GROWTH & DEVELOPMENT
Prof Rashmi Kumar
GROWTH & DEVELOPMENT
An essential feature of children which
distinguishes them from adults
Growth : Net increase in size or mass of
tissues. Due to
• increase in number of cells (2X 10 at birth, 6
X 10 in adults)
• increase in size of cells
• increase in ground substance
Development: Maturation of function
• Acquisition of skills
• Due to myelination of neurons
Characteristics of G&D:
• Continuous & orderly process, but rate
may not be uniform
• Specific periods when growth
accelerates, decelerates or is steady
• Generalised mass activity gives way to
specific responses
• G&D proceeds in a cephalocaudal
direction
• Different tissues grow at different rates
FACTORS AFFECTING G & D:
Genetic
parental phenotype & familial patterns
Race
Sex
Genetic disorders
-chromosomal
-gene defects
Environmental Postnatal
Intrauterine factors -nutrition
-Maternal nutrition -Infections
-anemia -trauma
-PET, HT -emotional factors
-Tobacco -cultural practices
-alcohol -Hormonal influences
-drugs -Growth hormone
- infections -insulin
-thyroid
-sex hormones
ASSESSMENT OF PHYSICAL GROWTH:
Growth Parameters:
Weight: child weighed nude on lever/electronic scale
• Spring balance less accurate
Length: For <2 yrs
• Child supine on rigid table/infantometer
• Legs straightened
• Feet at right angles
• Foot board brought upto child's heels
Height:
• Child stands upright against wall/stadiometer
• Heels, buttocks, back in contact with vertical surface
• Head held in Frankfurt's plane - line joining floor of external auditory
meatus to floor of orbit is horizontal
• Head piece firmly over vertex
Crown Rump length: Length from vertex to ischial tuberosity
Sitting Height:
ASSESSMENT OF PHYSICAL GROWTH:
Growth Parameters:
• Head Circumference: Maximum circumference from occipital
protuberance to forehead
• Chest Circumference: Measured at level of nipples midway
between inspiration & expiration in recumbent position.
• Body Proportions:
• US:LS ratio 1.7:1 at birth
• 1.3 at 3 yrs
• 1:1 at 6-7 yrs
• Mid Arm Circumference:
• Relatively constant between 1-5 yrs age independent
• Normal 1605 –17.5 cm
• <12.5 cm – malnourished
Z scores = standard deviations from median reference
Weight for Height: Differentiates acute malnutrition from chronic
wt for ht ht for age
>= 80% >=90% Normal
< 90% Stunted
< 80% >=90% wasted
<90% wasted +
stunted
GROWTH TABLES & CHARTS
• Derived from cross sectional/longitudinal
studies in large populations
• Growth parameters may be represented in
tabular/graphic form
• Growth varies between individuals
• Like all biologic measurements, growth
parameters follow a 'normal' distribution in the
population
The normal distribution
Percentiles : If 100 individuals are arranged according to
weight/height, then 50th percentile is one who has equal
number above & below
• Child is placed in relation to comparable population
Standard Deviation: > 2 or 3 SDs above/below mean maybe taken
as abnormal
• Depict the permissible limits of normalcy which may be
arbitrarily defined
• In a normal distribution, +/- 1 SD includes 68% of the
population
• +/- 2 SD includes 95% of the population
• +/- 3 SD includes 99% ,, ,,
• + 1 SD corresponds to 84th centile
• Usually 2 SDs above/below mean form the limits of normalcy
GROWTH STANDARDS:
• Country specific growth standards
usually taken from children of high
socioeconomic strata of society Eg:
ICMR/ Agarwal et al 1992
• International standards – NCHS (USA)
New WHO Growth Charts (2006)
• Study in 6 countries: developed & developing, 8500
children, Upto 5 years
• Wt for age, Ht for age, wt for ht, BMI, head
Circumference, mid arm, triceps, subscapular skin fold +
6 key motor milestones
• Only on breast fed babies with no environmental
constraints to growth
• Cross sectional + longitudinal data
• Lower weight for length, z scores, triceps and
sunscapular skin folds in breast fed
• Prescriptive rather than descriptive
• Detects both undernutrition & obesity
MNEMONICS:
Weight:
• Average birth weight 3 kg lose 10% body
weight regain BW by 10 days gain at 25-
30 gm/day for 1st 3 mths 400 gm /month till
end of 1st year
– Roughly, BW doubles by 5 mths
– trebles by 1 year
– 4 times by 2 yrs
– 6 times at 5 yrs
– 10 times at 10 yrs
• Or, gains 2 kg/yr between 3- 7 yrs
• 3 kg/yr after that till pubertal spurt
Height:
• 50 cm at birth
• 60 cm at 3 mths
• 75 cm at 1 yr
• 100 cm at 4 yrs
• gain 5 cm/yr till 10 yrs
Head Circumference:
• Birth - 35 cm
• 3 mths - 40 cm
• 12 mths - 45 cm
• 24 mths - 48 cm
• 12 yrs - 52 cm
Chest Circumference:
• 3 cm less than head circumference at birth,
equal at 1 yr
• After that, exceeds head circumference
VELOCITY OF GROWTH :
• Serial measurements of growth parameters over
a period of time. Derived from longitudinal
studies
• One time measurement does not indicate the
rate of growth
• An abnormal percentile may only present once
the factors retarding growth are profound or
persist for a long time
• Plotting growth over a period of time provides a
good epidemiologic tool for early detection of
malnutrition, infections & growth disorders eg:
Road to Health Charts
ERUPTION OF TEETH:
Primary Teeth
• Lower central incisors 5-8 mths
• Upper central incisors – a month later
• Lateral incisors – within next 3 months
• 1st Molars – 12-15 mths
• Canine - 18-21 mths
• 2nd Molars – 21 – 24 mths
Permanent teeth:
• 1st molar – 6 yrs
• Central & lateral incisors – 6-8 yrs
• Canines & premolars –9-12 yrs
• 2nd molar - 12 yrs
• 3rd molar – 18 yrs or later
BONE AGE:
• An indicator of physiological development
• Distinct from chronological age
• More advanced in girls - by 1 yr in early childhood; 2
yrs in mid childhood
• Assessed by number, shape & size of ossification
centers and density size & shape of ends of bones
• Which bones to Xray?
• Newborn – Xray of foot & knee
• Infant 3-9 mths – shoulder
• 1-13 yrs – wrist & hands
• 12-14 yrs – elbow & hip
BEHAVIORAL DEVELOPMENT:
• As age advances, child acquires better coordination
of motor activity and reacts to environment
willfully
• Development is a continuous process and different
levels of development (milestones) are achieved at
an anticipated age (+/- few months)
• Early primitive reflexes are lost
• 4 areas of development:
– Gross motor
– Fine motor (adaptive)
– Social
– Language
GROSS MOTOR : Involves control of child over his body. Tested in :
Ventral Suspension: Baby held in prone position and lifted off the bed.
Newborn – head flops down
• 4-12 wks – brings head to plane of body and then above plane of body
Supine :
• Child placed supine and gently pulled up by the arms
• Newborn – head lag
• By 16-20 wks – head in plane of body or ahead with back straight
Prone:
• Newborn – can turn head to 1 side
• 1 mth – lifts chin momentarily
• 3 mths – lifts head and upper chest
• 6 mths –liftd head & chest
• 5-8 mths – rolls over, first back to side and front
• 8 mths – crawls
Sitting:
• 5 mths – sits with support
• 8 mths – sits steadily with back straight, without support
• 10 mths – pulls from supine to sitting position
Standing:
• 4 mths-Bears weight on legs
• 9 mths – early stepping movements, pulls to standing with help of
furniture
• 10 mths – cruising
• 13 –15 mths – walks unsupported
• 15 mths – walks sideways/backwards
Climbing stairs –
• 2 yrs – climbs stairs – 2 feet per step
• 3 yrs – climbs up stairs – one foot per step
• 4 yrs – climbs down one foot per step
Key Gross motor milestones:
• 3 mths – neck holding
• 5 mths – sitting with support
• 8 mths – sitting without support
• 9 mths –standing with support
• 10 months – cruising
• 12 mths – standing without support
• 14 mths – walking without support
• 18 mths – running
• 24 mths – walking upstairs
Clinical Assessment
• FINE MOTOR OR ADAPTIVE MILESTONES: Includes
eye coordination, hand eye coordination, hand
mouth coordination and manipulation with hands
• Tested with red ring, pen torch, red cubes (2.5 cm),
pellet, cup with handle, spoon, book with thick
pages, red pencil/crayon, paper, wooden blocks,
doll, mirror
• Eye coordination:
• 4 wks – regards torch/red ring kept at 20 cm in front
• 6 wks – follows object from side to side –unsteadily
• 2-3 mths – follows with steady movements of eyes
• Binocular vision by 3-6 mths
Hand eye coordination:
• 4 mths – tries to grasp red ring dangling in front but may overshoot
• 5 mths – reaches out & grasps object with ulnar side
• 6 mths – radial grasp, transfers objects from hand to hand
• 10 mths – pincer grasp
Hand-mouth coordination:
1 yr – tries to feed with spoon but may spill
• 15 mths – feeds with spoon
• 18 mths – feeds self from cup
Hand skills: Book:
• 13 mths – turn 2-3 pages at a time
• 24 mths – turns 1 page at a time
Scribbling:
• 12-24 mths – scribbles
• 2 yrs – copies vertical line
• 2 ½ yrs –copies horizontal line
• 3 yrs – circle
• 4 yrs – cross, rectangle
• 5 yrs – copies cross, triangle
PERSONAL & SOCIAL DEVELOPMENT:
• 1 mth - regards face of
mother/caretaker
• 2 mth - social smile
• 3 mths - recognises mother/caretaker
• 6 mths - enjoys mirror
• 7-8 mths - separation anxiety
• 9 mths - waves bye-bye
LANGUAGE DEVELOPMENT:
• 1 mth - turns head towards sound
• 3-5 mths - vowel sounds, gurgles
• 6 mths - monosyllables
• 9 mths - bisyllables
• 10 mths - understands spoken speech
• 12 mths - speaks 2 words with meaning
• 18 mths - 20 words
• 24 mths - joins 2-3 words in a short sentence
• 3 yrs - 250 words
BOWEL & BLADDER CONTROL:
• Early months - gastrocolic reflex defecates asfter each feed
• 7 mths - no relation to feeds
• Toilet trainable by 18mths - 2 yrs
Developmental Delay
• 3 Step diagnosis
– Clinical
– Screening tools
– Psychometric scales
DEVELOPMENTAL SCREENING:
• Denver Development Screening Test:
Most widely used
• 4 scales
• 125 items
• Baroda Development Screening Test:
Adapted from Bayley scales for Indian children
• Trivandrum Development Screening
Test
