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Children's Health

Weight and head circumference

08/08/2007

Question:

Hello Dr. I am concerned about the growth of my daughter, especially her head circumference which is in 90th to 95th percentile, who is 9 months and 1 week. her apgar score was 9. her developement is as follow. Birth weight 2.9 kg. at 1-1/2 month weight 4.5 kg, length 56 cm , and HC 37.5 at 4 months 5.3 kg, 62 cm, and 41.2 cm. at 5 months 5.7 kg, 63 cm, and 42.5 cm. at 6-1/2 months 6.2 kg, 66 cm, and 44 cm. at at 8 months 6.7 kg, 67.5 cm, and 44.6 cm. at 9 months 7.2 kg, 70 cm, and 46 cm.

She has a poor appetite, most of the time i have to force the food down, otherwise she is active and crawls all around, walks holding furniture, when asked claps her hands, plays with the toys, cries initially for sometime when we have some visitors, and is right now teething. She has been healthy since her birth except little bit of cold twice and couple of time fever. We have no family history of large heads, father is 5 feet 8 inches, 74 kgs, and mother is 5 feet 2 inches, 48 kgs.

i will be very grateful to you if you will guide me on her developement and tell me if her head circumference is a thing of concern and how can i improve her weight. thanks

Answer:

All parents are concerned about the proper growth of their babies. It was very helpful that you offered all of her growth parameters for each month. It helped provide a good picture of her growth trajectory. I have carefully plotted your daughter's growth on a CDC 2000 growth chart. Here is what I see.

Her weight began at birth at the 10th percentile, briefly bumped up to the 25th percentile at at 11/2 months but has been tracking along between the 10th and 5th percentiles. This does not represent a significant slowing of weight gain, but rather, a sustained pattern of weight increase at the lower end of normal. If you are breastfeeding your baby, this is very much in keeping with the growth patterns seen in normal breastfed infants. It usually is at the lower end of normal. Your own weight is at the 10th percentile and, it turns out to be a consistent finding in research, that the mother's weight is the most important influence on child weight. So your daughter is likely reflecting her genetic heritage to be lighter weight.

We expect that in the first 2 months of life a baby will gain about 15-30 gm per day, which your daughter did. After two months, the growth rate settles to an average of 20 grams per day. However, your child has settled in at about 10-15 grams per day during that period. She has continued at 10 grams per day weight gain since 6 months of age, which is exactly normal for the second half of her infancy year. the growth rate drops in half at about 5-6 months of age and is matched by a drop in appetite to match to cut the child's calorie intake to match her growth rate. Many parents worry over this drop in take that occurs among all normal infants at 5-6 months of age.

We have learned from many years of research that children from birth to five years of age exactly match their calorie intake to their calorie expenditure in growth and activity, if we feed them based on their cues of hunger and fullness. This is critically important to child health over their lifespan. Many parents mistakenly believe that they must force their child to eat  amounts of food they believe to be sufficient, when the truth is that children will eat what they need. This is a battle royal the child always wins and sets up a frustrating feeding experience for both children and parents, as you are finding.

Even though children transition to table foods, they need a much smaller amount of food than do adults, since very young children such as your daughter need less than half of an adult's daily food intake. So a good rule of thumb is to offer 1 tablespoon of each food for each year of life. Portion sizes are very small for very small children. In your daughter's case, this means about 1 Tablespoon at each meal of each food. Also, if she refuses a food, continue to offer it. It may take 15-20 offerings before she accepts it. This helps build a varied diet so essential to good nutrition. Provide her with a comfortable small spoon to eat from, small amounts of soft foods she can pick up and feed herself, and a cup to learn to drink from, but not a slow flow cup that requires sucking. It is important to being the transition off of the bottle at her age, so that it can be discarded at 12 months.

Feed her when she is restless and making chewing movements with her mouth. Stop the feeding when she is no longer interested in the food, looking away from the food, or getting fussy. Do not offer her breastmilk or formula until she has finished eating as much of her solid foods as she wants. Be sure to advance the thickness and texture of her foods at this point. If you stick with smooth foods only, she will be stuck there for a long time. If you relax and enjoy the social feeding time, I think you find that your child also relaxes, eats better, and wastes fewer calories fighting off unwanted food, and she will have good weight gain.

It is also important to only offer healthful foods. Do not offer her pudding and french fries in the place of fruits and vegetables or soda pop and juice drinks in the place of her formula or breastmilk. I highly recommend that you read Ellyn Satter's book, Child of Mine: Feeding with Love and Good Sense. It is excellent advice endorsed by recommendations from the American Academy of Pediatrics. Ellyn's often repeated rules for healthful child nutrition are that parents are responsible for offering well prepared, healthful foods at regular intervals (this prevents extreme hunger and tantrums) the child can anticipate. The child is responsible for whether or not he or she eats and how much is eaten.

Let's move to her length. Her length began at the 50th percentile, which is the highest height percentile she would be expected to reach if we project ahead to her final adult height. Both you and her father at the 25th percentile for height, which is her most likely final growth percentile if we average the height percentiles for you and your husband. She may be as short as 58.5 cm or as tall as 66.5 cm, but her predicted height is 62.5 cm at the 25th percentile at 20 years of age. So, you need have no worries about her growth in length. This is the most sensitive growth measure for predicting a chronic illness in a young child if it begins to decline over time. This is not the case for your child. 

Your daughter's head circumference began at the 50th percentile, matching her length percentile, and tracked close to it until 4 months of age, when it moved up to the 75th percentile and somewhat above that at 61/2 and 8 months. At 9 months it jumped to the 95th percentile. So there are two possibilities. One is that there was significant measurement error at her 9 month visit. This jump in growth should have been verified by 3 repeat measurements with your child in a seated position with the measurement tape placed above her eyebrows, above and not over her ears, and around the bony prominence at the back of her head. If this was not done, and the measurement verified, I would not trust it. This is the growth measurement most commonly done with poor technique.

The other possibility is that this is a real change in size and is problematic. Given what you describe about your daughter's general behavior and development, I think this is unlikely. However, I am certain her doctor would be happy to refer you for developmental testing if he or she is not satisfied that your daughter is developing normally. For further information on a child's normal development, there are wonderful parent resources on the website for the Zero to Three website at http://www.zerotothree.org/.

I hope this provides you with a good perspective on your daughter's growth and development. Obviously you care about he a great deal. Tuning into her communications and following her lead about hunger and fullness is a wonderful way to convey to her that you love and respect her. You may also find it helpful to teach her infant sign language for hunger, more, and no more, to aid both of you. Bookstores offer great resources for this important pre-verbal communication time.

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Response by:

Mary M Gottesman, PhD, RN, CPNP, FAAN Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University