Prof. Dr. Quah Ban SengDepartment of Paediatrics

MMMC

Normal Growth and Development in Children

Objectives

• Phases of growth in children

• Common anthropometric measurements

• Pubertal changes

• Developmental milestones

Phases of Growth in Childhood

Years1 2 12Conception Birth

100

85

45

30

% A

dult

Hei

ght

Fetal 30%Uterine environment

Infantile 15%NutritionGood HealthThyroid hormones

Childhood 40%Growth HormoneThyroid HormonesGood HealthGenes

Pubertal 15%Sex HormonesGrowth Hormone

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

Height Measurement

Technique

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

Fixed measuring device attached to wall (stadiometer)

Movable head piece 90° to stadiometer

Hat/hair ornaments removedHead in line with head plate Horizontal axis of vision

Apply gentle traction beneath jaw to maintain position

Shoes off; heels together

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 ½ 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 footUpper 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 AgePremature 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 ChartsCharacteristic CDC (2000) Growth

ReferenceWHO (2006) Growth Standard

Data Source US children 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

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

Sample size 4,697 observations for 4,697 distinct children

18,973 observations for 882 distinct children

CDC versus WHO Growth ChartsCharacteristic CDC

(2000)WHO (2006)

Exclusions Very low birth weight (<1,500 g)

Low socioeconomic statusBirth at altitude >1,500 mBirth at <37 wks or ≥42 wksMultiple birthPerinatal morbiditiesChild health conditions known to affect growthMaternal smoking during pregnancy or lactationBreastfeeding for <12 mosComplementary foods <4 mos or >6 mosWt-for-length measurements >3 SD above or below study median for sex

CDC versus WHO Growth Charts

Characteristic CDC (2000) WHO (2006)Breastfeeding among infants in sample

Approximately 50% ever breastfed

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 monthsWHO 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

Hei

ght V

eloc

ity m

m/y

ear

Age (years)

Pre-pubertal dip

Pubertal Growth Spurt

5

10

15

25

20

7 9 111 3 5 13 15 17 19

Girls Boys

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

Mature stagePapilla only

projects, areola recessed to

general contour of breast

Breast & areola enlarged &

elevated, no separation of

contours

PrepubertalElevation

papilla only

Breast budElevation of

breast & papilla small mound

Areola diameter enlarged

Areola &papilla form 2° above

contour of breast

B1 B2 B3 B4 B5

Pubic Hair Changes

Adult quantity & type

Spread to medial thighs

Darker, coarser, more curledSpreads over

junction of pubes

PreadolescentNo sexual hair

Sparse, long slightly

pigmented downy hair, base of penis or along

labia

Hair adult typeArea covered

smaller

PH2PH1 PH3 PH4 PH5

Spread along linea alba (typical male)PH6

Male Genital Changes

Adult size and shape

G1 G2 G3 G4 G5

Scrotum

Penis

Preadolescent

Preadolescent

slightly enlarged,

reddening of skin, changes in

texture

Little /no enlargement

Slightly enlarged, 1st length then

breadth

more enlarged

further enlarged, growth in breadth;

development of glans

further enlargement, darkening of

skin

Adult size and shape

Testicular Volume

Genital Stage

Testicular Volume

(ml)G1 1‒2 PrepubertalG2 3‒4 Beginning of pubertyG3 8‒10 Beginning of height acceleration G4 12‒15 Maximum growth velocity G5 20 Passed peak growth spurt

Epiphysis fusion

Puberty Girls

Age (years)10 11 12 13 14 158 9 16 17

Pubic hair

Breast

Menarche

Height spurt

2 3 4 5

2 3 4 58‒13 13‒18

10‒16.5

9.5‒14.5

Puberty Boys

Age (years)10 11 12 13 14 158 9 16 17

Pubic hair

Testis

Penis

Height spurt

2 3 4 5

9.5‒13.5 13.5‒17

10.5‒14.5

Genitalia rating 2 3 4 5

4 ml 12‒15 ml

12.5‒16.5

10.5‒16 13.5‒17.5

Developmental Assessment

• Early detection of deviation in child’s 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 TestPersonal-

Social

Fine Motor-

Adaptive

Language

Gross MotorT Chen. Normal development of normal pre-school children. J Spore Paed Soc 1988;30:118

R Test Item

10 50 90

May pass by report

Gross Motor Assessment

Supine Pulled to sit Sitting

StandingVentral suspensionProne

Supine1 month

Head turn one side

L Arm extended

R Arm flexed

Knees apart, soles of feet turned inwards

Supine

3 months

Head midline

Waves arms symmetricallyHands loosely open

Brings hands together from sides into midline

Supine

Lifts leg vertical

6 months

Raise head from pillow to

look at feet

Grasps 1 foot, later 2 feet

Pulled to Sit

Marked head lag

Newborn

Head lags until body verticalAt vertical head held momentarily erect before falling forwards

1 month

Pulled to Sit

Little or no head lag

3-4 months

Braces shoulders &pulls himself to sit

6 months

Sitting

Completely rounded back

First 4 weeks

Rounded backHead up intermittently

1 month

Sitting

Back still rounded Raised head well Rounded lower lumbar

spine

4 months2 months

SittingSit without

support

7 months

Sit with hand support

6 monthsPivoting

11 months

Standing

Bearing almost all weight

5 monthsBearing some weight

3 months

Bears full weight

6 months

StandingWalks alone

Arms abducted, elbows flexed

Broad base gait

13 months

Stand with supportWalk holding on

11 months

Walks, 1 hand held

12 months

Ventral suspension

Head above line of bodyHips & shoulders extended

3 months

Head below plane of bodyLimbs hang downwards

Hips fully flexed

Newborn

Head in line with bodyHips semi-extended

1 month

PronePelvis high, Knees under abdomen

Pelvis flat; Hips extended

6-8 weeks

Pelvis lower, intermittent extension of hips

4-6 weeks

0-2 weeks

Prone

Weight on handsArms extended

6 months

Weight on forearmsPlane of face 90° to couch

3-4 months

Chin off couch intermittentlyPlane of face <45° to couch 6 weeks

Prone

Bear walking

12 months

Hands and knees crawling

9-10 months

Protective Reflexes

Forward ParachuteArms extend when suddenly lowered

towards couch

9 months

Lateral ParachuteArms extend laterally when child suddenly

tilted sideways during sitting

6-7 months

Downward ParachuteRapidly lowered; feet

meet ground plantigrade

5-6 months

Grasp

Intermediate grasp

7-8 months

Palmar grasp

4-6 months

Mature grasp

1 year

Grasp

Index approach

Finger thumb opposition

9 months

Fine Motor

Age (months) Milestones3 Grasp object when placed in hand4 Tries to reach object overshoots5 Reach & grasp; bidextrous approach6 Drops one cube when given another7 Unidextrous approach

Transfers objects from hand to handGrasp 2 cubes (one in each hand)

9 Pincer grasp

Fine Motor

Train with chimney 4 years

Tower of Cubes

Steps5 years

Bridge 3 years

18 mo

13-14 mo

2 yearsSteps4 years

Fine Motor

Age (yr) Milestone

1½ Imitates or scribbles spontaneously

2 Imitates vertical line or circular strokes

3 Copies circle

4 Copies cross

4½ Copies square

5 Copies triangle

Speech

Age (months) Milestones1-2 Coos2-6 Laughs and squeals8-9 Babbles: mama/dada10-12 Mama/dada specific 15 Jargon, several intelligible words18-20 20 to 30 words – 50% understood by strangers22-24 Two word sentences

>50 words, 75% understood by strangers30-36 Almost all speech understood by strangers

Personal Social

Age (mths) Milestones

1 Respond to cuddling

3 React to familiar situations

Shows pleasure to friendly handling

Regards mothers face during feeding

6 Still friendly to strangers

9 Stranger anxiety, plays peek-a-boo, imitates

hand clapping

Personal SocialWatches while plaything partly

hidden

Promptly finds it

Watches plaything

completely hidden

Distressed (Can’t find it)

9 months

Personal Social

Watches while toy hidden under cup

Regards & reaches for cup

Promptly finds toy

9 months

Personal Social

Plays pat-a-cakeExplores 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 mother’s voice– vocalizes delightedly when spoken to – may turn eyes and/or head towards sound-source– brows may wrinkle and eyes dilate

Development of Hearing

4 monthsHorizontal movement only in general direction of sound

5 monthsHorizontal movement followed by vertical movement in localizing sound below ear

6 monthsArc-like movement in localizing sound below ear

7 monthsDiagonal movement in localizing sound below ear

HearingAge (mths) Milestone

3 Turns to sound source

4Turns to sound source

Eyes look in same direction

5-6Turns to one side then downwards to sound made below ear

(1½ feet)

6 Turns to one side & then upwards to sound above ear

7-8 Turns head in curving arc towards sound

8-10 Turns head diagonally & directly towards sound

Free Field test

Tester

Distracter

Sound producing device

Parent

Child

Vision

Age (wks) Milestone

4 Follow dangling object (3ft from eyes) <90°

6 Follow to midline

8 Follow beyond midline

12 Follow 180°; hand regard

16 Regards dangling object immediately

Vision

Alert peripheral vision

Watches rolling ball 10 ft

9 months

Regards rolling ball 5-10 ft

6 months

Vision

Crawls to retrieve rolling ball

Points to mounted ball

12 months

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