Growth & Development

Dr. A. William, SpA, M.Kes

Dr. Rismarini, SpA(K)
• Child and adult is different
• Child does not a little neither mini adult

• Specific characteristic of child are

Growing and developing

• Growth and development are different

process, but don’t stand alone and
connected each other
 Growth
• Growth is an increase in number and size of the
cell and intercellular tissue  increase in size of
the body
• Quantitative  countable, measurable
• In length unit, or weight unit
• Indicator : - Body weight
- Body length / body height
- Head circumference
- Upper arm circumference
 The principles of growth
1. Changes of the size
 increasing in body weight, body height

2. Changes of the proportion of the body

 head proportion, central point of the
body
 The principles of growth
3. Loosing the old characteristic
 thymus gland, decidual teeth, primitive
reflexes

4. Appearing of the new characteristic

 permanent teeth, external genital signs
 Phenomenon of growth

• Growth rapid is irregular, with fluctuation

in growth rapid

• Every organ has their own growth pattern

4 growth curve pola

1. General growth curve

2. Head and brain growth curve
3. Lymphoid tissue growth curve
4. Reproductive organ curve
 General growth
• Growth keep continuing regularly since
conception to adolescence, with
fluctuation in growth rapid
• Maximum rapid start from fetus, then keep
in decreasing while passing the infant
period
• Preschool’s growth is slow
• Adolescence’s growth is fast and end after
adolescence period is finish
Reproduction organ growth

• Grow slowly in the first year

• Growth rapidly in adolescence period

 secondary genital signs

• Grow very fast after body’s growth end

 General factors affecting the
course of GD

GD is a result of many factors interaction,

that can be divided into :

• Internal factors

• External factors
Internal factors
• Genetics
• Race, ethnic, nation
• Age
• Gender
• Family history
• Chromosomal abnormalities
 External (environment) factors
1. Prenatal factors :
- Maternal nutrition
- Placental problem (maternal hypertension,
toxaemia, bleeding, fetal intra-uterine growth
retardation)
- Infection and drugs in pregnancy
- Immunologic distubances
- Endocrine problem (DM, hypothyroidism)
- Radiation, Toxic, chemical substances
- Mother’s psychology
2. Perinatal factors :

* Birth complication
* Head trauma
* Asphyxia
3. Postnatal factors
- Illness - Cultural practices
- Chronic Infection - Health surveilance
- Nutrition - Drugs
- Endocrine problems (GH, insulin, thyroid,sexH)
- Socioeconomic factors
- Management of handicap
- Parental health & attitudes
- Education & opportunities in life (stimulation)
- Physical and chemical environment
Growth and Development
Phases
 Growth & Develoment phases

1. Prenatal period
– Embryonic period (1 - 8 weeks of gestational)
– Fetal period (9 weeks – birth)
2. Newborn (neonatal period) 0-28 days
3. Infant period (1-2 years)
4. Chilhood period
– Prescool period
– School-age period
– Adolescence period
 The newborn (Neonatal period)
(0-28 days of age)

• Birth weight average 3000 g (2500-4500g)

• Birth length average 50 cm (45-55 cm)
• Birth head cicumference 34 – 35 cm
• Transition from Intrauterine to extrauterin
• Soon after birth, alert and ready to interact
Age 0 - 2 months
• 1 st wk, weight may decrease (< 10 %)
• 2 nd wk, regain or exceed birthweight
• Grow + 30 g/day during the 1 st mo

• Age 2-6 months

Physical development :
• 3-4 mo, growth slows, + 20 g/day

• Age 6-12 months:

• Growth slows more (15 g/day)
 Preschool years (2-5 yr of age)
Physical development :
• Somatic and brain growth slows
• Average child gain + 2 kg/yr, and 7 cm/yr
 Schoolaged
Physical development :
• Growth 3 – 3,5 kg/yr, and 6 cm/yr
• Head grows 2 – 3 cm
• Loss of deciduous teeth, replacement by adult
teeth
• Lymphoid tissue hypertrophy
• Muscular strength, coordination & stamina
increase progressively
• Sexual organ physically immature, but interest in
gender differences
 Adolescence
• Rapid changes in body size, shape,
physiology, psychologic, ans social
functioning
• Hormones set the development agenda
• Transition from childhood to adult
• Three distinct periods : early, middle, and
late
 Early adolescence
Biologic development :
• Production of androgen  development of
underarm odor and genital hair (adrenarche)
• GnRH, LH, FSH, androgen and estrogen
increases
• Somatic & physiologic changes gives rise to the
Sexual Maturity Rating (SMR) or Tanner stages
 key stages of breast, pubic hair, and testicle
and penile development
Perkembangan bentuk dan ukuran payudara (Dikutip dari Fig.14-2,
Behrman et al, Nelson textbook of Pediatrics, 2000, hal.54)
Perkembangan rambut pubis (Dikutip dari Fig.14-1, Behrman et al,
Nelson textbook of Pediatrics, 2000, hal.53)
Perkembangan bentuk dan ukuran genitalia (Dikutip dari Fig.18-14,
Vaughan & Litt: Child Adolescent Development: Clinical
Implication, 1990, hal.250)
Girls :
• 8 – 13 yr, the first visible sign of puberty is
the appearance of breast bud
• 9 – 16 yr, menarche, around the peak in
height velocity
Boys :
• 91/2 yr, testicular enlargement
• Breast hypertrophy occurs in 40 – 65% of
pubertal boys
• Growth acceleration begin in early
adolescence, but peak growth velocities
are not reached until SMR 3 or 4.
• Boys typically peak 2-3 yr later than girls,
and continue their linear growth for + 2-3
yr after girls have stopped
• Adrenal adrogens stimulate the sebaceous
glands  development of acne.
Middle Adolescence
Biologic development :
• Growth accelerates, rate of 6-7 cm/yr
• In girls, the growth spurt peaks at 11,5 yr
at a top velocity of 8,3 cm/yr, and then
slows to a stop at 16 yr.
• In boys, the growth spurt starts later,
peaks at 13,5 yr at 9,5 cm/yr, and then
slows to a stop at 18 yr.
• Weight gain parallels linear growth
• Muscle mass increases, follow by an increase in
strength
• Menarche,
in 30% of girls by SMR3 (+ 12-14 yr), and
in 90% by SMR4 (+ 13-15 yr)
 Late Adolescence
Biologic development :
• The somatic changes are modest by
comparison
• The final stages of breast, penile, and
pubic hair occur by 17-18 yr of age in 95%
adolescents
Normal Child

Rismarini
 Body Weight
• Birth weight for full term baby : 2.500 – 4.000 g
• Low birth weight : < 2.500 g
• Lose weight in the first week < 10 % BW
• BW regained in the second week
• First 6 mo : gain of 150-250 g/wk
 6 mo : 2 x birth weight
• 6-9 mo : 90-150 g/wk
• 9-12 mo : 60-90 g/wk
 12 mo : 3 x birth weight
• Second year : 40 g/wk
Age Body weight (kg)
Newborn 2,5 – 4,1 kg
5-6 mo 2 x birth weight
1 yr 3 x birth weight
2 yr 4 x birth weight
3 yr 5 x birth weight
> 3 yr 2n+8
Catch-up growth
• When a child has had an illness or period of
starvation and is then restored to health, he
shows catch-up growth  his growth rate is far
more rapid than normal until he has caught up to
the point which he would have reached but for
his illness.
• If the cause of the delayed growth lasts for a
long time, he may never catch up.
• The longer the illness lasts, the greater is the
eventual retardation, and the more the weight is
below its own growth curve
Body length / height

Age Body height / length

Newborn + 50 cm
1 yr 1,5 x birth length
4 yr 2 x birth length
5 yr 2 x birth length + 5 cm
13 yr 3 x birth length
Growth & Development
Assessment
 Growth Assessment
• Growth chart (body weight, body length,
stature, head circumference)
• Body proportions
• Skeletal maturation
• Dental development
• Sex Maturity
 The measure of linear growth
• The measure of linear growth for infants is
length, taken with the child supine on a
measuring board
• The measure for older
children is stature,
taken with a child
standing on a
stadiometer
 Growth Chart
• The standard growth charts from CDC
(WHO)
• Presented in 4 standard chart :
1. Weight for age
2. Height/length for age
3. Weight for height
4. Head circumference for age
• Separated chart for boys and girls
 Growth chart
• Each chart is composed of 7 percentile curves,
representing the distribution of weight, length,
stature, or head circumference value at each
age
• The precentile curve indicates the percentage of
children at a given age on the x-axis whose
measured value falls below the corresponding
value on the y-axis
• The 50th percentile is the median, it is also
termed the standard value (100%)
• The chart are useful because they facilitate
assessment of growth over time
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=RENTANG NILAI NORMAL
PENCATATAN
 Data yang diperlukan
• Usia
• Jenis kelamin
• Ras
 Teratur

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Harga mean dan SD pada kurva normal Gauss
 Proporsi tubuh

TABEL : SELISIH TINGGI BADAN

UPPER DAN LOWER SEGMEN
DAN RENTANG LENGAN ±
2,5-4 CM
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Genetic target height (Potensi tinggi genetik):

• Boy : (MH + 13) + FH ± 8,5 cm

2
• Girl : (FH - 13) + MH ± 8,5 cm
2

MH : mother’s height
FH : father’s height

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Analysis of growth patterns
• Growth is a process rather than a static
quality.

• An infant at the 5th percentile may be :

- growing normaly,
- failing to grow, or
- recovering from growth failure,
depending on the trajectory of the growth
curve
• Typically, infants and children stay within
one or two growth channels

• A normal exception commonly occurs

during the 1st 2 yr of life

• This canalization attest to the robust

control that genes exert over body size
Full term infants
:
• Size at birth reflects the influence of the
uterine environment
• Small neonates often shift percentiles
upward, large neonates often shift
downward to their parent’s mean
percentile
• Shift up/downward ending as an infants
achieves a new growth channel (+ 13 – 18
mo)
• Size at 2 yr correlates with mean parental
height, influence of the genes
 Premature
infants :
• Overdiagnosis of growth failure can be
avoided by subtracting the weeks of
prematurity from the post natal age when
plotting growth parameters
• Very low birthweight (<1.500 g) infants
may continue to show catch-up growth
through early school age
• Weight-for-age curve below 5th percentile
is indicator of acute undernutrition
• In chronic undernutrition may be short as
well as thin, height-for-age curve
drops (stunting), whereas the weight-for-
height curve may appear relatively normal
• Chronic and severe undernutrition can
also depress head growth, an aminous
predictor of later cognitive disability
• Typically, infants and children stay within
one or two growth channels
• Growth parameter < 5th percentile
necessary to express the value as
percentages of median or standard value

• Growth failure can be graded from mild to

severe

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 Growth parameter < 5th
percentile
• Necessary to express the value as
percentages of median or standard value
• Growth failure can be graded from mild to
severe
Grade of Weight for Height for Weight for
Malnutrition Age Age Height
(wasting) (stunting)
0, Normal 90 95 90
1, Mild 75 – 90 90 – 95 81 – 90
2, Moderate 60 – 74 85 – 89 70 – 80
3, Severe < 60 < 85 < 70
CONTOH MONITORING

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GAGAL
TUMBUH

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Perawakan dan pertumbuhan

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Yang mana yang bermasalah ?
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Umur 7 tahun Berat
badan 15 kg
Tinggi badan 112 cm

BERAT BADAN IDEAL : ?

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 Body proportion

• The head and trunk are relatively large at birth

• Proportionality can be assessed by measuring
the Lower body segment (from symphysis pubis
to the floor), and the Upper body segment (the
height – the lower body segment)
• U/L ratio + 1.7 at birth, 1.3 at 3 yr, and 1.0 after
7 yr
• Higher U/L ratio are characteristic of short-
limb dwarfism, or bone disorder such as rickets
 Skeletal Maturation
• Bone age correlated well with stage of
pubertal development and can be helpful in
predicting adult height in early or late
maturing adolescents.
• In familial short stature the bone age is
normal (comparable to chronologic age)
• In constitutional delay, endocrinologic short
stature and undernutrition, the bone age is
low and comparable to the height age
• The most commonly used standards are
those of Gruelich and Pyle, which require
radiographs of the left hand and wrist
• Skeletal maturation is linked more closely
to sexual maturity rating than to
chronologic age
• It is more rapid and less variable in girls
than in boys
 Sexual maturity
• Sexual Maturity Rating (SMR) or Tanner
stages based on somatic changes
• In boys : pubic hair, penis and testis
• In girls : pubic hair and breasts

• The first visible sign of puberty in girls is the

appearance of breast buds, between 8 -13 yr
• In boys, testicular enlargement begins as
early as 9 ½ yr
Short Stature

Rismarini
 Short stature

• Defined as a height below the 2nd

percentile
• Most such children will be normal, but the
further the child is below these centile, the
more likely it is that there will be a
pathological cause

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• The rate of growth may be pathological
long before a child’s height falls below this
value
• This growth failure can be identified from
the child’s height falling across centile
lines, even though the height is still above
the 2nd centile
• The height centile of a child must be
compared with the weight centile and an
estimate of their genetic target centile and
range calculated from their parents height
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Genetic target height :

• Boy : (MH + 13) + FH + 8,5 cm

2
• Girl : (FH - 13) + MH + 8,5 cm
2

MH : mother’s height
FH : father’s height
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Potensi tinggi
genetik

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• Most children are psychologically well
adjusted to their size

• May be problems from being teased or

bullied at school, poor self-esteem, and
disadvantage in competitive sport

• They are also assumed to be younger

than their age, and treated inappropriately

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 Causes
• Familial
• Intrauterine growth restriction (IUGR), and
extreme prematurity
• Nutritional / chronic illness
• Constitutional delay of growth and puberty
• Endocrine (hypothyroidism, GH deficiency
and steroid excess)
• Psychological deprivation
• Chromosomal disorder/syndrome
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 Familial short stature

• Most short children have short parents,

• The height falls within the centile target

range allowing for mid-parental height

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 IUGR and Extreme prematurity

• About 1/3 of children born with severe

IUGR or extreme prematurity remain short

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 Nutritional / chronic illness
• Common causes of abnormal growth
• Children ussually short and underweight
• Inadequate nutrition may be due to
insufficient food, restricted diet or poor
appetite associated with a chronic illness,
or from the increased nutritional
requiretment from a raised metabolic rate

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 Chronic illness include:

• Undernutrition
• Tuberculosis
• Congenital heart diseases
• Chronic renal failure
• Anemia
• GIT diseases

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 Constitutional delay of growth &
puberty
• This children have delayed puberty, which
is often familial
• Ussually having occured in he parent of
the same sex
• It is a variation of the normal timing of
puberty rather than abnormal condition
• It may also induced by dieting or exessive
physical training
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 Endocrine

• Hypothyroid
• GH deficiency
• Steroid excess

are uncommon causes of short stature

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 Psychological deprivation

• Children subjected to physical and

emotional deprivation may be short and
underweight, and delayed puberty
• May be difficult or imposible to identify
• Affected children show catch-up growth if
placed in a nurturing environment

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Chromosomal disorder/syndromes

• Down’s syndrome
• Turner’s syndrome
• Noonan’s syndrome

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 Making diagnosis

• Plotting present and previous height and

weight on growth charts
• Clinical feature
• Full blood count
• Mantoux test
• Chest x-ray
• Bone age

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 Treatment

• Depending on the cause

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