Growth monitoring during the early years

Lee Yung Seng

Professor, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore;
Senior Consultant, Division of Paediatric Endocrinology, Department of Paediatrics, Khoo Teck Puat – National University Children's Medical Institute, National University Hospital
 

Why is growth monitoring important?

Growth is an indicator of health and nutritional status.¹ It is known that undernutrition prevents children from reaching their maximum growth potential – both physically and cognitively. Likewise, excessive consumption of energy-dense foods may lead to obesity and other diet-related noncommunicable diseases, such as diabetes.²

Notably, it has been reported that about 30% of Singaporean parents were unable to correctly gauge whether their child was underweight or overweight based on body mass index (BMI).³ This is a concern because when a normal weight infant or child is perceived by its parents to be underweight, there is a tendency to overfeed, potentially putting the child at risk of obesity. These underscore the importance of tracking objective growth measures, i.e., height and weight, which are used to calculate BMI. Growth monitoring helps ensure that children receive adequate and appropriate nutrition to support optimum growth and development.

What can we do when parents express concerns about their child’s growth?

Many mothers are concerned about their child being underweight but are less likely to notice or feel negatively if their child is overweight.^4,5 This is troubling given that the number of overweight children under 5 years of age is increasing rapidly, especially in Asia.⁶

However, a study of children aged 12-36 months in Malaysia and Singapore has shown that the presence of parental concerns about feeding difficulties in their children predicts growth faltering during early childhood.⁷ Persistently inadequate caloric intake can lead to stunting or failure to thrive.

In these scenarios, physicians play a critical role in growth monitoring to alert the parents, and improve growth trajectories as early as possible. Weight alone is an inadequate measure as growth monitoring during childhood should track both height and weight, which are then used to calculate body mass index (BMI).⁸ When comparing a child’s measurements against growth charts (local height, weight, and BMI charts), physicians must use charts for the relevant population.¹

Download growth charts for Singaporean children from the National Healthcare Group Polyclinics here:

For boys

• Boy's height
• Boy's weight
• Boy's weight-height
• Boy's BMI
   

For girls

• Girl's height
• Girl's weight
• Girl's weight-height
• Girl's BMI
   

What can be done to promote catch-up growth in children with faltering growth?

Firstly, any underlying pathology that may explain or be associated with inadequate food intake and faltering growth – such as developmental abnormalities, neurological disabilities, and other medical conditions – should be ruled out or addressed.  It is important to recognise, however, that during the early years, it is common for children to cross percentiles on the growth charts. For example, infants born to tall parents may show upward crossing (catch-up growth) or babies that were heavy at birth may cross downward (catch-down growth). When crossing of growth percentiles occurs outside of infancy and during puberty, it is a cause for concern and warrants further evaluation.⁹

Children with non-organic feeding disorders (NOFEDs) should be supplied with adequate calories, protein, and other nutrients (nutritional rehabilitation). In many cases, the family and caregivers may also need guidance on how to provide a nurturing environment that encourages better feeding behaviours, and how to monitor growth and nutritional status.¹⁰ In children with NOFEDs, oral nutritional supplementation (ONS) can also help if they are unable to meet their nutritional requirements with normal foods alone.¹¹ It is worth noting, however, that following the WHO guidelines, nutritional management to support catch-up growth should focus on providing both adequate energy and protein.¹²

Finally, it should be noted that managing NOFEDs can be a long process and requires a multidisciplinary team that may involve a paediatrician/paediatric gastroenterologist, a nutritionist, speech and language therapists, occupational therapists and play therapists.¹⁰

Disclaimer:
The doctor who participated in the development of this article does not have financial relationships with any entities that have an interest related to the published work. The participation of the doctor in the development of this article does not constitute or imply an endorsement or recommendation. The content of this article is intended to be used for informational purposes only, and not intended to impart any medical or other advice.
 

References:

1. Yap F, Lee YS, Aw MMH. Growth assessment and monitoring during childhood. Ann Acad Med Singapore. 2018;47(4):149-55.
2. Lee YS. Consequences of childhood obesity. Ann Acad Med Singap. 2009 Jan;38(1):75-7.
3. Cheng TS, Loy SL, Cheung YB, et al. Singaporean mothers’ perception of their three-year-old child’s weight status: a cross-sectional study. PLoS One. 2016;11(1):e0147563.
4. Harrison M, Brodribb W, Davies PSW, Hepworth J. Impact of maternal infant weight perception on infant feeding and dietary intake. Matern Child Health J. 2018;22(8):1135-45.
5. Laraway KA, Birch LL, Shaffer ML, Paul IM. Parent perception of healthy infant and toddler growth. Clin Pediatr (Phila). 2010 Apr;49(4):343-9.
6. International Food Policy Research Institute. Global nutrition report 2016: from promise to impact: ending malnutrition by 2030. Washington, DC. 2016.
7. Lee WS, Tee CW, Tan AG, et al. Parental concern of feeding difficulty predicts poor growth status in their child. Pediatr Neonatol. 2019 Dec;60(6):676-683.
8. https://www.cdc.gov/obesity/downloads/BMIforPactitioners.pdf. Accessed June 2021.
9. Rogol AD, Clark PA, Roemmich JN. Growth and pubertal development in children and adolescents: effects of diet and physical activity. Am J Clin Nutr. 2000 Aug;72(2 Suppl):521S-8S.
10. Romano C, Hartman C, Privitera C, Cardile S, Shamir R. Current topics in the diagnosis and management of the pediatric non organic feeding disorders (NOFEDs). Clin Nutr. 2015 Apr;34(2):195-200.
11. King C, Davis T. Nutritional treatment of infants and children with faltering growth. Eur J Clin Nutr. 2010 May;64 Suppl 1:S11-3.
12. Sullivan PB, Goulet O. Growth faltering: how to catch up? Eur J Clin Nutr. 2010 May;64 Suppl 1:S1.