By Dr. Athal Luqman Humo

goal understand normal growth The goal of pediatric care is to optimize the growth and development of each child. Pediatricians need to understand normal growth, development, and behavior in order to monitor children's progress, identify delays or abnormalities in development, obtain needed services, and counsel parents. All who care for children must be familiar with normal patterns of growth and development so that they can recognize abnormal variations. 2

monitoring Periodically monitoring each child for the normal progression of growth and development & screening for abnormalities are important means of accomplishing this goal. 3

Are ― growth and ― development ‖ the same thing ? We often hear people refer to children’s growth and development. Are ― growth and ― development ‖ the same thing ? What does each of these terms mean? 4

increase in physical size Growth refers to an increase in physical size of the whole body or any of its parts. quantitative It is simply a quantitative change in the child ’ s body, such as: height, weight, head circumference, and body mass index. These size changes can easily be measured. 5

increase in function of processes related to body and mind.Development typically refers to an increase in function of processes related to body and mind. There is increase in complexity (a change from simple to more complex) Involves a progression in acquiring more refined knowledge, behavior, and skills. The sequence is basically the same for all children, however the rate varies. qualitativeIt is a qualitative change in the child’s functioning. It can be measured through observation. 6

7

Principles of Growth & Development Continuous process Predictable Sequence Don ’ t progress at the same rate (↑ periods of GR in early childhood and adolescents & ↓ periods of GR in middle childhood) Not all body parts grow in the same rate at the same time, body proportions follow a predictable sequence of changes with development. The head and trunk are relatively large at birth, with progressive lengthening of the limbs throughout development, particularly during puberty. The lower body segment is defined as the length from the symphysis pubis to the floor, and the upper body segment is the height minus the lower body segment. The ratio of upper body segment divided by lower body segment (U/L ratio) equals approximately 1.7 at birth, 1.3 at 3 yr of age, and 1 after 7 yr of age. Higher U/L ratios are characteristic of short-limb dwarfism or bone disorders, such as rickets 8

: Each child grows in his/her own unique way, there is wide individuals differences in growth pattern. G & D proceed in regular related directions :  Cephalo-caudal(head down to toes)  Proximodistal (center of the body to the peripheral) 9

Development proceeds from general to specific responses. e.g. react to stimuli with whole body and gradually learns to give specfic responses 10

Growth does not continue throghout life, it stops when maturity has been attained. While development continues throughout life and is progressive. GROWTH May or may not bring development e.g. a child may grow fat but by becoming fat no functional improvement may take place Development It is also possible without growth.e.g. a child may gain height, weight or size but can have functional improvement in other aspects 11

Factors affecting growth and development: Hereditary Environmental factors Combined 12

HeredityEnvironment COMBINED 13

Hereditary Factors Embryonic life begins with fertilized ovum, genetically determine by both parents, some children are small not because of endocrine or nutritional disturbances but because of their genetic constitution. (DNA) SEX: males usually are longer and heavier than females. RACE: some people have dark color, other too long… 14

Enviromental Factors  PRE NATAL ENVIRONMENT Factors related to fetus: Mechanical problems may be present leading to malposition in utero. Factors related to mothers during pregnancy: - Nutritional deficiencies - Diabetic mother - Exposure to radiation - Infection with German measles - Smoking - Use of drugs  POST NATAL ENVIRONMENT - socio-economic status of the family - child’s nutrition - climate and pollution - child’s ordinal position in the family - Number of siblings in the family - Family structure (single parent or extended family … ) - Family education & child’s intelligence - Hormonal influences - Emotion: mother infant bonding, parent child interaction, stimulation & care 15

16

Assessment of growth & development will provide insight into the general well being of the child & it include: 1.Assessment of physical growth-anthropometric measurments 2.Skeletal assessment. 3.Tissue growth assessment – SC fat- by skin fold callipers or by soft tissue radiography – Bone growth- by measuring bone width on wrist radiography – Muscle mass- using soft tissue radiography to distinguish muscle mass from SC fat & bone width. 4.Assessment of dental development-by counting the number of teeth erupted 5.Developmental assessment: it is useful to subdivide early childhood development into four functional skill: – Gross motor – Fine motor &vision – Speech, language & hearing – Social, emotional & behavior 17

Assessment of physical growth 18

Weight 1.newborn's weight may initially decrease 10% below birth weight in the 1st wk as a result of excretion of excess extravascular fluid and limited nutritional intake. Nutrition improves as colostrum is replaced by higher-fat breast milk, as infants learn to latch on and suck more efficiently, and as mothers become more comfortable with feeding techniques. 2.Infants regain or exceed birth weight by 2 wk of age and should grow at approximately 30 g/day during the 1st mo. This is the period of fastest postnatal growth. 19

3.The child will: – Double birth weight: 4-5 mo – Triple birth weight: 1 yr – Quadruple birth weight: 2 yr 4.Average weights: – At birth → 3.5 kg – At 1 yr → 10 kg – At 5 yr → 20 kg – At 10 yr → 30 kg 20

3.Daily weight gain: – g for first 3-4 mo – g for rest of the first yr 6.Average annual weight gain: a bout 2.25 kg between 2 yr and puberty. 21

Average length : 50 cm at birth 75 cm at 1 yr 87 cm at 2 yr 100 cm at 4 yr Then Ht increase 6m/ yr till puberty Height 22

Measuring height accurately in children. Measuring length in infants and young 23

Formulas for Approximate Average Height and Weight of Normal Infants and Children Age Wt (Kg) 3–12 mo Age(mo)+9/2 1–6 yr Age (yr) × –12 yr Age(yr)×7-5/2 Age Ht (cm) 2–12 yr Age (yr) ×

OFC OccipitoFrontal Circumference (OFC): measured from the supraorbital ridge in front to the farthest point of the occiput in back. Average HC: 35 cm at birth (13.5 inches) HC increases: 1 cm/mo for first yr – 2 cm/mo st 3mo – 1 cm/ mo nd 3mo – 0.5cm/mo for the next 6 mo – 10 cm for rest of life. 25

BMI The body mass index BMI is defined as body weight in kilograms divided by height in meters squared. The BMI is an index for classifying adiposity and is recommended as a screening tool for children and adolescents to determine whether an individual is: – Overweight: BMI above the 95th percentile for age – At risk for being overweight: BMI between the 85th and 95th percentile for age 26

CDC charts Growth is assessed by plotting accurate measurements on growth charts (Centers for Disease Control ”CDC” charts) and comparing each set of measurements with previous measurements. 27

28

29

30

31

32

33

34

Separate growth charts are available for: very low birth weight infants (weight <1500 g) Turner syndrome Down syndrome achondroplasia other dysmorphology syndromes. 35

What does "percentile" mean Percentiles rank the position of an individual by indicating what percent of the reference population the individual would equal or exceed E.g. If your 8-month-old son is in the 5th percentile for weight, that means 5% of 8-month-old boys weigh the same as or less than your baby, and 95% weigh more. If your baby is in the 50th percentile(median) for length, that means he falls right in the middle and is average length for baby boys his age. Median: is value above & bellow which 50% of the observations lie. 36

Analysis of Growth Patterns It is important to correct for various factors in plotting and interpreting growth charts: For premature infants, overdiagnosis of growth failure can be avoided by using growth charts developed specifically for this population. While VLBW infants may continue to show catch-up growth through early school age, most achieve weight catch-up during the second year and height catch-up by 2.5 yr of age 37

For children with particularly tall or short parents, there is a risk of overdiagnosing growth disorders if parental height is not taken into account or, conversely, of underdiagnosing growth disorders if parental height is accepted uncritically as the explanation. mid-parental height is calculated as follows: – Boys: [ Paternal height + Maternal height ] – Girls: [ Paternal height + Maternal height ] _

Assesment of Skeletal Growth An x-ray is taken of the left hand and wrist for the appearance of centers of ossification, it be the same as the chronological age if the child progress normally. In conditions such as hypothyrodism, malnutrition, constitutional delay of growth & puberty & growth hormone deficiency, bone age is delayed. Skeletal age may be advanced in thyrotoxicosis and precocious puberty. 39

40

Assesment of Tissue growth The forearm X-ray plates used for centers of ossification can used to measure the width of bone, muscle & subcutaneous fat. Subcutaneous fat under the skin of triceps, infrascapular area can be measured with skin fold calipers 41

Assessment of dental development Dentition assessed by counting the number of erupted teeth. Deciduous teeth are present from age 6 mo-2yr, and permanent teeth appear at 6-13 yr. 42

43

44