Growth and Development: Growth Charts, Milestones, and Failure to Thrive

Introduction

Child growth and development encompass physical growth (height, weight, head circumference), acquisition of developmental skills, and the progression of physiological systems. Monitoring growth and development through regular well-child visits allows early identification of deviations from normal patterns, enabling timely intervention. The CDC and WHO provide standardized growth charts for US children.

Growth Charts

CDC vs WHO Growth Charts

Aspect	WHO Charts (0-24 months)	CDC Charts (2-20 years)
Population standard	Breastfed infants (optimal growth)	US children (general population)
Age range	Birth to 24 months	2 to 20 years
Weight for length	Included	Included
Head circumference	Birth to 36 months	Birth to 36 months
BMI for age	Not included	2-20 years
Recommended by CDC	For ages 0-23 months	For ages 2+ years

Key Percentiles and What They Mean

Percentile	Interpretation	Clinical Action
<3rd percentile	Below normal range	Full evaluation for growth disorder
5th-10th	Borderline low	Monitor closely
25th-75th	Average	No concern
85th-95th	Overweight (BMI)	Lifestyle counseling
>95th	Obese (BMI) >97th: severe obesity	Intervention indicated
>97th	Above normal range	Evaluate for overgrowth syndromes

Growth Velocity

Age	Normal Height Velocity (cm/year)	Normal Weight Gain
0-3 months	20-30 cm/year	150-200 g/week
3-6 months	15-20 cm/year	100-150 g/week
6-12 months	10-15 cm/year	50-80 g/week
1-2 years	10-12 cm/year	2-3 kg/year
2-3 years	7-9 cm/year	2-2.5 kg/year
3-4 years	6-7 cm/year	2 kg/year
4 years to puberty	5-6 cm/year	2-3 kg/year

Head Circumference

Age	Average Head Circumference	Rate of Growth
Newborn	34-35 cm (13.5-13.8 in)	2 cm/month in first 3 months
3 months	40-41 cm	1 cm/month (3-6 months)
6 months	43-44 cm	0.5 cm/month (6-12 months)
12 months	46-47 cm	0.25 cm/month (12-24 months)
2 years	48-49 cm	2 cm (year 2-3)
3 years	49-50 cm	1 cm (year 3-5)

When to Be Concerned About Head Size

Finding	Concern
Microcephaly (<3rd percentile)	Genetic syndromes, congenital infection (Zika, CMV, toxoplasmosis, rubella), craniosynostosis, perinatal brain injury
Macrocephaly (>97th percentile)	Hydrocephalus, genetic overgrowth syndromes (Sotos, Weaver), familial macrocephaly, neurofibromatosis, brain tumors
Rapid crossing of percentiles (2+ lines)	Hydrocephalus, subdural hematoma, tumor
Head circumference discordant with height/weight	Genetic syndromes; metabolic disorders

Developmental Milestones (CDC - 2 Months to 5 Years)

2 Months

Domain	Milestone	Red Flag (if absent)
Social/Emotional	Calms down when held or spoken to; looks at face; smiles	Not responding to sounds; no visual tracking
Language/Communication	Coos; turns head toward sound	No response to loud sounds
Cognitive	Pays attention to faces; follows objects with eyes	No visual tracking
Motor	Holds head up briefly when on tummy; moves both arms and legs	Head lag (complete); doesn’t push up on arms

4 Months

Domain	Milestone	Red Flag
Social/Emotional	Smiles spontaneously; laughs; copies some movements	No social smile
Language	Babbles with expression; copies sounds	No cooing/babbling
Cognitive	Reaches for objects; puts objects in mouth	Not reaching for objects
Motor	Holds head steady without support; pushes up to elbows on tummy; rolls from tummy to back	Poor head control; not pushing up

6 Months

Domain	Milestone	Red Flag
Social/Emotional	Recognizes familiar faces; enjoys looking at mirror	No response to people
Language	Takes turns making sounds; strings vowels together; responds to name	No response to name
Cognitive	Looks at nearby objects; brings things to mouth; shows curiosity	Difficulty getting objects to mouth
Motor	Rolls both directions; sits with support; rocks on tummy; bears weight on legs when supported	Stiff or floppy arms/legs

9 Months

Domain	Milestone	Red Flag
Social/Emotional	Clings to familiar adults; fearful of strangers; plays peek-a-boo	No fear of strangers
Language	Understands “no”; makes many different sounds; points	No babbling
Cognitive	Watches where things fall; looks for hidden objects; puts things in mouth	Not tracking objects
Motor	Sits without support; crawls; pulls to stand	No sitting without support

12 Months

Domain	Milestone	Red Flag
Social/Emotional	Plays games (patty-cake); waves goodbye; shows fear	No gestures (waving, pointing)
Language	Says “mama” and “dada” specifically; understands “no”; attempts to speak	No single words
Cognitive	Explores objects in different ways (shaking, banging); finds hidden things	No searching for hidden objects
Motor	Pulls to stand, walks holding furniture; may take 2-3 steps independently	Not pulling to stand

15 Months

Domain	Milestone	Red Flag
Social/Emotional	Points to get attention; shows affection; protests when something is taken away	No pointing
Language	Says 1-2 words besides “mama/dada”; looks at familiar objects when named	No words; no response to “no”
Cognitive	Claps when excited; hugs stuffed toy; looks at a few body parts when named	No functional play
Motor	Takes a few steps independently; uses fingers to self-feed	Not walking

18 Months

Domain	Milestone	Red Flag
Social/Emotional	Moves away from parent but checks back; points to show interesting things; helps with dressing	Not showing interest in others
Language	Says 5-10 words; follows 1-step commands without gestures	<3 words
Cognitive	Knows what ordinary objects do; drinks from cup; points to get something	Not learning function of objects
Motor	Walks independently; walks up stairs with help; scribbles	Not walking

24 Months (2 Years)

Domain	Milestone	Red Flag
Social/Emotional	Notices when others are hurt; looks at face for reaction; plays alongside other children	No parallel play
Language	Says 50+ words; uses 2-4 word phrases; follows 2-step commands	<50 words; no 2-word phrases
Cognitive	Builds towers of 4+ blocks; uses one hand more than other; plays with multiple toys	Not sorting shapes/colors
Motor	Kicks a ball; runs; walks up/down stairs holding rail; stands on tiptoes	Not walking well

30 Months

Domain	Milestone	Red Flag
Social/Emotional	Plays make-believe with others; initiates play	No pretend play
Language	Uses 200+ words; uses me/you/I; knows first name; speaks clearly enough to be understood	Not using 2-word combinations
Cognitive	Holds crayon with thumb and fingers; turns book pages one at a time	No scribbling
Motor	Jumps with both feet; walks up stairs alternating feet; throws ball overhand	Not jumping

36 Months (3 Years)

Domain	Milestone	Red Flag
Social/Emotional	Shows concern for crying friends; takes turns in games; separates from parent easily	Not playing with others
Language	Converses using 2-3 sentences; asks “why”/“who”/“where”; uses plurals/pronouns	Not speaking in sentences
Cognitive	Completes 3-4 piece puzzles; turns door handles; uses toys with moving parts	Not understanding simple directions
Motor	Climbs well; pedals tricycle; walks up/down stairs alternating feet	Frequent falling; difficulty with stairs

48 Months (4 Years)

Domain	Milestone	Red Flag
Social/Emotional	Enjoys new things; plays “mom” and “dad”; creative make-believe	No interest in imaginative play
Language	Knows colors/numbers; tells stories; uses future tense; sings songs	Not understandable to strangers
Cognitive	Names some colors/numbers; understands counting; draws person with 2-4 body parts	Cannot draw simple shapes
Motor	Hops on 1 foot; catches bounced ball; cuts with child scissors	Difficulty with fine motor skills

60 Months (5 Years)

Domain	Milestone	Red Flag
Social/Emotional	Wants to please friends; likes to sing/dance; aware of gender; knows likes/dislikes	No interest in peer relationships
Language	Speaks clearly; tells long stories; uses future and past tense; knows address/phone	Cannot tell a simple story
Cognitive	Counts 10+ objects; draws person with 6+ body parts; prints some letters	Cannot copy simple shapes
Motor	Stands on 1 foot for 10+ seconds; swings; somersaults; uses fork/spoon well	Clumsiness interfering with daily activities

Failure to Thrive (FTT)

Definition

Criteria	Description
Weight	<3rd-5th percentile for age and sex
Weight deceleration	Crossing 2+ major percentile lines after having been at a higher percentile
Weight-for-length	<5th percentile
Growth velocity	Below expected for age (<5 cm/year after age 2)
Weight <80% of ideal body weight for length	For children <2 years

Etiology (Organic vs Inorganic/Environmental)

Category	Causes (Examples)
Inadequate caloric intake (most common)	Poor feeding technique, neglect, poverty, food insecurity, incorrect formula preparation, breastfeeding problems, oral motor dysfunction, GERD, mechanical feeding difficulty
Inadequate absorption	Celiac disease, cystic fibrosis, milk protein allergy, inflammatory bowel disease, giardia, short gut syndrome
Increased metabolic demand	Congenital heart disease, chronic lung disease (BPD), hyperthyroidism, chronic infection, malignancy, chronic inflammation
Defective utilization	Inborn errors of metabolism, endocrine (growth hormone deficiency, hypothyroidism)

Evaluation

Component	Assessment
History	Prenatal/perinatal history, birth weight, feeding history (type, quantity, frequency, behaviors), stool/urine pattern, developmental milestones, family/social history, review of systems (vomiting, diarrhea, fever, dysphagia)
Physical	Anthropometrics (weight, height/length, head circumference plotted over time), dysmorphic features, signs of malnutrition (temporal wasting, loss of subcutaneous fat), signs of specific disease
Labs	CBC, electrolytes, BUN/Cr, LFTs, celiac screen (TTG IgA + total IgA), lead level, urinalysis, stool studies (if GI symptoms); consider: TSH, HIV, sweat chloride, screening for metabolic disease
Dietary assessment	3-day food diary; calorie count; feeding observation
Psychosocial assessment	Home environment, caregiver-child interaction, maternal depression screening, food security

Management

Category	Intervention
Caloric density	Increase formula to 22-24-27-30 kcal/oz (add polycose, MCT oil, or modular formula); fortify breast milk; high-calorie solid foods
Feeding behavior	Scheduled feedings every 2.5-4 hours; limit grazing; no juice; positive reinforcement; feeding therapist (OT/SLP)
Treat underlying cause	GERD: thickened feedings, acid suppression; Celiac: gluten-free diet; Cystic fibrosis: pancreatic enzymes
Multidisciplinary	Pediatrician, dietitian, feeding therapist, social work, psychologist, occupational therapy
Nutritional supplements	PediaSure, Pedialyte, Duocal, MCT oil
Follow-up	Weekly weight checks; calorie counts; phone check with parent; home health nurse visits
Hospitalization	If severe (<70% IBW), dehydration, electrolyte abnormalities, failure of outpatient management, suspected neglect/abuse

Growth Disorders

Condition	Height	Growth Velocity	Bone Age	Cause	Treatment
Familial short stature	<5th percentile (short parents)	Normal (parallel to curve)	Normal	Genetic	None needed (normal height for family)
Constitutional delay (growth delay)	Short (pubertal delay)	Normal height velocity but delayed	Delayed	Late bloomer	Reassurance; will achieve normal adult height
Growth hormone deficiency	Very short (<1.2 percentile)	Low (<5 cm/year)	Delayed	Pituitary dysfunction (idiopathic, tumor, radiation)	rhGH (recombinant growth hormone)
Hypothyroidism	Short	Low	Delayed	Thyroid hormone deficiency	Levothyroxine
Turner syndrome (girls)	Short	Low; no pubertal growth spurt	Delayed	45,XO	rhGH (may add oxandrolone)
Celiac disease	Short	Low	Delayed	Gluten enteropathy	Gluten-free diet restores growth
Prader-Willi syndrome	Short (with obesity)	Low	Delayed	Chromosome 15 abnormality	rhGH improves growth and body composition
IUGR/SGA (born small)	Short	May catch up (70% by age 2)	Variable	Fetal growth restriction	rhGH if no catch-up by age 2-4
Overgrowth (Sotos, Beckwith-Wiedemann)	Tall	High (accelerated)	Advanced	Genetic	Address underlying syndrome; monitor for complications