Understanding Infant Growth Charts
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DR. MURPHY: At each visit to the pediatrician, your baby is weighed, his height taken and his head measured. You’re given a percentile on which he falls based on his size. But what does that percentile really mean? How do you know if your baby is thriving or if your baby size is telling you that more is going on that needs to be addressed? I’m Dr. James Murphy, a pediatrician and internationally board certified lactation consultant. You’re listening to Newbies.
KRISTEN STRATTON: Welcome to Newbies broadcasting from the Birth Education Center of San Diego. Newbies is your online, on-the-go support group guiding new mothers through their baby’s first year. I’m your host, Kristen Stratton. I’m also a certified birth doula, postpartum doula and owner of In Due Season Doula Services.
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SUNNY GAULT: Hi everybody. Thanks so much for listening to Newbies. The other day we got our first question submitted from a listener for our experts.
KRISTEN STRATTON: I heard that.
SUNNY GAULT: Yes. Very cool. I was very excited about that. You guys are participating in that segment which I love. That’s our “Ask the Expert” segment. If you guys have questions—we all do as we have new babies and different things happen with our babies, go ahead and email those to us. You can do that through our website. Tell us a little bit about your question and we’ll pair that up with one of our experts. And then we’ll have that expert answer that question on a future episode. We’ll put it up there so everyone can benefit from that.
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If you’re listening to this and you’re like, “I don’t want to just email something”, you can actually tell your story too. That’s what our voicemail is for. If you call 619-866-4775, you can go ahead and leave your question. Use your own voice and we’ll put that on the show as well.
KRISTEN STRATTON: Alright. Let’s go ahead and meet our panelists.
BRITTANY CIUFERRI: Hi. I’m Brittany Ciuferri. I’m 26, a stay-at-home mom and training to be a birth doula. I have one baby girl and she is seven months old.
KRISTEN STRATTON: Alright. Christine?
CHRISTINE ZOE: Hi. I’m Christine Zoe. I’m a mother to two children. I have two boys, three and seven. I’m also a child birth educator, a birth doula and a lactation educator.
KRISTEN STRATTON: Great. Welcome to the show.
SUNNY GAULT: Before we kick up today’s show, since we’re talking about infant growth charts. I found an app that I thought was pretty relevant to our conversation today.
KRISTEN STRATTON: You’re so resourceful.
SUNNY GAULT: I am right? It’s called Growth which sounds kind of a little weird. But then Growth, it says charts for baby and child tracking. Here’s what you can do. First of all, it’s a free app. it’s available on iOs. You can upgrade and spend $2.99 and get rid of all the in-app purchases. If you’re worried about your child going through and charging a bunch of stuff up, you just get annoyed with ads, you may want to take advantage of that.
Here’s the deal. First of all, it will ask you some basic information about your child. How old they are, their birthday, that kind of stuff and then it provides you with different charts that you can look at. The World Health Organization has their own infant growth chart, so does the Center for Disease Control. You can basically select which one you want to look at.
You can import your child’s information if you want to. You can compare it to other charts out there and basically just get an idea for where your child sits as far as their growth is concerned.
When I go to the pediatrician’s office, I always like to look at the charts. I know we’re talking about the grand saw we’re not talking about that today. I always like to kind of see parents always like to compare.
KRISTEN STRATTON: For better or for worse.
SUNNY GAULT: I was just thinking, it’s interesting to compare against my other kids, which I also know is a no-no but I still do it. If you upgrade the app, if you pay that $2.99, you get some other features where you can enter multiple children and you can do exactly what I said. You can plot them together, compare their different growth.
I actually get to think that would be very interesting to compare my twins. They are more apples to apples. You can also enter information for body mass index which is not available for the free version. Some other cool things too. You can import stuff and export, all that good stuff. Anyways, I want to toss it over to you guys in the studio and on the phone and see, is this something you would use? What do you think Kristen?
KRISTEN STRATTON: I probably would do it just for the sake of remembering all this information. Just because I’m terrible of keeping track of all these papers that I get at the pediatrician’s office. Just for the convenience sake of being able to look back and say, “oh yes, that’s right. That’s where they were”.
SUNNY GAULT: Instead of the baby book, you’re going to be like “here kid, look at this app. This is where you were. You were so cute. Look at the graph and now look at you”.
KRISTEN STRATTON: I think the only thing that would be confusing to the parent would be which app do I use? This is little Faye we have in the audience.
SUNNY GAULT: She’s telling us what she thinks about the app.
KRISTEN STRATTON: She’s super cute. We have a guest baby in the—
SUNNY GAULT: in the audience.
KRISTEN STRATTON: -in the studio. We’re just so famous we have an audience now.
I would just probably be confused about which chart to look at. We have the WHO, we have the CDC, they also have the preterm chart which is helpful if you had a pre-nate. Then they have the WHO zero to two years, CDC zero to three. So I think just as the parent who perhaps wasn’t familiar with—
SUNNY GAULT: All of that? If they haven’t listened to today’s episode to have a better idea—
KRISTEN STRATTON: Then I wouldn’t know where to plot it.
SUNNY GAULT: Dr. Murphy, let’s talk to you about this. Why all the charts? Actually are we talking about that later in the show? What’s a brief idea, brief explanation I guess?
DR. MURPHY: Like you said, we tell parents not to compare kids so closely. They are all different but everybody compares. We have to have what we call within normal limits. If your growth is within the extremes of normal limits 2 ½ standard deviations above and below the mean, if anybody knows what that means, then we’re happy. If your growth is plotting consistently, there’s no need to get concerned.
But if we have some measure that says you’re deviating for what’s normal, or you’re going outside what we call normal limits, then we need to look closely to find out if that’s still okay or is there something really wrong here that we need to correct and we have to find it before—
SUNNY GAULT: You have a preference between the WHO chart and the CDC chart?
DR. MURPHY: The WHO charts came into being because of the exclusive breastfeeding baby was being mistreated if you will in the medical profession because they were being compared to the formula fed babies. And so my eyeball somewhere along my career failed to now detect babies who were getting fat because every baby was fat. So they started to look normal.
We had to put them on the charts to find out where they were and then when BMIs came along the older individuals to find out just how much extra fat tissue you have, and will this impact your health, then we were able to counsel parents more effectively as to what we need to do. If you’re not in the normal range everybody would ask you why, what’s going on? What’s causing the problem?
The best that baby in the first six months is pretty much chubby usually, some are even Humpty Dumptys by six months. But in the second six months, then they thin out. They grow into their height and their head size which has been maintained normal level all along. So as they grow into that normal size that they’re supposed to be for being breastfed, when you compare it to the relatively fat formula fed babies, they look like they’re not thriving.
So unfortunately the physicians would say you need to supplement your baby. We need to give extra food and if you lived in an Italian cafe, the idea there is the mother would say you mama not feed you be at my house. I’m a feed you.
SUNNY GAULT: If you want to play around this app, maybe not to really compare your kids. Like why aren’t you as big as your brother? But just for kind of fun. Check it out, open it up on the website. Again, it’s free or if you want to get rid of those pesky ads, $2.99.
KRISTEN STRATTON: Today on Newbies, we’re discussing infant growth charts. Our expert, Dr. James Murphy is a fellow of the American Academy of Pediatrics, a fellow of the Academy of Breastfeeding Medicine, president of the San Diego County Breastfeeding Coalition, served one year on the governing Council of the International Affiliation of Tongue-tied Professionals, is a member of the International Lactation Consultants Association and an internationally board certified lactation consultant. Thanks so much for joining us Dr. Murphy and welcome to the show.
DR. MURPHY: Thank you and I’m glad to be here.
KRISTEN STRATTON: Dr. Murphy, what exactly is the infant growth chart and how did it become a part of a well-baby exam?
DR. MURPHY: The infant growth chart is a way for the physician to measure is growth for this infant, for the height, the weight and the head size, all falling within what we call normal limits. And so we try to track them on the growth chart to make sure that the rate of growth is normal because the rate of growth is what the chart shows. When you look at the curve it initially goes up very rapidly then keeps going slower and slower and slower. That indicates the rate of growth of the baby.
If the rate of growth is normal over a short period of time, we can project that that’s going to be normal over the long haul. For each of those items allows us to assess where are we for the growth for that head size, or length, or weight. It’s just the tool that we used that really help us to know when we need to step in and start looking for something that’s not right and see if this baby is truly normal or has some problem.
KRISTEN STRATTON: How are these percentiles calculated?
DR. MURPHY: This is a population assessment. You have a huge number of individuals that must be measured and so in that given population we know what a standard bell curve distribution is. When you’re outside the top 3%, lower 3%, you may still be normal because you’re in that population and some in that group are normal.
But this is where most of the problems arise with growth, excess growth or insufficient growth. When you start to move outside what we’re comfortable with as normal limits then we need to look closer at that particular problem and see what we need to do. Percentile just tells you relative to everybody else in your population. Where do you fit relative to height, weight and head size?
KRISTEN STRATTON: How often are these average weights, heights, head circumferences updated to accommodate the change in each generation?
DR. MURPHY: This is a judgement call. The Center for Disease Control and Prevention in Atlanta is the government organization that’s charged with following these growth charts. They’re the ones who monitor how we’re doing with these growth charts. We originally had growth charts that were based on individuals who are much larger than the average individuals. So the bell curve was shifted away from the mean for that population so they re-did the growth charts by doing population studies in the United States including everybody and reissued those growth charts and those became CDC growth charts.
Then the World Health Organization said yes, but this is mostly formula fed babies and so we know that the formula fed babies tend to be more heavy set and have more issues. Where’s the growth chart for the exclusively breastfed baby?
KRISTEN STRATTON: Okay. Let’s ask our panelists a little bit. Let’s start with Christine. As a brand new mom, what was your knowledge about infant growth charts?
CHRISTINE ZOE: I knew nothing about them. I knew that at doctor’s appointment, when I brought my friend for his well baby visit to be with Tommy. His percentile for where he was on the charts and that was about it. I have that mark in the baby book that he was 50% for weight, 80% for height and that was about it. Then all of the moms that I knew, he would compare percentiles like that actually meant something between baby to baby. That’s all I knew as a brand new mom.
KRISTEN STRATTON: What about you Brittany? What did you know?
BRITTANY CIUFERRI: I really didn’t know much about them. I knew that they existed but other than that—my pediatrician didn’t even bring it up at her appointments and then I finally asked him. He said you know, we kind of shy away from telling our patients that because things can change and then when parents see that there’s a change, they start worrying that their child’s not growing. He didn’t really bring it up until I asked.
KRISTEN STRATTON: I honestly didn’t know much either as a new mom. I have three children. So the difference between my three children is just quite astonishing between my older two who are always in the 90th, 99th percentile. And I had my little guy who’s always like in the 10th.
DR. MURPHY: Most of the time the pediatrician will just tell you the growth is normal. That pretty much ends the conversation because there’s no concern about the growth that has occurred so we don’t need to go further than that.
KRISTEN STRATTON: How would a mom know if her child is just genetically on the smaller or larger size versus having a medical problem that needs more investigation?
DR. MURPHY: Well the first thing is things run in families. So the first thing if the mom is concerned, she should consult the grandmothers. The grandmothers have the medical knowledge for the family and find out if that’s a trend or a trait within that family group. Most of the time when moms find something, they come to us and we say that can be normal or may not. We want to know what the family history is first. If we’re not reassured by that then we need to—we have extensive training and various syndromes, genetic abnormalities. If we’re going beyond that then we will refer to specialist that we think can tell us the answer for the question that we have.
KRISTEN STRATTON: How would a mother who is exclusively breastfeeding know if she should need to supplement or change how her child is feeding based on the results of the growth chart?
DR. MURPHY: Again, we try not to push too much on the growth chart but if it’s within normal limits, we’re not concerned. For the exclusively breastfed baby, we’re looking at the rate of growth. We’re looking at how is feeding going. Is the baby feeding all the time? Or are we having regular, relatively short feeding intervals, loading up and then once you’re tanked up, you can go for a good period of time before you need to feed again.
The volume of the stool usually relates to the calories that are going in so we’re very interested in how many stools, how large are these so we estimate the volume of the poop. And then again, if that’s within normal limits, we’re reassured and we’re fine.
Most breastfed babies just need to breastfeed. They don’t need to supplement anything. If we’re going to supplement breastfed babies, we have mommy pump and give her the extra milk that she has to the baby. And if the baby refuses, the baby’s usually smarter than we are, I don’t need these calories, put them away for later.
KRISTEN STRATTON: And do we have an entire episode all about baby poop. Dr. Murphy is our expert for that one as well so definitely tune in to that one. How would a mother who is formula feeding know if her baby is receiving the proper nutrition based on this chart?
DR. MURPHY: We try to educate moms that proper nutrition is really related to the growth chart for the exclusively breastfed baby. It’s a touchy subject when you’ve chosen to formula feed your baby. So you must use the regular charts or the - from birth to two years, using the exclusively breastfed growth charts.
Your baby then looks like they’re getting fat because they are. We want you to recognize that and not accept the baby’s statement when he pulls away from the bottle, he’s done and you look and announce “there’s still half in here”. Don’t give it. Follow the baby. What breastfed babies do is when they’re done, they’re done and you can’t force any more into them. Unfortunately, with bottles you can.
We want mommies to just look at the charts to see how their babies are doing relative to our gold standard which is the exclusive breastfed baby and try to adjust to get as close to that as you possibly can.
KRISTEN STRATTON: Thank you. When we come back, we’ll continue our discussion about infant growth charts by learning more about the term “failure to thrive”. We’ll be right back.
KRISTEN STRATTON: Welcome back to the show. We are talking with Dr. James Murphy all about infant growth charts. Dr. Murphy, what does failure to thrive mean?
DR. MURPHY: Failure to thrive was originally intended to mean that when the baby is getting all the nutrition that they need, they’re still not meeting the normal rate of growth for the height, weight, head size. They fall outside the 3% line and need an investigation.
But as we’ve live in the real world, sometimes it’s income that determines how much food is available and the baby may be failure to thrive because he’s just not getting enough to eat. The mother is deluding the formula to try and make it go further and just not getting enough calories.
So economic conditions can lead to a fault’s failure to thrive just from not enough nutrition. This can be solved of course with our social services.
The baby who is just being neglected has two problems. They may not be getting enough calories to grow and we need to be loved and held and carried in order to have optimal outcome emotionally. Some babies that are being left to cry for long periods of time and their needs are not being addressed also can have growth issues and can look like failure to thrive.
As I traveled around the world with the needy and got to see other cultures, I saw that babies especially in the Asian cultures are carried constantly. Somebody always has the baby. In the United States, this concept had to be reintroduced after the scientifically calculated way to feed your baby caused issues with nutrition and growth. We now call it attachment parenting which is really the natural way to raise your baby.
So taking the baby up and holding him and loving him, not letting him cry, etc. meets our emotional needs and takes that factor out of play.
Then we deal with caloric need and emotional need then we’re left with medical problems. There are genetic syndromes that will cause growth to be abnormal. We need to identify the common syndromes being sure that we identify them in the office. And then less than common ones which are now the book on genetic syndromes is growing by leaps and bounds. So we need to refer them to geneticists if that’s what we were expecting.
But a simple blood test, the most common factor that we find that’s medically related is problems with the thyroid and so we screen that at birth. But there can be secondary problem with the thyroid later on that can lead to growth. We have a panel of tests that we do for all the babies that are failure to thrive.
We admit them to the hospital usually. We feed them well so that we know that people who are good at feeding babies are taking care of this infant. If they can’t get this infant to take these calories in then this is a failure to thrive.
The parents are not—it’s not that the parents are not doing something that they should have been doing but it’s a medical issue at this point. The experts—we have a panel of things that we go through to find out where the problem is and then the appropriate expert takes over to review that. This is usually done initially by the nutrition guest or enterology division and then as we find out what’s going on, we go further.
KRISTEN STRATTON: When would a provider suggest a failure to thrive diagnosis in an infant?
DR. MURPHY: If the rate of growth falls of suddenly. Usually the head size is the last thing to stop to fall off the curve, the height next, and the first thing that goes is the weight. As the weight is falling, we can see that it’s falling. We look for a reason why it is. If we can’t find that and the baby is consistently falling off the growth chart for weight despite everything that we’re doing then we can—once they pass that 3% mark then they’re labeled as failure to thrive and a standard protocol is begun. We try to figure out what is going on with this infant. This infant is lying outside the normal range.
KRISTEN STRATTON: What would some of the recommendations for treatment in a child who has been diagnosed as failure to thrive--?
DR. MURPHY: The emotional factor that I mentioned, carrying the baby, meeting the baby’s needs, not letting the baby cry, doing the calorie count per day to make sure that the calories per kilo per day are atleast at what normal babies need and we increase that as we can in order to see if it’s really calorically driven. It’s just a matter of the test that are on the battery for failure to thrive infant. What’s suspicious? What’s normal? And then the treatment is tailored based to what we find.
KRISTEN STRATTON: We’ll open it up to our panelists. Christine, I know you had experience with this. Would you mind sharing with us a little bit of your story?
CHRISTINE ZOE: Yes. My oldest son, he’s seven now. At his 12 months appointment, the pediatrician that we were seeing which was I’ve never seen before either which was at a hospital where we didn’t see that same pediatrician necessarily every single time. She basically walked into the room and lifted this growth chart and said he had failure to thrive. You need to stop breastfeeding. You need to put him on this prescription formula that by the way your insurance will not cover and that was that.
I was a little upset. Like what is failure to thrive? I don’t even know what it is. I go home to research it and it’s talking about neglect. It’s talking about children who literally are not thriving at life and I was mortified. Because here I am, I am holding my baby, I am answering his cries, I am feeding him, doing everything that I’m supposed to be doing and my baby has failure to thrive? What on earth is going on? And she was being kind of defensive towards me. She wasn’t treating me very respectfully so I surely did believe she didn’t think I was taking care of my child.
So I searched for a new pediatrician. When I went to him, my son by that point, probably 13 months old was climbing around the room, walking around, looking inside of the drawers, and was exploring around the room. And he goes “actually right now, your son does not have failure to thrive. Because if he did, he would not want be exploring like this. He wouldn’t be interested. He wouldn’t be going to mom and sitting on your lap. He simply is small. He’s a skinny kid.
And it wasn’t a sudden drop off either. He was consistently about 20% height over weight on the growth chart I think by like three months and it did drop off in the last 6-12 months between that 6 months to where he was on the lower 3%. And still at seven, he’s at 3%.
In my situation, it was just I have a small child. I did as Dr. Murphy said. I can talk with the grandmother. I went to my mother in law and she said “oh my gosh. Everyone thought I was starving your husband and he’s just small”. I did have that in my mind going my husband wise, me and my brother, we were born very, very skinny children. Maybe it is just genetic.
Once I went to that new pediatrician, he said come back in one month. We want to make sure he’s growing and that I see he’s growing. After that I’m not going to speak to you about his weight again. We went back in a month, he was growing. And he said okay, you’ve got a small kid and everything’s fine.
KRISTEN STRATTON: Yes. I personally also have experience with that diagnosis with my youngest child. He’s now 2 ½. But at his 9 month well baby chat we saw that his weight dropped off. Suddenly he was still being breastfed. At that point he was also taking in solids but he really truly didn’t grow weight wise from the previous appointment.
And then his 12 month appointment, same problem, 15th month appointment, same problem, by the time we’ve got all these specialists involved in his care, we realized that he actually did have a genetic syndrome that was preventing him from growing. But the first thing they did was say, “you guys must not be feeding him enough”. Which sent us to a nutritionist and said just put butter on everything and that will get his weight up.
SUNNY GAULT: No way.
KRISTEN STRATTON: Just put butter and cheese on everything. That’s the best thing for my son.
DR. MURPHY: Did you ask to see her diploma?
CHRISTINE ZOE: Yes. My son’s favorite food that time was cucumbers and they were like smother it with ranch dressing. Give him pancakes, chicken nuggets and all of the high fatty, unhealthy food. I was like I am leaving this room right now and not listening to you.
KRISTEN STRATTON: They give terrible advice. Alright! Thank you so much for sharing that Christine. And Dr. Murphy, what can you recommend to moms who may be struggling to know if they are receiving the right diagnosis and correct feeding recommendations for their children?
DR. MURPHY: We already heard one solution. Find a second opinion and that’s perfectly normal. Any physician who objects to you getting a second opinion is not confident in their own opinion. So we should not in any way, shape or form feel that we’re being mistreated in any way by asking for a second opinion. That is always an appropriate alternative for a any significant problem.
As we heard with this mom, I said the rate of growth is the issue and you have to look at the rate of growth. Even when we’re in training our residents would feel that somebody’s failure to thrive and they were breasted. They’d send them to me.
When we plotted them out we found that the rate of growth threw up before it got below 3% then it suddenly turned and followed the growth rate from then on, indicating that this individual was going to be a very low weight and therefore much healthier individual in the future than those who are up at the height of the curve on the weight. They just have a better medical future.
First thing I would do is get a second opinion and find out more, research more about what the pediatrician told you is wrong and see if that really fits. This is also after you’ve already done your family research because that’s so important to know what’s going on with your family.
KRISTEN STRATTON: Absolutely. Thank you so much Dr. Murphy and our lovely panelists for chatting with us today about infant growth charts.
For our Newbies Club members our conversation will continue after the end of the show as Dr. Murphy will explain about Newborn Screening for metabolic disorders. For more information about the Newbies club please visit our website at www.newmommymedia.com.
SUNNY GAULT: Here’s a question from one of our listeners. This comes from Shelby. Shelby writes:
“I need some advice with infant reflux. Our little guy is three weeks old and he’s really struggling with this. He kicks, screams and arches his back during feedings. He cries and he looks like he’s in pain when he burps. I’ve cut dairy and he’s also on medication. We’re considering a visit to the chiropractor if this medicine doesn’t start working. Any tips, advice or words of encouragement are very much appreciated”.
DR. PEREZ: This is Dr. Tyson Perez. I’m a pediatric and family chiropractor at Elevation Family Chiropractic in Carlsbad, California. Hey Shelby. I wanted to answer your question regarding acid reflux and colic. It could be a really difficult thing for parents to deal with.
You mentioned that you had tried some of the medication and consider going to a chiropractor. I think that’s a great idea. The chiropractor, what they will do is look at the neurological function of the child to see if it’s working properly because what happens if there’s a problem between the communication between the brain and the body, then you can see symptoms such as acid reflux. Sometimes other things like gas and constipation and other things associated with digestion.
First and foremost, the chiropractor needs to do a nerve scan to see what’s going on internally to see if chiropractic would be a benefit. If it would, the chiropractor will use gentle pediatric adjustments that are very, very different from what a standard chiropractic adjustment would be. You can always talk to the chiropractor about that.
I recommend seeing a pediatric chiropractor and there’s a couple ways to go about that. You can either contact me through Elevation Family Chiropractic and I can put you in the right direction. The ICPA website also has a list of their chiropractors. Go to www.ICPAforkids.org and you can type in your zip code and you’ll find the nearest chiropractor in your area that deals with pediatrics. Again the website is www.ICPAforkids.org . Anyway Shelby, I hope this helps. I will talk to you later. Bye.
KRISTEN STRATTON: That wraps up our show for today. We appreciate you listening to Newbies.
Don’t forget to check out our sister show:
• Preggie Pals for expecting moms
• Parent Savers for moms and dads with infants and toddlers
• The Boob Group for moms who breastfeed and
• Twin Talks for parents with multiples.
Thanks for listening to Newbies. Your go-to source for new moms and new babies.
This has been a New Mommy Media production. The information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. While such information and materials are believed to be accurate, it is not intended to replace or substitute for professional, medical advice or care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.
SUNNY GAULT: New Mommy Media is expanding our line-up of shows for new and expecting parents. If you have an idea for a new series, or if you’re a business, or an organization interested in joining our network of shows through a co-branded podcast, visit www.NewMommyMedia.com .
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