Infant, child, youth growth (0-17 years)

• All young children have the same potential to grow. Many factors affect growth including nutrition, sleep, health and parent’s height
• Growth problems are usually caused by a combination of medical, social and/or environmental issues (eg food insecurity)
• Growth is a very important indicator of a child’s overall health and development. Growth problems can impact on a child’s learning and development and risk of chronic conditions later in life — see Child development concerns (0-5 years) and School aged child and youth behaviour or development concerns
• Preterm (less than 37 weeks) and low birth weight babies (<2500g) may need individual growth and nutrition plans — see Child health check (0–5 years)
• Management of growth problems needs a multi-disciplinary approach in partnership with the family

Monitoring growth

• Growth monitoring is one part of a child health check — follow the growth check schedule — see Postnatal care of baby,  Child health check (0–5 years) and School-aged and young person’s health check (6–17 years) or local endorsed program
• Regular growth checks mean that problems can be found and responded to early. It is very important to have accurate measurements
• If a problem is identified child will need extra monitoring and a care plan developed with family, child health nurses, dietitian and paediatrician

Do

• Always use calibrated equipment in good condition, use same equipment for ongoing checks if possible — see Clinical assessment of children

Measure weight

• Record to nearest 0.1kg
• Under 2 years old — on baby scales, naked (no nappy or singlet)
• 2–5 years — standing on adult scales, wearing dry nappy or underpants only, no shoes
• If unable to undress, document what child wearing in records
• If unable to weigh child alone — weigh carer only, then while they are still on the scales, tare (zero) the scales, then hand carer the child. Child’s weight will be final reading OR subtract carer weight from total weight of carer and child (less accurate)
• 5 years and over — on adult scales, wearing light clothing and no shoes

Measure length or height

• Record to nearest 0.1cm
• Under 2 years old — lying down (length), no nappy, on fixed board or measuring mat with 2 people holding the child
• 2 years and over — standing up using height measure, without shoes, hair ties or hat

Measure head circumference

• Babies and children under 3 years
• Find and measure widest part of head (horizontally) using a narrow (1cm wide), non-stretch tape measure

Calculate Body Mass Index (BMI)

BMI is a measurement of how proportional (balanced) a child’s weight is in relation to their height. Unlike adults the healthy BMI range for a child changes with age — BMI for children must be plotted onto a growth chart

• For children 2 years and over calculate BMI using the formula: weight (kg) divided by height (cm)² OR use anthropometric calculator (eg WHO Anthro)

Calculate Waist for Height

• 10 years and over
• Measure waist just above belly button. Divide waist measurement (cm) by height (cm)
• Waist for height ratio of 0.5 or more is a risk factor for chronic conditions — see School-aged and young person’s health check (6–17 years)

Interpreting growth

• Every time child is weighed and measured — plot growth onto a  growth chart — WHO charts are used for child aged under 2 years. Use chart approved by your organisation for child over 2 years
• Look at the growth chart to assess growth. Multiple measurements over time are needed to assess if a child is growing well — the shape of the growth curve is more important than height/weight numbers
• A baby should be back to or above birth weight 7 to 14 days after birth
• A baby who was preterm or low birth weight should still follow shape of a line on the chart

Growing well

• Weight and length/height generally follow one of the centile lines on the growth chart — Figure 3.3 and Figure 3.4 — AND BMI is between the -1 and +1 line on the BMI for age chart —  Figure 3.5
• There is good catch up growth if any weight loss during illness

Growth faltering

• Weight and/or length/height is beginning to flatten or go down compared to the centile line on growth chart — Figure 3.6 — AND/OR BMI is below the -1 line on the BMI for age chart — Figure 3.7
• Can be caused by undernutrition, infections or other medical problems

Excess growth

• Weight is  going up compared to the centile line on growth chart – Figure 3.8 — AND/OR BMI is above the +1 line on the BMI for age chart — Figure 3.9
• Waist for height measure in children over 10 years is more than 0.5

© WHO growth charts. https://www.who.int/tools/child-growth-standards/standards/weight-for-age August 2022. Adapted with permission

Do

• Show caregiver growth chart and talk about growth
• If growing well — do regular child or youth health check and encourage age appropriate diet
• If growth faltering or excess growth — start growth action plan — Flowchart 3.2

Growth Action Plan

• Investigate reasons for growth faltering immediately — act quickly and follow-up, including with other clinic if child moves to another community
• Medical consult if baby is not above birth weight 7-14 days after birth or if baby under 3 months old has lost weight 
• Involve carers in finding causes for growth problems and solutions.  Be sensitive to cultural beliefs and values — a growth action plan uses a multi-disciplinary approach with health staff and the family
• Consider medical, dietary, social, environmental issues. Do not judge or criticise
• Provide age appropriate support, education and reassurance

Ask

• About any current or recent illnesses or gastrointestinal symptoms — including vomiting, diarrhoea, constipation, ear or chest infections
• About child’s development and behaviour — see Child development concerns (0-5 years) or School aged child and youth behaviour or development concerns
• About current diet
• Breastfeeding — baby should feed regularly when hungry and should have several wet nappies each day and soft faeces. Mother should be pain free and comfortable — see Breastfeeding
• Formula fed — check using correct formula, prepared correctly and feeding regularly when hungry, ask how much taken and if stops feeding when baby shows signs of fullness — see Postnatal nutrition for mother and baby (up to 6 months old)
• Foods eaten — babies older than 6 months should eat iron rich solids foods (2-3 times daily), older children should be offered food regularly (4-6 times daily) — see Infant and child nutrition
• Any problems with child’s eating eg fussy eating or chewing problems
• About social and environmental issues
• Access to money and/or healthy foods, Centrelink payments
• Housing issues — including overcrowding, plumbing, power, food storage and cooking facilities
• Maternal depression — including low mood, exhaustion, helplessness, hopelessness
• Carer and family — access to support, mental health issues, domestic and family violence, drug or alcohol problems, gambling

Check

• Height, BMI
• Hb
• Head-to-toe exam — attention to
• Skin — look for sores or scabies, hydration
• Chest — for moist cough, frequent chest infections — see chronic lung conditions
• Ears
• Child or youth health check — if not recently completed
• Chronic condition screening for children with excess growth — see School aged and young person's health check

Do

• Urine for MC&S
• If diarrhoea — faeces for MC&S and OCP
• Listen and respond to carer’s concerns
• Treat any medical issues
• Medical consult if baby is not above birth weight 7 to 14 days after birth or if baby under 3 months has lost weight
• Refer any developmental concerns to child health nurse — see  Child development concerns (0-5 years) or School aged child and youth behaviour or development concerns
• Give medicines for growth faltering — Table 3.6, once at diagnosis
• Do not give for excess weight gain
• Medical consult and refer to child health nurse and dietitian
• Refer to paediatrician if signs of complications for child with excess growth — sleep apnoea, diabetes, high BP, hip problems (eg slipped femoral epiphysis) or if pre-existing conditions (eg asthma, reflux) getting worse 
• Explore solutions with family — refer to community based services that provide activities that support positive parenting and healthy eating, provide food or help with financial and housing issues (eg council, childcare, school)
• Provide education on age appropriate diet — see Infant and child nutrition
• If child recently sick they may not be hungry but should still be offered small healthy meals regularly, at least 6 times a day. Encourage but do not force child to eat
• Sick infants need extra fluids (breastmilk, formula) for hydration and energy. If trouble breastfeeding offer expressed breastmilk from a small clean cup — see Breastfeeding medical consult if any signs of dehydration
• If diarrhoea — give extra fluids (breastmilk, formula, water) to prevent/treat dehydration
• Sit children up to eat. Lying down is a choking hazard
• Encourage physical activity — at least 3 hours a day if 1–5 years and 2 hours if 5 years or over
• Encourage limiting screen time — TV, computer, electronic games, mobile phone — to 2 hours a day

Severe growth faltering may require Vitamin A supplementation if not given in previous 6 months — medical consult

Follow-up

• Check growth
• Weekly for 2 weeks for child under 5 years
• Fortnightly for one month for child over 5 years
• OR as per individual growth plan
• If not meeting expected weekly weight gain — Table 3.7 talk to child health nurse/dietitian for individualised plan   
• When managing excess growth, support and encourage small successes — slowing of weight gain, weight staying the same, height gain
• If inadequate or excess gain after 4 weeks — medical consult to escalate care — within one week for child under 1 year
• Repeat albendazole after 3 weeks  — see Table 3.6
• Growth action plan should be stopped within 3 months if growth is normal OR refer to paediatrician if ongoing growth concerns

Nutritional supplement drinks

• Used in growth faltering for 'catch-up' growth. Must be prescribed by doctor or dietitian and monitored by dietitian — refer to organisational guidelines
• Only used for a short time as part of growth action plan for children aged 1 to 5 years weighing more than 8kg
• If weight less than 8kg — refer to paediatrician and dietitian
• Not a substitute for food continue to promote healthy diet

Supporting resources

• RCH and WHO child growth and e-learning course