1. The document discusses growth and development in children from newborn to school age. It defines growth, development, and the different types of each. 2. Key milestones and measurements are provided for physical, motor, language, cognitive, and social development in newborns, infants, toddlers, preschoolers, and school-aged children. Growth charts and how to assess growth are also explained. 3. Determinants of growth such as genetics, environment, nutrition, and periods of rapid development are mentioned. Stages of dental development are outlined across ages.

1. Birhanu G.
Pediatrics and Child Health
Resident
Growth and Development

2. Objectives
• Define growth and development
• Principles of development
• To assess growth and development
• Mention types of growth and development
• Identify the stages of development based on age

3. Growth
• Growth refers to an increase in physical size of
the whole body or any of its parts.
• It is simply a quantitative change in the child’s
body.
• It can be measured in Kg, pounds, meters,
inches, ….. etc

4. Measuring weight

5. Growth chart

13. Assessment of growth
Growth Chart
 Growth chart is the most powerful tool in growth
assessment.
 The standard growth charts are based on data
collected by the National Center for Health
Statistics (NCHS).
 For infants the measure of linear growth is length,
taken by two examiners with the child supine on a
measuring board.
 For older children, the measure is stature, standing
on a stadiometer.

14. Cont’d
The data are presented in4 standard charts:
1. weight for age (WFH)
2. height for age (HFA)
3. head circumference for age and
4. weight for height (WFH)
 Each chart is composed of 7 percentile curves.
 The percentile curve indicates the percentage of
children at a given age on the x-axis whose
measured value falls below the corresponding
value on the y-axis.

15. Cont’d
-For example, on the wt chart for boys age 0-36 mo, the 9 mo
age line intersects the 25th percentile curve at 8.5kg,
indicating that 25% of the 9 mo old boys in the NCHS
sample weigh less than 8.5 kg (75% weigh more).
-By definition, the 50th percentile is the median, the value
above (and below) which 50% of the observed values fall.
It is also termed the standard value.
- NCHS curves are inappropriate for children with intrinsic
growth disorders like Down, Turner, and Klinefelter
syndromes or classic achondroplasia. These children have
their own growth charts.

16. Analysis of Growth Patterns
Growth is a process and not a static quality.
- An infant at the 5th percentile of wt for age may be
growing normally, may be failing to grow, or may
be recovering from growth failure, depending on
the trajectory of the growth curve.
- For premature infants, over diagnosis of growth
failure can be avoided by subtracting the weeks of
pre maturity from the postnatal age when plotting
the growth parameters up to 18mns,24mns and 40
mns of age for HC , Wt and Ht respectively.

17. Cont’d
 Children with low HFA who have normal WFH may have
experienced nutritional or growth failure in the past, whereas if
both HFA and WFH are strikingly low, then both past and current
nutritional or growth failure may be suspected.
 In contrast, children with normal HFA who have low WFH are
likely to have either acute nutritional or growth problem.
 When growth parameters fall below the 5th percentile, it becomes
necessary to express the value as percentage of the median or
standard value.
 Using the calculated percentage of the standard growth curve, it
can be graded from mild to severe.

18. Severity of Malnutrition: Stunting & Wasting
Grade of
malnutrition
WFA
(Gomez)
HFA
(Waterlow)
WFH
(Waterlow)
0, normal > 90 > 95 > 90
1, mild 75-90 90-95 81-90
2, moderate 60-74 85-89 70-80
3, severe < 60 < 85 < 70

19. Cont’d
 Nutritional insufficiency must be differentiated from
congenital, constitutional, familial and endocrine causes of
decreased linear growth.
 In the latter cases, the length declines first or at the same
time as the weight; WFH is normal or elevated.
 In nutritional causes, the weight declines before the length
and the WFH is low.
 Congenital pathological short stature
- infant is born small and growth gradually tapers off
throughout infancy.
- causes include chromosomal abnormality (Turner synd.,
Trisomy 21), congenital infections and extreme
prematurity.

20. Cont’d
 Constitutional growth delay
- WFH decrease near the end of infancy, parallel the normal
through middle childhood, and accelerate towards the end
of adolescence.
- adult size is normal.
- bone age is low and comparable to height age.
 Familial short stature
- both infant and parents are small.
- growth runs parallel to and just below the normal curves.
- bone age is normal i.e. comparable to chronological age.

21. Development
• Development refers to a progressive increase in skill
and capacity of function.
• It is a qualitative change in the child’s functioning.
• It can be measured through observation.

22. Developmental principles
 It is a continuous process
 Development proceeds cephalo-caudal fashion
 Depends on maturation and learning
 Proceeds from general to specific
 Proceeds from simple to more complex
 Unique individual rates of growth and development but the
sequence is same
 Rate of growth is more important than actual number

23.  How do you assess development?
 Ask
 Parental report on milestones achieved
 Observation
 12 month old walks into the examining room, 6 month old sitting
upright in mothers arms
 Examination
 Neurologic exam, hearing and vision screen
 Look for Warning signs/red Flags
 Early warning signs
Cntd…

24. Growth Pattern

25. Determinants of growth and development
I. Biologic influences
a. Genetic
b. Intelligence
c. Pre & postnatal conditions
d. Sex – girls tend to learn to walk, speak & acquire
sphincter control early and boys heavier and longer
e. Hormonal influences
f. Temperament

26. II. Physiological influences
a. Bonding
b. Attachment
III. Social & environnemental factor
a. Familial conditions
b. Order of birth
c. Handicaps – deafness, blindness, illnesses
d. nutrition
e. exercise
Cntd…

27. Periods of growth and development
 Embryo 0-8 weeks
 Fetus 9 wk – birth
 Neonate birth – 28 days
 Infant birth – 12 month
 Toddler 1-3 yrs
 Pre school 3-5 yrs
 School age 6-10yrs
 Adolescence 10-18 yrs

28. Types of growth and development
Types of growth:
- Physical growth (Ht, Wt, head & chest circumference)
- Physiological growth (vital signs …)
Types of development:
- Motor development
- language development
- Cognitive development
- Emotional development
- Social development

29. 0-2 months
1. Physical growth
 Average birth weight = 3.4kg
 Average length = 50cm
 Average head circumference= 35cm
 weight may initially decrease 10% below birth weight in the
1st wk
 Infants regain or exceed birth weight by 2 wk of age and
should grow at approximately 30 g/day during the 1st mo
 This is the period of fastest postnatal growth

30. 2. Physiological growth
 Respiration – The prime need of the newborn
 Circulation - Pulmonary vascular resistance falls &
peripheral vascular resistance increases
- The existing right to left should be
reversed
- Transition from fetal to adult type of
circulation
- Normally new born hearts beats 120-
160 min.
 Hematology - High hemoglobin level 17 -19 gm/dl
- Life span of RBCS is short
- High leukocyte count
Cntd…

31. 3. Neurodevelopment
Gross motor
When held in sitting position- Back bends
Ventral suspension- momentary tensing of neck
muscles.
Prone - momentarily holds chin off couch
Pull to sit- almost complete head lag
Movements are largely uncontrolled except in eye gaze,
head turning & sucking
Fine motor - Not yet developed
Cntd…

32. 3. Language & social
- Cries
- Protrudes tongue
- Hearing is well developed & prefers
high pitched sound
- Near sighted with focal length of 20 -
30cm
- Spontaneous smile
4. Cognitive/ Behavioral development
- Regards on face
Cntd…

33. 5. Primitive reflexes in the Newborn
1. Moro reflex
2. Startle reflex
3. Grasp reflex
4. Rooting or “Search” reflex
5. Sucking & swallowing
6. Placement reflex
Cntd…

34. Cntd…

36. Infancy
1. Physical growth
 Weight = Birth weight doubles by 5th mn and triples
by 11-12mn
Weight 3-12mn= age in mn + 9
2
 Length = increase by 25 = 75 cm at 12mn
 Head circumference = increase by 12cm in 1st yr
increase by 2cm/mn in 1st 3mn
increase by 1cm/mn 3-6mn
increase by 0.5cm/mn 6-12mn

37. 2. Dentition
 The sequence of events in dental development
includes mineralization, eruption, & exfoliation.
 Starts at age 5-6mn
 No teeth at age 4mn then
 Erupts 4 teeth every 4 month till 20 teeth
 Tooth eruption begins with the central incisors &
continues laterally.
Cntd…

38. 3. Motor development
Gross motor
• At 2 months
• Hold head erects in mid-position
• Turn from side to back
• Drop toys
• At 3 months
• Hold head erects and steady
• Open or close hand loosely
• Hold object put in hand
Cntd…

39.  4 months
• Sit with adequate support
• Roll over from front to back
• Hold head erect and steady while in sitting position
• Bring hands together in midline and plays with fingers
• Grasp objects with both hands
Cntd…

40.  5 months
• Balance head well when sitting
• Sit with slight support
• Pull feet up to mouth when supine
• Grasp objects with whole hand (Rt. or Lt.)
• Hold one object while looking at another
Cntd…

41. • At 6 – 8 month
• Sit alone briefly
• Turn completely over (back to abdomen)
• Lift chest and upper abdomen when prone
• Hold own bottle
• Imitates bye bye
• Inhibited by the word no.
Cntd…

42. • 9 months
• Rise to sitting position alone
• Crawl (i.e., pull body while in prone position)
• Hold one bottle with good hand-mouth coordination
• 10 months
• Creep well (use hands and legs)
• Walk but with help
• Bring the hands together
Cntd…

43.  11 months
• Walk holding on furniture
• Stand erect with minimal support
• 12 months
• Stand-alone for variable length of time
• Sit down from standing position alone
• Walk in few steps with help or alone (hands held at shoulder
height for balance)
• Pick up small bits of food and transfers them to his mouth
Cntd…

44. Fine motor
6-7 month Transfers object from one hand
to the other
9-10 month pincer grasp
Cntd…

45. 4. Language
• 1-2 months: coos
• 2-6 months: laughs and squeals
• 6-8 months babbles: mama/dada as sounds
• 10-12 months: “mama/dada specific
5. Social development
• learns that crying brings attention
• The infant smiles in response to smile of others
• 7mn shows fear of stranger (stranger anxiety).
• Responds socially to their name
• 8-9 month shows object permanence
Cntd…

50. Head Control
Newborn Age 6 months

51. Sitting Up
Age 2 months
Age 8 months

52. Ambulation
13 month old
Nine to 12-months

53. Fine Motor Development
in infancy
6-month-old
12-month-old

54. Toddler
1. Physical growth
 During this period, growth slows considerably
 Physical growth
 Weight for age > 1yr
Weight= (age in yrs X 2)+8
 Height – increases by 1cm/month
(Age in yrs X 5) +80
 Head circumference increases 10cm from 1yr till adulthood
 HC increases 2cm from 1st -2nd year

55. 2. Neurodevelopment growth
Gross motor
15 months
• Walk alone
• Creep upstairs
18 months
• Runs stiffly, walks up stairs with one hand held
• Carries and hugs doll
24 months
 Runs well, walks up and down stairs, one step at a time, jumps
Cntd…

56. Fine motor
15mn- Hold a cup with all fingers grasped around it
scribble
18mn- Hold cup with both hands
Transfer objects hand-to hand at will
24mn
-Can hold a crayon and color vertical strokes
-Turn the page of a book
-Build a tower of six blocks
Cntd…

57. 3. Adaptive/cognitive
15 mn
Makes tower of 3 cubes
18mn
Makes tower of 4 cubes, imitates
scribbling, imitates vertical stroke
24mn
Makes tower of 7 cubes, scribbles in circular
pattern, imitates horizontal stroke
Cntd…

58. 4. Social development
 15mn hugs parents
 18mn Feeds self
 24mn Handles spoon well, helps to undress
Cntd…

59. 5. Language
15 mn
 follows simple commands, may name a familiar object,
responds to name
18mn
 10 words (average), names pictures, identifies one or more
parts of body
24mn
 Puts 3 words together (subject, verb, object)
Cntd…

60. Preschool stage
1. Physical growth
 Weight: - 2 kg per year,
 Wt gain in the age 1-6 yrs
1-6 yr= (age in yr x 2)+ 8
 Linear growth: - height  by 6-7 cm per year
 Brain growth: HC increases by 1-2 cm per year
Dental development: - all 20 10 tooth erupted by
the age 3 yr.

61. 2. Neurodevelopment
Gross motor:
30mn - Goes up stairs alternating feet
3 yr - Rides tricycle, stands momentarily on
one foot
4yr - Hops on one foot; throws ball overhand,
uses scissors to cut out pictures, climbs well.
5yr - Skips
Fine motor: - 3rd year copies circle
- 3rd year rides tricycle
- 4th year copies a square

62. 3. Social/Language
- language development is rapid during the age of 2-3yr
- From 100 to 2,000 words
- From 3 word to complex sentences
Cntd…

63. 4. Cognitive/Adaptive
- Build a tower of 10 cubes, copies circle,
imitates cross at 3 yr
- handedness established by age of 3 year
- bowel and bladder control 24-30mn
- Knows sex and age by the age of 3 yr
- Gender role by the age of 4 yr
- Tells story, copies cross and square 4yr
-Draws triangle from copy 5 yr
Cntd…

67. Cntd…

68. School age
 Age between 6-11 years referred as middle child
hood or latency
 Self esteem becomes a central issue
- Able to evaluate themselves
- perceive others’ evaluation of them
 Lymphoid tissue hypertrophy occurs

69. • Muscular strength, coordination & stamina
increases progressively
• Sexual organs remain physically immature but
interest in gender differences & sexual behavior
become active & increase progressively until
puberty
Cntd…

70. 1. Physical growth
 Weight gain is 3-3.5Kg/ year
 Wt for age 7-12yr = (age (yr)x7)-5
2
 Height: -increase by 6cm per year
 Brain growth:- HC ↑ by 2-3 cm throughout this period
Dental development
 Loss of deciduous teeth starts by 6 year
 First molar (6year molar) erupts (The 1st permanent teeth)
 Replacement with adult teeth occurs at a rate 4 per year for
the next 5 years.
Cntd…

71. 2.Neurodevelopment
Gross motor
6-8 ride bicycle, sporty
Fine motor
6th year copies a diamond & draws a
man with12 details
At 7th yr draw a man with 16 detail
9-10yr draw man with many details
Typing skill
Musical instrument
Cntd…

72. 3. Social/language
 Receptive language
 Expressive language
 Identify with same sex parents adopting them
as role models
 Further separation from the family
Cntd…

73. 4. Cognitive/adaptive
- Thinking differs qualitatively
- Change from preoperational to
concrete logical operations
- Apply rules based observable
phenomena
- Long-term memory
- Selective attention
- At 6 yr reads one – syllable printed words
- At 6 yr differentiates (knows) morning
& afternoon
- At 8 yr defines words better than by use
Cntd…

74. Adolescent
 The age group of 10 -18 years
 Growth spurt occurs here
- Height increase by 6-7 cm
 Puberty is the biologic transition from childhood to
adulthood.
 Puberty occurs early in females
 Sexual Maturity Rating (SMR)/Tanner stage
- Rated from 1-5
1. Boys - Testes
- Penis
- Pubic hair
2. Girls - Breast
- Pubic hair

75. 1. Physical growth
Weight:
 Growth spurt begins earlier in girls (10–14 years,
while it is 12–16 in boys)
 Males gains 7 to 30kg, while female gains 7 to 25kg

76. Height:
• By the age of 13, the adolescent triples his birth length
• Males gains 10 to 30cm in height.
• Females gains less height than males as they gain 5 to
20cm.
• Growth in height ceases at 16 or 17 years in females and
18 to 20 in males
Cntd…

77. Secondary sexual characteristics
Male
 Genital changes
 Appearance of pubic,
axillary, and facial hair
 Voice change
Female
 Breast changes
 Growth of pubic and
axillary hair
 Onset of menarche

82. DEVELOPMENTAL DELAY
 Developmental disability, estimated to affect 5-10% of children.
 A disturbance in the acquisition of cognitive, motor, language, or
social skills with a significant and continuing impact on dev’tal
progress.
 The terms “delayed development,” “disordered development,”&
“developmental abnormality” are used synonymously.
 The diagnosis of mental retardation is reserved for children older
than 5 years,inwhom standardized IQ testing can be reliably
performed.

83. DEVELOPMENTAL REGRESSION
 When a child loses an already achived skill or fails to progress
beyond a prolonged plateau after a period of relatively normal dev’t.
 A progressive neurological disorder should be suspected.
 Children with a static encephalopathy can experience neurological
deterioration.
 Global developmental delay
significant delay seen across multiple domains of function & adaptation.
o significant : performance that is two standard deviations below the
mean for chronological peers.

84. ETIOLOGY OF DEVELOPMENTAL DELAY
BY TIME OF ONSET
PRENATAL / PERINATAL EXAMPLES
CONGENITAL MALFORMATIONS OF
CNS
LISSENCEPHALY,CHIARI
MALFORMATION
CHROMOSOMAL ABNORMALITIES DOWN , TURNER’S SYNDROME
ENDOGENOUS TOXINS FROM
MATERNAL ORGANS
MATERNAL HEPATIC OR RENAL
FAILURE
EXOGENOUS TOXINS FROM
MATERNAL USE
ALCOHOL,ANTICONVULSANTS,DRUG
S OF ABUSE
FETAL INFECTION CONGENITAL INFECTIONS (
TORCHS)
PREMATURITY & / OR FETAL
MALNUTRITION
PVL, IVH
PERINATAL TRAUMA INTRACRANIAL
HEMORRHAGE,SPINAL CORD
INJURY

85. POSTNATAL EXAMPLES
INBORN ERRORS OF METABOLISM AMINOACIDOPATHIES,MITOCHONDRI
AL DISEASES,UREA CYCLE DEFECTS
ABNORMAL STORAGE OF
METABOLITIES
GLYCOGEN STORAGE DISEASE
ABNORMAL POSTNATAL NUTRITION VITAMIN OR CALORIE DEFICEIENCY
ENDOGENOUS TOXINS FROM ORGAN
FAILURE
HEPATIC OR RENAL
FAILURE,KERNICTERUS
EXOGENOUS TOXINS DRUGS,ILLICIT SUBSTANCE,LEAD
ENDOCRINE FAILURE HYPOTHYROIDISM,ADDISON’S
DISEASE
CNS INFECTIONS MENINGITIS,BRAIN ABSCESS,VIRAL
MENINGOENCEPHALITIS,HIV
ENCEPHALOPATHY,SSPE
CNS TRAUMA TRAUMATIC AND NONTRAUMATIC
BRAIN INJURY
NEOPLASIA INFILTRATION,EDEMA,HYDROCEPHAL
US,RADIATION
NEUROCUTANEOUS SYNDROMES NEUROFIBROMATOSIS,TUBEROUS
SCLEROSIS

86. Evaluation and Diagnosis
 Children who fail developmental screening may need further
medical evaluation.
 Evaluation for iron deficiency anemia
 Evaluation for lead poisoning (if risk factors for lead poisoning present)
 Formal hearing testing (BAER)
 Vision testing (full ophthalmologic exam)
 Thyroid function testing
 Metabolic screening
 Neuroimaging (MRI vs CT)

87. Cntd…
 Chromosomal/Cytogenetic Testing (if +family history)
 Down Syndrome (karyotype),
 Fragile X (FMR1),
 Rett Syndrome(MECP2)
 Prader-Willi/Angelman (FISH)
 EEG if suspected seizure activity/encephalopathy (Landau-
Kleffner)
 CK/Aldolase if abnormal muscle tone (Muscular dystrophy)