HUMAN

GROWTH & DEVELOPMENT

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Introduction Introduction

The process of human growth and development The process of human growth and development is a complex phenomenon. It is under the is a complex phenomenon. It is under the control of both genetic and environmental control of both genetic and environmental influences, which operate in such a way that, influences, which operate in such a way that, at specific times during the period of growth, at specific times during the period of growth, one or the other may be the dominant one or the other may be the dominant influence. influence.

The concepts of growth and development are The concepts of growth and development are fundamental to the practice of nurses. fundamental to the practice of nurses.

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Throughout the period of child development, Throughout the period of child development, major milestones are accomplished. For each major milestones are accomplished. For each of these developmental periods, important of these developmental periods, important aspects of care involving areas of nutrition, aspects of care involving areas of nutrition, language, safety, and discipline must be language, safety, and discipline must be addressed. addressed.

Special areas involving communication, pain Special areas involving communication, pain perception, and medication administration are perception, and medication administration are essential for providing care for both mother essential for providing care for both mother and child. and child.

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Definitions

Growth: an increase in number and size of cells as they divide and synthesize new protein result in increased size of the whole or any of its part.

Development: Gradual maturation of organs and its functioning systems, maturation start from lower to more advanced stages of complexity.

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Growth is an essential feature of a child and this distinguishes him or her from an adult.

The process of growth starts from the time of

conception of the fertilized ovum and continues until the child grows into a fully mature adult.

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The two terms growth and development are often used together, they are not interchangeable because they represent two different aspects of dynamic of change, those of quantity and quality.

Growth and development usually proceed

concurrently; but not always interrelated.

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Determinants of growth

Genetic Influences: This refers to factors those are responsible for the characteristic and patterns of individual growth, certain anomalies and some of the familial diseases.

Phenotype: tall parents have tall children; the size

of head is more closely related to that of parents than the size and shape of hand and feet.

Race: growth potential of children of different

racial groups is variable.

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Sex: puberty growth spot occurs earlier in girls but at full maturity their mean height and weight is less.

Hormonal factors: pituitary growth Hormone (GH) is directly related to growth.

Genetic disorders: growth and development

are adversely affected by certain genetic disorders on two types:

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Chromosomal abnormalities: several chromosomal defects manifested in sever growth disturbances as turner syndrome "45 chromosomes that one X chromosome is missed" or down syndrome "47 chromosome with trisomy 21".

Gene mutation: result in inherited disorder of growth i.e. Classic galactosemia (a genetic condition in which the body can't process a simple sugar called galactose caused by deficiency in the enzyme galactose -1-phosphate transferase)

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Environmental Influences

1. Nutrition Fetuses those are belonged to undernourished and

anemic mothers are usually small. The average infant birth weight born to mothers receiving nutrition supplement during pregnancy is higher than those of infant of malnourished mothers.

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2. Chemical agents

Pregnant women who receive some drugs as thalidomide during the first trimester affect in differentiation of organs which are developing at that period thus resulting in birth defects (infants infants were born with were born with phocomelia (malformation of the (malformation of the limbslimbs).

Androgen hormones initially accelerate the skeletal growth but epiphyses of bones close prematurely so bone growth stop early result of born of infant shorter than normal.

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3. Trauma

Head injury may lead to brain damage. Fracture of the end of bone may damage the growing end thus retarded the skeletal growth.

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4. Infections

Maternal infection as TORCH infection leads to congenital malformation of the fetus and the children growth retarded. Also infections and parasitic disease in children reduce the velocity of growth.

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Social influences

1. Socioeconomic level

Children of families with high socioeconomic level have better nutrition and hygienic condition so there is less infection and may have more security and emotional stability and so they have the chance to grow better than those of low socio economic status families.

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2. Natural resources

Abundant natural resources, industrial and agricultural activity in the country, the raise in gross material product and per capita, income reflected in better nutrition and education of children in the community and so accelerate growth and development of children of those communities.

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3. Climate

The velocity of growth may vary in different seasons and usually lighter in spring and lower in summer. Infection and parasitic infestations are common in hot humid climate. On the other hand, climates have a significant effect on agriculture productivity, availability of food and capacity for hand work of people.

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4. Cultural factors

Methods of child rearing and infant feeding in the community are determined by cultural practices and traditions which influence the nutritional status and growth of the children.

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5. Parents and family Parents have an influence affects in the growth and development of their children in extreme manner as the next: Maternal age at infant birth. Health status of mother in pre and post-natal period. Number of family members and socioeconomic status. Education of the parents and their temperaments. Play and learning of the children in the family and community that learning and development are connect together as oxygen and hydrogen in water.

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Importance of study of growth and development

1. Public health screening

Assessment of growth and development is the most powerful tool for early identification of children who may not look obviously sick but has suboptimal health and nutrition or suffering from latent illness. Remedial measures undertake at this point of time are much more useful for prevention of diseases and promotion of their health.

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2. Indicator of general health and nutrition of the community

Pooled data of growth and development of children in the community is an indirect indicator of health and nutrition status of the entire community, when it is compared with similar data collected simultaneously from other population subgroup.

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3. Evaluation of social action

Effectiveness of medical or social measure for promotion health of the community can be evaluated by comparing the growth data before and after the remedial action is taken.

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4. Clinical aspects of practice Development history helps in determining retrospectively the time of onset of many diseases which are likely to affect the process of growth. Response to treatment in a sick child may be documented by observing its effect on the subsequent growth experiences of child.

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Laws of growth and development There are definite and predictable pattern in growth and development that are continues, orderly and progressive. These patterns which referred also as trends or principles are universal and basic to all human beings that discussed as the next:

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1. Directional trends Growth and development proceed in regular related directions and reflect to the physical development and maturation of neuromuscular functions according to the following directions:

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a. Cephalocaudal: head to tail direction that the head develops before the extremities that the children can control head before controlling of trunk and extremities, hold their back erect before they stand and use their eyes before hands.

b. Proximal to distal trend: Direction of development starts from midline to peripheral, that children control shoulder before mastery of their hands and control hand before fingers.

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c. Mass to specific: differentiation trend describe development from small operation to complex activities and functions from global to specific behavior.

d. Sequential trends: In all dimensions of growth and development there is definite predictable sequence with each child normally passing through every stage. Infant creeps before stand and stands before walk. Infant babbles before form words that finally forming sentence.

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2. Growth pattern of every individual is unique The growth and development of every child is individualized but the general pattern of growth and development is predictable.

3. Infant grows and develops at different ratesDifferent infant's tissue and organs are growing and mature at different rate during life span i.e. growth of male and female gonads begins to mature in the late childhood.

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Assessment of Growth

Assessment of infant‘s growth is crucial during different stages of life because periodic assessment of infants and children permits early detection of growth deficiencies and deviations from normal standards.

During assessment the nurse should take the following points in his/her consideration:

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Physical growth assessment is usually carried out using tables and charts.

The measurements which are commonly done

are weight, height, and head circumference. Newly chest circumference is done for newborns to assess fetal growth at birth.

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There is wide range of normal variation among infants and children of the same chronological age. These normal differences are described in terms of percentiles. Comparison of the child percentile with those of the previous examination of the same child can detect abnormalities in his growth.

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Assessment of Development Developmental pediatrics is referred to maturation of the structure and functioning of the organs from fetal viability to full growth. It's intimately related to the maturation of CNS.

Developmental assessment includes 4 areas as the next:

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1. Gross motor: the normal acquisition of motor skill depends on:

Loss of primitive reflexes. The development of postural control

(Cephalocaudal direction). Increase ability to interpret the visual information

as distance. The development of movement pattern which are

adjustable to environmental circumstances.

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2. Fine motor and vision Integration of visual input and motor output is

necessary for development of accurate manipulative skills.

Manipulative skills start from crude palm grasp and gradually developed till fine pincer grasp that reached at 12 months old.

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3. Speech and hearing Speech, as a system of communication is an

essential future of human life. Nurse should assess preferences of the baby for some human voices and face as parent.

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4. Personal-social Include assessment of child social reaction to other

persons. Even neonates are socially active as they are able to elicit attention of their parents.

During the second half of the first year, the baby starts to recognize the familiar adults and develop strong attachment to her/his care giver.

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Assessment of maturityAssessment of maturity

Maturity is continuous process through lifeMaturity is continuous process through lifeCan be assessed by three aspects:Can be assessed by three aspects: 1-sexual maturity can be assessed by development of 1-sexual maturity can be assessed by development of

secondary sex characters.secondary sex characters. 2-skeletal maturity is assessed by radiograph of wrist 2-skeletal maturity is assessed by radiograph of wrist

and is recorded as bone age (years) range from birth -and is recorded as bone age (years) range from birth -18 yrs.18 yrs.

Dental maturation is assessed by panorama of Dental maturation is assessed by panorama of mandible and maxilla and scoring the stage of mandible and maxilla and scoring the stage of maturation of each tooth.maturation of each tooth.

Catch-up growthCatch-up growth

Unusual acceleration of growth which follow recovery from Unusual acceleration of growth which follow recovery from acute illness.acute illness.

it is complete if the growth data for the child return to childit is complete if the growth data for the child return to child‘‘s s original percentile before deficit occur .original percentile before deficit occur .

Is not always complete ,however it appear to depend on the Is not always complete ,however it appear to depend on the timing ,severity and duration.timing ,severity and duration.

More common in infant but may be delayed.More common in infant but may be delayed. Can occur in Wt at any age until the time of epiphyseal fusion Can occur in Wt at any age until the time of epiphyseal fusion

and head circumference until the suture of cranial vault and head circumference until the suture of cranial vault interlock at 5 yearinterlock at 5 year

Growth velocity chartGrowth velocity chart

GV chart is used to assess a child GV chart is used to assess a child ‘‘s growth s growth over several period of time.over several period of time.

Calculate child growth rate by recording his Calculate child growth rate by recording his /her height at 2 points in time that are at least /her height at 2 points in time that are at least 150 day apart then compare it with normal 150 day apart then compare it with normal growth rate of children at the same age and growth rate of children at the same age and sex.sex.

Growth chartGrowth chart

Are the primary tool for recognition of unusual Are the primary tool for recognition of unusual growth .growth .

Some of these charts were developed from Some of these charts were developed from nationally representative sample to obtain nationally representative sample to obtain estimates for the total population estimates for the total population

The curve are usually for The curve are usually for 33rdrd,5,5thth,10,10thth,25,25thth,50,50thth,75,75thth,90,90thth.95.95thth, and the , and the 9797thth,percentile. ,percentile.

Children whose measurement fall within the Children whose measurement fall within the 55thth, and 95, and 95thth,are considered normal growth ,are considered normal growth range.range.

Sudden or sustained change in percentile Sudden or sustained change in percentile indicate chronic disorder, emotionally indicate chronic disorder, emotionally difficulty or nutritional intake problem.difficulty or nutritional intake problem.

These findings require further assessment of These findings require further assessment of the physical status of the child such as dietary the physical status of the child such as dietary intake or serum laboratory studies. intake or serum laboratory studies.

Growth disorderGrowth disorder

1-Intra uterine growth restriction (IUGR)1-Intra uterine growth restriction (IUGR)

Referred to fetal growth has been constrained .Referred to fetal growth has been constrained .

It is defined as birth weight less than the 10It is defined as birth weight less than the 10 thth, , percentile for weight for gestational age curve percentile for weight for gestational age curve small for gestational age ,commonly small for gestational age ,commonly synonymous to IUGRsynonymous to IUGR

It is compared by matching infant birth weight to It is compared by matching infant birth weight to his/her gestational age based on WHO fetal his/her gestational age based on WHO fetal growth standard chart.growth standard chart.

22 . .Failure to thriveFailure to thrive

Descriptive non specific term .Descriptive non specific term .

Include :malaise ,weight loss, poor self care that Include :malaise ,weight loss, poor self care that can be seen in older children.can be seen in older children.

The most common definition is weight less than The most common definition is weight less than the 3the 3rdrd,to 5,to 5thth, percentile for age on more than , percentile for age on more than one occasion .one occasion .

Or weight measures that fall 2 major percentile Or weight measures that fall 2 major percentile lines using the standard growth charts. lines using the standard growth charts.

33 . .KwashiorkorKwashiorkor

deficiency of protein with low or deficiency of protein with low or inadequate supply of calories .inadequate supply of calories .

Occur between 1-4 years of age when Occur between 1-4 years of age when infant weaned from breast once the infant weaned from breast once the second child is born.second child is born.

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44 . .MarasmusMarasmus

Is a condition primarily caused by deficiency in Is a condition primarily caused by deficiency in calories and energy .calories and energy .

marasmus is a form of severe protein energy marasmus is a form of severe protein energy malnutrition characterized by energy deficit. malnutrition characterized by energy deficit.

Child looks emaciated ,body weight may reduced Child looks emaciated ,body weight may reduced less than 80 %of the average weight that less than 80 %of the average weight that correspond to the height.correspond to the height.

Occurrences increase prior to age 1 year where as Occurrences increase prior to age 1 year where as kwashiorkor after than 18 months.kwashiorkor after than 18 months.

Prognosis is better than for kwashiorkor . Prognosis is better than for kwashiorkor .

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55 . .DwarfismDwarfism

Generally refers to a group of genetic disorder Generally refers to a group of genetic disorder characterized by shorter than normal skeletal characterized by shorter than normal skeletal growth(an adult height of less than 147 cm)growth(an adult height of less than 147 cm)

Majority of children with this condition have Majority of children with this condition have average sized parentsaverage sized parents

Primitive reflexesPrimitive reflexes

Most of newbornMost of newborn‘‘s physical behavior appear to be s physical behavior appear to be reflexive in nature.reflexive in nature.

These reflexes disappear as These reflexes disappear as theirtheir nervous system nervous system become mature.become mature.

Then they are replaced by more voluntary Then they are replaced by more voluntary ,, coordinated movement.coordinated movement.

Absence or persistence of the early reflexes is used to Absence or persistence of the early reflexes is used to evaluate the health and maturation of nervous system. evaluate the health and maturation of nervous system.

Moro reflexMoro reflex

Response of loud noise Response of loud noise ,,causing body to stiffen and causing body to stiffen and arm to go up and out then forward and toward each arm to go up and out then forward and toward each other thumb and index finger will assume C –shape.other thumb and index finger will assume C –shape.

Present at birth and disappear at 3-6 months of age.Present at birth and disappear at 3-6 months of age. Absent in brain damaged babies Absent in brain damaged babies ,,depressed babies depressed babies

due to narcotics at birth .due to narcotics at birth . Assymetrical reflex in fracture of clavicle or humerus Assymetrical reflex in fracture of clavicle or humerus

or brachial palsy and shoulder dislocation.or brachial palsy and shoulder dislocation. Persistent reflex in C.P.Persistent reflex in C.P.

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Stepping reflexStepping reflex

Elicited by holding the infant upright and inclined Elicited by holding the infant upright and inclined forward with sole of the foot touching flat surface forward with sole of the foot touching flat surface ,,the infant start to make stepping movement.the infant start to make stepping movement.

A step reflex is present at birth and should A step reflex is present at birth and should disappear by three or four months of age. It will disappear by three or four months of age. It will become a voluntary behavior when the baby become a voluntary behavior when the baby reaches around eight to 12 months old. This is the reaches around eight to 12 months old. This is the period when the baby begins to learn how to period when the baby begins to learn how to walk.walk.

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Neck rightingNeck righting

Consist of rotation of the trunk in the direction Consist of rotation of the trunk in the direction in which the head of the supine infant is in which the head of the supine infant is turned.turned.

Appears at age 4-6 months and disappear at Appears at age 4-6 months and disappear at age 24 months.age 24 months.

Absent or decreased in infant with C.P.Absent or decreased in infant with C.P.

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Parachute reflexParachute reflex

While the infant is held prone and lowered While the infant is held prone and lowered quickly toward a surface quickly toward a surface ,,he will extend arms he will extend arms and legs.and legs.

Appear at 9 months and persist thereafter.Appear at 9 months and persist thereafter.

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Suckling reflexSuckling reflex

Elicited by stroking of the lips .Elicited by stroking of the lips . Present at birth and persist 9 months. Present at birth and persist 9 months.

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Rooting reflexRooting reflex

When the corner of the mouth is touched and When the corner of the mouth is touched and object is moved toward cheek object is moved toward cheek ,,infant will turn infant will turn head toward object and open mouth.head toward object and open mouth.

Present at birth disappear by 4 months of age Present at birth disappear by 4 months of age (when the baby awake) 7 months (when the (when the baby awake) 7 months (when the baby is asleep).baby is asleep).

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Grasp reflexGrasp reflex

Elicited by applying light pressure on the Elicited by applying light pressure on the palms or soles which are closed around the palms or soles which are closed around the stimulating object.stimulating object.

palmar grasp appear at birth disappear at 6 palmar grasp appear at birth disappear at 6 month age.month age.

Planter grasp appear at birth disappear at 10 Planter grasp appear at birth disappear at 10 months age.months age.

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Hand openingHand opening

The hand will open by stroking the dorsum of The hand will open by stroking the dorsum of infantinfant‘‘s hand s hand

It appear at birth and disappear at 3It appear at birth and disappear at 3 rdrd month. month.

BabinskiBabinski‘‘s signs sign

Scratching sole of foot causing big toe to flex Scratching sole of foot causing big toe to flex and other toes to fan.and other toes to fan.

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Infant and children assessmentInfant and children assessment

Weight:Weight:It is the best index of nutrition and growth .It is the best index of nutrition and growth .Average birth weight is 3.5kg to 4.2kg.Average birth weight is 3.5kg to 4.2kg.At birth normally baby lose 10 % of his wt at At birth normally baby lose 10 % of his wt at

first 3-4 days .first 3-4 days .He regain this loss by 10-14 days of age.He regain this loss by 10-14 days of age.Birth weight double at 5 months and triple at 1 Birth weight double at 5 months and triple at 1

year. year.

During the first 4 months During the first 4 months ,,baby gains ¾ kg baby gains ¾ kg monthly.monthly.

During the second 4 months During the second 4 months ,,baby gains ½ kg baby gains ½ kg monthly.monthly.

During the third 4 months During the third 4 months , , baby gain ¼ kg baby gain ¼ kg monthly.monthly.

After the first year baby gains 2-2.5 kg /year After the first year baby gains 2-2.5 kg /year until puppetry until puppetry

Length :is the crown –heal measurement in Length :is the crown –heal measurement in recumbent position (used from birth to 3 year)recumbent position (used from birth to 3 year)

Height : is the crown –heal measurement in Height : is the crown –heal measurement in standing position (after 3year of life).standing position (after 3year of life).

They differ by ½ -1 cm due to widening of They differ by ½ -1 cm due to widening of joint space in the recumbent position. joint space in the recumbent position.

Average length at birth is 50 cm .Average length at birth is 50 cm .At one year about 75cm and100cm at 4years.At one year about 75cm and100cm at 4years.

Female child in average increased in height Female child in average increased in height more than male child until puberty.more than male child until puberty.

The ratio between upper to lower body The ratio between upper to lower body segment is :segment is :

At birth 1.7to 1.At birth 1.7to 1. At 5 years 1.25 to 1.At 5 years 1.25 to 1. At Puberty 1to 1.At Puberty 1to 1.

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Head and skullHead and skull

Head measurement is best index for brain maturation.Head measurement is best index for brain maturation. Head growth is greater than the rest of the body in the Head growth is greater than the rest of the body in the

uterus.uterus. At birth HC is 33-37 cm for mature newbornAt birth HC is 33-37 cm for mature newborn Become 43cm at 6 months and by 1 year become 47 Become 43cm at 6 months and by 1 year become 47

cm .cm . Cranial suture do not ossify until adulthood.Cranial suture do not ossify until adulthood. Head and chest circumference are equal during the Head and chest circumference are equal during the

first 4 years of life.first 4 years of life.

FontanelsFontanels

At birth skull has 6 fontanels At birth skull has 6 fontanels ::anterior anterior posterior posterior ,,2 sphenoid and 2mastoid.2 sphenoid and 2mastoid.

Anterior fontanel close at 10-14 months but Anterior fontanel close at 10-14 months but may close at 3 months or remain until 18 may close at 3 months or remain until 18 months.months.

Posterior fontanel close by the second month Posterior fontanel close by the second month of age or may closed at birth.of age or may closed at birth.

Body mass indexBody mass index

It is useful to adjust an observed weight for It is useful to adjust an observed weight for length /height .length /height .

BMI reflects body mass relative to height that BMI reflects body mass relative to height that calculated by dividing child weight /killograms by calculated by dividing child weight /killograms by the square of the height /meter .the square of the height /meter .

Classification of BMI:Classification of BMI:Under weight Under weight >18.5>18.5Normal 18.5-24.9.Normal 18.5-24.9.Over weight 25-29.9 obese 30 or greater.Over weight 25-29.9 obese 30 or greater.

Measurement of developmentMeasurement of development

Development problems in young children are Development problems in young children are difficult difficult ,,if not impossible to detect it in routine if not impossible to detect it in routine physical exam because of:physical exam because of:

Children with slow development often look normal.Children with slow development often look normal. Delays are not often detected until child enters Delays are not often detected until child enters

school.school. Denver development screening test(DDST)Denver development screening test(DDST) Developed to aid health providers to detect potential Developed to aid health providers to detect potential

problem.problem.

It is test for screening cognitive and behavioral problems in It is test for screening cognitive and behavioral problems in pre school children .pre school children .

Commonly known as Denver scale.Commonly known as Denver scale. It reflects what percentage of certain age group is able to do a It reflects what percentage of certain age group is able to do a

certain task.certain task. Tasks are social contact Tasks are social contact ,,fine motor skillfine motor skill,,language language ,,and gross and gross

motor skills such as:motor skills such as: Smile spontaneously ( performed by 90 %of three month old)Smile spontaneously ( performed by 90 %of three month old) Knock two building blocks against each other(90 % of 13 Knock two building blocks against each other(90 % of 13

months old)months old) Speaks three words other than mom and dad (90 % 21 months Speaks three words other than mom and dad (90 % 21 months

old).old).