GROWTH & DEVELOPMENT

Dr. Milap Sharma

Professor( Ped)
• Which diseases you can suspect on the
basis of abnormal G&D
 FIND OUT THE CAUSE

WEIGHT OF NEWBORN =1.5 kg

A BABY NOT ABLE TO WALK AT 18 MONTHS

HEAD SIZE OF NEWBORN =29 CM

NO PRIMARY DENTITION TILL THE AGE OF 13

MONTHS
 GUESS THE CAUSE
• Baby started walking at 15 months and at 4years
developed Gower sign and duck like gait

• Neurologically Bright but hypotonic and areflexic,

disease progressing continuously.

• Global delay hypotonic, reflexes present and static

disorder
 By the end of this session

• Define growth and • What is percentile

development
• Relation between
• What are different laws of percentile and z score
growth
• Different growth
• Factors affecting growth standards
• Anthropometry
• What are different growth • Development-milestones
charts
Child Growth (Image: WHO)
GROWTH & DEVELOPMENT

Growth : Net increase in size or mass of tissues.

• increase in number of cells

• increase in size of cells

• increase in ground substance

Development -Maturation of
function
• Development refers to a progressive
increase in skill and capacity of function.

• Acquisition of skills -myelination of

neurons

• Qualitative- It can be measured through

observation.
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-Brain, lymhpoid,gonads, somatic grow

at different rates
Changes in bodily proportions with age.
 Growth Patterns

The child’s pattern of growth is in a head-to-

toe direction, or cephalocaudal, and in
an inward to outward pattern called
proximodistal.
Growth Pattern
 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
 Percentile and SD
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
Correlation between percentile
and Z-score
The normal distribution
 Examples of Screening Risk
Factors

Anthropometrics: weight, Medical Conditions

length/height, BMI
•measures < 5th %ile Medications
•measures > 95th %ile
•alterations in growth Improper or inappropriate
patterns food/formula choices or
preparation
▫ change in Z-scores
▫ change 1-2 SD Psychosocial
▫ change percentile
channels Laboratory Values
GROWTH STANDARDS:
• International standards – NCHS (USA), CDC. WHO

• Country specific growth standards usually taken from

children of high socioeconomic strata of society Eg:
ICMR/ Agarwal et al 1992
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
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
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

• 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
Weight Gain (g/d) in one-month
increments – Girls and Boys
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
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
VELOCITY OF GROWTH :
• Serial measurements of growth parameters over
a period of time
• 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
Thanks
BEHAVIORAL DEVELOPMENT:
• 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 –lifts 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
 Sitting Up

Age 2
Age 8
months
months
 As an infant's vision develops, he or she may seem
preoccupied with watching surrounding objects and people
 Ambulation

13 month
old
Nine to 12-
months
 Head Control

Newborn Age 6
months
 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 after each feed

• 7 mths - no relation to feeds

• Toilet trainable by 18mths - 2 yrs

 Developmental Delay
• 3 Step diagnosis

– Clinical

– Screening tools

– Psychometric scales
Current research strongly supports the
observation that parents, regardless of
differences in socioeconomic status,
geographic location, or parental well-
being, can give accurate information about
their child's development.
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
• The Vineland Adaptive Behavior Scales
• The Pediatric Symptom Checklist
• The Battelle Developmental Inventory
Screening Test
• The Brigance Screens
• The Early Screening Inventory
• The Ages and Stages Questionnaires
The Denver The Bayley Infant
Developmental Screening Neurodevelopmental
Test- 20 to 30 minutes Screener- 3 to 24 months.
125 items four sections: Four areas:
• gross motor • Basic neurologic
functions -posture and
• fine motor/adaptive muscle tone
• Expressive -gross motor
skills, and oral or verbal
• personal/social
functions
• Receptive visual,
• language skills auditory, and verbal)
• Cognitive (ie, object
permanence, problem
solving).
 The Bayley Infant
Neurodevelopmental Screener
• Six item sets that are grouped according
to age (3-4 months, 5-6 months, 7-10
months, 16-20 months, 21-24 months)

• Each set contains approximately 11 to

13 items and takes between 15 and 20
minutes to administer and score. Items are
given a score of "optimal" or "nonoptimal
thanks