Growth and Development

- Growth and Development

- Learning objectives:
- Demonstrate steps in evaluation of growth
- Answer questions related to growth disorders

Growth and development are responsible for changing the child into a
full-grown and mature human being. Accordingly, their assessment is
essential components of each child medical evaluation, as deviations from
normal patterns may be early indicators of a serious disease.
Although the processes of growth and development are not completely
separate, it is convenient to refer to “growth” as increase in the mass and
dimensions of the body and its separate parts (largely caused by
multiplication of cells and increase in intracellular substance). It can be
assessed by measuring weight, height and head circumference. On the
other hand, development refers to changes in functional maturation and
acquisition of skills (including motor, visual, and speech, social and
behavioral aspects). It is related to maturation and myelination of the
central nervous system.

- Growth stages:
1- Prenatal stage (intra-uterine):
 Intra-uterine life begins by conception i.e. fertilization of the ovum
by the sperm and ends by delivery (normally 37-40 weeks).
 This stage is further divided into two
periods: A- Embryonic period first 8 weeks.
B- Fetal period 9-40 weeks.

Embryonic period:
During the first 8 weeks the fertilized ovum divides and
differentiates rapidly to form most of the organs of the future
human being, hence it is called the period of “organogenesis”.
Risk factors that may occur during this period may result in

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 either abortion or disturbances of the normal pattern of organs
formations (congenital malformations).
Fetal period (9-40 weeks):
It is marked by a high rate of increase in size and functional
maturation of the fetus. Risk factors for the fetus will not
affect organogenesis greatly, and so congenital anomalies are
not common. However, they may result in stillbirth, preterm
delivery or intra- uterine growth retardation.
Risk factors include:
1- Genetic disorders.
2- Intra-uterine infections.
3- Teratogenic drugs.
4- Maternal pelvic irradiation.
2- Post- natal stage:
The post-natal life begins by delivery and ends when the
developing human becomes a fully grown up and mature human
being. This stage is divided into:
- Neonatal period: first month.
- Infancy: first month to 2 years.
- Preschool age: 2-5 years.
- Early school years: 6-12years.
- Adolescence: 10-18 years.
- General rules for growth and
development: 1- It is a continuous
process:
It starts with the fertilization of the ovum and extends post-Nataly
from the neonatal period passing through infancy, childhood till the
end of Adolescence.

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2- It is not a uniform process:

Growth is not uniform neither in rate nor pattern.

Rate: a rapid rate of growth is found in infancy and Adolescence with
a less rapid rate of growth in preschool and early school periods.
Pattern: not all parts of the body grow at the same rate at the same
time. The head grows more rapidly than the body in the first two
years, because of the rapid growth of the brain. There is no growth in
the gonads in the childhood, while their maximum growth occurs in
adolescence.
3- It is liable to a wide range of normal variation:
For this reason, growth curves are plotted. Growth curves demonstrate
clearly the wide limits which the normal children of the same age
show.

Physical changes with growth

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  Factors affecting physical growth:
1- Genetic: the growth potential is determined within the ovum at the
time of fertilization. However, subsequent environmental conditions
may retard the growth process.
2- Race: there is a racial difference in rate and pattern of growth,
leading to racial differences seen in adult body built. Some of these
are genetically controlled, whereas others are related to climatic and
nutritional differences.
3- Sex: There is sex difference in the rate of growth and time of
adolescence. Girls grow faster than boys in the early years of life.
Also, girls start their puberty at a younger age than boys.
4- Nutrition: Malnutrition delays growth. For adequate growth,
adequate nutrition should be provided in the form of adequate
calories, protein, fats, carbohydrates, vitamins and minerals.
5- Socioeconomic conditions: social level, housing conditions and
access to health care have a significant impact on growth.
6- Endocrinal glands: growth is a complex process that requires many
hormones as growth hormone, thyroid hormone and insulin.
7- Chronic diseases: as chronic renal, gastrointestinal, liver or chest
diseases may delay growth.
8- Aspects of normal growth and development
9- 1. Physical growth
10- Main parameters: weight, length in infants (or height after -the age of 2
years) and head circumference.
11- Other parameters include the following:
12- ■ Body proportions: As upper/lower segment ratio.
13- ■ Dentition: It includes primary (deciduous) and secondary
(permanent) dentition.
14- ■ Vital signs: Heart rate, respiratory rate and blood pressure.
15- ■ Bone age (Radiological).
16- 2. Motor development: Gross motor as sitting, standing and walking,
etc. and Fine motor as hand and finger grip.
17- 3. Mental development: as social development and speech, .etc.
18- 4. Sexual development: it includes the stages of puberty.
19-

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 Assessment of physical growth
Growth assessment is an essential component of pediatric health
visits, because almost all medical problems can adversely affect
growth. Deviations in growth patterns are non- specific, but may be
important indicators of serious medical problems. They often provide
the first clue that something is wrong, when the parents do not suspect
a problem.
Aspects of physical growth:
1. Height or body length
2. Weight
3. Head circumference
4. Upper/ lower body segments
5. Dentition
- Growth charts:
The most important tools in growth assessment are growth charts. On
these charts, we can compare the weight, height or head circumference of
a given child at a given age with his colleagues of the same age and sex.
The values range between 3rd and 97th percentiles, and the mean values
are represented by the 50th percentile.
Growth Charts

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Normal children fall between the 3rd and 97th percentiles. Only 3% of
normal population falls below the third percentile, and 5% fall above the
97th percentile. If a child measurements fall below the 3 rd percentile, or
above the 97th percentile, he is considered significantly deviated, and
should be properly evaluated to exclude organic causes
3rd percentile lowest normal.
10th percentile low normal.
25th percentile below average.
50th percentile average.
75th percentile above average.
90th percentile high normal.
97th percentile highest normal.
 Serial measurements are much more important than a single
measurement, to determine the growth rate, and to detect deviations
from a particular child’s growth pattern even if the values remain
within normal limits.
 There are many types of growth charts to describe physical growth of
children and adolescents e.g. chart for weight, height, skull
circumference and skin folds. For all these measurements, there are
separate charts for boys and girls.
 Height measurement in most circumstances is the best single index
of growth.
 A child is genetically programmed to stay on 1–2 growth curves after
age 2 years.
 The height percentile at age 2 years correlates with final adult height
percentile.
 Low-birth-weight and very-low-birth-weight infants may continue to
show catch-up growth through early school age.
 Weight/height <5th percentile is the single best growth curve
indicator for acute malnutrition.
 In nutritional insufficiency, weight decreases before length, and
weight/height is low.
 For causes of decreased linear growth, length decreases first or at the
same time as weight (e.g., GH deficiency).

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- Assessment of height:

From birth to 2 years, length is measured with the infant in the supine position,
using a specific measuring board. Two persons are required to ensure that the
child is lying straight with legs extended.
In children above 2- 3 years, standing height is measured against a wall-
mounted or free- standing standiometer, with the child looking forwards in the
horizontal plan.
 Evaluation of Growth:
 Growth velocity (GV): yearly increments of growth; should follow
a growth curve slope: change in height
change in age
 Chronologic age (CA): actual age
 Bone age (BA): x-ray of left hand and wrist (non-dominant hand)
- Measurements of physical growth:
1- Weight:
- The average birth weight is 3000 – 3250 grams. In the first week of
life, a newborn typically loses up to 10% of birth weight (BW) due to
the elimination of large amounts of extravascular fluid.
- By 2 weeks, BW should be regained or surpassed.
- In the first month of life, a neonate should gain ~30 grams (1 oz) per
day, which slows to ~20 grams/day at 3–4 months.
- During the first 4 months, it is about 750gm/month.
 One month 3.750 kg.
 Two months 4.500 kg.
 Three months 5.250 kg.
 Four months 6 kg.
(The infant doubles his weight at the age of 4 months).
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 - During the second 4 months: the infant gains about 500 gm/month i.e.
2kg in the four months, and reaches 8 kg by the end of the 8th month.
- During the third 4 months: the infant gains about 250 gm/month i.e.
1kg in the four months, and reaches 9 kg (8- 10) by the end of the
first year.
(The infant triples his weight at the age of 1 year).
- During preschool period: the weight gain is about 2 kg/year.
- After the second year of life, we can calculate the weight of
the child from the following formula:
Average weight = age (in years) x 2 + 8
2- Length and height:
- Below the age of 2 years, length is measured in the supine position.
- After the age of 3 years, height is measured in the standing
position.
Birth height 50 cm
One year 75 cm
Two years 85 cm
Three years 93 cm
Four years 100 cm
(The child doubles his height at the age of 4 years).
- After the second year of life, we can calculate the height of
the child from the following formula:
Average height = age (in years) x 6 + 77
3- Skull circumference:
At birth: 35 cm
Six months 43 cm
One year 47 cm
Two years 49 cm
Four years 50 cm
Puberty 52 cm
4- Skull fontanels:
- Anterior fontanel: At birth: 3 fingers6 months: 2 fingers One
year: 1 finger18 months: closed
- Posterior fontanel: closed at birth
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5- Body proportions
- Upper segment (US): the distance between the top of the head and
the symphysis pubis.
- Lower segment (LS): the distance between the symphysis pubis to
the heel.
 At birth: US/ LS = 1.7
 At 3 years US/ LS = 1.3
 At 8 years – adults US/ LS = 1
- Significance: Short stature may be proportionate as in endocrinal
diseases or disproportionate as in skeletal diseases.

6- Dentition
The process of dentition is subjected to a wide range of variations. Teething in
the lower jaw usually precedes that in the upper jaw by 1-2 months.
Primary teeth (20)
Central incisors 5-7 months
Lateral incisors 7-9 months
Canines 16-20 months
First molars 10-16 months
Second molars 20-30 months
Secondary (permanent) teeth (32)
Central incisors 6-7 years
Lateral incisors 7-8 years
Canines 9-11 years
First premolars 10- 12 years
Second premolars 11 -13years
First molars 6-7 years
Second molars 12 -13 years

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 Bone age
Bone age can be assessed by counting the number of carpal ossific centers
and detecting epiphyseal fusion with bone metaphysis.
Assessment of bone age:
- In early childhood: by radiologic examination of the hand and wrist. In
general, one carpal ossific center develops each year.
At one year … two carpal ossify centers are present.
At two years … three carpal ossify centers are present.
And so on.
- In late childhood: detection of bone age may be difficult, and fusion
of epiphyses (e.g. distal ends of radius and ulna) is helpful. Reference
atlases are available for accurate bone age assessment.
- Significance: Normally bone age is proportionate to the chronological
age of the child.
- Delayed bone age can be detected in endocrinal diseases as
hypothyroidism and growth hormone deficiency.
- Advanced bone age may be detected in diseases associated with
excess sex hormones (as congenital adrenal hyperplasia) and
hyperthyroidism.
In Summary:
 In the first week of life, a newborn typically loses up to 10% of birth weight (BW)
due to the elimination of large amounts of extravascular fluid.
 By 2 weeks, BW should be regained or sur passed. In the first month of life, a
neonate should gain ~30 grams (1 oz) per day, which slows to ~20 grams/day at
3–4 months.

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  By 6 months, an infant typically doubles BW, and by 1 year, triples BW.
 Growth rate slows further between 6 and 12 months and then appetite begins to
decline through 18 months of age.
 Then height and weight increase at a steady rate, but head-circumference rate of
growth decreases somewhat (2–5 years).
 Between age 6 and 12 years: 3–6 growth spurts each year for 8-week periods each;
slower brain growth; myelination complete by age 7.
 Between age 10 and 20 years: acceleration in early adolescence. Boys’ highest
growth stops at age 18. Their average peak is 13.5 years (2–3 years later than
girls, and con tinues 2–3 years after girls have stopped). Girls’ average peak is
11.5 years and it stops at age 16.

- Abnormal growth
Abnormalities of head growth:
Abnormalities of head growth include abnormally small-sized head
(microcephaly and craniosynostosis) and large head (macrocephaly).

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- Microcephaly:
 As the name indicates microcephaly refers to an abnormally small head
circumference i.e. below the 5th percentile for age and sex.

 Microcephaly may have a genetic etiology as an isolated congenital

anomaly or as a component of a genetic syndrome. More frequently,
microcephaly is secondary to an early CNS insult inducing brain
damage and atrophy during fetal or early infantile age.
 Common prenatal causes include: Intra-uterine infections, teratogenic
drugs, maternal alcohol intake (fetal alcohol syndrome) and maternal
irradiation. Hypoxic ischemic injury is the leading natal cause. Main
postnatal causes include: CNS infections, intracranial hemorrhage and
kernicterus.
Craniosynostosis: is induced by early closure of skull sutures,
leading to skull deformity and increased intracranial
tension.
 It may occur as an isolated congenital anomaly or as a component
of a genetic syndrome. In few cases it may be induced by rare
metabolic disorders as idiopathic hypercalcemia.
 Examination reveals abnormally small head circumference and a
palpable ridge at the site of the prematurely closed skull suture.
Skull deformities and manifestations of increased intracranial
tension are also present.
 Skull x- ray examination reveals silver- beaten appearance.
 Surgical interference may be required because of raised intracranial
pressure or for cosmetic reasons.
- Macrocephaly:
Macrocephaly refers to an abnormally large head circumference i.e.
above the 95th percentile for age and sex. Macrocephaly may be induced
by increased intracranial pressure (as in hydrocephalus and brain tumors).
Other causes include familial large head, chronic hemolytic anemia and
skeletal deformities (as achondroplasia).

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- Short stature
Short stature is defined as a height below the 5th percentile for age and sex.
Etiology
A) Non- pathologic conditions:
Most cases of short stature are normal variants (non-
pathologic), with normal hormonal pattern. This group includes
two distinguished conditions: familial short stature and
constitutional delay of growth and puberty.
1- Familial
Most short children have short parents, and their heights
match their mid parental heights.
2- Constitutional delay of growth and puberty
These short stature children have also delayed puberty. The
condition is usually familial, and is more frequently
detected in males.
Familial (genetic) Constitutional
Parents Short Normal
Family history Short stature Delayed puberty
Growth velocity Normal Normal in early years, with
delaying pubertal age.
Bone age Normal Delayed
Puberty Normal Delayed
Adult height Short Normal

B) Pathologic causes include a wide range of diseases:

- Chromosomal and genetic disorders
Many chromosomal and genetic diseases are associated with
are associated with short stature, as Down, Turner's, Noonan's
and Russell-Silver syndromes.

- Endocrinal causes
Hypothyroidism, growth hormone (GH) deficiency and excess
steroid are uncommon causes of short stature.

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 - Nutritional disorders
This is a relatively common cause of abnormal growth in poor
and developing countries. These children are usually short and
underweight.

- Chronic illnesses
Chronic illnesses which may present with short stature include:
Celiac disease, malabsorption syndromes, chronic renal failure and
cystic fibrosis. Chronic infections as tuberculosis may also induce
short stature.
- Psychosocial deprivation
Children subjected to physical and emotional deprivation may
be short and underweight and show delayed puberty.
- Skeletal dysplasia: achondroplasia, rickets.
Assessment of a case of short stature:
History
- Family history of short stature or delayed puberty.
- History of c chronic illness.
- Medications (e.g. steroids)
Examination
- Assess mid-parental height.
- Assess US/LS ratio.
- Complete careful systemic examination to exclude:
- Chromosomal and genetic disorders.
- Endocrinal disorders.
- Chronic diseases.
Investigations:
- Assessment of bone age.
- Thyroid function tests.
- Karyotyping: Turner syndrome.
- Calcium, phosphorous and alkaline phosphatase assessment.
- Growth hormone assessment.

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- Tall stature
Defined as a height more than the 95th percentile for age and sex. Tall
stature is a less common complaint than short stature as most parents are
proud that their child is tall. Also, most tall children have tall parents.
Etiology:
 Familial tall stature is the most common cause.
 Pathological causes include:
- Obesity.
- Precocious puberty.
- Endocrinal causes: as hyperthyroidism and excess growth
hormone secretion.
- Chromosomal and genetic disorders: as Marfan and
Klinefelter syndromes.

- Failure to thrive
Definition: It is a descriptive term that refers to weight below 3 rd
percentile, failure to gain weight over a period of time, or a change
in rate of growth that has crossed two percentiles, e.g. 75th to 50th.
Causes:
A- Organic causes:
- Gastrointestinal: malabsorption, pyloric stenosis,
gastroesophageal reflux and inflammatory bowel
disease.
- -Neurological: mental retardation, cerebral palsy
- Renal: Chronic renal failure
- Cardiopulmonary: congenital heart diseases, asthma,
cystic fibrosis.
- Endocrine: hypothyroidism, diabetes mellitus.
- Infections: chronic diarrhea, tuberculosis,
human immunodeficiency virus.
- Genetic: inborn errors of metabolism, chromosomal disorders.
B- Non-organic causes:
Poverty, protein-calorie malnutrition, dysfunctional parent-
child relation.

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 Diagnosis:
1- Assessment of weight and height percentiles for age, sex and race.
2- History, physical examination and observation of parent-child
interaction to diagnose the cause.
3- Initial investigations are: urine and stool microscopy and
culture, complete blood picture, ESR, liver and kidney function.
4- Detailed laboratory investigations are needed only if history
and physical examination suggest organic cause, and to localize
the system involved.
Management:
1- Nutritional rehabilitation.
2- Treatment of the cause if possible.

Motor and mental development

There are four fields of developmental skills to consider whenever
a young child is seen:
1. Motor: either gross or fine motor
2. vision
3. hearing, speech and language
4. Social, emotional and behavioral.
 Assessment is based on acquisition of milestones occurring
sequentially and at a specific rate: each skill area has a
spectrum of normal and abnormal
 Abnormal development in one area increases likelihood of
abnormality in another area, so careful assessment of all
skills is needed
1- Motor:
We can say that maturation of the nervous systems precedes
from above downwards, so the normal child:
 Can hold his head erect during the 3rd month.
 Attempts to grasp objects during the 4th month.
 Can sit with support at 6 months and transfer objects from
hand to hand.
 Sits without support and stands with support at 9 months.
 Walks with support and begins to throw objects to floor

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 around the end of the first year.
 Climbs stairs at 18 months.
2- Other developmental milestones:
 1-2 weeks: follows light and fixes eyes on objects.
 1 month: pays attention to voices and music.
 2 months: smiles.
 4 months: laughs and turns head to voice.
 5-6 months: recognizes objects.
 8-10 months: says syllables (dada, mama...) and responses to
strangers.
 1 year: says 2-3 words, makes line marks with pencil on paper.
 1.5 years: associates words with objects and says more words,
and begins to use spoon or cup and feed himself.
 2 years: uses 3 word sentences, points to eyes, nose….
 3-4 years: rides tricycle, goes upstairs. Attends toilet
without help.

Major developmental disorders

- Intellectual disability: IQ <70–75 plus related limitation in ≥2
adaptive skills, e.g., self-care, home living, work,
communication
- Communication disorders (deficits of
comprehension, interpretation, production, or use of
language)
- Learning disabilities, one or more of (defined by federal
government; based on standardized tests): reading,
listening, speaking, writing, math
- Cerebral palsy
- Attention deficit/hyperactivity disorder
- Autism spectrum disorder

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 Developmental milestones:

Gross Motor Visual Motor Language Social Adaptive

Birth • Symmetric • Visually fixes • Alerts to sound • Regards face
movements in on an object
supine
• Head flat in prone
2 months • Head in midline • Follows past • Smiles in response • Recognizes parent
while held sitting midline to touch and voice
• Raises head in
prone
• Begins to lift chest
4 months • Holds head steadily • Reaches with • Laughs • Likes to look
• Supports on both arms • Orients to voice around
forearms in prone together
• Coos
• Rolls from • Hands to midline
prone to supine
6 months • Sits with • Unilateral reach • Babbles • Recognizes
support • Raking grasp that someone
(tripod) is a stranger
• Transfers object
• Feet in mouth
in supine
7 months • Rolls from
supine to prone
• May crawl
• Starts to sit
without support
9 months • Crawls well • Immature • “Mama,” • Plays gesture games
• Pulls to stand pincer grasp “dada,” • Explores
• Holds bottle indiscriminate environment
• Starting to cruise
ly (crawling and
• Throws object
(not overhand) • Understands “no” cruising)
• Understands
gestures
12 months • May walk alone • Mature pincer grasp • 1-2 words other • Imitates actions
(must by 18 • Crayon marks than “mama” and • Comes when called
months) “dada” (used
• Object • Cooperates
appropriately)
permanence with dressing
(from 10 • Follows 1-
months) step
command
with gesture
15 months • Creeps up stairs • Scribbles and • 4-6 words • Uses cup and
• Walks backward builds towers of spoon (variable
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 2 blocks in • Follows 1-step until 18 months)
imitation command
without gesture
18 months • Runs • Scribbles • 15-25 words • Imitates parents
• Throws spontaneous • Knows 5 body parts in tasks
objects ly • Plays in
overhand • Builds tower company of other
while of 3 blocks children
standing

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