GROWTH AND

DEVELOPMENT
Edward M. Santos, MD
 RATIONALE

Monitor children’s progress

Identify delays or abnormalities in
development
Counsel parents and prescribe treatment
 OUTLINE
Overview and Assessment of
Variability
Fetal Growth and Development
The Newborn
The First Year
The Second Year
Preschool Years
Middle Childhood
Adolescence
Assessment of Growth
Developmental Assessment
 DEFINITION OF TERMS

•Growth – process by which a living being

and any of its parts increase in size and
mass, either by multiplication or by
enlargement of component parts
•quantitative
•Development – enhancement of function,
skills and maturation
•qualitative
I. Overview

Genetics (nature)
Environment (nurture)
Both
Ex: height – genetic endowment
(biologic), personal habits of eating
(psychologic), and access to nutritious
food (social)
Biologic Influences

Genetics
Role of Teratogens
Postpartum illnesses
Exposure to hazardous substances
Maturation
Psychologic Influences
Attachment – tendency of a young child to seek
proximity with the parent during times of stress
Also refers to the relationship that alows securely
attached children to use their parents to reestablish a
sense of well-being after a stressfull experience
Contingency – when adult caregivers pay
attention to the verbal and non-verbal cues of
children and respond to them accordingly
Social Factors

Family Systems – role of parents; parent-

child dyad
Ecologic Model – parent-child dyad at
the center with the larger society at the
periphery
Developmental Domains and
Theories of Emotion and Cognition
Psychoanalytic Theories
The stages of development are qualitatively different
epochs in the development of emotion and cogniton
Freud, Erikson, and Piaget

Behavioral Theories
gradual modification of behavior and accumulation
of competence
BF Skinner
Classic Stage Theories
Theory Infancy (0-1) Toddlerhood Preschool School Age Adolescence
(2-3) (3-6) (6-12) (12-20)

Freud Oral Anal Oedipal Latency Adolescence

Erikson Basic Trust Autonomy vs Initiative vs Industry vs Identity vs

shame and Guilt Inferiority Identity
doubt confusion

Piaget Sensorimoto Sensorimoto Preoperation Concrete Formal

r r al operations operations
(Stages 1- (Stages
IV) V,VI)
Behavioral Theory

Skinner
Focuses on observable behaviors and
measurable factors
No stages
 A child’s developmental
level is the end result of a wide
variety of factors, namely:
prenatal, perinatal and
postnatal.
II. Fetal Growth and Development
Milestones of Prenatal Development
Week Developmental Events
2 Fertilization and Implantation
3 Endoderm and ectoderm appear
3 Mesoderm appears
4 Neural folds fuse
6 Lens placodes
7 Eyelids begin
8 Ovaries and testes are distinguishable
9 External genitals distinguishable
10 Usual lower of viability
11 Eyes open
37 Term
GROWTH PERIOD APPROXIMATE AGE

• PRENATAL
Ovum 0-14 days
Embryo 14 days – 9 wk
Fetus 9 wks - Birth

• BIRTH 37 – 42 wks
 3 PHASES (INTRAUTERINE
DEVELOPMENT)
• Ovular Phase
Fertilization  Implantation
• Embryonic Phase
2nd week  3rd month
“organogenesis”
• Fetal Phase
3rd month  Birth
“differentiation/maturation”
 OVUM
(0-14 days)
• characterized by increase in
complexity and cell multiplication
• little increase in total size
• self sufficient
• food stored in yolk sac
 EMBRYO
(14 days – 9 wks)
• parasitic
• derives nutrition from
maternal origin
• rapid differentiation
• all organ systems established
 FETUS
(9 weeks – Birth)

• early functional activities

apparent
• increase in body mass most
pronounced
 BIRTH

• parasitic existence
terminated
• greatest risk to life
• initiation of respiration, own
circulation, etc.
III. The Newborn

Adaptation to extrauterine life

requires rapid and profound
physiologic changes
This includes aeration of the lungs,
rerouting of the circulation and
activation of the GI tract
Behavioral states: quiet sleep, active
sleep, drowsy, alert, fussy, and crying
Newborn Behavior Assessment
Scale (NBAS) by Brazelton
provides a formal measure of an
infant’s neurodevelopmental
competencies
Also used to demonstrate to parents
an infant’s capabilities and
vulnerabilities
Correlates well with improvements in
the caretaking environment
IV. The First Year

Characterized by rapid growth

Acquisition of new competencies
Psychological reorganization
0-2 months

Physiologic weight loss

Average weight gain: 30g/day
Six behavioral states
Crying: peaks at 6 weeks of life
Healthy infants cry up to 3 hr/day
Trust vs mistrust
2-6 months

Emergence of social smile

Growth rate: 20g/day
Sleep requirement: 14-16 hr/day
Social hatching
Face to face interactions
6-12 months
Increased mobility and exploration of the
inanimate world
Slower growth
Increased myelinization and cerebellar
growth
Appearance of the pincer grasp (around 9
mo)
Object constancy (about 9 mo)
Appearance of tantrums
Dentition
V. The Second Year

Age 12-18 months

Slower growth rate
Independent walking
Receptive language precedes
expressive
Points to major body parts (15 mo)
18-24 months
Incremental motor development
Balance and agility
Object permanence is firmly established
Cause and effect is better understood
Rapprochement – increased clinginess
around 18 mo
Use of transitional objects
Linguistic development – most dramatic
(vocabulary balloons from 10-15 words to
100 words or more)
VI. Preschool Years

Between 2 and 5 years

Widening social sphere
Stubborn opposition and cheerful
compliance
Adaptation to new rules and
relationships
Physical Development

Slower somatic and brain growth

2 kg per year and 7 cms per year
Average sleep: 11-13 hr
Visual acuity at 20/20 at 4 years old
All primary teeth: 3 yr
Handedness at 3 yr
Bowel and bladder control
Language, Cognition and Play

Most rapid language development

Vocabulary expands from 100 to
2000 words
Mental retardation may first become
apparent with delayed speech at 2 yr
old
Developmental dysfluency and
stuttering
Preoperational stage: magical
thinking, egocentrism, and thinking
that is dominated by perception
Play is marked by increasing
complexity and imagination
VII. Middle Childhood

6-12 years
Increased separation time from
parents
Seeks acceptance from teachers and
other adults
Central issue: self-esteem
Production of socially valued outputs
Industry and inferiority
Physical Development

3-3.5 kg/yr, 6 cm/yr

Myelinization is complete by 7 years
old
Loss of deciduous teeth
Sexual organs remain physically
immature
Body habitus remains relatively stable
Cognitive and language
development
Concrete logical operations
Increasing cognitive demands in
school
Mastery of the elementary curriculum
Social and Emotional Development

Proceeds in 3 contexts: home,

school, neighborhood
Home remains the most influential
Conformity
VIII. Adolescence

10-20 years
Accelerated growth ( height and
weight)
Appearance of secondary sexual
characteristics
 ADOLESCENT GROWTH SPURT

Period characterized by rapid increase

in size of the body and other organs

WEIGHT SPURT
- rapid gain in weight noted at
adolescence

HEIGHT SPURT
- rapid increase in height observed at
adolescence
In girls: appearance of breast buds is
the first sign of puberty ( usually
between 8 and 13 years)
In boys: testicular enlargement
PHYSICAL GROWTH
Height Growth
Height velocity increases and peaks
during the adolescent growth spurt

Pubertal growth accounts for 20-25% of

final adult height

The average growth spurt lasts 24-36

months

The growth spurt is highly variable from

adolescent to adolescent
DIFFERENCES IN GROWTH SPURTS
BETWEEN MALES AND FEMALES

PHV occurs about 18-24 months

earlier in the females than in males

PHV in females averages 2 cms.

per year less than in males

PWV coincides with PHV in males,

but PWV occurs 6-9 months after
PHV in females
SECONDARY SEX CHARACTERISTIC
CHANGES

MALE FEMALE
genital breast
changes changes
appearance of growth of
pubic, axillary, pubic and
and facial hair axillary hair
voice change onset of
menarche
 EARLY ADOLESCENT
(10 -13 yrs)
SMR 1-2
Somatic: secondary sex
characteristics; beginning of rapid
growth; awkward
Sexual: interest exceeds activity
Cognitive and Moral: concrete
operations; conventional morality
Self Concept: Preoccupation with
changing body; self-consciousness
 EARLY ADOLESCENT
Family: Bids for increased independence;
ambivalence
Peers: Same sex groups; cliques
Relationship to Society: Middle school
adjustment – elementary to high school
 MIDDLE ADOLESCENT
14 – 16 years
SMR 3-5
Somatic: Height growth peaks; body
shape and composition change; acne
and odor; menarche; spermarche
Sexual: sexual drive surges;
experimentation; questions of sexual
orientation
 MIDDLE ADOLESCENT

Cognitive and Moral: Emergence of

abstract thought; questioning mores;
self centered
Self concept: Concern with
attractiveness, increasing
introspection
Family: Continued struggle for
acceptance of greater autonomy
 MIDDLE ADOLESCENT

Peers: Dating; peer groups

less important
Relationship to society:
Gauging skills and
opportunities
 LATE ADOLESCENT
(>17 YRS)

SMR 5
Slower growth
Consolidation of sexual identity
Idealism; absolutism
Relatively stable body image
Practical independence; family remains
secure base
 LATE ADOLESCENT
Peers: Intimacy; possibly commitment
Career decisions
 DRUG USE HISTORY

Inquiries about behaviors of peers in

school and social settings
Inquiries about personal practices
Determine which drugs are being used,
how often, and in what
circumstances
Elicit information regarding drug
related difficulties
Offer counseling and referral as
appropriate
 SEXUAL HISTORY

As part of menstrual and/or

developmental history
As part of the social history with
inquiries about dating practices
Determine need for contraceptive
devices
Offer counseling on abstinence
and risk avoidance
 VARIATIONS IN TIMING OF
PUBERTAL DEVELOPMENT
PREMATURE THELARCHE
- isolated breast enlargement in a
female <8 years of age

PREMATURE ADRENARCHE
- isolated pubic or axillary hair in a
female <8 years of age or in a
male <9 years of age
DELAYED PUBERTY
- no sign of puberty in a male by
14.5 years of age or in a female
by 13 years

ISOSEXUAL PRECOCIOUS PUBERTY

- the onset of puberty in female < 8
years or in a male < 9 years
 DELAYED PUBERTY
Differential Diagnosis

PUBERTAL DELAY WITHOUT SHORT

STATURE

- constitutional
delay of puberty
- acquired gonadotropin deficiency
- isolated gonadotropin deficiency
- acquired gonadal disorders
- congenital gonadal disorders
- androgen receptor defects
- chronic disease
PUBERTAL DELAY WITH SHORT
STATURE

- constitutional delay of puberty

normal variant short stature
- panhypopituitarism
- congenital syndromes
- glucocorticoid excess
- chronic disease
CONSTITUTIONAL DELAY OF
PUBERTY
CRITERIA FOR PROVISIONAL
DIAGNOSIS

REQUIRED FEATURES
SUPPORTIVE FEATURES
REQUIRED FEATURES

 Detailed negative review of systems

 Evidence of appropriate nutrition
 Linear growth of at least 3.7 cms./year
 Normal P.E.
 Normal CBC, ESR, Urinalysis, T4, LH, FSH
 Normal sella turcica by x-ray
 Bone age delayed 1.5-4.0 years compared
with the chronological age
 SUPPORTIVE FEATURES

1. Family history of constitutional

delay of puberty

2. Height between 3rd and 25th

percentiles for chronological age
 WEIGHT

• Best index of growth and nutrition

• Physiologic weight loss
• Average birth weight for Filipinos:
3000 gms
 WEIGHT
• Infants 3-12 mos
Wt. in gms = Age in mos +9

• 1-6 yrs 2

Wt. in gms = Age in yrs x 2 + 8

• 7-12 yrs
Wt. in gms = Age in years x 7-5
2
USUAL CHANGES IN WEIGHT
( at different ages)
4-5 months : BW x 2
1 year : BW x 3
2 years : BW x 4
3 years : BW x 5
5 years : BW x 6
7 years : BW x 7
10 years : BW x 10
 LENGTH or HEIGHT

• reliable criterion of growth

• not affected by excess fat or fluid
• reflects growth failure and chronic
malnutrition
 HEIGHT

• Average length at birth : 50 cms.

• At 1 year : length increased by 50%
4 years : doubled
13 years : tripled
• 2-12 yr = age in yr x 6 + 77
 HEIGHT

Acceleration of growth:
Girls: 10-12 years
Boys: 12–14 years
Cessation of growth:
Girls: 17-19 years
Boys: > 20 years
DISTRIBUTION OF GAINS IN LENGTH
( 1st year)

Birth – 3 months : 9 cms

4 months – 6 months : 8 cms
7 months – 9 months : 5 cms
10 months – 12 months : 3 cms
25 cms
Taking the length
Taking the length
Taking the height
Taking the height
HEAD CIRCUMFERENCE
• taken up to 3 years of age
• landmarks: glabella/supraorbital
ridge (anteriorly) and most
prominent part of the occiput
(posteriorly)
• related to intracranial volume
and rate of brain growth
 HEAD CIRCUMFERENCE
• range for any group is relatively
narrow
• almost no variation based on racial,
nutritional, or geographical factors
• at birth, average HC = 35 cms.
HC > CC
• at 6 months HC = CC
• at 12 months HC < CC
 HEAD CIRCUMFERENCE
(Mnemonics)
First year ----------> 4 inches (10 cms)
1st 4 mos : ½ inch/mo. = 2 inches
Next 8 mos : ¼ inch/mo. = 2 inches
Second year ---> 1 inch (2.54 cms)
3rd – 5th year ---> ½ inch/yr = 1.5 in.
6th – 20th year --> ½ inch/5 yrs = 1.5in.
 CHEST CIRCUMFERENCE
• taken at the level of the xiphoid
cartillage or substernal notch
Transverse
diameter
•THORACIC INDEX =-------------------------
A-P diameter

At birth : 1.0
1 year old : 1.25
ABDOMINAL MEASUREMENTS

• most prominent during infancy

and childhood
• CC = AC until age 2 years
• variable and relatively
unreliable measurement
 MIDARM CIRCUMFERENCE
• a good gauge of nutrition for the
under six child
• taken with the left arm hanging
naturally at the side
• circumference is measured at a
midpoint between the acromion
and the olecranon
 TRICEPS SKINFOLD
THICKNESS

• a rough estimate of body

composition
• measured over the posterior
surface of left arm by a caliper
halfway between the acromion
and olecranon
 BODY PROPORTIONS

• ratio between upper and lower

segments
• crown- symphysis to symphysis-
sole ratio
1.7 - at birth
1.0 - at 10 years old
BODY PROPORTIONS
 POSTURE
• secondary to variations in curves
of the vertebral column and the
shifting of the center of gravity
Birth - thoracic/sacral
3 mos old - cervical
3 years old - lumbar
PHYSIQUE

• athletic
• asthenic
• plump
 GROWTH MONITORING
• simple low-cost technology which
can significantly contribute to the
promotion of child health and
nutrition
• Phases of Growth Monitoring
Measurement
Recording
Interpretation
Intervention
 GROWTH CHARTS
• X – axis : Age of child
Y - axis : Measurement
• Majority in 50th percentile
P5 and P97 : 2 SDs from mean
• Allow comparison to peers;
reflects his progress
• Deviations may indicate factors
adversely affecting growth
 GROWTH CHART
• designed to monitor changes of
weight over time
• a single measurement is a poor
method of assessing a child’s
nutritional status
• more important: direction of the
curve
e.g. a flat or falling curve needs
WATERLOW CLASSIFICATION
(WASTING)
Actual weight
Ideal weight for actual length x 100 = %
CLASSIFICATION
Normal > = 90%
Mild 80% - 89%
Moderate 70% - 79%
Severe <70%
WATERLOW CLASSIFICATION
(STUNTING)
Actual height
Ideal height for age x 100 = ____ %
CLASSIFICATION
Normal > = 95%
Mild 87.5% - 95%
Moderate 80% - 87.5%
 MUSCLES
• largest part of increment is at 4 mos.
AOG to early gestational maturity
1/6 BW - mid-pregnancy
1/4 - 1/5 BW - birth
1/3 BW - early adolescence
2/5 BW - late adulthood
• strength doubles between 12 and 16
years
 CUTANEOUS STRUCTURES

• lanugo at birth; pubic hair/acne in

adolescence
• subcutaneous fat appears during the
last 3 months of gestation;
increases by 3 mos. of gestation up
to 1 year and during adolescence
• sweat glands have no function for
the temperature regulation until 1
mo. of age
 NERVOUS SYSTEM

• brain begins to develop at 4-6

months
• myelinization is completed
by 6-12 months
• pineal body calcifies at 10 y/o
 NERVOUS SYSTEM
Brain Growth
• rapid - infancy and childhood
• slowing - mid-childhood to 10 yrs
- adolescence
1/2 adult – 1 year old
3/4 adult – 3 years old
9/10 adult – 7 years old
• weight of the brain at 10 yrs. = adult
 NERVOUS SYSTEM

Critical Periods in Brain Development:

• Embryonic period or early fetal

period
• Late fetal life and infancy
 SENSORY DEVELOPMENT
•Pain Sensation
Evolution of pain responses:
• generalized movement and
crying: <1-2 mos.
• localize site of pain and
withdraw: 7-9 mos.
• shoves painful stimulus and
brings hand to irritated area:
12-16 mos.
SENSORY DEVELOPMENT

•Tactile Sensation
Face  Limbs  Trunk
(cephalocaudal)
 SENSORY DEVELOPMENT
• Visual Sensation

• clear vision achieved only at 16

weeks with maturation and
myelinization of the macula
and fovea
• VA of 20/20 achieved at 7 y/o
 SENSORY DEVELOPMENT

•Auditory Sensation
Birth – intact
6 mos. – localization of sound
•Taste
NB
3 mos. – taste discrimination
 CIRCULATORY SYSTEM

HEART
•12 wks AOG - (+) EKG
- index of fetal viability
•Birth – midway between crown and
buttocks
•1 year – weight has doubled
 CIRCULATORY SYSTEM

• ductus arteriosus
• normal fetal HR = 140-160/min.
1-2 y/o = 100-110/min.
older children = 60-100/min.
 CIRCULATORY SYSTEM

BLOOD VOLUME

NB - 80-100 ml/kg
Infant/Child - 75-90 ml/kg
Adult - 70-85 ml/kg
CIRCULATORY SYSTEM

BLOOD PRESSURE

 varies according to age

 LYMPHATIC SYSTEM
• spleen is relatively the largest
lymphoid organ in proportion to
the body at birth (12x)
• hypertrophy of the tonsils and
adenoids coincides with the time
when there is greater
susceptibility to infections
(6to7years old)
 HEMATOPOIETIC SYSTEM

Blood –Forming Organs

Connective tissue (mesenchyme)
Liver
Spleen
Mesonephros
Bone marrow - Birth
 IMMUNITY
• antibodies passively transferred
from mother protect baby up
to 6 or 9 months
• antitoxin or antiviral antibodies
are transferred better than
antibacterial antibodies
 DIGESTIVE SYSTEM

• STOMACH CAPACITY:
•Birth – 30 to 90 ml
•1 month – 90-150 ml
•1 year – 210-360 ml
•2 years – 500 ml
•Later childhood – 750 to 900 ml
 DIGESTIVE SYSTEM…
• DIGESTIVE ENZYMES ACTIVITY:
• renin, trypsin - normal (birth)
• amylase, lipase – low (newborn)
•Lipase – low (throughout childhood)
•BACTERIAL FLORA:
• breastfed – L. bifidus
• artificially-fed – L. acidophilus
 DIGESTIVE SYSTEM
• STOOLS:
• meconium > transitional >
normal
• breastfed vs. artificially fed

•LIVER IMMATURITY
 RESPIRATORY SYSTEM

• arises as an outpouching from the

pharyngeal pouch (entoderm)
• right vs. left primary bronchus
- larger, more obtuse
• larynx – 1/6 adult size at birth
• trachea – 1/2 adult size at birth
•
 URINARY SYSTEM

EXTRACELLULAR FLUID
NB - 2x adult
Infancy/adolescence – decrease
ELECTROLYTE CONCENTRATION
Infants>Adults
 URINARY SYSTEM
RENAL SIZE
6 mos - 2x birth size
1 yr - 3x
5 yrs - 5x
Puberty - 10x
No new glomeruli formed after birth
Mature renal function – 5 to 6 yrs
 SKELETAL SYSTEM
• SKELETAL DEVELOPMENT:
• ANTENATAL CALCIFICATION
•Maternal levels of calcium,
phosphorous, vitamin D, and
proteins
•POSTNATAL CALCIFICATION
•Status of the parathyroids, thyroid,
kidney, and supply of the above
 SKELETAL SYSTEM
SKELETAL AGE

0-5 years: presence of ossification

centers

5-14 years: calcification of

cartilaginous areas

14-25 years: epiphyseal fusion

 GENITAL ORGANS

FEMALE
Germ cells – 3 months AOG
Ovarian cortex (primordial follicles)
birth
mature
menarche
 GENITAL ORGANS
MALE:
Seminiferous tubules
Birth: solid
Childhood: lumens
Puberty
Testes
4th-7th fetal month – abdomen
8th month – scrotum
Birth: 90% (term) – descended
70% (PT) – descended
50% (undescended) descend at 1 month of
age
 DENTITION

FIRST YEAR OF LIFE

No. of teeth = age in months – 6

Teething when delayed >12

months: investigation of
ectoderm derivatives
 CHRONOLOGY OF HUMAN DENTITION
(PRIMARY)

AGES (MOS) AGES (MOS)

Maxillary Mandibular
Central 6-9 5-8
incisors
Lateral incisors 9-11 7-10
Cuspids 11-22 17-21
First molars 11-17 12-18
Second molars 22-30 22-30
CHRONOLOGY OF HUMAN DENTITION
(PERMANENT TEETH)

AGES AGES

Maxillary Mandibular

Central 6½-7½ 6½-7

incisors
Lateral incisors 6½ -8½ 6½-7½

Cuspids 11-12 11-12

CHRONOLOGY OF HUMAN DENTITION
(PERMANENT TEETH)

AGES AGES
Maxillary Mandibular
First premolars 10-11 10-11
Second 11-12 11-12
premolars
First molars 6-7 ½ 5½-6½
Second molars 12-13 11 ½ - 12 ½
Third molars 18-22 17-24