Normal Growth and Development

MBBS YEAR 3
DR.SWE ZIN AYE
[email protected]
Aims
• To develop ideas and understanding of the sequence of normal child
growth & development.
Learning Outcomes:
At the end of this session, the students are expected to:
• identify the sequence of normal child growth & development.
• be able to measure weight, height/length and head circumference.
• be able to plot growth parameters on a centile chart and understand the
importance of this in clinical cases.
• gain insight into clinical assessment of development through history,
observation and play.
Normal Growth and Development
• Growth : increase in size
• Development: increase in skills

• Conception to end ( 16 to 18 years) when sexual maturation and final height

reached
• Both sexes are of a comparable shape & size during infancy and childhood.
Normal Growth Pattern
Normal Growth Pattern
Segmental Growth During Childhood
Growth Spurts
1. Rapid growth in infancy & early childhood
• Mediated predominantly by Nutrition

2. Slow, steady growth in middle childhood

• Dependent on GH

3. Rapid growth during puberty

• Dependent on GH and Sex hormone

4. Gradual growth slowing in adolescence

until adult height reached
•Thyroid hormone +
• Cortisol –
• Genetic influence
How to measure length?
• Length is the linear measurement for infants up to 24 months.
• Children may exhibit slow growth in length if they have been undernourished for
a long time.
How to measure height and weight?
Why do babies lose weight?
• Weight loss in 1st few days (up to 10%)

• 80% regain birth weight about 10 day

• Closer evaluation if not by 2 weeks

• The most common theory

• extra fluid accumulated with the stress caused by labor and the transition to
extra uterine life.
How often are babies weighed?
• Babies should be weighed when there • Should not be weighed more often
is routine health service contact: than once a month from 2 weeks to 6
• Birth months of age,
• Midwife visits in neonatal period • No more than every 2 month upto 1
• 6 week check year of age
• Immunisations (2 months, 3 • No more than every 3 months after
months, 4 months, 13 months) that.
• More often if concerns
Post natal growth
• First year 22-25 cm/year
• Second year 10-12 cm/year
• Third year 8 cm/year
• Thereafter to onset puberty 5-7 cm/year

• Puberty spurt 25 cm

In the first year of life there is:

• 300% increase in weight
• 50% increase in length.
How to measure OFC?
• typically taken with non-stretchable tape in children ages 0-3 years old.
• Take the measurement three times and select the largest measurement.

• It indirectly reflects brain size and growth.

• Because almost all brain growth occurs before the age of two, plotting head
growth can be used as a general indicator of a young child’s brain health.
Introduction to Growth Charts
Birth to 24 months: Girls
Length-for-age and Weight-for-age percentiles

98
95
90
75
50
25
10
5
2

Separate charts for boys and girls

98

95

90

Separate pages for infancy and childhood 75

50

25

10
5
2

Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www .who.int/childgrowth/en)
Introduction to Growth Charts

Separate charts for boys and girls

Separate pages for infancy and childhood
Introduction to Growth Charts
Birth to 24 months: Girls
Head circumference-for-age and NAME
Weight-for-length percentiles RECORD #

Birth
in cm cm in H
E
A
52 52
D
20 20
50 98 50 C
95 I
90 R
H 19 19 C
48 75 48
E U
50
A M
D 18 46 25 46 18 F
10 E
5 R
C 44 2 44 E
I 17 17 N
R C
C 42
24 E
U 52
16 23
M 40 50
F 22 48

Separate charts for boys and girls E

R
E
N
15

14
38

36
98
95
90
21
20
19
46
44
42
C

OFC is general indicator of a young child’s brain health before the age of two
E
13
34

32
75

50

25
18
17
16
40
38
36
10 34
12 5 15
30 2 32
14
30 W
28 13 28 E
12 12 I
26 26 G
24 11 11 24 H
22 10 10 22 T
20 9 9 20
18 8 8 18
16 16
W 7 7
E 14 14
6 6
I 12
14 12
G 5 5
10 kg lb
H 4 LENGTH
T 8
64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100102104106108 110 cm
6 3
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 in
4 2
Date Age Weight Length Head Circ. Comment
2 1
lb kg
cm 46 48 50 52 54 56 58 60 62
in 18 19 20 21 22 23 24
Published by the Centers for Disease Control and Prevention, November 1, 200 9
SOURCE: WHO Child Growth Standards (http://ww w.who.int/childgrowth/en)
How to calculate the corrected age?
• If born at <37 weeks, correct for gestational age (Until 2 years old)
• Baby girlBorn 12 weeks ago at 32 weeks gestation

• Her chronological age is 12 weeks.

• Her corrected age = chronological age – weeks premature
= 12- (40-32)
= 12-8= 4 weeks
Term—40 weeks
Gestational age at delivery—32 weeks

• No need to correct if born ≥37 week

Factors affecting Height
• Age • Parental heights
• Sex • General height- chronic illness
• Race • Specific growth disorder-
• Nutrition • Socioeconomic status
• Birthweight- little effect on childhood • Severe psychosocial deprivation
height unless SGA • Genetic
• Pubertal status- early developer are
taller for age
 158 cm 174cm
Final Adult Height (Target Height Range)
95%CI
• MPH ± 8.5 cm in girl
• MPH ±10 cm in boys

Mid-parental Height (MPH)

Boy : F +M +7 cm= 174+158 +7=173
• 2 2
Girl : F +M - 7 cm= 174+158 - 7=159
2 2

Final Adult Height (Target Height Range)

• 173 ±10 cm in boys = 163-183 cm
• 159 ±8.5 cm in girls = 150.5-167.5 cm
 Final Adult Height (Target Height Range)
95%CI
• MPH ± 8.5 cm in girl
• MPH ±10 cm in boys

• Mid-parental Height (MPH)

Boy : F +M +7 cm= 174+158 +7=173
2 2
Girl : F +M - 7 cm= 174+158 -7=159
2 2

Final Adult Height (Target Height Range)

• 173 ±10 cm in boys = 163-183 cm
• 159 ±8.5 cm in girls = 150.5-167.5 cm
Mid parental Height
• MPH and target range considered as the growth centiles for family concerned
• MPH correspond to the 50th centile
• The upper end is the 91st centile and lower and is the 9th centile
• Under normal circumstances the child's height will fall within the parental target
centiles
• 90% of children will achieve an adult height within this range
What does that mean?
• A 2 year old boy who is 11 Kg is at the 75th percentile for his weight.

• It means that he weighs more than about 75% of boys his age.
• It also means that 25% of 2 year old boys weigh more than he does.
• 75% of boys that age weigh less than he does and 25% of 2-year-old boys
weigh more.

The higher the percentile number, the bigger a child is compared with other kids
of the same age and gender, whether it's for height or weight.
If the child is above 95th centile or below 5th
centile:
• Plotting the child's weight and height at different ages and seeing if he/she
follows a growth curve is more important than where he/she is at any one time.

• He has always been at the 5th percentile, then he is likely growing normally,
which usually doesn't mean there is a problem.

• It would be concerning and it might mean there was a problem with his growth if
he had previously been at the 50th or 75th percentile and had now fallen down
to the 5th percentile.
FALTERING GROWTH
What does it mean?
• Mild -Crosses 2 centile lines(alert for primary care)
• Severe - crosses 3 centile lines
• As many as 50% of children under 5 years of age will experience an episode of
growth faltering at some stage

Exceptions
• Constitutionally small
• ‘Catch-down’ growth?- initial growth maybe falsely accelerated and then the
natural, but slower percentile is followed
Plotting Growth Charts

Plotting the chart

Use dots, do not join up
Expected Use pencil
centile
position
Actual
centile
position

Fall through 2 weight centile

spaces (1.3 SD) adjusted for initial
centile position
Growth Charts: Case 1
Growth Charts: Case 2
Child Development
• The rapid acquisition of skills acquired by children between birth
and 5 years
• 4 areas of Development
1. Gross motor
2. Fine motor and vision
3. Speech, Language and Hearing
4. Social, Emotional, Behaviour and Play
Child Development
• Developmental delay —slow acquisition of developmental skills in 0-5 years age
group.
• Global delay—2 or more skills
• Specific delay—one particular field
• Learning Difficulty —used in children of school age, may be
• Cognitive
• Physical
• Both (complex)
Factors influencing development
• Genetic—Chromosomal abnormality, autism, ADHD
• Psychosocial factors—parenting, attachment problems, neglect, parental conflict,
parent’s mental illness.
• Biological factors—Brain damage:
• Prenatally—placental insufficiency causing nutritional deficiencies, toxins and
infections
• Postnatally—illness, non-accidental injury, accidents and deficiencies
• Defect in special sense—Defect in vision and hearing
How to assess development?
• Informal assessment in all children that you encounter.
• Formal assessment should be considered if concerns are raised:
• Schedule of growing skills
• Bayley’s assessment – formal training required, used as a research tool
• Denver Screening charts
Children don’t develop at exactly the same
rate!!!!
Children are all different and develop at different speeds.

MEDIAN AGE
Is when half the population achieve that level
LIMIT AGE
The age by which a skill should be attained

You will be screening all of these skills and describe

1. What a child is able to do and
2. What the child cannot do.
Limit age or red flags
• 50% of children take their first steps are 12 months
• 90 % by 15 months
• 97.5% by 18 months.

THEREFORE 18 MONTHS IS SET AS AN AGE LIMIT FOR NORMAL DEVELOPMENT.

Limit age or red flags: Birth-1 year
• Persistent fisting >3mths • Smile Absent Between 4-6 mths
• Head lag when pulled to sit > 4 mths • Persistent primitive reflexes > 6 mths
• Failure to reach for objects > 5 mths • Absent babbling > 6 mths
• Not sitting propped > 6 mths • Absent stranger anxiety > 7 mths
• Not sitting unsupported >10 mths
Limit age or red flags: 1 year-5 year
• No 1st word except mama/dada >18 • Has limited/unintelligible vocabulary
months at 3-5 year.
• Not walking independently >18 • Should be sociable, prefers playing
months with peers than alone at 3-5 year
• Loss of speech / social skills/
• No joining of two words by 2 years development regression at any age
• Hand dominance <18 months
• No imitative play >18 months
• Can’t follow 1 step commands >15
months
What in particular should you be looking
out for in examination?
• Observe the child from first moment seen.
• Make it fun. Your examination should be perceived as a game by the child.
• Toys to use are—cubes, a ball, doll, pencil and paper, picture book, pegboard,
scissors, adapting their use to the child.
Gross Motor
• Do all infants learn to walk the same way?
• Commando crawl
• 4 limb crawl
• Bottom shuffler
• 12 months - walking unsteady (Median)
• 15 months steady
• 2 and a half years run and jump
Fine motor and vision
• When do babies reach out for toys?
• 4mths
• Palmar grasp?
• 6mths
• Pincer grip?
• 9mths
• Make marks with a crayon?
• 16-8mths
• Building towers?
• 14mths-4yrs
 Normal language development
Receptive-Understanding Expressive--communication
• Startles to sound • Babbles – ma-ma-ma, ba-ba-ba
• Recognises mother’s voice and turns to • Pretend speech – more constanants
it
• First words (12mths)
• Recognises name
• Puts 2 words together (2yr)
• Recognises ‘no’ (9mths)
• Puts 3 words together (3yr)
• Follows commands
• Sentences (4yr)
Social emotional and behaviour development
All connected to psychological development
• Smiling - 6 weeks
• Waving - 10-12 months
• Drinks from a cup - 12 months
• Holds cup and spoon - 18 months
• Simulation (Pretend) play - 18 months to 2 years –imitate adult action
• Toilet trained - 2 years
• Parallel play—Play alongside other children
• Imaginative play (Associated play)- 3 years
• Cooperative play –4 years
Clinical signs to look for that may aid
diagnosis or guide investigations are:
• Patterns of growthHeight, weight, OFC with
centile plotting
• Dysmorphic featuresface, limbs, body
proportions, cardiac, genitalia
• Skinneurocutaneous stigmata, injuries,
cleanliness, nutrition.
• CNSwasting abnormal posture/symmetry,
power, tone, deep tendon reflexes, clonus, planter
response, sensory examination, cranial nerves.
Primitive reflexes: Abnormal if not present at
birth, or persists
• Rooting reflex
• Sucking reflex
• Grasp reflex
• Asymmetric tonic neck reflex
• Stepping reflex
• Moro reflex
Investigation plan in all developmental delay
• Hearing assessment, vision assessment.
• CPK
• Chromosomal and DNA analysis for fragile X.

• Karyotyping in children with dysmorphic features

• TFT—hypothyroidism
• Blood calcium—pseudohypoparathyriodism
Additional Investigations in severe delay
• Metabolic screenblood and urine amino acid, urinary mucopolysaccharides,
blood ammonia, uric acid, cholesterol, white cell enzymes.
• MRI brainabnormal head shape, associated CP/Epilepsy
• EEGepilepsy, developmental regression
• Assessment by a clinical geneticistdysmorphic features
• TORCH screenpossible congenital infections suggested by H/O
• Maternal phenylalanineunexplained microcephaly
Developmental mile stones
• New born http://www.youtube.com/watch?v=_JXPym0Aa5E&index=1&list=PL177DF26BF08715F1
• 8 weeks
http://www.youtube.com/watch?v=6Yx_D_PPrqY
http://www.youtube.com/watch?v=JH8HEu1YZlk
http://www.youtube.com/watch?v=e9MDU8ktB08
• 4 month http://www.youtube.com/watch?v=Tx90L0nD1E4
• 6 month http://www.youtube.com/watch?v=uQmqRIR2YxA
• 10 month http://www.youtube.com/watch?v=dAGQ1uCJRKM
• 12-18 month http://www.youtube.com/watch?v=9_lTCMURNu4
• 2-3 year http://www.youtube.com/watch?v=PpRMAxih5g0
• 3-5 year http://www.youtube.com/watch?v=o0TGczdbiV4
Conclusion
• Take in to account the corrected age of premature babies (up to age 2)

• Routinely assess all children's development to:

1.Reassurance about normality
2.Identify specific problems
3.Aid diagnosis of syndromes/underlying medical problems

• Awareness of limit age or red flags.

References:
• Nelson Essentials of Pediatrics 7th edition 2015 by K. Marcdante MD,R. M.
Kliegman MD,R. E. Behrman MD
• Malaysia paediatrics protocol, 3rd Edition.
• Illustrated Textbook of Paediatrics (4th Edition) | International Edition by Tom
Lissauer, Will Carroll