. Majdi
AlJasim
Typical look of chromosomal
short stature curve
(Bone age = chronological age)

71. Tall stature

72. Dr. Majdi
AlJasim
Overview
Tallstatureisdefinedasaheightmorethantwostandarddeviationsabovethe
meanforage(greaterthanthe97thpercentile)orprojectedheightmorethantwo
standarddeviationsfromthemid-parentalheight.
Historyandphysicalexaminationfindingsshouldguidefurther
evaluationforpathologiccausesofshortandtallstature.
Mid-parentalheightgrowthvelocityshouldbecalculatedto
evaluateachild'sgrowthvs.potentialheight.
Children with tall stature are much less likely to be referred to subspecialty care.

73. Dr. Majdi
AlJasim
Tall stature evaluation algorithm
Tall child (BA ≥ CA)
Isthe patient dysmorphic?
YES
YesNo
YesNo
Chromosomal
disorder
NO
Is the curve
parallel
BA: Bone age CA: Chronological age
Signs of puberty?
Hormonal
(IGF1, TSH)
Precocious
puberty
Is projected
height within
mid-parental
height range?
Obesity or normal variant
Yes
Familial tall stature
No
Referral
Referral

74. TALL CHILD #1
Ghadeeris a 17 year old girl who has been overweight “for as long as she can
remember.” and taller than her other girls-classmates.
Her family history is positive for obesity on both the paternal and maternal sides
of the family.
Her father is 165 cm height, and her mother is 150 cm height.
Her dietary history is notable for bad eating habits and skipping meals; she has a
high intake of fat and concentrated sweets. She has regular menses.
Her breast and pubic hair development are Tanner V. Her bone age is normal for
age.
How are you going to proceed?
Dr. Majdi
AlJasim

75. TALL CHILD #1
Themeasuredfatherheightis165cm
Themeasuredmotherheightis150cm
Theheightcurveisparalleltoother
centiles.
Projectedheightis168cm
Mid-parentalheightis151cm
Theacceptedrangeis(141–161)
TheprojectedheightisABOVEthe
range.
Boneageisnormal.
Currentweightcrosses>2centiles
(chroniccase)andisabovetheupper
centile.
Dr. Majdi
AlJasim
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76. Dr. Majdi
AlJasim
TALL CHILD #1
Tall child (BA ≥ CA)
Isthe patient dysmorphic?
YES
YesNo
YesNo
Chromosomal
disorder
NO
Is the curve
parallel
BA: Bone age CA: Chronological age
Signs of puberty?
Hormonal
(IGF1, TSH)
Precocious
puberty
Is projected
height within
mid-parental
height range?
Obesity or normal variant
Yes
Familial tall stature
No
Referral
Referral

77. Dr. Majdi
AlJasim
Characterized by:
Body mass index is > 95
th
percentile.
Slightlyearly onset of puberty.
Modesttall stature.
Normalto minimaladvanced bone age.
Management:
For height:reassurance.
For weight:initially, dietary and nutritional consultation.
Obesity and tall stature

78. TALL CHILD #2
Amalis a 4 year and 9 months old girl who developed breast buds at age 3 year
and 10 months.
Height acceleration was noted from the age of 4 years.
Her father is 165 cm height, and her mother is 150 cm height.
Pubic hair development and apocrine axillary odor were noted at age 4 years and
6 months. Her bone age is advanced for her age.
How are you going to proceed?
Dr. Majdi
AlJasim

79. TALL CHILD #2
Themeasuredfatherheightis165cm
Themeasuredmotherheightis150cm
Mid-parentalheightis151cm
Boneageisadvanced.
Developmentofpubertysignsatearly
4years.
TheheightcurveisNOTparallelto
othercentiles.
ProjectedheightcanNOTbeplot
becauseofun-parallelcurve
Dr. Majdi
AlJasim

80. Dr. Majdi
AlJasim
TALL CHILD #2
Tall child (BA ≥ CA)
Isthe patient dysmorphic?
YES
YesNo
YesNo
Chromosomal
disorder
NO
Is the curve
parallel
BA: Bone age CA: Chronological age
Signs of puberty?
Hormonal
(IGF1, TSH)
Precocious
puberty
Is projected
height within
mid-parental
height range?
Obesity or normal variant
Yes
Familial tall stature
No
Referral
Referral

81. Dr. Majdi
AlJasim
It is the appearance of secondary sexual characteristic's in
Girlsbefore 8 years of age.
Boysbefore 9 years of age.
Bone age is generally advancedrelative to chronologic age in
precocious puberty.
Common causes:
Idiopathic (80%)
CNS lesions.
Primary hypothyroidism.
Ovarian cyst / gonadal tumors.
Precocious puberty

82. TALL CHILD #3
Salem is an 18 years old male presented to the clinic concerning about his weird looking
chest cage.
His physical exam is remarkable for:
Tall stature (210 cm), thin, pectus carinatumchest deformity, arachnodactyly,
increased arm span/height, malar hypoplasia, retrognathia, grade 3 pansystolic
murmer, and oral high arched palate.
His father is 170 cm height, and his mother is 160 cm height.
His genital and pubic hair development is Tanner V, and bone age is appropriate for his
age.
How are you going to proceed?
Dr. Majdi
AlJasim

83. TALL CHILD #3
Themeasuredfatherheightis170cm
Themeasuredmotherheightis160cm
Mid-parentalheightis171.5cm
Thecurveisparallel.
Theprojectedheightis210cm.
Theacceptedmid-parentalrangeis
(161.5–181.5)
Theprojectedheightisabovetherange
Boneageisnormal.
Thepatienthasdysmorphicfeaturesof
Marfansyndrome.
Dr. Majdi
AlJasim
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84. Dr. Majdi
AlJasim
TALL CHILD #3
Tall child (BA ≥ CA)
Isthe patient dysmorphic?
YES
YesNo
YesNo
Chromosomal
disorder
NO
Is the curve
parallel
BA: Bone age CA: Chronological age
Signs of puberty?
Hormonal
(IGF1, TSH)
Precocious
puberty
Is projected
height within
mid-parental
height range?
Obesity or normal variant
Yes
Familial tall stature
No
Referral
Referral

85. Dr. Majdi
AlJasim
Chromosomal disorders tall stature
Themostcommoncausesare:
Marfansyndrome (as in this case scenario).
Klinefeltersyndrome (XXY).
Fragile X syndrome.
Weaver syndrome.
Investigation: Karyotype and genetic mutation analysis.
Growth chart consideration: Replot the measurements on the
specialized growth chart for the syndrome.

86. Dr. Majdi
AlJasim
Chromosomal disorders tall stature
Special growth curve of patients with Marfansyndrome. (A) Male. (B) Female

87. Bottom line!!
Dr. Majdi
AlJasim
Rememberto…
Sharemanagementwithpediatrics
subspecialtyforanychildwith
dysmorphicfeatureorun-parallel
growthcurve.