in brief
In Brief
Normal Growth and Revised Growth Charts
Centers for Disease Control and Pre-
vention 2000 Growth Charts for the
United States: Improvements to the
1977 National Center for Health
Statistics Version. Ogden CL, Kucz-
marski RJ, Flegal KM, et al. Pediat-
rics. 2002;109:45– 60
www.cdc.gov/growthcharts
Developmental and Behavioral Pediat-
rics. Sulkes SB, Dosa NP. In: Behrman
RE, Kliegman RM, eds. Nelson Essen-
tials of Pediatrics. 4th ed. 2002.
Philadelphia, Pa: WB Saunders;
2002:4
Obesity Evaluation and Treatment: Ex-
pert Committee Recommendations.
Barlow SE, Dietz WH. Pediatrics.
1998;102:e29. Available at: http://
www.pediatrics.org/cgi/content/full/
102/3/e29
Clinical Assessment of Growth. Berhane
R, Dietz WH. In: Kessler DB, Dawson
P, eds. Failure to Thrive and Pediatric
Undernutrition. Baltimore, Md: Paul
H. Brookes; 1999:195–214
When monitoring children’s growth, it
is helpful to remember several rules of
thumb:
●
Term infants usually lose 5% to 10%
of their birthweight immediately af-
ter birth, but regain their birthweight
within 2 weeks.
●
Term infants double their birthweight
in 4 to 5 months and triple it by 1
year of age.
●
A child’s height doubles from that at
birth by 3 to 4 years of age.
●
The average size of 4-year-old chil-
dren is 40 in and 35 lb.
●
From 3 to 10 years of age, children
grow an average of 2.5 in/y.
The pediatrician can monitor children’s
growth more accurately by using
growth charts, and the charts should be
used at all health supervision visits. In
January 2002, the Centers for Disease
Control and Prevention (CDC) published
in Pediatrics the revised growth charts
for children to replace those published
in 1977. The revised charts, accompa-
nied by technical reports, are also avail-
able at www.cdc.gov/growthcharts.
The revision provides technical im-
provements in the infant charts. The old
charts were based on a small sample of
children from 1929 to 1975; the revised
charts are based on five recent, ethni-
cally diverse, national samples. The old
charts were based largely on bottle-fed
infants; the revised charts include in-
fants who were breastfed. The old
charts had a disjunction when making
the transition from length (measured
recumbent) in the infant sample (based
in Ohio) to height (measured standing)
for older children in the national sam-
ple; the revised charts all are based on
the same national samples. Finally, the
revised charts are for all ethnic groups.
The revised charts include three new
features: 1) The age range has been
extended up to the 20th birthday;
2) The back of the charts for children
ages 2 to 20 years shows the body mass
index (BMI), a measure of obesity; and
3) Although clinicians generally use
charts that have the 5th and 95th
percentile lines, charts showing the 3rd
and 97th percentiles (for cases at the
extremes of growth) are available at
the website. A statistical program, Epi
Info, enables the clinician to calculate
exact percentiles and standard-
deviation scores (z-scores) for statisti-
cal summaries and comparisons.
The website offers “clinical” growth
charts, with the grids for graphing data
aligned with metric units, and English
units (pounds and inches) on the sec-
ondary scale. There are tables for data
entry and two charts to a page. Also
available are “individual” growth
charts, with grids aligned to English
units and metric units on the secondary
scale, but with no tables for data entry
and only one chart to a page.
It is important to use the back of the
growth charts to monitor not only the
growth of the head, but also to identify
children who are becoming thin or fat.
For children younger than 3 years,
the charts show weight-for-length. This
index is important for detecting chil-
dren who are becoming thin because of
inadequate nutrition, illness, or other
factors. If these children are tall for
their age, their weight may not be
below the 5th percentile, and their
thinness may be missed without the use
of the weight-for-length measurement.
Other children’s poor growth may man-
ifest in poor linear growth, which may
be due to normal shifting percentiles
and family growth patterns but can
also be due to undernutrition and ill-
ness.
For children younger than 24
months, the clinician measures recum-
bent length; for those older than 3
years, standing height is measured. Be-
tween 24 and 36 months, infant charts
(0 to 36 mo) or charts for older children
(2 to 20 y) can be used. The infant chart
requires measurement of recumbent
length, and the older chart requires
measurement of standing height. The
infant charts show data more clearly;
those for older children allow earlier
use of the BMI.
For children ages 2 to 20 years, the
back of the revised growth charts pro-
vides the BMI. Because BMI varies with
age, the charts show BMI-for-age. The
BMI correlates well with body fat in
measurements of body composition and
Pediatrics in Review Vol.23 No.7 July 2002 255
in brief
so indicates overweight. The charts
show the 85th percentile line as repre-
senting “at risk of overweight” and the
95th as “overweight.” In revising the
growth charts for children 6 years and
older, the most recent national survey
(NHANES III) was not used because the
proportion of children who were over-
weight had increased.
BMI is defined as weight divided by
the square of height. It can be calcu-
lated directly from metric units (meters
and kilograms); with English units
(inches and pounds), the data must be
multiplied by 703. In clinical practice,
BMI can be derived in four ways: with a
pocket calculator; with an online cal-
In Brief
Effects on the Fetus of Maternal Drugs During Labor
Drugs in Pregnancy and Lactation. 5th
ed. Briggs GG. Baltimore, Md: Wil-
liams & Wilkins; 1998:100 –104,
122–123, 432– 433, 539 –547,
578 –571, 610 – 612 629 – 630,
641– 646, 672– 674, 746 –748,
752–753, 768 –771, 947–952,
1004 –1008
The Impact of Maternal Illness on the
Neonate. Landy HJ. In: Avery GB,
Fletcher MA, MacDonald MG, eds.
Neonatology: Pathophysiology and
Management of the Newborn. 5th
ed. Philadelphia, Pa: Lippincott, Wil-
liams & Wilkins; 1999:187–208
Obstetric Analgesia and Anesthesia.
Rosen MA. In: Avery GB, Fletcher
MA, MacDonald MG, eds. Neonatol-
ogy: Pathophysiology and Manage-
ment of the Newborn. 5th ed. Phila-
delphia, Pa: Lippincott, Williams &
Wilkins; 1999:237–253
Obstetric Analgesia and Anesthesia.
Fishburne JI Jr. In: Scott JR, ed. Dan-
forth’s Obstetrics and Gynecology.
8th ed. Philadelphia, Pa: Lippincott,
Williams & Wilkins; 1999:111–126
Maternal Analgesia During Labor Dis-
256 Pediatrics in Review Vol.23 No.7 July 2002
culator available at the CDC website;
with a table available at the CDC web-
site; and with a PDA (personal digital
assistant), using the program STAT
Growth Charts (available at no charge
from www.statcoder.com).
Training modules at the website
provide additional information about
use of the revised charts. One module
gives instructions and practice in cal-
culating and graphing the BMI. The
modules on proper weighing and mea-
suring can enhance the training of
pediatric office staff to make accurate
measurements. The modules emphasize
not weighing children wearing too
many clothes and the use of a length
turbs Newborn Behavior: Effects On
Breastfeeding, Temperature, and
Crying. Ransjo-Arvidson AB, Mat-
thiesen AS, Lilja G, Nissen E, Wid-
strom AM, Uvnas-Moberg K. Birth.
2001:28:5–12
For pediatricians, the concern during
labor and delivery is the welfare of the
baby. Many of the drugs routinely ad-
ministered to the mother can have
profound effects on the newborn that
the pediatrician in the delivery room
and nursery must manage. This brief
considers the drugs commonly admin-
istered to healthy mothers in labor. (See
also the article by Boyle RJ. Pediatr Rev.
2002;23:17–24.)
Although some women prefer to
give birth without pain medicine, most
do receive analgesia. Several types of
analgesics, including mepivacaine, bu-
pivacaine, and meperidine, have been
shown to delay spontaneous breast-
seeking of the newborn and breastfeed-
ing behaviors in the newborn period
board for infants and a wall-mounted
stadiometer for older children. The
module on special-needs children con-
tains special measurement techniques
and advises caution in the use of
growth charts specific to special condi-
tions such as Down syndrome. Other
modules address growth in head size,
poor growth in infants and toddlers,
growth and changes in the BMI during
adolescence, summary and comparison
of the growth of groups of children, and
recommendations for overweight chil-
dren and adolescents.
Peter Dawson, MD, MPH
Boulder, CO
compared with infants of mothers who
did not receive analgesia. Meperidine
can cause decreased respiratory effort,
decreased behavioral response, and
electroencephalographic changes for
several days after birth. Other narcotics,
such as butorphanol and nalbuphine,
cause a sinusoidal fetal heart rate pat-
tern that can mimic signs of hypoxia,
although these drugs do not cause
hypoxic injury.
Lorazepam sometimes is used to
potentiate the effects of opioids and
provide anxiolysis. Its use may prompt
the “floppy infant syndrome,” which
resolves spontaneously with no se-
quelae. Ketamine is used occasionally
and can increase muscle tone, which
subsequently can cause respiratory dis-
tress and lead to difficulties in intuba-
tion. Local anesthetics are used for
epidural infusion and for direct injec-
tion at the site of an episiotomy. Al-
though rare, there is a possibility of
directly injecting the anesthetic into

the fetus. A local anesthetic entering
the bloodstream of the fetus could
cause apnea, hypotonia, tachycardia,
and seizures.
Oxytocin is a natural hormone that
causes uterine contraction and is used
to induce or augment labor. Oxytocin
can cause the uterus to become tetanic,
which can compromise placental blood
flow and cause fetal distress. The drug
also has the potential for producing
forceful contractions of the uterus be-
fore the cervix dilates completely,
which could lead to uterine rupture and
trauma to the infant. Misoprostol is
used for cervical ripening and labor
induction, although the United States
Food and Drug Administration has not
approved it for this indication. Uterine
hyperstimulation, with changes in the
fetal heart rate and frequency of
meconium-stained amniotic fluid, were
more common among women given
misoprostol than women given other
uterine stimulants, but the birth out-
comes were the same.
Among the drugs used for tocolysis,
In Brief
Viral Causes of Diarrhea
Rotavirus and Other Viral Causes of
Gastroenteritis. Lieberman JM. Pedi-
atr Ann. 1994;2310:529 –535
Viral Gastroenteritis. Matson DO, Pick-
ering LK, Mitchell DK. In: McMillan
JA, DeAngelis CD, Feigin RD, War-
shaw JB, eds. Oski’s Pediatrics: Prin-
ciples and Practice. 3rd ed. Philadel-
phia, Pa: Lippincott, Williams &
Wilkins; 1999:1147–1151
Gastroenteritis. Northrup RS, Flanigan
TP. Pediatr Rev. 1994;15:461– 472
Epidemiology of Diarrheal Disease
Among Children Enrolled in Four
West Coast Health Maintenance
Organizations. Parashar UD, Holman
indomethacin can have deleterious ef-
fects on the newborn, although it has
been reported to be less of a problem
when administered before 32 weeks’
gestation. When administered at deliv-
ery, it can cause acute renal failure,
bleeding (eg, intraventricular hemor-
rhage) due to inhibition of platelet
aggregation, and intestinal perforation.
When administered chronically for to-
colysis, it can cause oligohydramnios
and possibly premature closure of the
ductus arteriosus. An additive constric-
tive effect occurs when betamethasone
is administered to mothers in preterm
labor to aid in fetal lung maturation.
When women on beta blockers receive
indomethacin, the interaction can
cause severe hypertension and fetal
death.
Other tocolytic drugs are better tol-
erated. It has been hypothesized that
magnesium sulfate reduces the risk of
neonatal brain lesions in low-
birthweight infants. However, magne-
sium can make an infant areflexic and
neurologically depressed and may cause
RC, Bresee JS, et al. Pediatr Infect
Dis J. 1998;17:605– 611
Rotavirus is the most commonly recog-
nized viral pathogen that produces di-
arrheal disease in children and the most
common cause of severe gastroenteritis
requiring hospitalization. However, a
number of other viruses can cause di-
arrhea, and their clinical manifestations
are important to recognize in the care
of children who have gastroenteritis.
The viruses include adenovirus, Norwalk
virus, astrovirus, and calicivirus.
Some generalizations can be made
in brief
a reduction in calcium concentrations
due to inhibition of parathyroid hor-
mone. Nifedipine is generally well-
tolerated. Ritodrine is a beta-mimetic
drug that, because of its sympathetic
action, increases glycogen breakdown
and causes hyperglycemia in the
mother and hyperinsulinemia in the
newborn. The baby may be hypoglyce-
mic at birth. Ritodrine also can cause
septal hypertrophy when used long
term.
Tocolytic, analgesic, and labor-
stimulating drugs are among the most
common agents administered to
healthy mothers. Awareness of the ad-
verse effects associated with these
medications, such as respiratory dis-
tress, whether from opiates or a prema-
turely closed ductus arteriosus, is es-
sential to providing care for newborns.
Andrew Hoyer, MD
Children’s National Medical Center
Washington, DC
about viral diarrheal disease in infants
and young children. Incubation periods
are brief, usually 1 to 3 days. Infections
can be asymptomatic, but if diarrhea
develops, it frequently is associated
with vomiting and fever. With the ex-
ception of rotavirus, the diarrhea pro-
duced by viral infection typically is mild
to moderate. If stool studies are per-
formed, they rarely reveal white blood
cells or occult blood in the stool, and
results of stool cultures are negative.
Second only to rotavirus in fre-
quency is adenovirus, which accounts
for 5% to 10% of pediatric hospitaliza-
Pediatrics in Review Vol.23 No.7 July 2002 257
in brief
tions for acute gastroenteritis (com-
pared with the 30% to 70% attributed
to rotavirus). Serotypes 40 and 41 are
the enteric strains known to cause gas-
troenteritis in children; these strains do
not cause any of the respiratory symp-
toms commonly associated with other
adenoviruses. The mean age of clinical
illness in children is 1 to 2 years of age.
Like rotavirus, transmission is by the
fecal-oral route. Adenovirus has an in-
cubation period of 8 to 10 days, which
is considerably longer than that of the
other common viruses. Symptoms last
5 to 12 days on average, with one third
of children experiencing diarrhea for
longer than 14 days. Patients may have
vomiting or fever with adenoviral infec-
tion. Unlike rotavirus, there is very little
seasonality associated with adenoviral
gastroenteritis. An enzyme immunoas-
say test is available for detection of
adenovirus, but it is not used frequently
outside of research studies.
Norwalk virus is also an important
cause of viral gastroenteritis. This virus
is spread both by the fecal-oral route
and via contaminated food and water
258 Pediatrics in Review Vol.23 No.7 July 2002
sources. Outbreaks of diarrheal disease
can occur in child care, schools, and
other settings, commonly affecting
older children and adults. The incuba-
tion period is usually less than 48 hours.
Unlike adenovirus, the course of illness
with Norwalk virus gastroenteritis is
brief, lasting fewer than 48 hours, and
generally is characterized by vomiting.
Less commonly recognized causes of
viral diarrhea include astroviruses and
caliciviruses. Astrovirus infections can
be asymptomatic, but also can cause
diarrheal illness, with more than 50%
of children also experiencing vomiting
and fever. Detected most commonly in
the winter, astroviruses have a short
incubation period of 1 to 2 days. Cali-
civiruses also can cause mild diarrhea in
infants and toddlers, although symp-
toms are seen in older children and
adults as well. Both of these virus
families have been associated with out-
breaks at child care centers and in
association with consumption of con-
taminated food or water.
The primary concern for all diarrheal
disease is prevention and treatment of
dehydration. Oral rehydration solutions,
which are very effective in preventing
and treating dehydration, are commer-
cially available for children, and appro-
priate intravenous solutions may be
used for fluid resuscitation of patients
who do not tolerate oral fluids. All of
the viral gastroenteritides are self-
limited, and antibiotics play no role in
their treatment.
Marsha D. Spitzer, MD
Guam Memorial Hospital
Tamuning, Guam
Comment: Worldwide, viruses are
the leading cause of diarrhea. Among
viruses, rotavirus is the major cause of
severe diarrhea (Pediatr Rev. 1999;20:
39 –71). Unfortunately, vaccines have
not provided the answer to rotaviral
disease prevention. Handwashing and
ensuring safe food and water supplies
continue to be the mainstays of pre-
vention of viral diarrhea.
Tina L. Cheng, MD, MPH
Associate Editor, In Brief
Experienced clinicians and specialists have much to teach us. Although textbooks
and journal articles can be valuable sources of information, the person who deals
regularly with specific clinical situations often can provide important insights
that may be overlooked in general education. We would like to offer readers a
chance to submit questions regarding problems they have encountered in their
clinical practices to experts in the field. Have you noticed a changing clinical
trend in your practice that you can’t explain? Did you have a patient just last
week whose presentation caused you to think twice before proceeding with treat-
ment? Have you read of new medications or techniques, but have not had a chance
to apply them to your patients? Whatever your question, please submit it to us, and
we will pass it on to an expert in the field to provide you with the information you
need. Send your questions to:
Robert J. Haggerty, MD
Department of Pediatrics
University of Rochester
School of Medicine and Dentistry
601 Elmwood Avenue, Box 777
Rochester, NY 14642
We will handle your question promptly and publish a reply as quickly as possible.

Pediatrics in Review Vol.23 No.7 July 2002 259