you won't believe what I heard on the elevator

I was riding the elevator in the hospital the other day.

Two women were chatting with each other about a recent visit of the child who was with them to the pediatrician.

Woman #1: "How was his height and weight?"Woman #2: "His height was good--its ninety five percent, but his weight is only fifty five percent"Woman #1: "What are you going to do about it?"Woman #2: "Feed him as much as possible."

At which point woman #2 took the little boy's hand and the three of them exited the elevator.

What is your image of this little boy? He looked like he was about 4 years old. The child was tall and of about average weight. He seemed perfectly healthy.

Did he only weigh HALF of what he should have?

What were they talking about? Take a look at the graph below which comes from the Centers for Disease Control and Prevention (CDC)

 

When you look at the graph, you are looking at lines that are called percentiles, not per cents. The lines are labeled as 5, 10, 25, 50, 75, 90 and 95. These are the percentile lines. If you are at the 90th percentile for height, you are TALLER THAN 90% OF THE POPULATION. Likewise, if you are at the 50th percentile for weight, you weigh MORE THAN 50% OF THE CHILDREN AT THAT AGE AND 50% LESS THAN THE CHILDREN AT THAT AGE. In other words, you are at the median or average weight for a child of that age.

The graphs are complicated, but can be used to follow the expected growth in height and weight in infants and children: there is a separate graph to look at expected head growth in children up to the age of two as well. Every doctor's office that provides health care for children should be "plotting" the child on such a growth chart with every visit. That is how we know if a child is typical or not. More recently, we have been tracking BMI in children as the obesity epidemic has gotten worse.

At first I thought the conversation I overheard was humorous, but then I started to worry.

Are we ever giving the impression to a family or caretaker that a child should be at 100% to be normal?

As always, communication is important in healthcare. We must be certain our patients and their families understand not only the words we say, but also what they mean.

Have you had any experiences with misinterpretation of the data or information your doctor has provided for you? I would love to hear about them!

For more information about growth charts, and to print out your own for your child(ren) follow this link to the CDC website

Comments

Thuy--this is a great idea. There is clearly a lot that I DIDN'T say about the use of growth curves--this was just a short post to emphasize that providers may need to explain the data to families a bit better, and not let them leave the office thinking that they should do something (fatten the child up) when in fact he was perfectly "normal" at least according to the CDC charts. I didn't talk about how to interpret where your child should be on the charts and how we determine symmetry. Obviously not all children should be at the 50th percentile, as much depends upon their genetics. We will talk about growth in a future blog post. Thanks for the suggestion!

Thanks Lauren, and thanks for helping me to teach appropriate, caring, and compassionate care techniques to the learners. It is only by parents insisting that they are respected even if we as providers disagree that we make progress with patient and family care. Thanks for reading the blog, and thanks for taking the time to comment.

I would hope that you WOULD tell me if I ever make you feel the way you describe. Sometimes we say things or do things with great intentions, but they come out wrong. I have been "guilty" of that many times I am afraid. Especially when really busy, or stressed by having too many patients with diseases or problems that are not easily explainable. I can only learn when I get feedback. I think that is true for all of us humans.

Hi Dr. Ackerman, I really enjoy reading your blog, and the range of topics you discuss.

Could you give a history of the growth curves - when were they created (and last updated) and population that data was based on? With the trend of Americans getting taller and bigger each generation, would these curves get updated? Also, are these curves different than the WHO curves? A friend prefers to use the WHO curves because her kids are smaller.

So true! It can be scary to be a parent and not understand what is going on with your child, and the most frightening and frustrating thing is when you feel as though you cannot ask questions without being judged for being an advocate for your child. (I've never felt that way with you, don't worry!).

I enjoy reading your blog... please keep up the great work.

That is a very scary conversation. As a parent, I make it my business to do my own research and find out what the percentiles mean. My children have always been low in the weight percentiles and not big eaters, but so was I as a child. They eat when they're hungry now and it goes in cycles. When they hit a growth spurt, they eat more.

I suppose in this case, the mother needed more education to go along with her child's percentile. However, I am a bit concerned that she can't simply look at her child and know he is fine. My daughter has historically fallen below 10%, but I know that she met all her milestones either on time or before time. She's perfectly healthy and active, she just happens to be thin. I think a lot of times parents don't rely on their own instincts when it comes to their children. Though the doctor should be trusted, it's the parents who are with the child each day.
In this case, the doctor can do more to educate the parent, but should also help the parent build build confidence.

Susan
Thanks for your insightful comments. Of course my slice of this pie was very small, and I didn't interact with either woman to find out how much they knew or understood about the child's growth and development to date. I have no idea what the social situation was, or whether either woman was his mother, social worker, foster parent, etc. I agree that most moms would have a conversation with the doctor regarding the overall health of the child, and would have a pretty good idea about how their child was doing. My point in writing this was just that it seemed so amazing to me that the visit could have ended without the takeaway being clearly that he was at an appropriate weight and height.

There is more we need to know to be able to tell how the child was doing, and clearly I need to write a more detailed post about growth curves, how to tell how well your child is doing, and how critical it is to look at it over time, and not just one point in time. In your case, I presume you are watching your daughter be small, but growing in an appropriate fashion. She has not "fallen off" the growth chart, but is growing along her own particular curve, and clearly her development is fine!

Yes, exactly- she's low on the curve, but she's consistent in growth. I have had a doctor or two tell me that I should put her through testing. I declined on the basis that she was thriving, she just happens to be of slight build. Being that I see her everyday, I know that she's just fine.

I'm very pro-education. I feel that many people fail to educate themselves properly on things that pertain to their children and rely solely on doctors or teachers or other professionals. I like to ask questions and research. It sounds like this person simply didn't realize that they didn't interpret the information correctly. That is a much bigger problem.

I enjoy your posts and I'm thankful for doctors like you.

As a practicing pediatrician, I find that many parents who bring their children to see me for the first time don't understand how to read a growth chart. So I usually take an extra minute to show them how to read it. I like to think this helps to prevent confusion later on.

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