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Pediatrician Dr. Stephanie Grice joins Allison to explain how growth charts work, what percentiles really mean, when parents should be concerned, and why healthy growth is about patterns over time, not a single number.

Dr. Grice explains how pediatricians use growth charts to monitor a child’s health over time, why percentiles are often misunderstood, and what parents should focus on instead. She also discusses common reasons a pediatrician may become concerned about a child’s growth, how growth charts factor into feeding and nutrition conversations, and why growth patterns matter far more than any single number.

If you’ve ever worried that your child is too small, too big, not gaining enough weight, or falling off their curve, this episode will help you better understand what growth charts can, and cannot, tell us.

In This Episode, You’ll Learn:
— What growth chart percentiles actually mean
— Why a higher percentile is not necessarily better
— How pediatricians evaluate healthy growth over time
— When a child’s growth pattern may warrant further investigation
— Why genetics play an important role in growth
— How growth charts are used when evaluating infant feeding concerns
— The connection between growth, nutrition, and development
— How growth charts can help guide decisions about dropping night feedings
— Why parents should avoid obsessing over percentile rankings
— What pediatricians wish parents understood about growth charts

Resources Mentioned
Episode 246. [ENCORE] Making The Most of Your Child’s Well Visit with Dr. Stephanie Grice – Summer Pediatrician Series #1
Episode 43. Every Breastfeeding & Feeding Journey is Unique with Dr. Stephanie Grice
Connect with Dr. Grice on Instagram or her website

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Scroll down for a full transcript of this episode.

247. [ENCORE] Understanding the Growth Chart with Dr. Stephanie Grice – Summer Pediatrician Series #2

Allison Egidi: This is episode two of my summer pediatrician series with Dr. Stephanie Grice. If you missed the first episode, it’s episode 87 and we discussed how you can make the most of your child’s well visit. This week we are talking about the growth chart. This is going to be a good one, guys.

Before you dive in, I just want to note that everything that Dr. Grice shares today is intended to be educational and should not be considered medical advice.

Hi there, Dr. Grice. Welcome back. Thanks for joining me again for the second episode in our summer pediatrician series. This time we are discussing growth charts, which is a topic I hear a lot about from clients.

Dr. Stephanie Grice: Oh, yes, yes. Thank you for having me back, and I am very excited to talk about this topic.

All right, well, let’s dive right in. Let’s start with the very basic question. What is the growth chart and why do pediatricians use it?

So the growth chart, there’s, there’s actually two different versions of the growth chart. There’s one that is, um, used for kids age zero to two, and then there’s one generally for kids, two and up, and there’s a difference for boys and girls. There’s also, just, by the way, if you have a preemie, there are preemie growth charts as well. Or if you are a child with Down Syndrome, there’s special charts for kids with Down Syndrome as well.

But the whole point of their growth chart is for a pediatric provider to try to monitor that child’s individual growth, uh, and make sure that they are growing as they should in terms of the rate of weight gain, the rate of their, uh, linear velocity, which is their height, um, and their head circumference as well in the first, uh, two years versus, um, over two years, we’d be looking at their BMI, which is the measure of how proportional their weight is to their height.

So we’re, as pediatric providers, we are really looking at the rate of growth and trying to make sure that is on track for that kid.

Okay, perfect. And I think we all grew up, I think just with test scores and everything where our mentality is 95% is good, that’s better than say, fifth percentile. And I know that’s not the case with growth charts correct?

Absolutely. That that is probably the source of a lot of the angst about growth charts. Uh, I think you hit the mail on the head there. Um, it’s not at all about where the child is on the chart, if they are fifth or they are 95th or they are 50th, it’s not the goal to be a certain percentile. The goal I’m looking for is that their child is generally consistent with where they have been and what their genetics would predict that they would be.

For me, it has nothing to do with if you’re fifth or 95th, so, throw that out.

I don’t think I know a parent, including myself, who hasn’t had that internal dialogue like, oh my gosh, because I have a fifth percentile child. Although she was just reminding me yesterday, she’s now up, we were trying to remember her 10th appointment, um, she’s had a huge growth spurt, of course she’s in the early pre-puberty growth spurt and she jumped up either the 35th or the 40th. It was a big leap and she’s slowly moved a little bit.

But I remember even at her third visit, because they said that was where they, when they would kind of declare her petite, that she was still in the fifth percentile and, even though I knew better, even though they had coached me, even though I fed her through the night until she was nearly two years old and that had nothing to do with it. I still had this like twinge when they’d say, yeah, she’s still in the fifth percentile, where it’s like, Ugh. And so I just think it’s a big leap to adjust to that, and I just think it’s, all parents, even when we know better, we struggle. And so many parents come to me with so much pride when they’re like, he’s in the 90th percentile. And it’s like, well, that’s great, but doesn’t mean a whole lot as far as their sleep.

Well, I, I think you, you’ve just outlined so many of the issues, the good and the bad about growth charts and, um, and I as a parent as well, you know, we recently took measurements on my son Bennett and I went on the, you know, calculator online and what’s his percentile. But, um, I, to some extent, sometimes it can be fun to share what the numbers are, but I definitely want to make the point today. Please, as parents, do not let yourself be driven crazy by the percentiles. The the message here is going to be forget the growth chart.

Don’t worry about it. Throw it out. Break up with the growth chart and break up with the percentiles because, um, you, you pointed out just so nicely, like your observation of your child’s health and growth. You knew that she was doing okay and yet the numbers were eating, and sometimes that’s, that’s, um, our fault as the pediatric provider.

I know we’ve got these sheets where you write down what the height is and then you put the percentile right next to it. And a lot of parents ask me if that’s blank. They want that filled out. They want to know what the percentile, write it down and keep it for the records. But lately I think I’m really moving away from sharing the growth chart with families.

I’m looking at it to see how the kid is on track, but I’m, I’m not going to be as willing to share that information because it’s just, it, it, the numbers I think are just taking too much of the stage and, and what I don’t want to have happen is losing the focus on how that child is growing, you know?

Right.

To your point, labeling somebody, uh, some way or to have feelings about their growth being inadequate because, uh, a number wasn’t what you wanted it to be. I guess that’s what, you know, some of the issue is with the growth chart.

Right. So when you’re looking at a growth chart, uh, particularly I’d say in the, the first six months is where I, I feel like I feel the most angst from parents I work with.

What constitutes as good? For you, from your perspective, what are you looking for?

I am generally looking for some sort of consistent trajectory that might be following along a particular curve. But it may not stick right on that particular curve. And, um, that’s where a lot of, uh, complexity can come in with the growth chart is if the weights or length is not actually following that particular curve that they started on, but kind of taking a different trajectory.

That might lead to some questions about, uh, are they, is the infant getting enough to sustain their growth. Uh, but what I’ve found, uh, professionally and personally is that there’s just so much variability even in those early months of how a child will grow, uh, that, that the chart that the graph doesn’t account for.

Uh, for example, if you have a really busy baby, just really active, they’re burning a ton of calories. So probably their intake is going to be the same as another baby, uh, whether they be breastfed, bottle fed, formula, pumped milk. Um, but the activity level will definitely account for how fast or slow they’re gaining weight or growing in length.

And, and so does their genetics play a huge role. So the, the chart itself, it doesn’t, uh, that that that one line that they started on doesn’t always account for all those variabilities, but I’m generally looking for, are they going up in some right direction? Uh, that looks like it’s consistent. That’s not where they are.

I think that’s such a great point because, um, my older daughter is very lean and she’s the petite one too. So she’s petite and then super lean. And so at some point, you know, she was at the fifth percentile I think for, well, as you said, the charts changed, so whenever it changed over, I think they might have been starting to focus on the Body Mass Index.

I didn’t even realize that the charts changed. Yes. So thank you for teaching me that here today. Um, so I remember there was an appointment. She was a walking, talking little person where the doctor said, Can you talk me through what you ate all of yesterday? Tell me what you ate. And I remember again feeling like, oh, she’s like going after me like I don’t feed my child, but so my daughter like rattled off, I ate a whole bowl of olives and I ate an avocado and she was like, rattling. And she’s like, no, really? Just yesterday. She’s like, no, that’s what I ate yesterday. And I remember the doctor said, okay, well I, I’m just keeping an eye on it.

She said, I was curious what she would say she ate. And uh, and she said, I’m keeping an eye on it because she’s not on the chart for, I guess Body Mass Index. However, her weight compared to her height. Not even on the chart.

Yes. Gotcha.

And so for a couple visits, they tracked it and they would talk to her about what she ate. And I, I got more comfortable with the fact that we were having this conversation and I did switch my mindset to, okay, this is not an attack on me. They’re trying to see if there’s something we need to investigate.

Sure.

So that was a good mind shift for me. And then this visit I brought up to her, I have since had a couple of her sport coaches approach me, because you know, people love to overstep.

Oh, yes.

And tell me that I must not be feeding her enough. And I said I, I realize that people say things they don’t need to say and I should just brush that off, but while we’re here, can we just confirm that we still feel good about where things are? Because she eats more than I eat. Legitimately consumes more food than I do. And the pediatrician had a great answer.

She said, Allison, she’s taken a unique path. She’s not on she, you’re right, she’s not on this chart for her weight compared to her height. In fact, as she’s now had this growth spurt, I think we might even be like not even close to being on this chart. And she said, but this has been her path. She said, this has been her path for years now we’ve watched it.

And so it’s not like I’m watching her suddenly fall off the chart. This is her path and we feel good about. Her eating, her development. And so I think to your point, there’s no one size fits all. You’re using it as a gauge. Is that fair to say?

Absolutely. The, the growth chart itself as a tool is actually very much limited by the, in inflexibility of it, um, to reflect what, uh, different growth patterns kids can have.

Um, they act the way that it was constructed was actually taking various static time points. So your child at her 10th birthday and my child at three years old and, and kind of plotting all of those numbers and coming up with a range that might be normal at that particular age, but not necessarily where your daughter was at two years and three years and four years, and how she grew.

So it really lacks that, the differences in velocity of growth that you can see. It’s more of a range of where kids are at any one point in time. Um, so it is very much limited when you’re, when you’re trying. So, so your situation of seeing she’s taking her own path, I think is actually very common. And, and it’s an, um, a mistake that people can make when they’re looking at a growth chart.

Sometimes if they’re not really key into the whole picture, if you’re just focusing on the numbers, you’re just focusing on the percentiles, you may read into that too much, uh, that they’re not growing the way they should be. And, uh, and there’s some different points in time where a kid might, um, uh, stray from the path that they’ve been on and then pick it back up again.

Um, or, uh, and most of that is all just following their genetics. Um, so my favorite question to ask is, where’s grandma? What does grandma have to say about you as, uh, as a child? What did you look like? How did you grow? Um, and, and you know, the grandmother of the biologic parents, I think is the key to the growth, because she’s the most likely to know, um, if the child is appropriate or, um, or if there’s an issue.

Yeah, I love that you bring that up because I am5’8″, so you know, pretty standard slash tall, and I was a really early grower, so I was off the charts in the opposite direction and they told my parents she’ll probably be six feet tall.

So that, I remember that as a kid. And of course my dad was like, yes, basketball player. Perfect. And then I remember I blew out a knee, um, after sixth grade and I had the knee reconstructed and it, I remember they said, well, good news, her growth plates are closed. And my dad was like, what are you talking about?

She’s like, five eight. Like, what? And they’re like, oh no, that it’s over. She’s done. And so, but, and so I remember actually a pediatrician telling me at a very early well visit, she should be five eight and like one of my first well visits, because your husband’s six one, you’re five, eight, whatever these charts are. She’ll be five eight.

And I think that actually was not great because it added to my angst as she hit that fifth percentile. Because I was like, what’s wrong? She’s supposed to be five eight. Sure. Um, and at some point my now current pediatrician had said, uh, tell me about your mom. And I was like, oh, my mom’s five two.

And she’s like, what about your grandma? And I was like, my grandma’s maybe five one. And she’s like, okay, well she’s coming by it honestly, like it might not be you and your husband. And then my husband has a, petite sisters. And so she’s like, it’s in, it is in your gene pool. It’s just not the two of you.

Yes.

And so that gene pool is important, like you do have petite people.

Absolutely. Yeah. Um, um, there’s a calculation you can do using the mother’s and father’s height. Um, depending on if it’s a male or female, there’s a calculation you can do that predicts the height within two inches, plus or minus. So that’s still, you know, a four inch window of height.

But huge factors related to number one puberty, which you mentioned as well. Um, when you have your growth spurt can affect your overall height. Um, if it’s earlier or later, uh, and that’s going to be when you really jump from one person tall to another in the end. Uh, so you might have been tracking, uh, like you said, you were tracking towards six foot, but depending on when you had puberty, and it sounds like maybe for your family, it seems like it came a little earlier than what dad was expecting based on that.

But that’s, uh, so you ended up tracking onto a different percentile than where you probably were when you were five. Um, and, uh, but, and then we also see even in the same family, so I mentioned there’s a standard calculation between mom and dad, biologic mom and dad’s heights, but siblings, maybe two brothers, um, you know, one at three and one at five, the three and the five-year old, uh, sorry, the three-year-old and the five-year-old when he was three are on totally different growth charts, totally different percentiles and tracking differently. So, um, the, the sex alone can’t account for why they’re on different percentiles. But I do find my next question to ask is, who do you think this child looks the most like? Who, you know, the features of this child. Who, are they more like mom? Are they more like dad? And often, again, you’re going to see that some of the, the facial features or the structure, uh, the resemblance takes after the parent that their height is more likely to be taken after at that point.

Oh, so interesting.

It’s, it’s not all proven science at this point. Yeah. But having a kid, uh, is just like the, just your own study of genetics right there. Um, with all of my background, I just look at my son and I’m like, okay, yep. This is our genetics. Okay. Yep. Okay.

So interesting. So what if we just look at the first year, which I feel like there’s a lot of angst in that year. Um, what kind of variability on these curves do you classify as normal, as far as kind of jumping around on the different lines?

So, um, like I said, I’m mostly, I’m mostly looking for some kind of upward trajectory. Maybe, uh, the child started out at the 60th percentile for weight, and then the next time was 45, and then the next time was 35. But that’s tracking in a generally upward direction. Um, the major thing that I’m looking for in terms of indications something might be wrong is a very flat curve. And so maybe the baby really only gained a few ounces in a month versus gaining a pound to two pounds in those early months. Uh, the you know, the main thing I’m going to be looking for there is perhaps an issue with feeding, especially, um, that might pertain to a, a breasted infant where you’re just really not sure how much volume they’re getting. Um, I, I’ve had certainly some cases where the growth chart helped us pick up an issue.

Uh, for example, one uh, family that I worked with, mom had actually cut out certain number of calories that she needed for her milk to be rich enough. So the baby really did have a flat weight and we figured out it was, um, just her own nutrient intake, corrected that, and then he corrected his weight curve. So that’s, that’s what we are looking for. That, you know, that’s, we’re looking for those kinds of issues as the growth chart being the signal since, um, in a lot of cases like this, the baby, he was just happy go-lucky.

He really didn’t cry that he was hungry. He was just, I’ll take what I can get. But, um, but correcting that, that nutritional intake really made us, you know, an impact on his growth. So that’s the main focus again for us.

Yeah, it just seems like it allows you to ask more questions similar to with my daughter, right? Like, just do a little more investigating. To make an educated decision on whether you should try something else or if this is their path.

Absolutely. And you know, we, we’ve talked before about how every feeding journey is different, uh, early on, and, and there’s so many variabilities there and there’s so many, um, just unique situations.

And then, for the parents, so much insecurity about whether or not your baby is getting enough, you know? So, um, the growth chart can be an important tool, like you said, to ask more questions if we feel like there might be something off about it, to make sure that they are getting what they need and, and that is the point of it at the end of the day.

But it’s a tool that’s not the be all, end all of how you’re doing or the measure of how you’re doing. It’s a tool to look for any issues that might be there that you otherwise couldn’t detect based on, um, you know, the report of how they’re feeding.

Right, exactly. Well, as you can imagine, I often get asked about feedings, growth charts, dropping night feedings, and kind of how that all plays together. And I always tell parents that there’s no right answer or evidence-based answer on when a baby is no longer going to need or benefit from a night feeding. But I also always tell people that this is a great conversation to have with your provider at the four month checkup. And so I’m always encouraging people to have that conversation with their pediatrician.

And so when a parent comes in to that four month checkup and they ask you the question about dropping the night feeding, how does the growth chart play into your answer?

Yeah, it’s an excellent, um, point to direct that question towards their, the pediatric provider because they do have that growth data to look at and see has this baby been on track and is the baby gaining appropriately with some kind of upward trajectory, um, that would indicate they are now able to consolidate their feeds and go longer stretch at night.

Um, a general rule of thumb in the pediatric handbook is about 12 pounds, somewhere between three and four ounce, uh, four months as, as the timeline for when most babies should be able or could be able to sleep through the night. Four months is a really good visit to check in on where they are with their growth to ensure that they seem, um, like they could go those longer stretches that they’re gaining appropriately. Um, but developmentally most babies are probably there. Um, but then I save those, those really busy babies, those babies who just kick and burn calories all day, who might be not quite, um, going on that, staying on that curve, maybe it’s just going to take them a little bit longer.

They may still be relying on some of those, uh, that, those nighttime calories to sustain. So I I, you’re absolutely right to check in. It’s a good question. And four months is a good time to ask about that.

Perfect. So is there anything else that you wish parents just understood about growth charts or one I would say just overarching thought on them.

Yeah. Break up with it. Oh. Um, yeah, I, I think that, you know, we’ve touched on, it’s a source of anxiety for parents and there’s a lot of focus on the numbers and it’s not going to, it’s almost never going to positively impact how you’re parenting your child, how you’re, you’re feeding your child or, or your child’s health in general, to, uh, harp on those numbers.

I mentioned some particular examples like an infant who might, you know, if the breast milk supply has changed, or we might pick it up on the growth chart and there are some other health conditions that we’re looking for that we’re going to see then on the growth chart. Um, but that’s the, that’s the work that we do.

And it’s okay to hand that one over and say, you know, is everything looking okay there, doc? You just let me know if there’s an issue. Otherwise, you are going to be knowing that they’re growing, okay? Because you’re buying them new shoes every year and their pants are getting too short in the summer. And, um, your otherwise, um, see them growing and feel that they’re looking the way that they’re supposed to based on your genetics.

Um, certainly a large emphasis on trying to have healthy, balanced diets. So, um, we talked a bit about being on the lower side of the curve, we’re, um, also trying to help kids prevent obesity and staying a healthy weight for their height. So that’s another important, uh, use for the growth chart. But there’s so many just, um, you know, so many important complexities there that focusing on what percentile, whether it be fifth or 95th or somewhere in the middle, that’s just not, like you said, it’s the whole picture.

Are they getting the right nutrition? Are they getting plenty of exercise? So let the numbers go. There’s a lot to worry about as a parent. Let this one go. I’ll hand it over to the provider and, and if you do have a concern, uh, that your child’s not growing appropriately, please ask. Um, but you don’t have to make it your job to make sure there’re a certain number.

Totally. And nutrition could be a whole nother episode that we could cover.

I’d love to. Yeah.

Well, Dr. Grice, this has been great and I really, really hope that this episode helps put some parents’ mind at ease. And in case folks missed your previous episodes, can you please tell everyone how they can find you?

Yes, thank you. Um, @parenting_gricefully on Instagram, and I’m at Wellspring Pediatrics.

Perfect. We will link to that in the show notes. Thanks again and I look forward to our August episode where we’re going to talk about how to know when you should take your child in for a sick visit versus staying at home or seeing someone else.

Perfect timing.

Perfect. Bye for now.

Thank you.