Dr Nishant Verma Assistant Professor Department of Pediatrics

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

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 Ovum 0-14 days of gestation Embryo 14d-9wk Fetus 9wk-birth Newborn 1st 4wk of life Infancy 1st year Toddler 1-3yr Preschool 3-6yr School age 6-12yr Adolescence 10-20yr

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

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

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

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

19. Growth Charts

20. Growth Charts 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 • Development is continuous process • Sequence of development is same in all children, but rate of development varies • Generalised mass reflexes replaced by specific responses • Cephalocaudal direction • Early primitive reflexes lost

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

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. Gross motor milestones 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

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. Fine Motor milestones 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 9 mo 5 mo 7 mo 6 mo 12 mo

35. Fine Motor milestones 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

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 - vowelsounds, 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