1. Dr Nishant Verma Assistant Professor Department of Pediatrics King George’s Medical University, Lucknow Normal Growth and Development

2. Definitions Growth – Increase in size or mass – Wt, Ht, HC Development – Maturation of functions – Motor, Language, Vision, Hearing

3. Growth

4. Why is it important ? Is my child normal ???

5. Laws of Growth 1.Growth is a continuous and orderly process Ovum0-14 days of gestation Embryo14d-9wk Fetus9wk-birth Newborn 1 st 4wk of life Infancy 1 st year Toddler1-3yr Preschool 3-6yr School age 6-12yr Adolescence 10-20yr

6. Laws of Growth 2.Growth pattern of every individual is unique – Order of growth is cephalocaudal and distal to proximal

7. Laws of Growth 3. Different tissues grow at different rates

8. Factors affecting growth Fetal Growth Post natal Growth

9. Fetal Growth Maternal Factors Sex Fetal Hormones Placental factors Fetal Growth Factors Genetic potential Nutrition Infections Age Built Complications T4, Insulin, GH, Glucocorticoids

10. Postnatal Growth Social Factors Nutrition Infections and Diseases Hormones Sex Genetic potential

11. Postnatal Growth Social Factors Infections and Diseases Hormones Nutrition Sex Genetic potential Parental Education Cultural Factors Emotional Factors Poverty

12. How to measure growth ?

13. Anthropometric measures Weight Length / Height Head circumference Chest circumference Mid upper arm circumference BMI Others: Arm span, US:LS ratio

14. Weight Minimum clothing Device Birth wt Double – 5mo Triple – 1yr Quadruple – 2yr 3 – 12 mo (Age in mo + 9)/2 1 – 6 yr 2 (Age in yr) + 8 7– 12 yr [7 (Age in yr ) -5]/2

15. Length / Height Age 0 -2 yr – length Age > 2yr – standing height Length at birth ~ 50cm 1yr ~ 75cm ; 2yr ~ 90cm Doubles How to measure 2 – 12 yr 6 x(Age in yr) + 77

16. Length / Height

17. Head/Chest/MUA circumference

18. How to interpret growth ? 4 yr boy Weight – 10kg Height – 85cm Head circ – 48cm

19. Growth Charts

20. 4 yr boy Weight – 10kg Height – 85cm Head circ – 48cm

21. WHO Growth Charts (2006) Study in 6 countries: developed & developing, Upto 5 years Wt for age, Ht for age, Wt for Ht, BMI, Head Circumference, mid arm, triceps, subscapular skin fold Only on breast fed babies with no environmental constraints to growth Cross sectional + longitudinal data Z scores

22. Z – scores Normal distribution Z = (Observed value - mean) / SD

25. How to differentiate acute from chronic malnutrition from growth chart ?

27. Development

28. Principles of Development 1.Development is continuous process 2.Sequence of development is same in all children, but rate of development varies 3.Generalised mass reflexes replaced by specific responses 4.Cephalocaudal direction 5.Early primitive reflexes lost

29. Domains of Development Gross Motor Fine Motor (Adaptive) Vision Social Hearing Language

30. Gross motor milestones Ventral Suspension Newborn – head flops down 4-12 wks – brings head to plane of body and then above plane of body Pull to sit 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

31. 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 Gross motor milestones

32. 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

33. Fine Motor 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 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

34. Hand eye coordination: 3 mths – Grasp reflex disappears 4 mths – tries to grasp red ring dangling in front but may overshoot 5 mths – reaches out & grasps object with ulnar side 6 mths – immature palmar grasp, transfers objects from hand to hand 9-12 mths – immature to mature pincer grasp Fine Motor milestones 5 mo 6 mo 7 mo 9 mo 12 mo

35. 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 Handedness Tower of cubes Fine Motor milestones Age Tower 15mo 2 18mo 3 2yr 6; Imitates Train 2.5yr 8; Imitates Train with chimney 3yr 9; Imitates Bridge 4yr Imitates Gate

36. Personal & Social Development 1 mth - regards face of mother/caretaker 2 mth - social smile 3 mths - recognizes mother/caretaker 6 mths - enjoys mirror 7-8 mths - separation anxiety 9 mths - waves bye-bye

37. 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

38. Developmental Screening Developmental Surveillance

39. 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