GROWTH

DR OMAR ALI NAFI MRCP

Mutah university

Definition

Its an increase in the size of the body and it can

be easily measured. While development is an
increase in the function of processes related to
body and mind.
Growth is the best general index of the health of
an individual child. It permits early detection of
malnutrition

Growth rates

Height.
Neural growth.
Lymphoid tissue.
Genital growth
Fat.

Height

The rate of growth in height is not

constant throughout childhood.
it is at its greatest when the child is
born
3-10years growth in height is
comparatively slow and steady
The adolescent growth spurt
commences just before puberty , this
rapid rate continues during puberty,
followed by sharp deceleration falling
to zero when adult status is reached.

Nueral growth

It represent particularly the brain.

The human brain growth spurt begins in mid-pregnancy
and is largely complete by the third year.
In fact there
are two spurts:
Neural cell multiplication occurring between 15& 20 weeks
gestation.
Glial cell multiplication starting at 25 weeks and extending
into the second year with myelination continuing into the
third or forth years.

Lymphoid tissue
It grows progressively throughout
childhood but ceases at the age of 10-12
years, before the puberty growth spurt. ,
these changes can be watched in the
tonsils which are barely visible at birth,
becomes very obvious by the age of 4-5
years and get smaller in the early teens

Genital growth
Growth is minimal during infancy and
childhood but becomes very rapid with the
onset of puberty.

Fat
It increases rapidly during the first 12 months
of life, being followed by a small steady loss until
the age of 7 years; thereafter the amount of fat
remains constant until its pre-pubertal spurt
which occurs before that of bone and muscle.
The increase in the amount of fat during the
childs first year is of vital importance as to
whether or not the individual becomes obese.

Nutrition and growth

Its difficult to assess the

influence of nutrition on
growth since it is seldom
the only factor involved
Retardation of growth
occurs only if malnutrition
is severe

During a period of illness or starvation the

rate of growth is slowed , but after the
incident is over and adequate diet is
maintained , the child grows more rapidly
than usual so that he catches up to his
original growth curve .
When caloric intake is inadequate, the weight
percentile falls first, then the height and last
the head circumference.

Hormones and growth

Hormonal control during childhood is brought

about by thyroxine and growth hormone
working synergistically thyroxine
predominantly required for skeletal
maturation. And growth hormone for linear
growth.
The adolescent growth spurt is largely brought
about in boys by the rise in adrenal and
testicular androgens.

The adolescent growth spurt in girls is brought

by the rise in ovarian oestrogens together
with adrenal androgens and oestrogens.

Anabolic steroids, androgens and oestrogens

accelerate bone age more than height,
thereby causing the ultimate height to be less
than expected.

Rules of thumb for growth.

Weight:

1- weight loss in first few days: 5%-10% of birth weight.

2- return to birth weight: 7-10days of age
double birth weight: 4-5 months
triple birth weight: 1 year
quadruple birth weight:2 years
3- average weights : 3.5kg at birth
10kg at 1year
20kg at 5 years
30kg at 10 years
4- daily weight gain: 20-30g for first 3-4 months
15-20g for rest of the first year

Height:

1- average length: 50 cm at birth,

2- 75cm at 1 year.
3- at age 4 years, the average child is 100
cm tall( double birth length)
4- average annual height increase : 5-6
cm between age 4 years and puberty.

Head circumference (HC):

1- average HC: 35cm at

birth.
2- HC increases:
1cm/month for first year
( 2cm/month for first 3
months, then slower);
10cm for rest of life.

Growth monitoring

The AAP recommends routine office visits in the :

1. 1st week of life ( depending on
nursery discharge)
2. At 2 weeks
3. At 2,4,6,12,15,and 18 months.
4. At 2 years and then annually up to
the age of 6
5. Every 2 years between age 6 and
adolescence
An accurate measurement of the height, weight and head
circumference should be obtained at every health supervision
visit. Then they are compared with the statistical norms in a
standard fashion on growth charts.

When plotting growth, serial

measurements are much more useful
than single measurement because they
can detect deviations from a particular
childs growth pattern even if the value
remains within the statistically defined
normal limits (i.e between the 3rd and
the 97th percentile)

How to asses?!!

Growth Charts:
-Using these charts, health care
providers can compare growth in
infants, children, and adolescents with
a nationally representative reference
based on children of all ages and racial
or ethnic groups.

- Available growth charts: (CDC, 2000)

- for 0-36 months:
1. weight for age
2. length for age
3. head circumference for age
4. weight for length

- For ages 2-20 years:

1. weight for age
2. height for age
3. BMI for age
- for premature infants:
1. length-for gestation- adjusted age
2. weight for-gestation-adjusted age

Premature Girls :
Length to age

Premature Girls :
weight to age

Premature Boys:
Length to age

Premature Boys:
weight to age

Interpretation

What the percentiles mean?

How useful is each chart? And what are

the significant values?

What the Percentiles Mean?!

When you look at the standard growth charts,

you will see seven curves that follow the same
pattern. Each curve represents a different
percentile: 5th, 10th, 25th, 50th, 75th, 90th,
and 95th. The 50th percentile line represents
the average for a particular age group. The
child's measurements will be plotted on the
charts, so that yo can see how your child's
measurements compare to the average for his
or her age group.

Examples:

1. If the measurement for an infant's head circumference

is in the 90th percentile, that means that the child's
head measurement is greater than about 90% of
children that age in the country. Only 10% of infants
that age have head measurements that exceed those of
that infant.

2. If a 4-year-old's weight at a checkup is at the

20th percentile, that means about 80% of
children that age weigh more than that child, and
20% of kids in the country weigh less than that
child.

BMI for age :

- Its an index for classifying adiposity
- If the BMI is between the 85th and 95th
percentiles the child is at risk for being
overweight
- IF the BMI is > 95th percentile the child is
overweight.

Factors affecting growth

pattern

Gestational age
Birth weight
Parental stature: is considered before
assuming there is a health or nutrition
concern.
Presence of a chronic illness
Special health care need

puberty

Definition
Puberty from Latin 'pubes" meaning hair.
Refers to the process of physical changes by
which a child's body becomes an adult body
capable of reproduction.
Transitional stage from childhood to adulthood
manifested by physiological changes &
development of SSC.
The normal age of puberty :
1- in male : about 14 years
2- in female : about 12 years

The cause of this GnRH rise is complex. Puberty begins at

around 47 kg for girls and 55 kg for boys.
This dependence on bodyweight makes leptin a good
candidate for causing GnRH rise.
The levels of leptin change in line with the onset of puberty,
and then decline to adult levels.

A simple description of hormonal puberty is :

The brain's hypothalamus begins to release pulses of GnRH.
Cells in the anterior pituitary respond by secreting LH and FSH
into the circulation.
The ovaries or testes respond to the rising amounts of LH and
FSH by growing and beginning to produce estradiol and
testosterone

Rising levels of estradiol and testosterone produce the

body changes of female and male puberty.
The onset of this neurohormonal process may precede
the first visible body changes by 1-2 years.

Physical changes in
males

1-Testicular size, function,

and fertility

In boys, testicular enlargement is the first physical

manifestation of puberty
Testes in prepubertal boys change little in size from
about 1 year of age to the onset of puberty,
averaging about 23 cc in volume and about 1.52 cm in length. Testicular size continue to
increase throughout puberty, reaching maximal
adult size about 6 years later.While 18-20 cc is an
average adult size, there is wide variation in the
normal population

The testes have two primary functions:

1- to produce hormones
2- to produce sperm.
The Leydig cells produce testosterone , which
in turn produces most of the changes of male
sexual maturation and maintains libido .
However, most of the increasing bulk of
testicular tissue is spermatogenic tissue

Sperm can be detected in the morning urine of most

boys after the first year of pubertal changes
Potential fertility is reached at about 13 years old in
boys, but full fertility will not be gained until 14-16
years of age.

2-Pubic hair
Pubic hair often appears on a boy shortly after the
genitalia begin to grow..
the hair growing continue till it spread the thighs and
upward towards the umbibilicus as part of the
developing abdominal hair.

3-Body and facial hair

Other areas of skin which respond to androgens
develop heavier hair (androgenic hair) in
roughly the following sequence: axillary hair,
perianal hair, upper lip hair, preauricular hair,
and the rest of the body area.
There is a large range in amount of body hair
among adult men, and significant differences
in timing and quantity of hair growth among
different ethnic groups

4-Voice change

Under the influence of androgens, causes

hypertrophy of the laryngeal mucosa
and enlargement of larynx
Voice may start cracking for a period of time
but gradually change into the typical
adult voice

5-muscle development and

body shape

6-Body odor, skin changes,

acne
Rising levels of androgens can change the fatty acid
composition of perspiration, resulting in a more
"adult" body odor.
Skin becomes more oily , and more thickness
Body will sweat more.
Acne may develop

Physical changes in
females

1-Breast development
The first physical sign of puberty in females is usually a firm,
tender lump under the center of the areola of one or both
breasts, occurring on average at about 10 years of age.
Within six to 12 months, the swelling has clearly begun in
both sides, softened, and can be felt and seen extending
under the edges of the areola .
By another 12 months , the breasts are becomes mature
size and shape .there is so much variation in sizes and
shapes of adult breasts

2-Hair:
increased activity of the suprarenal cortex at puberty with
increased production of adrenal androgens which lead
to appearance of pubic and axillary hair
Hair growth begins shortly after breast development .

3- Vagina, uterus, ovaries

The mucosal surface of the vagina also changes in

response to increasing levels of estrogen,
becoming thicker and a more pink in color
Whitish secretions are a normal effect of estrogen as
well.
The uterus and ovaries increase in size, and follicles
in the ovaries reach larger sizes.

4- Menstruation and fertility

The first Menses is referred to as menarche.
Menses are not always regular and occures monthly and last
from 3 to 7 days .
Ovulation is necessary for fertility, but may or may not present
in The first Menses.

4- Body shape, fat distribution, and body

composition

During this period, also in response to rising levels of

estrogen, the lower part of the pelvis and hips widen.
Fat tissue increases to a greater percentage of the body
composition than in males, especially in the typical
female distribution of breasts, hips, buttocks, thighs,
upper arms, and pubis.

5- Body odor, skin changes, and acne

Rising levels of estrogen can change the fatty acid
composition of perspiration, resulting in a more "adult"
body odor.
Skin becomes more oily.
Body will sweat more.
Acne may develop

Emotional Changes:
sexes

In both

Start to care more about what others think.

Want to be accepted and liked.
Often begin to separate from parents and
identify more with friends.
May become self conscious about these growth
changes (too tall, too short, too fat, too thin).

precocious puberty

appearance of any of the secondary sexual

characters before the age of
8 years in females and
9 years in males

in females

this is usu idiopathic or familial and follows the

normal sequence of puberty ,
the organic causes are rare and
are ass w :

dissonance when the sequence of pubertal changes is

abnl , eg: isolated pubic hair with virilisation of the
genitalia , suggesting excess androgen
rapid onset
neurological symptoms and signs , eg :
neurofibromatosis

in males

this is uncommon and usu has an organic cause

examination of the testes may be helpful :

bilateral enlargement suggest gonadotrophin

release

small testes suggest an adrenal cause

a unilateral enlarge testis suggest a gonadal tumor

causes of precocious puberty:

1)

gonadotrophin dependant = (central , true )

(inc LH, FSH )

familial /idiopathic
CNS abnormalities
congenital anomalies , eg: hydrocephalus
acquired , eg: post irradiation , infx
hypothyroidism
2) gonadotropin independent = (peripheral , false )
(dec LH, FSH)
adrenal disorders - tumors, congenital adrenal hyperplasia
ovarian tumors
testicular tumors

delayed puberty
- the absence of pubertal development by 14 years
of age in females and 15 years in males
in contrast to precocious puberty , the problem is
common in males , in whom it is mostly due to
contitutional delay

causes of delayed puberty :

1) constitutional delay of growth and puberty

2) high gonadotrophin secretion
- chromosomal abnormalities ( klinefelters syndrome.turners syndrome)
- steroid hormone enzyme deficiencies
- acquired gonadal damage
3) low gonadotrophin secretion
- Systemic disease: cystic fibrosis , severe asthma , crohns disease , anorexia
nervosa
- Hypothalamopituitary disorders: panhypopituitarism , intracranial tumors,
- kallmanns syndrome (LHRH dificiency and inability to smell )

Thank you