Growth and development
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Transcript of Growth and development
GROWTH AND DEVELOPMENT
September Board Review 2012
Test QuestionWhat Board Review Topic should we do
next?A. Allergy & ImmunologyB. Adolescent Medicine and Gynecology
NORMAL GROWTH
Growth Affected by:
Prenatal factors: Maternal nutrition and uterine size
Genetic growth potential Nutrition throughout childhood Multiple hormones
Growth, thyroid, insulin, sex hormones Despite all these factors, growth is
predictable Carefully documented growth charts are
powerful tool to measure health and well-being
Growth
Postnatal growth Healthy term infants lose 10% of their birth
weight in the first days after birth Regain it back by 2-3 weeks of age
Normal: Gain 20-30g/day for first 3 months This rapid phase of growth is influenced
primarily by growth hormone (GH) and thyroid hormones
Question #1At what age to most healthy, term infants
typically triple their birth weight?A. 6 monthsB. 12 monthsC. 18monthsD. 2 yearsE. 3 years
Growth Milestones Birth weight triples by 1 year Birth length doubles by 3-4 years
During puberty: sex hormones become significant factor Slight deceleration of growth just prior to
puberty Followed by rapid acceleration of growth
Males later than females Females BEFORE menarche
Accurate Measurements Scales calibrated regularly Weigh in underwear or
diaper Length/height should be
measured supine in age <2 years Legs fully extended, head
resting on unmovable board, moveable footboard
Standing height for >2yrs Wall-mounted stadiometer If cannot stand: arm span is
good substitute
Growth Charts Growth charts from CDC or WHO
Specific charts for special populations LBW and VLBW premies Trisomy 21, Turner, Klinefelter, achondroplasia
Each child should be considered in terms of their genetic growth potential Estimate with mid-parental height
Boys= [Father’s height(cm) + mother’s height(cm) +13]/2
Girls = [Father’s height(cm) + mother’s height(cm) -13]/2
Growth Charts Shifts across 2 or more percentile lines
may indicate an abnormality in growth Shifts in the early life can be normal
Birth size reflects maternal factors (uterine size, etc) Genetic factors take over after birth Small infant born to large parents catches up
around 6mos Large infant born to small parents slows down
around 12 months After age 3, shifts are uncommon and
warrant investigation
Question#2
What is the most likely diagnosis?
A. NormalB. Constitutional
Growth DelayC. Familial Short
StatureD. HypothyroidismE. Cushing syndrome
TH = target height
Abnormal growth Malnourished
Drop in weight first, then height, then head circumference
Linear growth problems Indicates congenital,
genetic, or endocrine abnormality Hypothyroidism or GH
deficiency: normal or elevated weight with decreased height
Familial short stature Height and weight
are normal for 2-3 years
Height then drifts downward across percentiles
Growth curve follows normal growth curve at lower percentile
After initial drop off, have normal growth velocity
ConstitutionalGrowth Delay Variation of normal growth Reduced tempo of
development Height and weight both cross
percentiles Normal or near normal
growth rate during prepubertal years
Bone age is delayed Delayed puberty
Fall further off curve Complete pubertal growth in
late teens/early 20’s Achieve normal range
height (might be slightly lower than MPH)
BMI Begin plotting BMI for every patient at
age 2 Weight (kg)/height(m)2
85th-95th %ile = overweight >95%ile = obseity <5th%ile = underweight
Does not differentiate lean muscle from fat
HEAD GROWTH
Head size Normal head
circumference of full-term infant at birth Range 32-38cm Average 35cm
Microcephaly 2 SDs below mean for
age/sex (<2nd %ile) Macrocephaly
2 SDs above mean for age/sex (>98th %ile)
Microcephaly Congenital:
Trisomy 13, 18, 21 Cornelia de Lange, Smith-Lemli-Optiz, Rett Inborn errors of metabolism, hypothyroidism
Acquired: Normal head circumference at birth followed by
development of microcephaly over months to years Lack of brain development or growth
Causes: Stroke, meningitis, encephalitis, toxoplasmosis, rubella, CMV, teratogen exposure in utero, hypoxic-ischemic encephalopathy
MRI most helpful in head size <3SDs below mean and neurologic abnormalities
Question #3Which of the following is commonly
associated with hydrocephalus?A. Large parental head circumferenceB. Increased amount of brain parenchymaC. Normal CNS imagingD. Developmental delay, hypertonia,
hyperreflexiaE. Skeletal dysplasias
Macrocephaly vs Hydrocephalus
Macrocephaly Causes range in
severity from benign to severe
Familial Benign Normal development Parents with large
heads Accelerated rate of
head growth which stabilizes by 12-18 months
Hydrocephalus Excessive
accumulation of CSF Congenital: present
at birth Acquired:
accelerated growth over several months
Irritability, vomiting, bulging fontanelle, upward gaze
Macrocephaly vs Hydrocephaly Can distinguish the two using clinical
exam Look for signs of increased ICP Developmental delay, hypertonia,
hyperreflexia Imaging
Ultrasound: if fontanelle is open CT: fast, available, does not always detect
posterior fossa pathology MRI: shows more specific detail, but is not
always easily accessible
FAILURE TO THRIVE
Question #4You are seeing an 18 month old child for the first
time. She is developing well, and the parents have no concerns. Her growth chart reveals a weight at the 3%, height at the 25%, and HC between the 25-50%. What is the MOST likely cause of this patient’s poor weight gain?
A. Inborn error of metabolismB. Congenital heart defectC. Inadequate caloric intakeD. Growth hormone deficiencyE. Hypothyroidism
Definition FTT is no longer viewed as simply
nonorganic vs. organic syndrome NOW…
It is a physical sign that a child is receiving inadequate nutrition for optimal growth and development
Causes of this may vary…and it is our job to figure that out MOST cases are due to inadequate caloric
intake (nutritional) There are medical causes, too
Differential Diagnosis 3 mechanisms can cause under-
nutrition
Inadequate intake (Ingesting insufficient nutrients for growth)
Malabsorption
Increased metabolic demands
Poor feeding techniques often cause FTT
May be a manifestation of parental neglect/inadequacy
Some clues to the cause may be elicited from simple observation Oromotor problems Food aversions Poor parent/child
interaction
Question #5A mom brings in her 2yo boy with Down syndrome.
She is concerned that he is not gaining weight well. The nurse plotted him on a typical male growth chart at 5% for weight. He is a picky eater and often spits up after feeds. There is no history of cardiac or intestinal malformation, but he does have a history of frequent otitis media. Of the following, what is the most important next step?
A. Order an echo to look at his heartB. Refer him to a nutritionist for dietary counselingC. Send him to ENT for tympanostomy tubesD. Plot his growth parameters on a different growth
chartE. Start Zantac for his reflux
Growth Charts
Plotting the weight, length, and head circumference is an important step in assessing a child’s growth.
Remember subtle differences are important Weight tends to fall 1st with poor caloric intake,
then HC and length For endocrine disorders, the patient is short
(<50%) with relative sparing of weight Special growth charts for certain genetic
conditions (Down, Turner, Williams syndromes)
Evaluation In the past, children underwent an extensive
medical/lab evaluation for organic causes of FTT Now…the majority of FTT work-ups are
observational with dietary management and can be accomplished in the outpatient setting**
If outpatient management fails, then admission and laboratory evaluation may be needed** CBC with RBC indices CMP (test for renal and hepatic function) Celiac screening OTHER
Long-Term Consequences
Many children who experience FTT in early life eventually seem to have normal function
However…the overall trend is worrisone Persistent intellectual deficits Behavioral problems
Conflicting evidence on emotional outcomes or future growth parameters
MOTOR DEVELOPMENT
Gross Motor Goal: to gain independent and volitional
movement Primitive reflexes develop during
gestation Prepare the infant for acquisition of skills Disappear as CNS matures to allow infant to
make purposeful movements
Question #6At what age should this reflex disappear?A. 1 monthB. 2 monthsC. 6 monthsD. 9 monthsE. 12 months
Reflexes
Moro reflex: Birth – 6 mos
Protective Extension: emerges at 6 - 9mos
Positive support: Birth - 4-6 months
Gross Motor Milestones
Question #7A mother brings her child for a health
supervision visit. He is able to pull to stand, take a few independent steps, and use his thumb and 2nd digit to grasp a piece of cereal. These milestones are MOST typical for a child who age is:
A. 6 monthsB. 9 monthsC. 12 monthsD. 15 monthsE. 18 months
Gross Motor Milestones 2 months: lifts head
and chest while prone 4 months: no head lag,
steady head control while sitting, rolls front to back, props on wrists
6 months: sits propped on hands, rolls over in both directions
9 months: begins creeping, pulls to stand, walks on hands and feet
Gross Motor Milestones 12 months: pulls to
stand and cruises well, takes independent steps
15 months: walks independently, stoops to floor/recovers to standing position
18 months: walks up steps with hand held, throws ball
24 months: runs well, kicks ball, jumps with 2 feet off the floor, throws ball overhand
Gross Motor Milestones 3 years: broad jumps,
stands momentarily on one foot, pedals tricycle
4 years: balances on one foot for 3 seconds
5 years: skips, alternating feet
6 years: rides bicycle without training wheels, tandem walks
Question #8Of the following scenarios, which is the LEAST
concerning?A. An 18 month old who cannot walk
independently B. A 4 month old who lacks steady head
control while sittingC. A 9 month old who is unable to sit
unassistedD. A 30 month old who does not runE. A 10 month old who does not crawl
Fine Motor Development Use of upper extremities to engage and
manipulate the environment Self-help tasks, play, do work
First play a role in balance and mobility At birth – no voluntary use of hands
Due to primitive grasp reflex Can’t hold or transfer objects until this goes
away Once gross motor development allows for
stable upright position hands for more free and purposeful exploration
Question #9You observe a child who is holding two blocks
and bangs them together. Then she picks up a cheerio using an immature pincer grasp and feeds it to herself. These milestones are MOST consistent with a child who is:
A. 4 monthsB. 6 monthsC. 9 monthsD. 12 monthsE. 15 months
Development of pincer grasp
Raking Scissor Immature Inferior Fine
Fine Motor Milestones 2 months: regards object and
follows 180 degrees, hands unfisted 50% of time, hands held together, hands to midline
4 months: hands open, reaches for objects, clutches at clothes
6 months: transfers object from one hand to another, reaches with one hand, raking grasp
9 months: feeds self with fingers, plays gesture games (pat a cake) in imitation, bangs objects together, holds two objects at a time, immature pincer grasp
Question #10You observe a child as he walks into the exam room. He
is holding a small ball. When you ask him to let you see the ball, he gives it to you. He stoops to the floor to pick up a crayon and recovers to a standing position. He uses the crayon to scribble on a piece of paper you gave him. When he sees a few blocks on the floor, he picks up two and stacks one on top of the other. These milestones are MOST typical for a child whose age is:
A. 9 monthsB. 12 monthsC. 15 monthsD. 18 monthsE. 24 months
Fine Motor Milestones 12 months: fine pincer
grasp, holds crayon, attempts to scribble after demonstration
15 months: plays ball with examiner, gives and takes a toy, drinks from a cup, makes a line with a crayon, makes 2-3 cube tower
18 months: feeds self with spoon, 3-4 cube tower
24 months: washes and dries hands, removes clothing, 4-6 cube tower, feeds self with spoon and fork
Fine Motor Milestones 3 years: independent eating,
helps with dressing (unbuttons clothing, puts on shoes), 10 cube tower, copies circle
4 years: brushes teeth, copies cross/square, draws simple figure of person (head plus 1 body part)
5 years: dresses and undresses, cuts with scissors, draws person with 6 body parts, copies triangle, independent dressing
6 years: , ties shoes, draws diamond, writes first and last name
COGNITIVE DEVELOPMENT
Cognitive Development The foundation of intelligence Progression through developmental stages
involves object permanence, causality, and symbolic thinking
Depends on two developmental domains Language
Both an expressive and a receptive process Language skills are the SINGLE best indication of
intellectual ability Problem-solving
The manipulation of objects to achieve a specific goal
The Newborn
Alerts to sound Bell Voice
Visually fixates at 9-12”
Demonstrates visual preference for human face
Cognitive Development 9-12 months: object
permanence
18 months: deduce location even if hidden
18-24months: pretend play and symbolic thinking
School age: cognitive reasoning
Question #11You are examining a young boy during a health supervision
visit. His mother reports that he says “mama,” “dada,” “bye,” “ball,” and “dog.” Following the exam, he sits on the floor in front of his mom while playing with a toy car. When he sees a jack-in-the-box on a shelf, he points to it. After his mom says (no gestures) “Bring me the Jack-in-the-box,” he brings it to her.
These developmental milestones suggest that the child is CLOSEST to
A. 12 monthsB. 15 monthsC. 18 monthsD. 21 monthsE. 24 months
LANGUAGE
2 months Alerts to sound or voice Coos, vowel-like noises Reciprocal vocalizations,
social smile (6 weeks) 4 months
Orients head in direction of voice
Stops crying to soothing voice Laughs out loud, squeals
6 months Turns directly to sound and
voice Stops briefly to “no” Babbles consonants, imitates
speech sounds
9 months Understands own name Says “mama” and “dada”
nonspecifically
Language
1 year Follows 1 step command with gesture Points to get desired object Says “mama” and “dada” with meaning and at least 1 other word
15 months Follows simple commands, identifies 1 body part Uses 3 to 6 words Mature jargoning with real words
18 months Identifies 3 body parts, points to self Says 7-25 words, uses words for wants or needs Understands “mine”
2 years 50+ words, 50% intelligible (2/4), 2-3 word sentences Points to 5-10 pictures Uses “I”, “me”, and “mine”
Language
3 years Points to parts of pictures, names body parts with function Knows meaning of simple adjectives (eg. tired, hungry, thirsty) 200+ words, 5-8 word sentences 75% intelligible (3/4), uses pronouns correctly
4 years Follows 3 step commands 300-1000 words, speech fully intelligible (4/4) Asks “when, why, how?”, tells stories
5 years 2,000 words Defines simple words or asks questions about meaning of words Responds to “why” questions
6 years 10,000 words, 8-10 word sentences Describes events in order
Language
PROBLEM SOLVING
Question #12I can count to 10, draw a person with 8-10
body parts, know 4-10 of my colors, and recognize my numbers and letters (even if they are out of order). How old am I???
A. 2 yearsB. 3 yearsC. 4 yearsD. 5 yearsE. 6 years
2 months Recognizes mother Follows large, highly contrasting objects *tracks objects in circle at 3 months*
4 months Stares longer at unfamiliar faces Mouths objects Reaches for ring/rattle, shakes rattle
6 months Touches reflection in mirror and vocalizes Bangs and shakes toys
9 months Inspects and rings a bell Pulls a string to obtain toy at the end
Problem Solving
1 year Understands object permanence Rattles spoon in a cup Lifts box lid to find a toy
15 months Turns pages in a book Places circle in a single-shape puzzle
18 months Matches pairs of objects Imitates household tasks (cleaning, cooking, etc.)
2 years Sorts objects and matches objects to pictures Shows how to use a familiar object
Problem Solving
3 years Draws a 2-3 part person Knows age and gender
4 years Draws a 4-6 part person Counts 4 objects Points to 5 or 6 colors and letters/numbers when named
5 years Counts to 10, names 4*-10 colors, 8-10 part person Identifies letters and numbers
6 years (*think of finishing kindergarten!) Draws 12-14 part person Writes name, reads (250 words by end of 1st grade) Simple addition and subtraction Knows left from right across midline
Problem Solving
Question #13You have had multiple well child checks in clinic
today, and all the developmental milestones are getting confusing!! You feel confident that at least you know the red flags to worry about! Which of the following DOES NOT concern you?
A. A 36 month old who can’t say a 4-word sentence
B. A 9 month old with no babblingC. A 4 month old that doesn’t visually trackD. A 24 month old that doesn’t say any wordsE. A 6 month old that doesn’t turn to sound/voice
Red Flags
SOCIAL/EMOTIONAL
Social/Emotional Development
Most children are born with an inherent drive to connect with others and share feelings, thoughts, and actions
The earliest social milestone is bonding of the caregiver with an infant
Emotional development is influenced by a child’s temperament as well as the interactions between the care-giver and the child
Question #14How old are kids when they develop separation
anxiety and stranger anxiety?
A. Stranger anxiety 6 months, separation anxiety 9 months
B. Stranger anxiety 9 months, separation anxiety 12 months
C. Stranger anxiety and separation anxiety at 6 months
D. Stranger anxiety and separation anxiety at 9 months
E. Stranger anxiety 6 months, separation anxiety 12 months
2 months Reciprocal smiling Responds to adult voice and smile
4 months Smiles spontaneously at pleasurable sights/sounds Initiates social interactions Alternating (to and fro) vocalizations
6 months Stranger anxiety
9 months Follows a point,”oh look at…” Recognizes familiar people/objects Separation anxiety
Social/Emotional
1 year Shows object to parent to show interest Points to get desired object (proto-imperative)
15 months Shows empathy (looks sad if someone else cries) Points at object to express interest (proto-declarative)
18 months Engages in pretend play with other people Shows embarrassment or possessiveness
2 years Parallel play
Best with one other kid, side by side but not cooperative!!
Social/Emotional
3 years Starts to share, play become more cooperative Fears imaginary things Imaginative play
4 years Further development of pretend play, GROUP play Deception: tricks others or are scared to be tricked Has a preferred friend
5 years Plays board games or card games Has group of friends Apologizes for mistakes
6 years Has best friend of the same sex Distinguishes fantasy from reality Enjoys school
Social/Emotional
Question #15All of the following are social/emotional red flags
EXCEPT…
A. A 12 month old who doesn’t respond to his name
B. A 15 month old who will not point to what he enjoys or finds interesting (proto-declarative)
C. A 2 year old who pointed for what he wanted 3 months ago but no longer does so
D. A 6 month old who doesn’t smileE. A 15 month old who doesn’t engage in simple
pretend play
Red Flags
Able to separate from parents for several hours at a time
Plays well with other children
Takes turns
Follows directions in group activities
Able to relate personal experiences
Tells stories
Kindergarten Readiness
THANKS