In Paediatrics, Growth and Development are very important. Growth is the assessment of child's nutritional status. This lecture is the backbone of Paediatrics.

2. Lecture-2
Normal Growth
Prof. Dr. Sunil Natha Mhaske
Dean
Dr. Vithalrao Vikhe Patil Foundation’s Medical College and Hospital,
Ahmednagar (M.S.) India-414111
Mo- 7588024773
Mail-sunilmhaske1970@gmail.com

3. • It is increase in size or mass of body due to cell
multiplication.
• It is a progressive increase in the size of a child or parts of a
child.
• Growth comprises several changes including increase in the
size and complexity of body function.
• Growth comprises spaces in the individual: cells; tissues; and
process at the organic level mediated by the interrelation
between genome and local physiology to set specific ways
through which the organism increases in the size and age of
the immature system.
• Growth can be considered as a quantitative change.
Definition of Growth –

4. Principles of Growth:
It is a continuous process.
It is governed by complex chain of hormonal interaction, genetic &
environmental factors.
 In the first 3 year of life , growth is curvilinear whereas after 3
year it is Linear
Growth in the first year is mainly controlled by inheritied
potential of cell and later by several factors(enviornmenal and
genetic)
Growth spurt occur in late foetal period and pubertal period
4 phases of growth
Phase I Hyperplasia
Phase II Hyperplasia + Hypertrophy
Phase III Hypertrophy alone
Phase IV Maturity
Growth does not follow normal distribution curve.

5. Periods of Growth
Intra uterine growth period:
Ovum :- Conception-14days
Embryo:- 14days to 9th week
Fetus:- 9th week to birth.
Extra uterine growth period:
 Neonate:-Early neonatal:- Birth to 7 days
- Late Neonatal:-8 days to 28 day.
 Infancy:-1 month to 1 year
 Toddler:-1-3 years
 Preschool:-3-6 years
 School age:- 6 to 12 years
 Adolescent- Early:-10-13 years
- Middle:-14-16 years
-Late:-17-20 years

6. Factors affecting growth
1. Genetic factor:-
-Parenteral characteristics
-Race
-Sex
-Biorhythm and maturation
-Genetic disorders:
a) Chromosomal abnormalities
b)Gene mutation

7. A. Intrauterine:
-Maternal nutrition/age
-Maternal infection
-Multiple pregnancy
-Drugs in pregnancy
-Maternal endocrine disorder
-Irradiation
-Maternal stress
-Post maturity
-Abnormalities of placenta, umbilical cord
2. Environmental Factors
B. Extrauterine:
Neonatal hypoxia Neonatal convulsion
Low birth weight Social
Nutrition Drugs
Infection and infestation Emotional factors
Cultural factors

8. Laws of growth
Growth and development
is a continuous and orderly
process.
Growth pattern is Unique
but in human being is
cephalocaudal and
proximodistal

9. Types of Growth
1. General or somatic growth-
• It is a sigmoid fashion with period
of accerlated growth and slow
growth.
• It pertains to body as a whole ,
external dimensions, respiratory and
digestive organs, aorta and
pulmonary trunk, kidney, spleen and
blood volume and the whole
musculature and skeleton.
• There are two growth spurt in
general body growth –
1st rapid growth occur in first 2
year of life.
2nd growth spurt in pubertal
period.

10. 2. Neural Growth / Brain
Growth
• There is rapid
myelination of CNS.
• 70% brain growth take
place in Fetal period of
life.
• 15% of growth of brain
is completed by Infancy.
• 10% by 6 year of life.

11. 3. Lymphoid growth
• There is hypertrophy of
Adenoids, Tonsils and lymph
nodes.
• Occur rapidly in infants and get
accerlated in childhood.
• There is rapid growth upto 20
years after that regressing.
• Then slows down in adults.

12. 4. Pubertal growth –
 Remains in dormant stages in early
period of life.
 Then under the influence of SEX
Hormones, it rapidly shoots up by 12 –
13 year of life.
 Overall girls attain puberty earlier than
boys.
 The pattern of growth in girls is from
upwards downwards ,that is first there is
thelarche then menarche.
 The pattern of growth in boys is from
downwards upward that is there is first
maturation of testis than there is Facial
hairs.

13. Adolescent Growth Spurt-
This is the rapid increase in physical growth that marks the
beginning of adolescence.
Girls typically enter the growth spurt by age 10.5,
reach their peak growth by age 12,
return to a slower rate of growth by age 13 to 13.5
Boys lag behind girls by 2 to 3 years.
Typically begin their growth spurt by age 13,
peak at age 14,
return to a more gradual rate of growth by age 16
In addition to growing taller and heavier, the body assumes an
adult like appearance during the adolescent growth spurt.
Widening of hips for girls.
Broadening of shoulders for boys.

14. Skeletal growth
• The skeletal structures that form during the
prenatal period are initially soft cartilage that
will gradually harden into bony material.
• Skull bones are separated by six soft
fontanels, that are gradually filled in by
minerals to form a single skull by age 2 year
• Skeletal age research has been used to
determine that girls mature faster then boys.
• At birth ,girls are only 4 to 6 weeks ahead of
boys in skeletal maturity.
• By age 12 the gender “maturation gap” has
widened to 2 full years.

15. • At birth, muscle tissue is 35% water, and it accounts for
not more than 18 to 24% of a baby’s body weight.
• Muscle fibers soon begin to grow as the cellular fluid in
muscle tissue is boosted by the addition of protein and
salts.
• Muscular development proceeds in cephalo-caudal and
proximo-distal directions.
• Maturation of muscle tissues occurs very gradually
during childhood and then accelerated during early
adolescence.
• By the mid twenties, skeletal muscle accounts for 40%
of the body weight for a man and 24% of the body
weight for a female.
Muscular Development-

16. • Body fat layers appear in the fetus between the 7th and 8th
prenatal months.
• Between birth and 6 - 9 months, body fat mass will increase
10 - 20% before tapering off.
• Females have more body fat than males.
Body fat growth-

17. Parameters for assessment of growth-
A. Age dependent factors-
1)Weight
2)Height / Length
3)Head circumference
4)Chest Circumference
B. Age independent factors-
1)Mid Arm Circumference
2)Weight for height
3)Mid upper arm / height ratio
4)Skin fold thickness
5)Enderberg index
6)Kanawati index:-midarm/head
circumference ratio
7)Rao and Singh’s Criteria
8)Dugdale’s index
9)Quetlet’s index
10)Body mass Index
11)Chest/Head circumference ratio

18. • Weight is of important parameter of
assessing Acute nutrition.
• There is physiological weight loss by 10%
for the first 10 days.
• It is to be measured by placing the child
without clothes on the weighing machine .
Same weighing machine is to be used .
• On weighing machine, keep paper to
prevent heat loss.
Weight

19. Increase in weight by 25 to 30 gm/day from first 10th day to 3rd month
of age.
3rd month to 1st year kg = 9+age(month)
2
1st year to 6th year Kg = 2(age in year)+8
6th year to 12th year Kg = 7(age in year ) - 5
2
Weight-
doubles by 5 month
Triples by 1 year
4 times by 2year
5 times by3 year
6 times by 5 year
10 times by 10 year

20. Length
Infantometer
1)Length is measured from birth to the age of 2 years of age.
2)Infant head is kept first and then the legs are supposed to
be kept straight then another end of infantometer is to be
approximate .

21. 1)For height, Child should stand straight with shoes
and socks are to removed.
2)He should look straight.
3)He should stand in a relaxed state with arm kept at
the side.
4)He should stand with both feet and knees close
together.
5)The head should be kept in Frankfurt plane:-the
line joining the lower margin of orbit and the upper
margin of orbit and the upper margin of external
auditory canal should be straight.
Height
Stadiometer

22. Height:-
It is index of long time nutritional status.
Height after 2 year of age Cm = 6 (age)+77
Birth 50cm
1st year 75cm
2nd year 87cm
3rd year 94cm
4th year 100 cm

23. Length/Height increase by
25 cm / year for 1st year
12 cm/ year for 2nd year
6 cm/year for 3rd year
4-5 cm/year for next year till puberty.
• Girls achieve the height earlier than that of boys.
• Maximum gain of height in girls by age of 12-13 year then it start
slows down.
• But in boys maximum gain in height by age of 14-17 year of age
then it slows down.

24. Head circumference
Measuring Tape-
• The tape we use should be
fibroblastic and the most
important is that its initial part
should not be large which results
in human error.
• It should be very thin .
Tailor’s tape should not be used
for the same as it is broad and it
initial part is large which does not
approximate properly which results
in variation.

25. The change of head circumference corresponds to growth of brain
and skull.
The head circumference (Occipito-frontal head circumference )
Should be measured with narrow non stretchable fiberglass tape.
The tape should encircle over the most prominent parts of occiput
and supra orbital frontal area with sufficient pressure to compress
hair.
Place the tape over the occipital protuberance at the back and just
over the supraorbital ridge and the glabella in the front.
If scalp edema or cranial molding is present Head circumference
should be taken on 3rd -4th day.

26. Birth 33-35cm
1st 3 months 2cm increase/month
4 to 6 month 1cm increase/month
7 to 12th month 0.5cm increase/month(46cm)
1 to 2 year 2cm increase(48cm)
Upto 3 year 1cm increase
Upto 4 year 0.5 cm increase
Upto 5 year 0.25cm increase(50cm)
Adult 55-56cm
Large head(Macrocephaly) HC is more than 2SD above the mean.
It is sign of Hydrocephalous or Intracranial mass.
Small head(Microcephaly)- HC is less than 2SD below the mean.
It is due to early closure of sutures or lack of brain development.

27. Chest circumference:-
Represents growth of thorax and lung
How to measure chest circumference:
• Below 5 year of age it is to be taken at the level of nipples at
supine position.
• After 5 years of age it is to be taken at the level of nipples at
standing position.
• The Chest circumference may be measured at the level of
xiphisternal junction because of location may be variable
Birth CC<HC by 1-3 cm
1st year CC=HC
After 1st year CC>HC

28. Mid arm circumference-
1-5 year of age MAC remain static between 16-17 cm because fat of
infancy is replaced by muscles.
Upper point is anterior process of scapula and lower point is
olecronon process and midway is the point we have to measure.

29. SHAKIR’s tape-
For mild PEM:- >13.5 cm (GREEN)
For moderate PEM:- 2.5 to13.5cm
(YELLOW)
For severe PEM:- <12.5cm (RED)
BANGLE test-
• Quick assessment of arm circumference.
• A fiber glass ring of internal diameter of 4cm
is to be passed without squeezing.
• If it passes above elbow it means arm
circumference is less than 12.5 cm and that
baby is malnourished.

30. Mid arm & height ratio-
It is a good indicator of nutrition
Normal values:-0.32-0.33
Malnourished :-<0.29
Mid arm & head circumference ratio-
It is use to detect malnutrition.
Malnutrition Mild :-0.280-0.314
Moderate:-0.250-0.279
Severe:-<0.249

31. Quack stick test-
It is developed on the principle that
acute starvation affects mid arm
circumference while height is
unaffected.
The child appears thin tall and
wasted.
The quack stick is a meter rod with 2
set of markings.
The expected height of child against
various sizes of mac is marked on rod.
The malnourished child is taller than
anticipated height derived from mid
arm circumference.
It is applicable for the height
from70-132cm.

32. Arm Span
It is the distance between the tip of middle fingers of both arm when they
are outstretched at right angle to the body.
It is to be measured across the back of the body of child.
It is 1-2 cm less than length/height in children below 5 year of age.
By 10 year of age both will be equal.
After that Arm span exceeds the height.
Arm span is more than height in following condition:-
Marfan Syndrome
Klienfelter syndrome
Homocystinuria
Coarctation of aorta
Arm span is less than height in following condition:-
Achondroplasia
Cretinism
Dwarfism

33. Crown rump length / sitting height
• It gives the measure of length
and trunk.
• It is measurement of distance
from highest point on head to base
sitting surface.
• During 1st year of life ,Spinal
increase is faster than
extremities.
• Later extremities grow at faster
than trunk which contributes to
body length.

34. It is percentage of total height or recumbent length
Stem Stature Index:-Crown rump length x 100
Standing height
Stem Stature index:-

35. Upper / lower segment :-

36. Skin Fold Thickness
• It is to be measured by HERPEDEN CALlIPER Over triceps or
subscapular region or biceps or supra iliac area.
• The skin fold with subcutaneous fat is picked with thumb and index
finger ,Calliper is applied beyond the pinch.
• The fat thickness is 10mm or more in healthy children between 1-6
year of life.
• If it is less than 6 mm then indicate severe degree of malnutrition.

37. Ponderal Index (PI) is a measure of leanness of a person calculated as
a relationship between mass and height.
 It was first proposed 1921 as "Corpulence Index" by Rohrer.
 It is similar to the body mass index, but the mass is normalized with
the third power of body height rather than the second power.
with mass in kg (kilograms) and height in m (meter)
The normal values for infants are about twice as high as for adults,
which is the result of their relatively short legs.
It is basically use for IUGR babies
BROCA’S INDEX:
IBW For Adult Males = Height (cm)- minus 100
IBW For Adult Females = (Height cm- 100) – 10% of (Height cm-
100)

39. Bone Age
It is based upon 1)Number , Shape and Size of Epiphyseal center 2)Size shape and
Density of end bones of bones
Tanner and Whitehouse described 8-9 stages of development of ossification centers
and gave them Maturity Scoring -
50% for Carpal Bones
20% for radius and ulna
30% for Phalanges
20 Ossification center are used for estimation of bone
age which includes
i) Carpal bones
ii)Metacarpal and Patella
iii)Distal middle Phalanges in boys ; Distal and proximal phalanges in
girls
iv)Distal and proximal toes
For age estimation-
Newborn:- Foot and Ankle
(3-9 months):- X-ray of Shoulder
For 1-13 year:- X-ray of wrist
For 12-14 Year:- X-ray of Elbow and Hip

43. Dentition
Types of teeth
 Incisors – the front teeth located in the upper and lower jaws. Each incisor has a thin
cutting edge. The upper and lower incisors come together like a pair of scissors to cut
the food
 canines – the pointy teeth on both sides of the incisors in the upper and lower jaws;
used to tear food
 premolars – which have flat surfaces to crush food
 molars – these are larger than premolars, with broad, flat surfaces that grind food.

44. Upper Teeth When tooth emerges When tooth falls out
Central incisor 8 to 12 months 6 to 7 years
Lateral incisor 9 to 13 months 7 to 8 years
Canine (cuspid) 16 to 22 months 10 to 12 years
First molar 13 to 19 months 9 to 11 years
Second molar 25 to 33 months 10 to 12 years
Lower Teeth When tooth emerges When tooth falls out
Second molar 23 to 31 months 10 to 12 years
First molar 14 to 18 months 9 to 11 years
Canine (cuspid) 17 to 23 months 9 to 12 years
Lateral incisor 10 to 16 months 7 to 8 years
Central incisor 6 to 10 months 6 to 7 years
Primary Teeths

45. Permanent
teeth
Upper Teeth When tooth emerges
Central incisor 7 to 8 years
Lateral incisor 8 to 9 years
Canine (cuspid) 11 to 12 years
First premolar (first bicuspid) 10 to 11 years
Second premolar (second
bicuspid)
10 to 12 years
First molar 6 to 7 years
Second molar 12 to 13 years
Third molar (wisdom teeth) 17 to 21 years
Lower Teeth When tooth emerges
Third molar (wisdom tooth) 17 to 21 years
Second molar 11 to 13 years
First molar 6 to 7 years
Second premolar (second
bicuspid)
11 to 12 years
First premolar (first bicuspid) 10 to 12 years
Canine (cuspid) 9 to 10 years
Lateral incisor 7 to 8 years
Central incisor 6 to 7 years

46. Tanner scale
also known as the Tanner
stages or Sexual Maturity Rating
(SMR)) is a scale of physical
development in
children, adolescents and adults.
This scale was first identified in
1969 by James Tanner, a British
pediatrician.

47. Pubic Hair Scale (both males and females)
 Stage 1: No hair
 Stage 2: Downy hair
 Stage 3: Scant terminal hair
 Stage 4: Terminal hair that fills the entire triangle overlying the pubic region
 Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh
Female Breast Development Scale
 Stage 1: No glandular breast tissue palpable
 Stage 2: Breast bud palpable under areola (1st pubertal sign in females)
 Stage 3: Breast tissue palpable outside areola; no areolar development
 Stage 4: Areola elevated above contour of the breast, forming “double scoop” appearance
 Stage 5: Areolar mound recedes back into single breast contour with areolar
hyperpigmentation, papillae development and nipple protrusion

48. Male External Genitalia Scale
 Stage 1: Testicular volume < 4 ml or long axis < 2.5 cm
 Stage 2: 4 ml-8 ml (or 2.5-3.3 cm long), 1st pubertal sign in
males
 Stage 3: 9 ml-12 ml (or 3.4-4.0 cm long)
 Stage 4: 15-20 ml (or 4.1-4.5 cm long)
 Stage 5: > 20 ml (or > 4.5 cm long)

49. Orchidometer (Orchiometer)-
 is a instrument used to measure the volume of
the testicles.
 The orchidometer was introduced in 1966 by
pediatric endocrinologist Prof. Dr. hc. Andrea
Prader of the University of Zurich.
 It consists of a string of 12 numbered wooden
or plastic beads of size from about 1 to 25 mm.
It is also called as "Prader's balls"
 The beads are compared with the testicles of
the patient, and the volume is read off the bead
which matches most closely in size.
 Prepubertal sizes are 1–3 ml
 Pubertal sizes are considered 4 ml
 Adult sizes are 12–25 ml.
 Small testes can indicate either primary or
secondary hypogonadism.
 Testicular size can help distinguish between
different types of precocious puberty.
 Large testes (macroorchidism) can give clue of
mental retardation, fragile X syndrome.

50. Types of body builds-
Shedon Somatotype Classification of human Physique ,
indvidual can be :-
Ectomorphic:-Linear, light bone structure , small
musculature and subcutaneous tissue in relation to body
length and large surface area.
Endomorphic :- Stocky build and large amount of soft
tissue.
Mesomorphic :- Between ectomorphic and endomorphic .
Relative predonderance of muscle , bone and connective
tissue with heavy physique of rectangular outline.

51. Growth chart are also known as road to health chart
1st designed by David Morley
Later modified by WHO
Growth chart is a visible graphical display of child physical
growth and development designed primarily for the longitudinal
follow up of child so that changes over time can be interpreted and
progress of growth monitored
Growth chart offers a simple and inexpensive way of monitoring
weight gain.
Any deviation from “normal” detected by comparison with
reference curves.
Growth chart

52. Types of growth chart
Who Growth Chart
ICDS chart
NCHS Chart
CDC Chart
ICMR Chart

53. The WHO growth chart
It has two reference curves.
Upper reference curve -the median (50th percentile)
for boys. Lower reference curve – 3rd
percentile for girls
Space between two growth curves called weight
channel or Road To Health – zone of normality
INTERPRETATION
Normal - growth line above 3rd percentile and will run
parallel to reference curves
Abnormal- flattening or falling of child’s weight
curves signals growth failure
Earliest sign of PEM
Precede clinical signs by weeks or even months such
a child needs special care –objective; keep child
above 3rd percentile

55. 1. Physical Growth of Infants and Children By Evan G. Graber -
https://www.msdmanuals.com/home/children-s-health-issues/growth-
and-development/physical-growth-of-infants-and-children
2. https://www.longstreetclinic.com/child-growth-development/
3. https://www.stanfordchildrens.org/en/topic/default?id=normal-growth-
90-P01625
4. https://education.stateuniversity.com/pages/1826/Child-Development-
Stages-Growth.html
5. https://www.ccrcca.org/parents/your-childs-growth-and-development
6. https://en.wikipedia.org/wiki/Tanner_scale
7. https://medlineplus.gov/ency/article/002456.htm
8. https://www.thechildren.com/health-info/conditions-and-
illnesses/importance-growth-charts
9. https://www.slideshare.net/kunalmodak2/who-growth-chart
References-

56. Thanks a lot