Pediatric Growth and Development

  1. Objective
  2. To be familiar with normal growth and milestone development
  3. Early identification of children with growth retardation or milestone delays
  4. Growth
  5. Continuous dynamic process which continues from conception to maturity
  6. Development

  1. Maturation of organ systems
  2. Acquisition of skills
  3. Ability to perform tasks

  1. How doe we study Growth and Development
  2. Serial evaluation

  1. Height
  2. Weight
  3. Head circumference

  1. Direct observation
  2. Screening tests
  3. Reports from parents and caregivers
  4. Developmental milestones
  5. AAP recommends that all infants and young children should be screened for developmental delays
  6. Screening is designed for asymptomatic patients
  7. Brief assessment to identify children who need more intensive studies or treatment
  1. Factors that influence growth
  2. Intrinsic

  1. Genetics
  2. Heredity
  3. Chronic illness

  1. Extrinsic

  1. Parenteral involvement
  2. Socioeconomic status
  3. Climate
  4. Toxins/hazardous substances

  1. Nature vs. Nurture
  2. Biologic influences
  3. Teratogens, post-partum illnesses, hazardous substances, chronic illnesses
  4. Psychologic influences
  5. Adult caregivers who respond to verbal and nonverbal clues given by a child
  6. Social
  7. Birth order, culture, society, extended family

0-1y.o. / 2-3y.o. / 3-6y.o. / 6-12y.o. / 12-18y.o.
Freud / Oral / Anal / Oedipal / Latency / Adolescence
Erikson / Basic trust / Autonomy vs. shame/doubt / Initiative vs. guilt / Industry vs. inferiority / Identity vs. identity diffusion
Piaget / Sensorimotor I-IV / Sensorimotor V-VI / Pre-operational / Concrete operational / Formal operational
  1. Fetal Growth and Development
  2. Embryonic period
  3. 6 days post conception- blastocyst
  4. 2 weeks- endoderm, ectoderm
  5. 3 weeks- neural tube, blood vessels, heart tubes
  6. 5th week- forebrain, midbrain, and hindbrain form
  7. 4-8 weeks- budding arms and legs, brain grows rapidly, facial structures
  8. Fetal period- 9-40 weeks
  9. Increase in cell numbers, remodeling of organ systems
  10. 10 weeks- human face
  11. 12 weeks- external genitalia, lungs begin to develop
  12. 20-24 weeks- alveoli form, surfactant production
  13. Third trimester- weight triples, length doubles
  14. 26 weeks- eye opening
  15. Weight
  16. Doubles birth weight by 4-5 months
  17. Triples by 1 year
  18. Formula
  19. Weight 1-6 y.o.= age (yrs) x 5+17
  20. Weight 7-12 y.o.= age (yrs) x 7+5
  21. Height

  1. Birth- 20”
  2. 1 year- add 10”
  3. 2nd year grows 5”
  4. 3rd year grows 3-4”
  5. Grows 2-3”/year until puberty

  1. Respiratory System
  2. Infants have a rounded chest
  3. Respiratory rate decreases in childhood

  1. 1y.o. 30 breaths/min
  2. 2y.o. 25 breaths/min
  3. 8y.o. 20 breaths/min
  4. 15y.o. 18 breaths/min

  1. Sinuses

  1. Maxillary/ethmoid
  2. Sphenoid
  3. Mastoid
  4. Frontal

  1. Cardiovascular system
  2. Heart rate falls steadily throughout childhood

  1. Birth- 130bpm
  2. 2 y.o.- 105bpm
  3. 4y.o.- 90bpm
  4. 6y.o.- 80bpm
  5. 10y.o.- 70bpm

  1. Functional “innocent” murmur

  1. Systolic
  2. Peak age 6-9 y.o.
  3. Newborn murmur
  4. Peripheral arterial Pulmonic stenosis
  5. Still murmur
  6. Pulmonary ejection murmur
  7. Venous hum

  1. Hematopoietic System
  2. Fetal Hgb- persist for 1st few months of life
  3. Hematocrit
  4. 55% at birth, then physiologic nadir, then return to normal
  5. WBC’s
  6. Increased at birth with lymphocyte predominance
  7. Eosinophil count high during infancy
  8. Gastrointestinal Tract

  1. Liver and spleen palpable in infancy
  2. Abdomen protuberant
  3. Incomplete protein digestion
  4. Infants have faster transit time than adults

  1. Urinary Tract
  2. 1st week of life, urine scanty and dilute
  3. Urine volume

  1. 1st 24th 15-50ml/day
  2. 2 mos. – 250-400ml/day
  3. 5-8 y.o.- 700-1000ml/day
  4. 8-14 y.o.- 700-1500ml/day

  1. Musculoskeletal System
  2. Fat
  3. Laid down during 1st months of gestation
  4. Gradual decrease in body stores from 6 months-6 years
  5. Reaccumulates from 7 years to puberty when fat decrease in males and continues to increase in females
  6. Muscle
  7. Small portion of body weight compared to adults
  8. Extremities

  1. Short in infants
  2. Flat feet
  3. Bowing of legs
  4. Pigeon toes
  5. Posture

  1. Vision

  1. Birth- aware of light and dark
  2. 4 weeks- follow large object
  3. 8 weeks- follows moving object with jerky movement
  4. 20 weeks- pursues lost object
  5. 24 weeks- binocular vision established
  6. 40 weeks- interest in tiny objects
  7. 4-5 years- vision is 20/20

  1. Hearing

  1. Present at birth, not totally mature
  2. Audiological evaluation prior to leaving nursery
  3. Localize sounds by 6 months

  1. Sleep

  1. 1 week old- 16.5hrs/day
  2. 1 month old- 15.5hrs/day
  3. 3 month old- 15hrs/day
  4. 1 year old-13.75 hours/day
  5. 2 year old-13 hours/day
  6. 4 year old- 11.5 hours/day
  7. 17 year old- 8.25 hours/day

  1. Developmental Milestones
  2. 2 month old

  1. Recognize parents
  2. Social smile
  3. Beginning to visually fix on objects

  1. 4 month old

  1. Fading of moro, tonic neck and rooting reflex
  2. Sit up while propped
  3. Raise head 90 degrees while prone
  4. Roll from back to side
  5. Laugh
  6. Reach for objects with hands

  1. 6 month old

  1. Lift head, chest while prone
  2. Begin teething
  3. Roll back to belly
  4. Hold bottle
  5. Pick up dropped object
  6. Sit without support for short time
  7. Palmar grasp/wave bye-bye
  8. Firmly control head
  9. Babbles

  1. 9 month old

  1. Crawl/pull to stand
  2. Sit unsupported for prolonged period
  3. Pincer grasp
  4. Object constancy
  5. Separation anxiety

  1. 12 month old

  1. 6-8 teeth
  2. Walk without support or with 1 hand support
  3. Build tower with 2 blocks
  4. Says mama, papa, and 2 other words
  5. Follow one step verbal commands

  1. 18 month old

  1. Runs without coordination
  2. 4-20 word vocabulary
  3. Walk up stairs holding 1 hand
  4. Build tower with 3-4 blocks
  5. Push/pull toys
  6. Scribbling
  7. Feeds self
  8. “my”

  1. 24 month old

  1. 16 teeth
  2. Run with better coordination
  3. Kick and throw ball
  4. Build tower with 6-7 blocks
  5. Turn door knob
  6. 300 words
  7. 2-3 word phrase
  8. Can put on simple articles of clothing
  9. Jigsaw puzzle
  10. Point to named object

  1. 36 month old

  1. Good balance
  2. Daytime control of bowel/bladder
  3. Balance on 1 foot
  4. Alternating feet on stairs
  5. Build tower with >9 cubes
  6. 3-4 word sentences
  7. Copy circle
  8. Rides tricycle

  1. 4 year old

  1. Hop on 1 foot
  2. Throw ball overhand
  3. 4-5 word sentences
  4. Count to 4
  5. Sing and learn simple songs
  6. Can use safety scissor
  7. Right or left hand dominance

  1. 5 year old

  1. Catch ball
  2. Skip smoothly
  3. Simple chores at home
  4. Tie shoelaces
  5. 2100 words
  6. Knows coins
  7. Draws a person with 2 appendages

  1. Adolescence
  2. Begins and progresses across a wide range of chronological ages
  3. Both sexes have a growth spurt
  4. Females mature earlier than males
  5. Female Sexual Development
  6. Height
  7. Maximal height velocity occurs the year before menarche
  8. Menarche- average between 12-14 y.o.
  9. Breast development
  10. 9-11 y.o.
  11. Hypertrophy and breast budding
  12. 12-13 y.o.
  13. Further enlargement and pigmentation
  14. 16-18y.o.
  15. Mature, adult breast
  16. Pubic hair
  17. 10-12 y.o. appears initially
  18. Initially sparse, then abundant and curly
  19. Axillary hair
  20. 12-14 y.o.
  21. Acne
  22. 12-18 y.o.
  23. Male Sexual Development

  1. Breast
  2. 12-14 y.o. some hypertrophy
  3. Penis and Testes
  4. 10-12 y.o.- increase in size
  5. 14-15 y.o.- rapid growth and lengthening
  6. Pubic hair
  7. 12-14 y.o.- appears initially
  8. 14-15 y.o.- abundant and curly
  9. Axillary hair
  10. 13-16 y.o. initially appears
  11. Acne
  12. 14-18 y.o.
  13. Mature sperm
  14. 14-16 y.o.

  1. Development

  1. Continuous process beginning with conception
  2. Orderly and sequential= rapid growth/plateaus
  3. Not always constant

  1. As healthcare providers, we must

  1. Screen regularly to detect developmental dysfunction
  2. Monitor developmental problems
  3. Initiate proper referral and treatment
  4. Early intervention
  5. School system

  1. Developmental Disabilities- 16% of US children

  1. Cerebral palsy
  2. Mental retardation
  3. Autism
  4. ADHD
  5. Communicative disorders

  1. All different, but result in disruption of the normal sequence of development
  1. Denver Developmental Screening Test II (DDST II)
  2. Screening tool- compares child’s performance to other children of that age
  3. Relatively quick and inexpensive procedure
  4. Given to apparently asymptomatic population
  5. Identifies individuals with suspected developmental abnormalities who require diagnostic follow-up
  6. History
  7. Developed in 1967 and reconstructed in 1988
  8. Uses
  9. Designed for apparently well children from birth-6 years of age
  10. Assess a child’s performance by various age appropriate tasks
  11. Screens asymptomatic children for developmental delays
  12. Confirms intuitive suspicions with an objective measure
  13. DDST II is not

  1. An IQ test
  2. A predictor of future adaptive of intellectual ability
  3. Designed to generate diagnostic labels

  1. Performed at all well child visits as part of the physical exam

  1. 2,4,6,9,12,15,18,24,36 months old
  2. 4,5,6 years old

  1. 125 tasks arranged in 4 groups

  1. Personal-social
  2. Fine motor adaptive
  3. Language
  4. Gross motor adaptive

  1. Scoring
  2. Some tasks are directly observed by physician while other must be reported from parents/caregivers
  3. “P” or pass means the child successfully performs the task or the caregiver reports that the child does the task
  4. “F” or fail, the child does not successfully perform the task or the caregiver reports that the child does not do the task
  5. “No” for no opportunity for the child to perform the activity due to caregiver restrictions
  6. “R” for refusal- child refuses to attempt the item
  7. Delays- suspect in 1 or more delays or 1 delay and a caution; 2 or more delays refer
  8. Failed or refused item that falls completely to the left of the age line (90% of children younger can do this task)
  9. Caution
  10. Failed or refused items that run on line or between 75-90%
  11. Interpretation

  1. Normal
  2. No delays
  3. maximum of 1 caution
  4. Suspect
  5. 1 or more delays
  6. Rescreen in 1-2 weeks to rule out temporary problems
  7. Referral
  8. 2 or more delays

  1. Early intervention
  2. Available for all children, regardless of socioeconomic background
  3. However, child must be identified as having a developmental delay by a healthcare practitioner before receiving services
  4. 16% of children in US have a disability
  5. Speech, learning, emotional, behavioral
  6. Identification is the key!!!!