Paediatrics: Growth Development

• Child health basics: The Healthy Child Programme | The Immunisation Schedule | Immunisation in Practice
• Growth: Measuring Growth | Faltering Growth | Short Stature | Tall Stature | Childhood Obesity
• Puberty: Normal Puberty | Early Puberty | Delayed Puberty
• Development: Developmental Milestones | Developmental Delay | Speech, Language and Hearing | Learning Disability
• Feeding and nutrition: Infant Feeding and Weaning | Cow's Milk Allergy and Food Allergy | Crying Babies and Colic | Rickets and Vitamin D | Iron Deficiency and Other Deficiencies
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

📏 Growth, development and nutrition are the foundations of child health. A child who is growing and developing normally is usually well; faltering growth, a drop across centiles, or loss of skills tells you something is wrong. Plot every measurement on the right chart, know the key milestones and their limit ages, and keep up to date with the immunisation schedule (which changed in 2025–26).
Your four questions for every child: What does the growth chart show over time (weight, height, head)? Are milestones normal for age — and have any skills been lost? Is the child eating a healthy, age-appropriate diet? Are immunisations up to date?

The Healthy Child Programme

• Health visitor reviews (England):
  • Antenatal contact (from 28 weeks).
  • New birth visit (10–14 days).
  • 6–8 week review (with the GP NIPE check).
  • 1-year review (9–12 months).
  • 2–2½ year review (development, often using Ages and Stages Questionnaires).
• Personal child health record ("red book") — growth charts, immunisations, checks.
• School-age — vision screening at 4–5 (orthoptist); hearing screening at school entry in some areas; National Child Measurement Programme (height and weight in Reception and Year 6).
• Dental care — brush twice daily with fluoride toothpaste from the first tooth; dental visits from the first tooth; limit sugary drinks and snacks.
• Accident prevention — car seats, stair gates, safe storage of medicines and button batteries, window locks, water safety, hot drinks.

↑ Back to index

The Immunisation Schedule

UK routine schedule (for children born from 1 July 2024, after the changes in July 2025 and January 2026 — always check the current Green Book):

• Changes to note:
  • Hib/MenC at 1 year has been removed and replaced by extra 6-in-1 doses.
  • Chickenpox vaccine now part of the routine schedule (MMRV), with a catch-up for older children (2026–28).
  • Children born before July 2024 follow the older schedule (e.g. an extra 6-in-1 at 1 year and MMR at 3 years 4 months).
• Selective (targeted) immunisations:
  • Hepatitis B — babies of mothers with hepatitis B: at birth, 4 weeks, then with the 6-in-1, plus 1 year (blood test); hepatitis B immunoglobulin for some.
  • BCG — babies at higher risk of TB (high-incidence areas or family origin), at about 28 days (after the SCID screening result where offered).
  • RSV — maternal vaccine in pregnancy from 28 weeks; antibody (e.g. nirsevimab) for high-risk infants.
  • Pertussis — maternal vaccine in pregnancy from 16 weeks.
  • Flu and pneumococcal vaccines for children with long-term conditions; MenACWY and MenB for asplenia.

↑ Back to index

Immunisation in Practice

• Preterm babies — vaccinate at the usual chronological age (not corrected age). Babies born under 28 weeks may need breathing monitoring for 48–72 hours after the first vaccines in hospital.
• Rotavirus — oral; the first dose must be given by 15 weeks and the course completed by 24 weeks (small risk of intussusception in older infants). Not for severe combined immunodeficiency (live vaccine).
• Paracetamol after MenB — give 3 doses of infant paracetamol after the 8- and 12-week MenB vaccines (fever is common).
• True contraindications (rare):
  • Anaphylaxis to a previous dose or a vaccine component.
  • Live vaccines (MMRV, rotavirus, BCG, nasal flu) — not in significant immunosuppression (chemotherapy, high-dose steroids, some biologics, SCID) or pregnancy.
  • Nasal flu — not in severe egg allergy with anaphylaxis needing ICU (most egg-allergic children can have it), severe asthma or active wheezing; not in close contacts of severely immunocompromised people.
• Not contraindications — minor illness without fever, stable neurological conditions, family history of reactions, prematurity, breastfeeding, mild egg allergy (MMR is fine), being on antibiotics.
• Postpone if acutely unwell with a fever.
• Side effects — sore arm, fever (MenB), irritability; MMR(V) — fever and rash at 7–10 days, swollen glands, rarely febrile seizure or low platelets.
• MMR and autism — there is no link (the original study was fraudulent and retracted).
• Consent — from a person with parental responsibility, or a Gillick-competent young person.
• Vaccine hesitancy — listen, explore concerns, give clear information; falling uptake has led to measles outbreaks in the UK.

↑ Back to index

Measuring Growth

• UK-WHO growth charts (0–4 years) and UK 2–18 charts; special charts for Down syndrome, Turner syndrome, and preterm babies (plot at corrected age until 2 years).
• Measure accurately:
  • Weight — naked for babies.
  • Length (lying, under 2 years) or height (standing, over 2 years) with a proper measuring device.
  • Head circumference (occipitofrontal) — under 2 years.
• Centiles — most children track along a centile; crossing two or more centile lines needs explanation (though some movement in the first year is normal as babies find their genetic centile).
• Mid-parental height — estimates target adult height:
  • Boys — (father's height + mother's height + 13 cm) ÷ 2.
  • Girls — (father's height + mother's height − 13 cm) ÷ 2.
  • Range about ±10 cm (8.5 cm for girls).
• BMI centile (from 2 years) — overweight at the 91st centile or above, obese at the 98th or above (clinical use).
• Head size:
  • Microcephaly (under 2nd centile) — familial, congenital infection (CMV, Zika), genetic syndromes, fetal alcohol, brain injury.
  • Macrocephaly (over 98th) — familial (parents' heads), hydrocephalus (crossing centiles, bulging fontanelle, sunsetting eyes), subdural collections (consider NAI), metabolic disease, NF1.

↑ Back to index

Faltering Growth

• Definition (NICE NG75) — slower weight gain than expected:
  • A fall across 1 or more weight centile spaces if birth weight was below the 9th centile.
  • A fall across 2 or more centile spaces if birth weight was between the 9th and 91st.
  • A fall across 3 or more if birth weight was above the 91st.
  • Or current weight below the 2nd centile, whatever the birth weight.
• Causes:
  • Inadequate intake (the commonest) — feeding difficulties (breastfeeding problems, poor technique), poor appetite, oromotor problems, neglect, poverty, food insecurity.
  • Inadequate absorption — coeliac disease, cystic fibrosis, cow's milk protein allergy, IBD, short bowel.
  • Increased losses — vomiting (GORD, pyloric stenosis), diarrhoea.
  • Increased needs — congenital heart disease, chronic lung disease, chronic infection (HIV, TB), hyperthyroidism, cancer.
  • Other chronic conditions — CKD, metabolic and genetic disorders, cerebral palsy.
• Assessment:
  • Feeding history and observe a feed; food diary for older children.
  • Development, behaviour, family and social history (safeguarding).
  • Examination for signs of chronic disease or neglect.
  • Tests only if indicated — urine culture (UTI), FBC, ferritin, U&E, LFTs, TFTs, coeliac serology (once eating gluten), sweat test.
• Management — feeding support (health visitor, infant feeding specialist, dietitian), treat the cause, regular weight monitoring; safeguarding referral if neglect is suspected; admission rarely needed.

↑ Back to index

Short Stature

• Definition — height below the 2nd centile (or well below the mid-parental target), or slowing height velocity (crossing centiles downwards).
• Normal variants (most):
  • Familial short stature — short parents; growing normally along a low centile; normal bone age.
  • Constitutional delay of growth and puberty — "late bloomers" (often boys, family history of late puberty): short in childhood, delayed bone age, late growth spurt, normal final height.
• Pathological causes:
  • Endocrine — hypothyroidism, growth hormone deficiency, Cushing's syndrome (or long-term steroids — often overweight), poorly controlled diabetes.
  • Chronic disease — coeliac disease, Crohn's disease, CKD, cystic fibrosis, congenital heart disease, severe asthma.
  • Genetic syndromes — Turner syndrome (always consider in short girls), Noonan, Prader–Willi, Down, Russell–Silver, SHOX deficiency.
  • Skeletal dysplasias — achondroplasia (disproportionate — short limbs).
  • Born small for gestational age without catch-up growth.
  • Psychosocial deprivation and neglect.
  • Malnutrition.
• Clues to pathology — height well below the parental target, slowing growth velocity, disproportion, dysmorphic features, overweight with short stature (endocrine), underweight with short stature (chronic disease, malnutrition).
• Tests — FBC, ESR, U&E, LFTs, TFTs, coeliac serology, karyotype in girls (Turner), IGF-1 (growth hormone stimulation tests in specialist care), bone age (X-ray of the left hand and wrist).
• Growth hormone treatment (NICE TA188) — GH deficiency, Turner syndrome, Prader–Willi syndrome, CKD, born SGA without catch-up, SHOX deficiency.

↑ Back to index

Tall Stature

• Familial — the commonest.
• Obesity — children are often tall for age (bone age advanced), but end up at normal adult height.
• Early puberty — tall as a child, short adult (early fusion of growth plates).
• Hyperthyroidism; growth hormone excess (gigantism — rare); CAH.
• Syndromes — Marfan syndrome (long limbs, arachnodactyly, lens dislocation, aortic root dilatation), Klinefelter syndrome (boys — small testes, learning difficulties), homocystinuria, Sotos syndrome (large head, learning difficulties), Beckwith–Wiedemann syndrome.

↑ Back to index

Childhood Obesity

• How common — about 1 in 5 children in Year 6 in England are obese (higher in deprived areas).
• Definitions (clinical) — BMI 91st centile or above = overweight; 98th or above = obese; 99.6th or above = severe obesity.
• Causes — mainly energy imbalance (diet, inactivity, screen time, sleep); family and environmental factors.
• Look for underlying causes if:
  • Short stature or slowing height — hypothyroidism, Cushing's syndrome, GH deficiency.
  • Learning disability and dysmorphic features — Prader–Willi syndrome (floppy as a baby, then insatiable appetite), Bardet–Biedl.
  • Very early onset (under 5) severe obesity — genetic causes (e.g. MC4R, leptin pathway).
  • Drugs — steroids, antipsychotics, some antiepileptics.
• Complications:
  • Type 2 diabetes, insulin resistance (acanthosis nigricans), high BP, dyslipidaemia.
  • Fatty liver (MASLD).
  • Obstructive sleep apnoea; asthma.
  • Slipped capital femoral epiphysis; Blount's disease; flat feet.
  • Idiopathic intracranial hypertension.
  • PCOS; early puberty.
  • Low self-esteem, bullying, depression.
• Management:
  • Family-based lifestyle programmes — healthy eating, portion sizes, less sugary drinks, at least 60 minutes of physical activity a day, less screen time, good sleep.
  • Aim to maintain weight while the child grows taller (younger children) or gradual weight loss (older, severe obesity).
  • Screen for complications (BP, HbA1c, lipids, LFTs) in older or severely obese children.
  • Specialist — drugs (e.g. orlistat; GLP-1 receptor agonists are licensed in adolescents); bariatric surgery in exceptional cases.
  • Avoid stigmatising language.

↑ Back to index

Normal Puberty

↑ Back to index

Early Puberty

• Precocious puberty — signs of puberty before 8 in girls or 9 in boys.
• Central (gonadotrophin-dependent) — early activation of the normal hypothalamic–pituitary axis; puberty follows the normal sequence.
  • Girls — usually idiopathic (but younger girls need MRI).
  • Boys — more often pathological — brain tumours (hypothalamic hamartoma, glioma), hydrocephalus, brain injury — always image.
• Peripheral (gonadotrophin-independent) — sex hormones from elsewhere; low LH and FSH:
  • Congenital adrenal hyperplasia (virilisation; small testes in boys).
  • Adrenal tumours; ovarian or testicular tumours (one large testis); hCG-secreting tumours.
  • McCune–Albright syndrome (café-au-lait patches, bone lesions, early puberty).
  • Exogenous hormones (creams, gels from parents).
• Clue in boys — testicular volume: large testes suggest central puberty; small testes with virilisation suggest an adrenal cause.
• Benign variants (no treatment, monitor):
  • Premature thelarche — breast development alone in girls under 3; no growth spurt.
  • Premature adrenarche — early pubic hair and body odour (ages 6–8), normal growth; check for CAH if virilised; linked to later PCOS.
• Tests — growth chart, bone age, LH and FSH (GnRH stimulation test), oestradiol or testosterone, 17-hydroxyprogesterone, pelvic ultrasound (girls), MRI brain (central).
• Treatment — GnRH agonist (e.g. leuprorelin, triptorelin) to pause central puberty; treat the underlying cause.

↑ Back to index

Delayed Puberty

• Definition — no breast development by 13 in girls, or no testicular enlargement by 14 in boys (or no menarche by 15).
• Causes:
  • Constitutional delay — the commonest, especially in boys; family history; delayed bone age; normal eventual puberty.
  • Hypogonadotrophic hypogonadism (low FSH and LH):
    • Chronic illness (IBD, coeliac, CF, CKD), low weight, excessive exercise, anorexia nervosa.
    • Kallmann syndrome (anosmia), pituitary tumours (craniopharyngioma), hypothyroidism, hyperprolactinaemia.
  • Hypergonadotrophic hypogonadism (high FSH and LH — gonads not working):
    • Turner syndrome (girls), Klinefelter syndrome (boys — puberty often starts but doesn't progress).
    • Gonadal damage — chemotherapy, radiotherapy, mumps, torsion.
• Tests — growth chart, bone age, LH, FSH, oestradiol or testosterone, TFTs, prolactin, coeliac serology, FBC, ESR; karyotype if FSH and LH high; MRI pituitary if indicated.
• Management — treat the cause; reassurance for constitutional delay; short courses of low-dose testosterone (boys) or oestrogen (girls) to start puberty (psychological benefit).

↑ Back to index

Developmental Milestones

• Red flags (limit ages) — refer for assessment if:
  • No social smile by 8 weeks.
  • Not sitting unsupported by 9–12 months.
  • Not walking by 18 months (check CK in boys — Duchenne muscular dystrophy).
  • No words by 18 months; not joining words by 2½ years.
  • Hand preference before 12 months (suggests weakness of the other side — cerebral palsy).
  • Not pointing or responding to name by 12–18 months (autism).
  • Loss of previously gained skills (regression) at any age — urgent (neurodegenerative or metabolic disease, Rett syndrome, autism, epilepsy).
  • Parental concern — always take seriously.

↑ Back to index

Developmental Delay

• Global developmental delay — significant delay in two or more areas (gross motor, fine motor, speech and language, social and cognitive) in a child under 5.
• Specific delay — one area (e.g. motor — cerebral palsy or neuromuscular; speech — hearing loss).
• Causes:
  • Genetic — Down syndrome, fragile X, microdeletions (22q11), Rett, Angelman, other chromosomal and single-gene disorders.
  • Antenatal — congenital infection (CMV, rubella, toxoplasmosis), fetal alcohol spectrum disorder, drugs.
  • Perinatal — prematurity, HIE, kernicterus, neonatal hypoglycaemia.
  • Postnatal — meningitis, encephalitis, head injury (including NAI), hypothyroidism, lead poisoning, severe neglect.
  • Metabolic and neurodegenerative disorders.
  • Unknown (many).
• Assessment — detailed history, family history, examination (growth, head size, dysmorphic features, skin — neurocutaneous signs, neurology), hearing and vision tests.
• Investigations (specialist) — chromosomal microarray and genetic tests (fragile X), TFTs, CK (boys with motor delay), lead, metabolic tests, MRI if neurological signs or head size abnormal.
• Management — multidisciplinary child development team (paediatrician, physiotherapy, occupational therapy, speech and language therapy, educational psychology); education support — Education, Health and Care plan (EHCP); family support and benefits.

↑ Back to index

Speech, Language and Hearing

• Speech and language delay — common (about 1 in 10); boys more than girls.
• Causes:
  • Hearing loss — always test hearing (glue ear is the commonest cause).
  • Autism (with social communication problems).
  • Global developmental delay or learning disability.
  • Developmental language disorder (specific).
  • Lack of stimulation; neglect.
  • Structural — cleft palate, tongue problems.
  • Bilingual homes — normal milestones across both languages combined.
• Stammering (stuttering) — common between 2 and 5; most resolve; refer if persistent or distressing.
• Hearing loss in children:
  • Congenital — genetic (connexin 26), CMV, rubella, prematurity, meningitis, kernicterus, ototoxic drugs; detected by newborn screening.
  • Acquired — glue ear (conductive), meningitis (sensorineural — check hearing after every case), mumps, measles, head injury.
  • Tests — newborn screening; distraction testing (6–18 months), visual reinforcement audiometry, play audiometry, pure-tone audiometry (school age).
  • Management — hearing aids, cochlear implants, grommets for glue ear, speech therapy, sign language, education support.

↑ Back to index

Learning Disability

• Definition — significantly reduced ability to understand new or complex information and learn new skills, with reduced ability to cope independently, starting in childhood. (Learning difficulty — e.g. dyslexia — is a specific problem without overall intellectual impairment.)
• Severity — mild (IQ about 50–69), moderate (35–49), severe (20–34), profound (under 20).
• Causes — as for global developmental delay (Down syndrome and fragile X are the commonest genetic causes).
• Health issues — epilepsy, sensory impairment, constipation, reflux, dental problems, obesity or underweight, mental health problems, behaviour that challenges (often communicating pain or distress), early death.
• Good care:
  • Reasonable adjustments — easy-read information, longer appointments, involve carers.
  • Annual health checks from age 14.
  • Hospital passports.
  • Mental Capacity Act for those aged 16 and over.
  • Avoid "diagnostic overshadowing" (blaming new symptoms on the disability).
  • LeDeR — learning from deaths of people with a learning disability.

↑ Back to index

Infant Feeding and Weaning

• Milk:
  • Exclusive breastfeeding for around the first 6 months (see the Labour, Birth and Postnatal Care chapter).
  • First infant formula (cow's milk based) is the only formula needed until 12 months; "follow-on" and "growing up" milks aren't necessary.
  • Cow's milk as a main drink only from 12 months (can be used in cooking from 6 months). Too much cow's milk (over about 500 mL a day) in toddlers causes iron deficiency.
  • Water — tap water (boiled until 6 months) is fine.
• Weaning (introducing solid food):
  • At around 6 months (not before 17 weeks).
  • Signs of readiness — sits up, holds head steady, coordinates hands and mouth, swallows food.
  • Start with smooth or soft foods, then mashed and finger foods; move to family foods by 12 months.
  • Common allergens (egg, peanut, milk, wheat, fish) can be introduced from around 6 months, one at a time — early introduction may reduce allergy risk.
  • Avoid — honey under 1 year (infant botulism); whole nuts under 5 (choking); added salt and sugar; rice milk under 5 (arsenic); raw or lightly cooked eggs without the Lion mark; shark, swordfish, marlin.
• Vitamins — vitamins A, C and D drops for children aged 6 months to 5 years (unless having over 500 mL of formula a day); vitamin D from birth for breastfed babies.
• Vegan or vegetarian diets — need careful planning (B12, iron, iodine, calcium, vitamin D, omega-3); dietitian advice.

↑ Back to index

Cow's Milk Allergy and Food Allergy

• Cow's milk protein allergy (CMPA) — the commonest food allergy in infants (about 2–3%); usually starts when formula or dairy is introduced (can occur in breastfed babies through the mother's diet).
• Two types:
  • IgE-mediated (fast — within minutes to 2 hours) — urticaria, lip and face swelling, vomiting, wheeze, anaphylaxis. Tests — skin prick or specific IgE.
  • Non-IgE-mediated (delayed — hours to days) — reflux and vomiting, colic and irritability, eczema, diarrhoea, constipation, blood and mucus in stools, faltering growth. Diagnosed by elimination and reintroduction.
• Management:
  • Formula-fed — extensively hydrolysed formula first line; amino acid formula if severe, anaphylaxis, or no response.
  • Breastfed — continue breastfeeding; the mother avoids all dairy (with calcium and vitamin D supplements).
  • Soya formula — not under 6 months (phytoestrogens).
  • Reintroduction — most outgrow non-IgE CMPA by 1–3 years; reintroduce gradually using the "milk ladder" at home (non-IgE) or in hospital (IgE).
  • Dietitian support (calcium, growth).
• Lactose intolerance — not an allergy; secondary lactose intolerance after gastroenteritis (diarrhoea, bloating) is common and temporary; primary lactose intolerance develops later in childhood in some ethnic groups.
• Other food allergies — egg, peanut, tree nuts, sesame, fish, shellfish:
  • Eczema in infancy raises the risk (skin barrier).
  • Adrenaline auto-injectors (two to carry at all times) and an allergy action plan for children at risk of anaphylaxis; train families and schools.
  • Peanut and tree nut allergy usually persist; milk and egg often outgrown.

↑ Back to index

Crying Babies and Colic

• Normal crying peaks at about 6 weeks and settles by 3–4 months.
• Infantile colic — repeated episodes of excessive, inconsolable crying in a healthy, thriving baby under 3–4 months (often in the evening), with drawing up of the legs and a red face.
  • "Rule of threes" — crying for over 3 hours a day, over 3 days a week, for over 3 weeks.
  • Management — reassurance (it settles), holding, soothing, white noise, support for parents; check feeding technique. Simeticone, lactase drops and probiotics have limited evidence. A trial of hydrolysed formula if CMPA suspected.
• Look for other causes — infection (UTI, otitis media, meningitis), hunger, reflux, CMPA, constipation, hernia, testicular torsion, hair tourniquet, fracture or injury (NAI), raised intracranial pressure.
• Crying is the main trigger for shaking — teach coping strategies ("ICON": Infant crying is normal, Comforting methods can help, It's OK to walk away, Never shake a baby).
• Red flags — fever, poor feeding, vomiting (especially bilious), weight loss, high-pitched or weak cry, lethargy, bruising, bulging fontanelle.

↑ Back to index

Rickets and Vitamin D

• Rickets — poor mineralisation of growing bones (osteomalacia in adults), usually from vitamin D deficiency.
• Risk factors — darker skin, covered skin, little sunlight, exclusive breastfeeding without vitamin D drops, maternal deficiency, restrictive diets, malabsorption (coeliac, CF), CKD, liver disease, anticonvulsants.
• Features:
  • Bowed legs (genu varum) or knock knees; widened wrists and ankles.
  • Rachitic rosary (swelling at the rib–cartilage joints); Harrison's sulcus.
  • Delayed walking, waddling gait, bone pain, muscle weakness.
  • Delayed tooth eruption, enamel problems; delayed fontanelle closure; frontal bossing.
  • Hypocalcaemia — tetany, seizures, and rarely cardiomyopathy (infants).
• Tests — low 25-OH vitamin D, low or normal calcium, low phosphate, raised ALP, raised PTH; X-ray of the wrist — cupping, splaying and fraying of the metaphyses.
• Treatment — colecalciferol (treatment doses for 8–12 weeks, then maintenance); calcium supplements; treat family members; IV calcium for symptomatic hypocalcaemia.
• Other types — X-linked hypophosphataemic rickets (low phosphate, normal vitamin D — burosumab), renal rickets (CKD).
• Prevention — vitamin D supplements for breastfed babies, all children 6 months–5 years, pregnant and breastfeeding women.

↑ Back to index

Iron Deficiency and Other Deficiencies

• Iron deficiency anaemia — the commonest nutritional deficiency in children:
  • Toddlers — excessive cow's milk (low in iron, displaces food, can cause gut blood loss), late weaning, poor diet; adolescent girls — heavy periods, diet.
  • Preterm babies (low stores); coeliac disease; IBD; chronic blood loss.
  • Features — pallor, tiredness, irritability, poor appetite, pica, poor concentration; developmental effects.
  • Management — limit cow's milk to about 500 mL a day; iron-rich foods; oral iron (e.g. sodium feredetate or ferrous fumarate) for about 3 months after Hb normalises.
• Vitamin B12 deficiency — breastfed babies of vegan mothers or mothers with pernicious anaemia: developmental regression, anaemia.
• Malnutrition (undernutrition) — wasting (low weight for height), stunting (low height for age); in the UK linked to poverty, neglect, chronic illness, eating disorders; risk of refeeding syndrome.
• Scurvy (vitamin C) — rare; very restricted diets (autism): bleeding gums, bone pain, poor wound healing.
• Iodine — mild deficiency in some UK diets (dairy and fish are main sources).

↑ Back to index

Drug Reference Table

↑ Back to index

Spot the Diagnosis