Look at any class picture and you’ll see kids from different backgrounds, genders and all shapes and sizes. Some classmates may be a head taller than their peers, even when they're in the same grade or around the same age. So, how do parents know what’s “normal” as children grow up?

Dr. Amra Zuzo, a female pediatrician in Charlotte, North Carolina, smiles for a photo.
Dr. Amra Zuzo

Pediatricians like Dr. Amra Zuzo at Novant Health Pediatrics Berewick are able to monitor healthy development by tracking growth on a curve, known as the pediatric growth chart, to ensure that a child is developing proportionally.

"Some may be shorter or heavier than others, but what’s most important is that they follow a smooth, consistent curve," Zuzo said. "It drives home the importance of an annual physical, even when a child is doing well."

Health care providers also use the growth chart to compare development in children of the same age and gender. It’s been a standard in pediatrics since the 1970s and still today, plays a critical role in catching early signs of disease and preventing future health problems.

“It’s one of the best ways to catch a problem early on,” Zuzo said. “We may notice a child’s weight gain is dropping around 2 to 6 months, for example, which can help us catch metabolic issues or inherited syndromes with no other symptoms.”


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Birth to two years

Pediatricians look for inconsistencies in growth from birth to 18 years, but Zuzo said children are most closely tracked the first 1 to 2 years of life. During this time, Novant Health uses the World Health Organization pediatric growth chart to track weight, length and head circumference.

If a child's growth curve is inconsistent, it could point to intracranial problems, such as swelling of the brain, which would trigger a visit with a neurosurgeon. Alternatively, if an infant isn’t gaining enough weight, Zuzo will ask their parent about feeding patterns.

"For infants and toddlers, I ask questions like 'How often and how long are you feeding your child?' If they're breast-fed, I review mom's diet, any medications or supplements she's taking, and offer suggestions," she said. "For formula-fed babies, I ask which formula they use, where they get it and how they mix it."

That said, Zuzo understands the formula shortage has been a challenge for some parents. It can be difficult, for example, to stay consistent with one formula brand.

“I also realize that formula is expensive, but I find that some parents try to dilute it to stretch it out longer," she said. "Alternatively, if a child is gaining too much weight, I make sure their formula isn't too concentrated, which can add extra calories.”

Diluted formula puts a child at risk for electrolyte abnormalities, which Zuzo said can cause development issues or even swelling in the brain. Signs a child may be lacking electrolytes include vomiting, drowsiness or a change in demeanor. She described it as a child “not acting like themselves.”

When children are healthy, however, Zuzo said the growth chart can provide a comfort level for parents.

“I have some parents who see the little rolls down their children’s side or their belly, and they come to me and say, ‘Are they overweight?' So, it can be reassuring to review their growth curve and compare the child to others around the same age,” she said.


At age 2, Novant Health transitions to the Center for Disease Control growth curve, which compares children from all over the U.S. It’s also at this age that girls and boys are measured on different charts, Zuzo said, because they grow at different rates and in different patterns.

In addition to height and weight measurements, pediatricians begin tracking body mass index (BMI) – a measure of fat based on height and weight – at age 3. Zuzo said BMI is an important indicator of healthy growth and development.

Into early adulthood

In early adulthood, the growth chart can help diagnose kids at risk for obesity. Children age 3 and above who are in the 85th BMI percentile (or higher) for their gender are considered overweight. This can set a child up for “a lot of medical concerns” at a very young age – including high blood pressure, high cholesterol, diabetes, heart disease and sleep apnea, a sleep disorder that causes breathing to stop and start.

If children are overweight, Zuzo asks what the child is eating and how often. Sometimes, fast food and calories consumed from sugary beverages are the culprit.

"On the other hand, if a teenager is losing weight, that's a red flag for me," she said. "I ask questions to learn if the child is trying to lose weight. Maybe they’re fasting or avoiding carbohydrates. We talk through it to make sure they aren't at risk for an easting disorder."

As far as percentages go, some children are in the 10th percentile and others the 80th, but there is no one ideal number. Zuzo reminds parents that healthy children can come in all shapes and sizes.