Pediatric Nursing Skill

MEASURING PHYSICAL GROWTH

Assessing physical growth is one of the most frequently used skills in pediatric nursing. Physical
growth parameters include weight, height, head and chest circumferences, and body mass index.
By accurate completion and correct plotting on growth charts, a visual representation of growth
emerges. Trends revealed through serial measurements are sensitive indicators of health and
nutritional status in children.

Related Text Chapter 33, Physical Assessment of

Children Anthropometric
measurement, p. 818

Nursing Diagnoses
Health-seeking behaviors (growth assessment) related to promotion of infant/child physical
growth Altered growth and development related to illness, stress, nutritional intake, and/or
parental knowledge deficit.

STEPS RATIONALE

Assessment
1. Determine presence of any physical anomalies.
Certain physical anomalies may interfere with
accurate growth measurements. For example,
deformities that prevent full extension preclude
accurate measurement of height, or presence of a
cast does not allow accurate weight measurement.

Special Considerations: If accurate measurement

2. Calculate child's age. Age is rounded to nearest
month on birth to 36-month charts, or to nearest 3
months on 2- to 18-year charts.
is not possible, that growth parameter can be
deferred or omitted, or special techniques maybe
necessary, such as sitting height or crown-to-rump
length.
Age determines which growth measurements are to
be completed and assists in selection of proper
measuring devices. Correct age is also essential for
accurate plotting on growth charts. Special
Considerations: For premature infants,weeks of
prematurity are subtracted from actual age before
plotting on growth charts. Adjustments are made
until 18 months of age for head circumference, 21
months of age for weight, and 36 months of age for
length or stature.

Copyright © 2006 by Elsevier, Inc. 1

3. Determine which growth measurements are to be The growth parameters to be measured will
obtained. a. Weight is measured at all ages. b. Recumbent guide selection of equipment and growth
length is measured for children under 24 months of age. charts needed for accurate determinations.
Stature, or standing height, is measured for children over
36 months of age. Either measurement may be used from
24 to 36 months; recumbent length must be plotted on
birth to 36-month charts, and stature must be plotted on 2-
to 18-year charts.

The growth parameters to be measured will

3. Determine which growth measurements are to be
guide selection of equipment and growth
obtained,
charts needed for accurate determinations.
a. Weight is measured at all ages.
b. Recumbent length is measured for children under
24 months of age. Stature, or standing height, is
measured for children over 36 months of age.
Either measurement may be used from 24 to 36
months; recumbent length must be plotted on birth
to 36- month charts, and stature must be plotted on
2- to 18-year charts.
c. Head circumference is commonly measured up to
2 years of age.
Marked disproportion between head and
d. Chest circumference may be measured for
chest circumference is generally the result
comparison with head circumference.
of abnormal head growth.

Copyright © 2006 by Elsevier, Inc. 2


4. Obtain family history relating to growth parameters,
including heights, weights, and head circumferences of
parents and siblings, if known. Information regarding
general growth patterns of siblings may also be beneficial.
Planning and Goal Setting
1. Assemble and prepare equipment.
a. Calibrate digital scale or balance beam scale,
either pediatric or adult model, depending on
child's age. Before using a balance beam scale,
balance scale by placing weights at zero position
and adjusting screws as necessary until beam is in
zero balance. Pediatric scales should be covered
with clean paper that is changed aftereach use; if
paper is to be used, scales should be balanced with
paper in place. Scales should be cleaned with
disinfectant daily or more often if contaminated.
b. Infant measuring board if recumbent length is to
be measured or wall-mounted measuring board if
stature is to be measured. Check to see that sliding
headboards and footboards move easily, are not
worn, loose, jagged, or broken, and are
perpendicular to measurement surface. If device is
not available, a nonstretchable measuring tape or
yardstick may be used. It should be attached to a
rigid surface (door, wall without baseboard, table
top) with “0” mark either at floor if child is to be
measured standing, or at fixed headboard if
recumbent length is to be measured; a right angle
board is required to complete the measurement.
c. Flexible, nonstretchable tape measure (paper or
plastic) for measuring head and chest
circumferences.
Copyright © 2006 by Elsevier, Inc.
Growth is significantly influenced by
genetic make-up. Thus tall parents tend to
have tall children; small parents have small
children.
Properly selected and maintained equipment
is essential in achieving accurate growth
measurements.
If measurements are to be compared with
standardized norms, length or stature
measurements must be accurate to ensure
valid
interpretation of findings. Special
Considerations: Measuring devicesshould
be in same unit of measure, such as inches
or centimeters, used within agency to avoid
calculation errors. Movable measuring rods
attached to platform scales are unstableand
do not ensure accurate measurement of
length or stature. Marking at child's head
and feet as closely as possible, then
measuring distance between marks,
provides only an estimate of length or
stature in absence of proper equipment.
Caution must be used in interpreting such
measurements by comparisonwith
standardized norms.
Cloth tape measures stretch, giving a falsely
small measurement Some metal tape
measures may not be adequately flexible
and may injure the child.
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2. Select appropriate National Center for HealthStatistics
(NCHS) growth chart. Sixteen charts and an easy-to-use
BMI calculator are available online:
http://www.cdc.gov/growthcharts/. Choose the charts
appropriate to the sex of the child. a. From birth to 36
months: • Chart showing norms for recumbent length by
weight and age. • Chart showing norms for head
circumference by age and we1ght by recumbent length. b.
From 2 to 18 years: • Chart showing norms for stature,
weight, and body mass index (BMI) by age.
3. Develop individualized goals of nursing care:
• Accurate, age-appropriate growthmeasurements will be
obtained.
• Growth measurements will be correctly plotted on
appropriate NCHS growth charts.
• Growth measurements falling outside normal parameters
and child's own growth curve will be identified.
Implementation
1. Prepare child.
a. For infants and some toddlers, distraction may be
necessary to keep them still during measurement.
For cooperative toddlers and older children, age-
appropriate explanations of procedures,
equipment, and results are given.
b. Remove child's clothing. • Infants are completely
undressed. • For children, all but minimal indoor
clothing is removed: coats, shoes, caps, etc.
Copyright © 2006 by Elsevier, Inc.
The correct standardized norms are essential
for accurate interpretation. Growth norms
may vary based on sex, age, measurement
by recumbent length, or stature. The weight-
by-age, recumbent length-by-age, stature-
by-age, and head circumference-by-age
charts compares the child's measurements
with those of the same-age children in the
general population. The weight-by-
recumbent length or weight-by-stature
charts allows comparison of the proportions
of the child's body measurements. BMI-for-
age permits identification of children and
adolescents who are at risk or overweight.
By allaying anxiety and fear of unknown,
child is better able to cooperate.
Special Considerations: If child is
uncooperative and resistant, making
accurate measurementimpossible, postpone
or omit measurement. Document reason.
Removal of clothing is required for accurate
weight determination. Removal of shoes and
headwear is necessary to measure length or
stature. Removal of headwear is also
essential for accurate measurement of head
circumference.
Special Considerations: Serial
measurements will provide a more accurate
picture if same approach is used each time
child is measured, such as if the infant is
always nude.
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2. Obtain height measurement. a. To obtain recumbent
length, place child supine on measuring board; have parent
or attendant hold head firmly against headboard with
child's line of vision straight up. Completely extend legs
by gently pushing down on both knees while positioning
footboard firmly against heels with toes straight up. Read
measurement to nearest 1/8 inch (0.3 cm).
b. To obtain stature, have child stand with heels slightly
apart, feet flat on floor, back straight, chin level, and eyes
looking straight ahead; heels, buttocks, and shoulder
blades should touch measuring surface. Lower headboard
to rest firmly on child's head. Read measurement to nearest
1/4 inch (0.6 cm).
3. Obtain weight measurement. Place undressed child in
middle of weighing surface. Infants and young children are
weighed while lying or sitting on pediatric scales; keep
hand close to but not touching child to prevent accidental
falls. Children over 2 to 3 years of age may be weighed
standing on adult scales. Read digital display or adjust
beam weights on scale until horizontal beam is balanced at
zero. Read weight to nearest ½ ounce (15 g) on pediatric
scales or ¼ pound (0.1 kg) on adult scales.
Copyright © 2006 by Elsevier, Inc.
Along with weight, height is a good
indicator of overall growth. Serial
measurements provide good representation
of growth rate. Shortness may be caused by
chronic malnutrition, chronic disease
affecting absorption or utilization of
nutrients, or inadequate growth hormone; it
may also be related to genetic factors and be
a normal growth pattern. Tallness is
generally related to genetic factors and a
normal growth pattern, although excessively
rapid growth may result from hormonal
imbalance or accelerated maturation.
Special Considerations: A child normally
grows approximately 10 inches (25 cm) in
first year of life, 5 inches (13 cm) in the
second year, 3 to 4 inches (8 to 10 cm) in
the third year, and then 2 to 3 inches (5 to 8
cm) per year until pubertalgrowth spurt.
Birth length is normally doubled by 4 years
and tripled by 13 years. Greatest height
gain usually occurs in spring, and least
gain, in fall.
Serial weight measurements provide a good
indicator of growth rate. Rapid or sudden
weight loss suggests serious, acute disease
or dehydration. Gradual weight loss
suggests chronic disease or malnutrition.
Underweight with normal growth rate may
be caused by inadequate nutrition or may be
related to genetic factors and normal for a
specific child. Rapidweight gain usually
indicates overfeeding, but may be a sign of
fluid retention. Generalized overweight or
obesity is generally due to overeating and/or
underactivity but may be caused by
endocrine disorders.
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4. Measure head and chest circumferences. a. Place tape
measure around largest part of head, the frontal-occipital
circumference (FOC), passing it over forehead just above
eyebrows, above ears, and around occipital prominence.
Place tape 3 times to ensure accuracy; record greatest
circumference. b. Measure chest circumference at nipple
line midway between inspiration and expiration.
Copyright © 2006 by Elsevier, Inc.
Special Considerations: Birth weight is
normally doubled by 5 to 6 months, tripled
by 12 months, and quadrupled by 2 to 2½
years. During first 3 months, infants gain
about 1 ounce (30 g) perday or 2 pounds (1
kg) per month; between ages 3 to 12
months, weight gain is about 1 pound (0.5
kg) per month. During second year of life,
weight gain is approximately ½ pound (0.25
kg) per month. After 2 years of age, weight
gain averages 5 pounds (2.25 kg) per year
until puberty, when growth spurt occurs.
Greatest weight gain usually occurs in
fall,and least gain, in spring.
Head circumference is an indicator of head
and brain growth. Chest circumference is
measured primarily for comparison with
head circumference; marked disproportion
between head and chest circumference is
generally due to abnormal head growth
rather than abnormal chest growth. A large
head circumference suggests hydrocephalus.
Small head suggests microcephaly,
craniostenosis, or genetic disorders. .
Special Considerations: To prevent paper
cuts,use caution not to slide or pull paper
tape against the skin of the child. Special
Considerations: FOC normally
increasesabout 12 cm (5 inches) during first
year of life, and another 10 cm (4 inches)
from 1 to 16 years. Average chest
circumference at birth is 1 cm (0.75 inch)
less than FOC. Chest remains about same
circumference as head until approximately
1 to 2 years of age. At 2 years, chest
circumference exceeds head circumference.
During childhood chest circumference
exceeds FOC by 5 to 7 cm (2 to 3 inches),
although it may be greater in children with
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4. Calculate body mass index (see text, Appendix E).
5. Plot growth measurements on appropriate NCHS growth
chart. Find child's age on horizontal scale and growth
measurement on vertical scale; make dot or cross where
two lines intersect. Repeat for each measurement obtained.
On weight-by-length or weight-by-stature graphs, find
length or stature on horizontal scale and weight on vertical
scale. Age is plotted to nearest month on birth to 36-month
chart and to nearest quarter year on 2- to 18-year chart.
6. Interpret measurements by comparison with percentiles
on charts. In general, normal measurements for height,
weight, and head circumference should fall between the
5th and 95th percentiles after making any indicated
adjustment for prematurity. Serial measurements should
follow the normal growth curve.
Evaluation Outcomes
1. Accurate, appropriate growth measurements are
obtained.
Copyright © 2006 by Elsevier, Inc.
chronic respiratory problems, such as
asthma or cystic fibrosis.
Accurate plotting on appropriate charts is
required for comparison with norms and
interpretation. Special Considerations: For
premature infants,weeks of prematurity are
recorded on growth chart and then
subtracted from actual age before plotting
on growth charts. Adjustments are made
until 18 months of age for FOC, 21 months
for weight, and 36 months for length or
stature.
If accurate measurements have been
obtained, measurements falling about 95th
percentile or below 5th percentile or serial
measurements showing marked change in
percentile levels are suggestive of health or
nutrition problems. A change from one edge
of percentile zone to other edge of that zone
or shift across percentile zones away from
50th percentile is significant. The greater
the change in growth percentile since
previous measurements, the quicker the
change has occurred, and the younger the
age of child, the greater the reason for
concern. Special Considerations:
Additional techniquesfor assessment of
growth are available, such as skin fold
thickness measurements, water-resistance
measure for percent of body fat, ultrasound
methods, and incremental growth
measurements. These tools may be used for
more accurate assessment of children
falling outside of normal range on general
growth parameters.
Observational Guidelines
Accuracy may be confirmed by repeating all
measurements 3 times. Weight is obtained
on all children. Recumbent length is
measured if child is under 24 months and
stature is measured if over 36 months;
between 24 and 36 months, either
measurement is acceptable. FOC is
measured if child is under 12 to 24 months
of age. BMI is calculated. Other
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2. Growth measurements are correctly plotted on
appropriate NCHS growth chart.
3. Growth measurements falling outside range of normal
are identified.
Documentation
Date and actual numerical values of all measurements
completed are recorded and plotted on appropriate NCHS
growth charts.
Any factors that may affect accuracy or interpretation
of measurements, such as clothing, prosthesis, casts,
prematurity, physical anomalies, or an uncooperative
child, are documented.
Nursing diagnoses and plan of care, including referrals, are
documented.
Copyright © 2006 by Elsevier, Inc.
measurements are completed on an
individual basis.
Confirm accuracy by rechecking plot points
on chart. Recumbent length is graphed on
birth to 36-month chart; stature is plotted on
2- to 18year chart. Adjustments are made
for prematurity, if indicated.
Measurements above 95th percentile or
below 5th percentile, or serial measurements
showing significant change in percentile are
documentedand referrals are made as
appropriate.
Child and Family Teaching
Results of physical growth assessment
should always be reviewed with the family
and child.
Growth charts are shared and the meaning
of plotted points is explained. For example,
if child falls at 25th percentile on weight
for age, explain that if 100 children of the
same age were compared, approximately 75
would weigh more and 25 would weigh less
than this child. Normalcy is important to
family and child and can be reassuring.
This is particularly important to adolescents
for whom body image is a primary concern.
For those falling outside norms, sharing
growth charts can provide an opening for
developing intervention plans with family
and child, such as discussing nutrition in
more detail or referring family to
nutritionist.
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