GROWTH AND DEVELOPMENTEdward M. Santos, MD

RATIONALEMonitor childrens progress Identify delays or abnormalities in development Counsel parents and prescribe treatment

OUTLINEOverview 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 TERMSGrowth 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. OverviewGenetics (nature) Environment (nurture) Both Ex: height genetic endowment (biologic), personal habits of eating (psychologic), and access to nutritious food (social)

Biologic InfluencesGenetics Role of Teratogens Postpartum illnesses Exposure to hazardous substances Maturation

Psychologic InfluencesAttachment tendency of a young child to seek proximity with the parent during times of stressAlso 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 FactorsFamily Systems role of parents; parentchild dyad Ecologic Model parent-child dyad at the center with the larger society at the periphery

Developmental Domains and Theories of Emotion and CognitionPsychoanalytic TheoriesThe stages of development are qualitatively different epochs in the development of emotion and cogniton Freud, Erikson, and Piaget

Behavioral Theoriesgradual modification of behavior and accumulation of competence BF Skinner

Classic Stage TheoriesTheory Infancy (0-1) Toddlerhood (2-3) Preschool (3-6) School Age (6-12) Adolescence (12-20)

Freud

Oral

Anal

Oedipal

Latency

Adolescence

Erikson

Basic Trust

Autonomy vs shame and doubt

Initiative vs Guilt

Industry vs Inferiority

Identity vs Identity confusion

Piaget

Sensorimoto r (Stages 1IV)

Sensorimoto r (Stages V,VI)

Preoperation al

Concrete operations

Formal operations

Behavioral TheorySkinner Focuses on observable behaviors and measurable factors No stages

A childs developmental level is the end result of a wide variety of factors, namely: prenatal, perinatal and postnatal.

II. Fetal Growth and DevelopmentMilestones of Prenatal DevelopmentWeek2 3

3 46

78 9 10 11

37

Developmental Events Fertilization and Implantation Endoderm and ectoderm appear Mesoderm appears Neural folds fuse Lens placodes Eyelids begin Ovaries and testes are distinguishable External genitals distinguishable Usual lower of viability Eyes open Term

GROWTH PERIOD

APPROXIMATE AGE

PRENATALOvum Embryo Fetus 0-14 days 14 days 9 wk 9 wks - Birth 37 42 wks

BIRTH

3 PHASES (INTRAUTERINE DEVELOPMENT)

Ovular PhaseFertilization Implantation Embryonic Phase 2nd week 3rd month organogenesis Fetal Phase 3rd month Birth differentiation/maturation

(0-14 days) characterized by increase in

OVUM

complexity and cell self sufficient

multiplication

little increase in total size 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 NewbornAdaptation 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 Brazeltonprovides a formal measure of an infants neurodevelopmental competencies Also used to demonstrate to parents an infants capabilities and vulnerabilities Correlates well with improvements in the caretaking environment

IV. The First YearCharacterized by rapid growth Acquisition of new competencies Psychological reorganization

0-2 monthsPhysiologic 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 monthsEmergence of social smile Growth rate: 20g/day Sleep requirement: 14-16 hr/day Social hatching Face to face interactions

6-12 monthsIncreased 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 YearAge 12-18 monthsSlower growth rate Independent walking Receptive language precedes expressive Points to major body parts (15 mo)

18-24 monthsIncremental 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 YearsBetween 2 and 5 years Widening social sphere Stubborn opposition and cheerful compliance Adaptation to new rules and relationships

Physical DevelopmentSlower 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 PlayMost 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 Childhood6-12 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 Development3-3.5 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 developmentConcrete logical operations Increasing cognitive demands in school Mastery of the elementary curriculum

Social and Emotional DevelopmentProceeds in 3 contexts: home, school, neighborhood Home remains the most influential Conformity

VIII. Adolescence10-20 years Accelerated growth ( height and weight) Appearance of secondary sexual characteristics

ADOLESCENT GROWTH SPURTPeriod 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 GrowthHeight 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 genital changes appearance of pubic, axillary, and facial hair voice change FEMALE breast changes growth of pubic and axillary hair 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 ADOLESCENTFamily: Bids for increased independence; ambivalence Peers: Same sex groups; cliques Relationship to Society: Middle school adjustment elementary to high school

MIDDLE ADOLESCENT14 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 ADOLESCENTCognitive 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 ADOLESCENTPeers: Intimacy; possibly commitment Career decisions

DRUG USE HISTORYInquiries 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 HISTORYAs 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 DEVELOPMENTPREMATURE THELARCHE - isolated breast enlargement in a female 4 inches (10 cms) 1st 4 mos : inch/mo. = 2 inches

Next 8 mos : inch/mo. = 2 inches Second year ---> 1 inch (2.54 cms) 3rd 5th year ---> inch/yr = 1.5 in. 6th 20th year --> inch/5 yrs = 1.5in.

CHEST CIRCUMFERENCE taken at the level of the xiphoidcartillage or substernal notchTransverse diameter THORACIC INDEX =------------------------A-P diameter

At birth 1 year old

: :

1.0 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 symphysissole 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

simple low-cost technology whichcan significantly contribute to the promotion of child health and nutrition Phases of Growth MonitoringMeasurement Recording Interpretation Intervention

GROWTH MONITORING

GROWTH CHARTS X axis : Age of childY - 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 ofweight over time a single measurement is a poor method of assessing a childs 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 Mild Moderate Severe > = 90% 80% - 89% 70% - 79% = 95% 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 inadolescence 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 SYSTEMBrain 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 SYSTEMCritical Periods in Brain Development:

Embryonic period or early fetal period Late fetal life and infancy

SENSORY DEVELOPMENT Pain SensationEvolution of pain responses:

generalized movement andcrying: 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 SYSTEMEXTRACELLULAR FLUID NB - 2x adult

Infancy/adolescence decrease ELECTROLYTE CONCENTRATION Infants>Adults

URINARY SYSTEMRENAL SIZE 6 mos 1 yr 5 yrs Puberty - 2x birth size - 3x - 5x - 10x

No new glomeruli formed after birth Mature renal function 5 to 6 yrs

SKELETAL SYSTEM SKELETAL DEVELOPMENT: ANTENATAL CALCIFICATIONMaternal levels of calcium, phosphorous, vitamin D, and proteins POSTNATAL CALCIFICATION Status of the parathyroids, thyroid, kidney, and supply of the above

SKELETAL SYSTEMSKELETAL AGE0-5 years: presence of ossification centers 5-14 years: calcification of cartilaginous areas 14-25 years: epiphyseal fusion

GENITAL ORGANSFEMALEGerm cells 3 months AOG Ovarian cortex (primordial follicles)

birth mature menarche

GENITAL ORGANSMALE:Seminiferous tubulesBirth: solid Childhood: lumens Puberty

Testes4th-7th fetal month abdomen 8th month scrotum Birth: 90% (term) descended 70% (PT) descended 50% (undescended) descend at 1 month of age

DENTITIONFIRST YEAR OF LIFENo. of teeth = age in months 6 Teething when delayed >12 months: investigation of ectoderm derivatives

CHRONOLOGY OF HUMAN DENTITION (PRIMARY)

AGES (MOS) Maxillary Central incisors Lateral incisors Cuspids First molars Second molars 6-9 9-11 11-22 11-17 22-30

AGES (MOS) Mandibular 5-8 7-10 17-21 12-18 22-30

CHRONOLOGY OF HUMAN DENTITION (PERMANENT TEETH)

AGES Maxillary Central incisors Lateral incisors Cuspids 6-7 6 -8 11-12

AGES Mandibular 6-7 6-7 11-12

CHRONOLOGY OF HUMAN DENTITION (PERMANENT TEETH)

AGES Maxillary First premolars Second premolars First molars Second molars Third molars 10-11 11-12 6-7 12-13 18-22

AGES Mandibular 10-11 11-12 5-6 11 - 12 17-24