Pediatric Growth and Development

Objectives

• Growth vs Development

• Growth: Weight, Height, Head Circumference

• Discrepancies in Measurement

• Normal Development & Psychosocial Assessment

• Developmental Screening

• Milestones

• Language Screening and Speech Delays

• Adolescence

Growth vs Development Growth: in size of the body • Normal growth pattern:

between 3rd and 97th percentiles • Body Mass Index (ages 2y-20y)

– Wt(kg)/ht(cm)2 x 10,000 – Overweight is >95th percentiles – Risk of being overweight is in 85-95 percentiles

Development: in function of

processes related to body and mind

Rule of Thumb :Weight • Wt loss in 1st few days of life: 5-10% of BW • Return to BW at 7-10 days of

age

Double BW at 4-5mo Triple BW at 1 yr

Quadruple BW at 2 yr

• Daily wt gain – 20-30g/day for 3-4mo – 15-20g/day for rest of 1st yr • Avg Annual Wt gain – 5 lbs between 2yr-puberty

• Average Wts – Birth: 3.5 Kg – 1 yr: 10 Kg – 5 yr: 20 Kg – 10 yr: 30 Kg

Rule of Thumb : Height

• Birth length increases by 50% by age 1y • Birth length doubles by age 4y • Birth length triples by age 13y • Avg lengths

– Birth: 20 in – 1 yr: 30 in – 3yrs: 3ft – 4 yrs: 40 in (double birth length)

• Avg annual ht increase: 2-3 in between 4yrs and puberty

Rule of Thumb : Head Circumference • Avg HC at birth: 35 cm (13.5in) • HC increases: - 1cm/month for 1st 6months

(fastest in 1st 3 months) - 0.5 cm/month for 6-12months

• Plot HC until 3 years of age • Re-Check HC

• Large shifts in percentiles warrant attention, as do large discrepancies among height, weight, and head circumference percentiles.

• Children growing <5cm/yr should be evaluated for GH deficiency or hypothyroidism

• Inadequate caloric intake Weight Height Head Circumference

Discrepancies

Normal Development • Newborn Period

– Primitive neonatal reflexes are consequence of continued development of the CNS

– Growth of the nervous system is the most rapid in the first 2 years

– Normal reflexes: Moro Rooting Sucking Grasp Tonic neck

Reflexes in the Newborn Period Moro: Allowing head to gently

move back suddenly results in abduction and upward movement of the arms followed by adduction and flexion - Disappears at 4-6 mo

Rooting: Touching the corner of the mouth results in lowering of the lip and tongue movement towards the stimulus.

– Disappears at 4-6 mo

Reflexes in the Newborn Period Sucking: Put an object in the

mouth and the baby responds with vigorous sucking. Replaced by voluntary sucking

Grasp: Palmar disappears at 3-4 mo

Plantar disappears at 6-8 mo

Asymmetric tonic neck reflex: In supine position, baby, turns head to the side ipsilateral extension of the arm and leg with contralateral flexion

– Diappears at 2-3 mo

Later in Infancy • Control of posture

– Proximal (1st) and then distal musculature

• Check for ortho deformities – Fixed deformities warrant a consult

• Evaluation of vision and ocular

movements to prevent outcomes

of strabismus – Check cover test and light reflex

Late School Age - Early Adolescent Child

• Comprehensive sports physical exam and evaluation of the Cardiovascular system

• Worrisome signs/ symptoms/ history: – Hx of heart disease or murmur

– Dyspnea, CP on exertion, Irregular HR, Syncope, Seizure

– Fam Hx of atherosclerosis < 50 yrs or sudden death

• Contact sports: assess for vulnerabilities (ex. WPW, kidney disease/damage)

• Assess vision

Adolescence • Show sensitivity

• Scoliosis

• Obesity

• Trauma Ortho probs

• Sexual Maturity Rating

• Menstrual cycles, Dysmenorrhea

• Gynecomastia

Psychosocial Assessment • Bonding - occurs shortly after birth and reflects the

feelings of the parent toward the newborn (unidirectional)

• Attachment - involves reciprocal feelings (bidirectional) between parent and infant and develops gradually over the first year (*postpartum)

• Stranger Anxiety- between 9 and 18 mo

• Autonomy – ages 2-3 yrs

• School Readiness— depends on autonomy and the ability of the parent and child to separate for hours at a time.

Psychosocial Assessment • Preacademic Skills: colors, counts to 10, knows age,

names, address, phone number, copies shapes, stands on 1 foot, skips, bounces a ball and can dress him or herself.

• At 3-4 years, Preschool helps develops socialization,, improve language, increase skill buidling and problem solving.

• Kindergarten helps develop emotional maturity, social skills, cognitive abilities, and fine and gross motor skills. Children do better in kindergarten if their 5th b-day is at least 4-6 months before starting school. Girls are usually ready earlier than boys.

Development

18% of children in the US have

Developmental and Behavior disabilities

25% have Psychosocial Problems

Developmental Screening

• Compares the developmental skills of a child with the skills of a population of children to identify delays and who will need further testing.

• <= 6y : Assess achievement of milestones

• > 6y : Ask about academic achievement and behavior

Denver Developmental Screening Test II

Age birth to 6 years

Testing Four Domains:

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

Other Screening Tests

• Ages and Stages Questionnaires

• Child Development Inventories

• Parents’ Evaluations of Developmental Status

Parent reported screenings have good validity compared with office based screenings

Age Newborn

- 2w 1m 2m 4m 6m 9m

12m 1y

15m 18m 2y

Age Motor Cognitive Behavioral

Language Social

Full Term Infant

(+)Moro Reflex

Alert to sound of Voice

Fixates on face and briefly follows

2m -Follows objects past midline -Lifts head and shoulders off bed when placed in prone position

Coos

4m *Head lag and Moro disappear* -Bears weight on forearms when prone -Rolls back to front -Bears weight while held standing -Holds hands open predominantly

Laughs outloud Squeals!

Imitates social interaction

Age Motor Cognitive Behavioral

Language Social

6m -Transfers objects from hand to hand -Reaches/rakes for objects -Sits with support -Rolls over both ways -Bangs/shakes toys

Turns directly to sound/voice

- Babbles consonant sounds - Imitates speech

9m -Bangs two blocks together -Sits without support! -Inferior pincer grasp

-Turns when name is called -Plays peekaboo -Plays pattycake

Mama-Dada (nonspecific)

-Stranger anxiety -Recognizes common objects and people

12m -Pulls to stand/cruises -Takes a few steps -Walks with one hand held -Waves bye-bye -Fine pincer grasp -Drinks from cup held by another person

Assists with dressing

-Mama- Dada (specific) -One additional word

Follows a single step command with a gesture

Age Motor Cognitive Behavioral

Language Social

15m -Gives and takes ball -Drinks from a cup -Puts cube into a cup -Walks independently -Stoops to floor and recovers to standing

-3-6 additional words - Points to one body part

Follows a single step command without gesture

18m -Self feeding with a spoon -Stacks 2-3 cube tower -Throws a ball -Walks upstairs while holding hand -Climbs into and sits on chair -Spontaneous scribbling

Imitates household chores

10-20 words

24m -Builds a 6 cube tower -Washes and dries hands -Throws a ball overhand -Removes clothing -Kicks a ball -Jumps with 2ft

>50words -Pronouns -Speech 50% intelligible to stranger

Follows 2step commands

Age Motor Cognitive Behavioral

Language Social

3y - Copies a circle -Puts on shirt/shorts -Builds a 8 cube tower -Balances on 1ft for 1-2s -Pedals tricycle -Goes up stairs with alternating feet -Hops once

- Knows the name of a friend - Understands basic adjectives

-5-8word sentences -Uses pronouns correctly -Speech 75%intelligible to strangers -Starts using “what” and “who”

4y - Hops on one foot several times -Walks up and down stair -Balances on 1ft or 4s -Draws a person with 4 body parts

-Dresses and brushes teeth without help -Names 4 colors -Can identify opposites -Counts to 4

-Asks questions - Speech 100% intelligible to stranger

Pretend plays

Age Motor Cognitive Behavioral

Language Social

5y - Draws a person with 6 body parts -Skips -Walks backwards -Prepares a bowl for food -Holds pencil correct way -Ties a knot -Prints letters

-Plays board games -Counts to 5 -Names all primary colors

-Defines words

6y -Ties Shoelaces -Rides bike

-Writes name -Knows left from right -Counts to 10

-

Milestones

Language Screening

Age (y) 1y 2y 3y 4y

Divide by

4

1 / 4

2/4

3/ 4

4/4

%

25%

50%

75%

100%

Language Delay

Consider hearing deficit

High Risk Conditions:

• Hyperbilirubinemia (Bili > 19; exchange transfusion)

• Infection (congenital rubella, meningitis)

• Structural anomalies

• Hypoxemia (apnea, persistent fetal circulation)

• Ototoxic drug exposure (aminoglycosides, loop diuretics)

Dysfluency (aka stuttering) is common is 3-4 yr olds, transient

S ensorineural P sychomotor E nvironment A utism K inetics

Physical Growth and Development of Adolescents

• Sexual Maturity Rating (SMR) aka Tanner Stages

• Stages I-V

• Biological maturation can be related to specific lab values and physical conditions – Higher hematocrit values in adolescent boys are the result

of greater androgenic stimulation of the BM

– Alkaline phosphatase levels increase during puberty because of rapid bone turnover, especially during a growth spurt

Girls • Average age for puberty: 11 yrs (range: 8-13 yrs)

• SMR Stage II

– Thelarche: Breast budding under the areola. Mean age 9y – Adrenarche/Pubarche: Mean age of adrenarche 10y. Mean age of menarche 12y

• Peak growth spurt occurs 1 yr after thelarche

• Interval from thelarche to onset of menarche: 2 yrs

• Precocious puberty = pubertal changes before 6 -7 yo

Tanner Stages for Girls • Stage I: Breasts are

preadolescent. Elevation of the papilla only

• Stage II: Breast bud stage.

Areolar diameter increases • Stage III: further enlargement of

breast and areola • Stage IV: Projection of the areola

and papilla to form a secondary mound

• Stage V: Mature female, areola

has recessed to the general contour of the breast

Tanner Stages for Girls

Boys

• Adrenarche: Followed by pubic hair development at the base of the penis

• Growth spurt occurs 10-16 yrs (late event)

• Deepening of the voice, facial hair, acne indicate early stages of puberty

Tanner Stages for Boys • Stage I: penis, testes, and

scrotum are of childhood size • Stage II: enlargement of the

scrotum and testes only, scrotal skin reddens

• Stage III: further growth of

testes and scrotum, enlargement of the penis in length

• Stage IV: Increased size of the penis in breadth

• Stage V: Adult in size and

shape

Objectives

• Growth vs Development

• Growth: Weight, Height, Head Circumference

• Discrepancies in Measurement

• Normal Development & Psychosocial Assessment

• Developmental Screening

• Milestones

• Language Screening and Speech Delays

• Adolescence

“I am a child, I last a while . . . You can’t conceive of

the pleasure in my smile.” -Neil Young

References

• Frankenburg, W.K., et al. (1992). The Denver II: A Major Revision and Restandardization of the Denver Developmental Screening Test. Pediatrics, 89 (1), 91-97.

• Kliegman, R.M., Marcdante, K.J., Jenson, H.B., Behrman, R.E. (2006). Nelson essentials of pediatrics (5th ed.). Pennsylvania: Elsevier Saunders.

• LaRosa, A., Glascoe, F.P. “Developmental Surveillance and Screening in Primary Care.” Up to Date (1997). Online. Internet. Available: www.uptodate.com

• Robertson, J., & Shilkofski, N. (Eds). (2005). The Harriet Lane Handbook (17th ed.). Pennsylvania: Elsevier Saunders.