Normal Growth and Development in Children

Prof. Dr. Quah Ban Seng Department of Paediatrics MMMC

Objectives
Phases of growth in children Common anthropometric measurements Pubertal changes

Developmental milestones

Phases of Growth in Childhood

Fetal 30% Uterine environment 100 Infantile 15% Nutrition Good Health Thyroid hormones Childhood 40% Growth Hormone Thyroid Hormones Good Health Genes 1 2 Pubertal 15% Sex Hormones Growth Hormone

% Adult Height

85

45 30

Conception

Birth

Years

12

Anthropometric Measurements
Height Weight Head Circumference

Measuring Weight
>36 months weighed standing on scale Wearing lightweight clothing Recorded to nearest 0.01 kg

Stands on center of scale platform

Repositioned & measurement repeated

Readings agree within 0.1 kg

Weight Gain Infancy & Childhood

Term neonates: regain birth weight by 10 to 14 days Weight gain:
30 gm/day until 3 months of age 20 gm/day 3 and 12 months of age

Infants
Double birth weight by 4 months of age

Triple birth weight by 1 year of age

Children gain 2 kg/year between 2 years and puberty

Weight Charts

Frankfort Horizontal Plane

Line from most inferior point of orbital margin to left tragion
Tragion: deepest point in notch superior to tragus of the auricle

Align Frankfort plane 90 to stadiometer & parallel to headpiece

Movable head piece 90 to stadiometer

Hat/hair ornaments removed Head in line with head plate Horizontal axis of vision Fixed measuring device attached to wall (stadiometer)

Apply gentle traction beneath jaw to maintain position

Height Measurement Technique

Shoes off; heels together

Head, shoulders, buttocks, & heels in contact with vertical surface

Measuring Length
Recumbent Length:
<24 months of age or child 2 to 3 yrs (cannot stand unassisted)

No shoes, no hair ornaments & wearing light underclothing or diaper Measure length to nearest 0.1 cm Reposition and Repeat measurement Both readings agree within 1 cm
Length board with fixed headpiece & moveable footpiece 90 to surface of table

Length/Height Gain
Average length at birth (term) 50 cm 25 cm during 1st year of life 10 cm between 12 and 24 months 7.5 cm between 24 and 48 months Reach adult height by 24 to 30 months 4-5 cm/year between age 4 years and puberty

Upper segment/lower segment ratio

Birth 1.7 3 yrs 1.33 5 yrs 1.19 10 yrs 1.0

Lower segment: Top of symphysis pubis to plantar surface of the foot Upper segment: Sitting height

Length / Height Charts

Head Circumference
Recorded routinely until 2-3 years old Measure at end of physical examination Use a flexible, non-stretchable tape Encircle head 1 2 cm above glabella anteriorly & most prominent portion of occiput posteriorly (largest circumference)

Measurement read to nearest 0.1 cm Reposition tape & remeasure Measures agree within 0.2 cm

Head Circumference
Average at birth 35 cm Increases 1 cm/month 1st year

of life
Most rapid growth first 6 months

Weight for Length

<5th percentile undernutrition >95th percentile obesity Normal in constitutional growth delay or familial short stature

Body Mass Index (BMI)

Screening tool for undernutrition and to diagnose overweight and obesity <15th percentile "at risk" for undernutrition 85th to 95th percentiles overweight 95th percentile obese

Corrections for Gestational Age Premature Babies

Weight through 24 months of age Stature through 40 months of age Head circumference through 18 months of age

Special Growth Charts

Turner syndrome Down syndrome William syndrome

Achondroplasia

CDC versus WHO Growth Charts

Characteristic
Data Source

CDC (2000) Growth Reference US children

WHO (2006) Growth Standard

Brazil, Ghana, India, Norway, Oman, California

Data collection Cross-sectional data starting at age 2 mos, Mathematical models used to connect birth weights and lengths to survey data Sample size 4,697 observations for 4,697 distinct children

Longitudinal data with measurements at birth; 1, 2, 4, 6, and 8 wks; and 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, and 24 mos 18,973 observations for 882 distinct children

CDC versus WHO Growth Charts

Characteristic Exclusions CDC (2000) Very low birth weight (<1,500 g) WHO (2006) Low socioeconomic status Birth at altitude >1,500 m Birth at <37 wks or 42 wks Multiple birth Perinatal morbidities Child health conditions known to affect growth Maternal smoking during pregnancy or lactation Breastfeeding for <12 mos Complementary foods <4 mos or >6 mos Wt-for-length measurements >3 SD above or below study median for sex

CDC versus WHO Growth Charts

Characteristic CDC (2000) WHO (2006)

Breastfeeding Approximately 50% ever among infants breastfed in sample Approximately 33% breastfeeding at 3 mos

100% ever breastfed

100% predominantly breastfeeding at 4 mos 100% still breastfeeding at 12 mos

Complementary foods introduced at mean age of 5.4 mos

Mean length measurements of children aged <24 months WHO multicentre Growth Reference Study, 2006

Acta Paediatr Suppl 2006;450:56--65

Comparison WHO & CDC growth chart weight-for-age <24 months

Girls
Boys

Comparison WHO & CDC growth chart length/stature-for-age <5yrs

Girls
Boys

CDC Recommendations
WHO curves for children aged <24 months First 3 months of age slower rate of weight gain typical for formula fed infants Differences in the length-for-age WHO and CDC charts are small, and clinical differences based on these charts are expected to be insignificant

Height Velocity Curve

25 20 Pre-pubertal dip

Height Velocity mm/year

15

Pubertal Growth Spurt

10

5 Girls
1 3 5 7 9 11 13 15

Boys
17 19

Age (years)

Normal Pubertal Development

Maturation of the primary sexual characteristics
Hypothalamic Pituitary Ovarian Axis

Development of secondary sexual characteristics

Sexual hair, Breasts, Genitalia

Dramatic growth spurt Psychological changes: mental & emotional maturity

Female Breast Changes

B1 B2 B3 B4 B5

Prepubertal Elevation papilla only

Breast bud Elevation of breast & papilla small mound Areola diameter enlarged

Breast & areola enlarged & elevated, no separation of contours

Areola &papilla form 2 above contour of breast

Mature stage Papilla only projects, areola recessed to general contour of breast

Pubic Hair Changes

PH1 PH2 PH3 PH4 PH5

Preadolescent No sexual hair

Sparse, long slightly pigmented downy hair, base of penis or along labia

Darker, coarser, more curled Spreads over junction of pubes

Hair adult type Area covered smaller

Adult quantity & type Spread to medial thighs

PH6

Spread along linea alba (typical male)

Male Genital Changes

G1 G2 G3 G4 G5

Scrotum
Preadolescent slightly enlarged, reddening of skin, changes in texture Little /no enlargement more enlarged further enlargement, darkening of skin Adult size and shape

Penis
Preadolescent Slightly enlarged, 1st length then breadth further enlarged, growth in breadth; development of glans Adult size and shape

Testicular Volume
Genital Stage G1 G2 G3 G4 G5 Testicular Volume (ml) 12 34 810 1215 20

Prepubertal Beginning of puberty Beginning of height acceleration Maximum growth velocity Passed peak growth spurt Epiphysis fusion

Puberty Girls
Height spurt Menarche Breast Pubic hair
8 9 10 2 813 2 3 9.514.5

1016.5 4 5 1318 5

11

12

13

14

15

16

17

Age (years)

Puberty Boys
Height spurt
10.516 13.517.5 12.516.5 1215 ml 13.517 3 2 10 11 12 13 3 4 4 14 5 5 15 16 17

Penis Testis Genitalia rating Pubic hair

8 9 4 ml

10.514.5 9.513.5 2

Age (years)

Developmental Assessment
Early detection of deviation in childs pattern of development

Simple and time efficient mechanism to ensure

adequate surveillance of developmental progress

Developmental Pattern
Head-to-toe direction (cephalocaudal) Inward to outward pattern (proximodistal)

Principles of Development
Continuous process related to maturation of CNS Same sequence of development Different rate of development

Generalized mass activity replaced by specific individual responses Primitive reflexes lost before corresponding voluntary movement acquired

Developmental Domains
Gross motor Fine motor adaptive Language Personal Social Hearing Vision

Malaysian Modification of Denver Developmental Screening Test

PersonalSocial

10

50 Test Item

90

Fine MotorAdaptive
Language

May pass by report R

T Chen. Normal development of normal preschool children. J Spore Paed Soc 1988;30:118

Gross Motor

Gross Motor Assessment

Supine Pulled to sit Sitting

Prone

Ventral suspension

Standing

Supine
1 month
Head turn one side R Arm flexed

L Arm extended

Knees apart, soles of feet turned inwards

Supine
Waves arms symmetrically Hands loosely open Brings hands together from sides into midline

3 months

Head midline

Supine
6 months
Grasps 1 foot, later 2 feet
Lifts leg vertical Raise head from pillow to look at feet

Pulled to Sit
Newborn
Marked head lag

1 month
Head lags until body vertical At vertical head held momentarily erect before falling forwards

Pulled to Sit
Little or no head lag

6 months
Braces shoulders & pulls himself to sit

3-4 months

Sitting
Completely rounded back

1 month
Rounded back Head up intermittently

First 4 weeks

2 months
Back still rounded Raised head well

Sitting
4 months
Rounded lower lumbar spine

Sitting
Sit with hand support Sit without support

11 months

7 months

6 months
Pivoting

Standing
Bearing some weight

5 months
Bearing almost all weight Bears full weight

3 months
6 months

Standing
Stand with support Walk holding on

Walks, 1 hand held

Walks alone Arms abducted, elbows flexed Broad base gait

11 months

12 months 13 months

Ventral suspension
Head below plane of body Limbs hang downwards Hips fully flexed

Head in line with body Hips semi-extended

1 month
Head above line of body Hips & shoulders extended

Newborn
3 months

Pelvis high, Knees under abdomen

Prone

Pelvis flat; Hips extended

0-2 weeks
Pelvis lower, intermittent extension of hips

6-8 weeks

4-6 weeks

Chin off couch intermittently Plane of face <45 to couch

Prone
6 weeks

6 months
Weight on hands Arms extended

Weight on forearms Plane of face 90 to couch

3-4 months

Prone
9-10 months
Hands and knees crawling

12 months

Bear walking

5-6 months

Protective Reflexes
6-7 months
Lateral Parachute Arms extend laterally when child suddenly tilted sideways during sitting

9 months
Forward Parachute Arms extend when suddenly lowered towards couch

Downward Parachute Rapidly lowered; feet meet ground plantigrade

4-6 months

Grasp
7-8 months

Palmar grasp

1 year
Intermediate grasp

Mature grasp

Grasp
Index approach

9 months
Finger thumb opposition

Fine Motor
Age (months) 3 4 5 6 7 Milestones Grasp object when placed in hand Tries to reach object overshoots Reach & grasp; bidextrous approach Drops one cube when given another Unidextrous approach Transfers objects from hand to hand Grasp 2 cubes (one in each hand) Pincer grasp

Fine Motor
2 years Tower of Cubes Steps 4 years

18 mo
13-14 mo Steps 5 years

Train with chimney 4 years

Bridge 3 years

Fine Motor
Age (yr) 1 2 3 4 4 5 Milestone Imitates or scribbles spontaneously Imitates vertical line or circular strokes Copies circle Copies cross Copies square Copies triangle

Speech
Age (months) 1-2 2-6 8-9 10-12 15 18-20 Coos Laughs and squeals Babbles: mama/dada Mama/dada specific Jargon, several intelligible words 20 to 30 words 50% understood by strangers Milestones

22-24
30-36

Two word sentences >50 words, 75% understood by strangers Almost all speech understood by strangers

Personal Social
Age (mths) 1 3 Milestones Respond to cuddling React to familiar situations Shows pleasure to friendly handling Regards mothers face during feeding 6 9 Still friendly to strangers Stranger anxiety, plays peek-a-boo, imitates hand clapping

Watches while plaything partly hidden

Personal Social
Watches plaything completely hidden

9 months

Promptly finds it

Distressed (Cant find it)

Personal Social
9 months

Watches while toy hidden under cup

Regards & reaches for cup

Promptly finds toy

Personal Social
Plays pat-a-cake
Explores every possibility of bell

12 months

Hearing
1 month
startled by sudden noises turns head to voice

3 months
quieting or smiling to sound of mothers voice vocalizes delightedly when spoken to may turn eyes and/or head towards sound-source brows may wrinkle and eyes dilate

Development of Hearing
5 months Horizontal movement followed by vertical movement in localizing sound below ear

4 months Horizontal movement only in general direction of sound

6 months Arc-like movement in localizing sound below ear

7 months Diagonal movement in localizing sound below ear

Hearing
Age (mths)
3 Turns to sound source Turns to sound source Eyes look in same direction Turns to one side then downwards to sound made below ear

Milestone

5-6 6 7-8 8-10

(1 feet)
Turns to one side & then upwards to sound above ear Turns head in curving arc towards sound Turns head diagonally & directly towards sound

Free Field test

Tester Sound producing device Parent Distracter Child

Vision
Age (wks) Milestone

4
6

Follow dangling object (3ft from eyes) <90

Follow to midline

8
12

Follow beyond midline

Follow 180; hand regard

16

Regards dangling object immediately

6 months
Regards rolling ball 5-10 ft

Vision

Alert peripheral vision

9 months
Watches rolling ball 10 ft

Vision
12 months
Crawls to retrieve rolling ball

Points to mounted ball

Red Flags in Infant Development

Unable to sit alone by age 9 months Unable to transfer objects from hand to hand by age 1 year Abnormal pincer grip or grasp by age 15 months Unable to walk alone by 18 months Failure to speak recognizable words by 2 years