Evaluating Growth in Adoptees

Almost every medical report has at least one set of growth measurements. It is always advisable, and usually possible, to request an updated series of measurements on a newly referred child. Growth is an objective measure of the child’s nutritional and medical status and may be the most reliable information available prior to adoption. However, weight errors can occur from measuring children in winter clothes versus unclothed, and height and head circumference seem especially susceptible to erratic measurements, due to technique or old stretched-out measuring tapes. Growth charts specific to children from certain countries are available, but these measurements are usually plotted on the revised United States growth charts (see below). It is generally the pattern of growth over time, rather than growth indices at a specific age, that is of greatest value.

Unfortunately, an orphanage is far from the ideal environment for childhood growth. Many children exhibit evidence of malnutrition and psychosocial dwarfism. Most are stunted in linear growth (height). Generally, we expect children to lose about 1 month of linear growth for every 3 months in institutional care. Although most children who are malnourished and poorly stimulated maintain brain growth, over time even head circumference may not be spared. Microcephaly is a red flag. Children who have microcephaly that is extreme or present from early in infancy may have medical diagnoses other than malnutrition or deprivation, such as fetal alcohol syndrome, a genetic disorder, or a perinatal brain injury. Although most orphans exhibit dramatic catch-up growth after adoption, even in head circumference, it is not yet known whether this recovery of brain mass means that the brain will function normally.

We recommend that you download the revised CDC growth charts for tracking weight, height, and head circumference along with us. These are what we use for children from Eastern Europe, as well as most children from other regions. While there are some ethnic differences in growth, many of the country-specific growth charts are problematic – for example, the China growth charts date from the early 1960s, and may be “normalizing” malnutrition.

For children from China or Korea with borderline growth it may be reasonable, however, to give them the benefit of the doubt. Growth charts for these populations and for premature infants can be found in our Growth Charts section.

If percentiles are confusing at first, think of it this way - a child at the 10th percentile for height is 10th in line of a hundred kids of the same age and gender lined up by height. 50th in line, or 50th percentile, is average. The broad definition of "normal" is from the 3rd percentile to the 97th percentile, or "within 2 standard deviations of the mean", for the engineers out there. But again, trends of growth over time are usually more meaningful than the percentile at any given moment .

Comments

[MNMom2Be]

We are in the process of adopting a two year old boy from China. He has a repaired ASD. We just received an update on his growth and it appears that his height and weight is in the 50th percentile on the growth charts but his head circumference is in the 15 to 20th percentile. Is this cause for concern?

[Julian Davies, MD]

In general, I'm not at all concerned if a head circumference is at a different percentile than weight or height - they don't need to be perfectly proportional, as long as the head size is increasing steadily at an established percentile that's in the normal range. Rapid increases or decelerations across percentiles can be reason for concern, provided the measurements are accurate (they frequently aren't).

[Christi]

I was referred a baby from China whose inital head measurement was 30cm, 1-2mo. 34cm, 3-4mo. 38.5cm, and then progresses steadily to the current assessment of 45cm at 14mo. What do you think?

[Julian Davies, MD]

As much as I care about head circumference, I do take a somewhat more holistic approach to thinking about growth and risk ... so I don't generally feel comfortable making pronouncements about a child's head size without looking at the full referral. If you have concerns about your referral, I'd recommend discussing them with your pediatrician, or an international adoption doc.

In general, when early head circumference measurements are small but things "catch up" steadily, I wonder about early undermeasurement due to head shape molding from the birth process ("conehead"), other measurement errors/variation, prematurity, or prenatal growth problems with postnatal catchup. Looking at her other measurements, photos, and development may be helpful in that regard.

[Sarah Harm]

I'm thinking about adopting a child who at 32 completed weeks weighs 4 1/2 lbs and has a head circumference measuring 33.1cm. I'm wondering is the head circumference off the standard deviation? Is she susceptible to hydrocephalus or autism?

[Mary E. Francis]

We adopted our daughter from Orissa, India. We brought her home in December 2009. She is now 37 months old. Here height , weight , and head circumference is below 3%.We have several growth measurements from the orphanage, and she is gaining weight and has been consistently small. Our pediatrician would like to refer her to an endocrinologist (her TSH is WNL) for possible evaluation for growth hormone. I am not opposed to taking her to an endocrinologist, I am not sure I would feel comfortable giving her growth hormone. My observation of the people in Orissa is that they are tiny--I was bigger than most men( even men who have means)--I am 5' 5'' and 140 lbs. When is OK to say that our daughter is tiny. PS she is doing very well--very active, eating and sleeping.
Thanks, Mary Francis