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OGUNLESI TA (FWACP)1 GROWTH AND DEVELOPMENT. OGUNLESI TA (FWACP)2 GROWTH Growth is the increase in size of a child while development is the acquisition.

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Presentation on theme: "OGUNLESI TA (FWACP)1 GROWTH AND DEVELOPMENT. OGUNLESI TA (FWACP)2 GROWTH Growth is the increase in size of a child while development is the acquisition."— Presentation transcript:

1 OGUNLESI TA (FWACP)1 GROWTH AND DEVELOPMENT

2 OGUNLESI TA (FWACP)2 GROWTH Growth is the increase in size of a child while development is the acquisition of skills. Growth is the best general index of HEALTH and NUTRITION. Components of growth include changes in body SIZE, SHAPE & WEIGHT. There is a normal pattern with which normal children grow: a definite range in age at which they reach certain weight or height.

3 OGUNLESI TA (FWACP)3 GROWTH Initially, growth is dependent on rapid cell division & increase in total number of cell number (hyperplasia). Subsequently, growth is determined by increase in sizes of the individual tissues & organs (hypertrophy).

4 OGUNLESI TA (FWACP)4 GROWTH Growth is a smooth process but programmed such that different organs grow at different rates at different times in every normal child. This normal trend is further influenced by intrinsic and extrinsic factors like genetics & environmental influences. General somatic growth is most rapid during the first 4 years & between 12 and 16 years of age.

5 OGUNLESI TA (FWACP)5 GROWTH Brain growth which determines head growth is most rapid during the perinatal period. It is ≈ 60% adult size by age 2 and ≈ 90% adult size by the age of 5 years. Lymphoid tissues (including the tonsils) are barely noticed in the newborn period but subsequently grow very rapidly till age 8- 10yrs & thereafter regress to adult size. Reproductive organs only develop rapidly during puberty in preparation for procreation and regress when that task is complete.

6 OGUNLESI TA (FWACP)6 FORMS OF GROWTH Somatic – General body size Bone Ossification Lymphoid Tissue Reproductive System

7 OGUNLESI TA (FWACP)7 PHASES OF GROWTH (PERINATAL) Weight, length & OFC at birth are used to assess Intra-uterine Growth Pattern. These are influenced by duration of gestation & adequacy of nourishments.

8 OGUNLESI TA (FWACP)8 PHASES OF GROWTH (PERINATAL) Placental functions determine the quality & quantity of nourishments. Maternal factors which cause placental insufficiency also cause poor fetal growth.

9 OGUNLESI TA (FWACP)9 PHASES OF GROWTH (PERINATAL) On the average:  Weight at birth = 3.0kg  Length at birth = 50 ± 2cm  Occipito-frontal Circumference = 35 ± 2cm LBW = Birth Weight < 2.5kg (Includes VLBW & ELBW) VLBW = Birth Weight < 1.5kg ELBW = Birth Weight < 1.0kg Macrosomia = Birth Weight > 4.0kg

10 OGUNLESI TA (FWACP)10 PHASES OF GROWTH (PERINATAL) Babies are further classified into 3 based on the pattern of Intra-Uterine Growth  LGA – Birth weight > 90 th centile  AGA – Birth weight 10 – 90 th centile  SGA – Birth weight < 10 th centile

11 OGUNLESI TA (FWACP)11 PHASES OF GROWTH (PERINATAL) SGA babies may be further classified into:  Symmetric – uniformly ↓wt, lgth & OFC  Asymmetric – Normal OFC but ↓ wt & lgth.

12 OGUNLESI TA (FWACP)12 MEASURING & MONITORING SOMATIC GROWTH Growth faltering is the most sensitive sign of illness in children. Therefore, records of Weight & Length on a single occasion are of limited value. Thus, it is better to plot the growth as a graph rather than a series of numbers.

13 OGUNLESI TA (FWACP)13 MEASURING & MONITORING SOMATIC GROWTH In practice, the weight & height of a child is plotted against the chronological age on a standard normogram or graph. Specifically, growth monitoring is done by plotting series of weight of the child on a graph known as the ROAD-TO-HEALTH CHART. The details and significance of this chart would be discussed under Nutrition & Nutritional Disorders.

14 OGUNLESI TA (FWACP)14 MEASURING & MONITORING SOMATIC GROWTH OFC is measured using the most prominent part of the occiput and the glabella as the Reference Points. OFC is important because it reflects brain growth. CC is measured along the nipple line. CC is more useful when it is interpreted in comparison with OFC:  OFC > CC before the age of 1 year  OFC = CC at the age of 1 year  OFC < CC after the age of 1 year

15 OGUNLESI TA (FWACP)15 MEASURING & MONITORING SOMATIC GROWTH If OFC < CC before the age of 1 year: OFC may be abnormally small (MICROCEPHALY) or CC is abnormally large (OVERWEIGHT & OBESITY) If OFC > CC after the age of 1 year: OFC may be abnormally large (MACROCEPHALY) or CC is abnormally small (SEVERE WASTING)

16 OGUNLESI TA (FWACP)16 MEASURING & MONITORING SOMATIC GROWTH OFC increases by ≈2cm/ month for the first 3 months of life (1m to 3m) Subsequently, by ≈1cm/ month for the next 3 months of life (4m to 6m) For the remaining 6m in infancy, it increases by 0.5cm/ month Total increment over infancy = 12cm.

17 OGUNLESI TA (FWACP)17 MEASURING & MONITORING SOMATIC GROWTH Subsequently:  0.25cm/ month for the 2 nd & 3 rd years of life  0.1cm/ month for the 4 th & 5 th years of life.  0.5cm/ year till the adult size of 55cm is reached. At birth, OFC is 35 ± 2cm. It increases to 47 ± 2cm at 1year and 55 cm in the adult. This means rate of brain growth in the first year of life is more than the rate of growth in the rest of life!

18 OGUNLESI TA (FWACP)18 MEASURING & MONITORING SOMATIC GROWTH WEIGHT is measured in KILOGRAMS with:  BEAM BALANCE WEIGHING SCALE (Usually combined with Stadiometer)  SPRING BALANCE WEIGHING SCALE (Bathroom scale & Basinet scale are examples)

19 OGUNLESI TA (FWACP)19 MEASURING & MONITORING SOMATIC GROWTH Newborn babies lose 5 to 10% of the birth weight over the first 2 to 3 days of life and regain the birth weight by 7 to 10 days in term babies OR by 10 to 14 days in preterm babies. SGA babies may not experience this physiologic weight loss.

20 OGUNLESI TA (FWACP)20 MEASURING & MONITORING SOMATIC GROWTH Subsequently:  Term babies gain weight at the rate of 30g/ day (150 to 200g/ week) for the 1 st and 2 nd months.  Between the 3 rd and 5 th months, the rate among term babies reduces to 20g/day.  Term babies double the birth weight at about the 5 th month and triple the birth weight by 12 months.  Preterm babies gain weight at the rate of 15 to 20g/kg/ day.

21 OGUNLESI TA (FWACP)21 MEASURING & MONITORING SOMATIC GROWTH Thereafter, weight is estimated from the age using the following formulae: 3 to 12 months: (n+9)/2 {where n is age in months} 1 to 6 years: (2n + 8) {where n is age in years} OR 7 to 12 years: (7n-5)/2 OR 3n {where n is age in years)

22 OGUNLESI TA (FWACP)22 MEASURING & MONITORING SOMATIC GROWTH Length is measured in centimeters using an Infantometer (Measure Mat) till age 2yrs. From age 3yrs, height is measured in centimeters using a Stadiometer. An infant gains ≈25cm length over the 1 st year (averagely 2cm/ month). Length/Height after infancy: 6n + 75cm (where n is age in years)

23 OGUNLESI TA (FWACP)23 DENTITION AS AN INDEX OF GROWTH Tooth eruption and exfoliation proceed at a specific sequence: Primary Dentition:  First to erupt – Central Incisors (6 – 7m)  Exfoliation starts – Central Incisors (6 – 7yrs) Secondary Dentition:  First to erupt – Central Incisors (6 – 7yrs) Rough estimate for children >6m: Age (months) = Number of teeth + 6

24 OGUNLESI TA (FWACP)24 DENTITION AS AN INDEX OF GROWTH Delayed tooth eruption (no tooth eruption by 13m of age)  Familial  Idiopathic  Prematurity  Hypothyroidism  Rickets

25 OGUNLESI TA (FWACP)25 DENTITION AS AN INDEX OF GROWTH Early exfoliation (Shedding occurring before age 5yrs)  Idiopathic  Trauma  Scurvy  Gingivitis Natal teeth – intra-uterine tooth eruption (usually loose and may be spontaneously dislocated with the risk of aspiration and airway obstruction).

26 OGUNLESI TA (FWACP)26 BONE OSSIFICATION AS AN INDEX OF GROWTH Bone ossification proceeds in a regular sequence. In the fetus, the shaft of the long bones (diaphyses) ossify shortly before birth. Ossification continues at the epiphyses of long bones at different rates after birth. Skeletal maturity is assessed by comparing ossification centers seen on X-Ray of the wrist, elbow, knee and foot with standardized atlas.

27 OGUNLESI TA (FWACP)27 BONE OSSIFICATION AS AN INDEX OF GROWTH The following ossification centers are present at birth:  Lower Femur  Upper Tibia  Talus and calcaneus

28 OGUNLESI TA (FWACP)28 BONE OSSIFICATION AS AN INDEX OF GROWTH The following ossification centers appear after birth:  Radial epiphyseal centers: m  Ulnar epiphyseal centers: 4 – 9 years  Hamate & Capitate carpal: 2m  Lunate carpal: 3 yrs  Trapezoid carpal: 5 yrs  Pisiform carpal: 12 yrs

29 OGUNLESI TA (FWACP)29 BONE OSSIFICATION AS AN INDEX OF GROWTH Delayed bone age Hypopituitarism Hypothyroidism Delayed puberty Malnutrition Advanced bone age Gigantism Hyperthyroidism Precocious puberty

30 OGUNLESI TA (FWACP)30 GROWTH CHARACTERISTICS OF ADOLESCENCE Hormone-induced Growth spurt (trunk more than legs) which starts at age 11yrs in girls and 13yrs in boys Tanner Sexual Maturity Staging  Genital development in boys ( 1 to 4)  Pubic Hair growth in both sexes (1 to 4)  Breast development in girls (1 to 4) Details will be given under Endocrinology

31 OGUNLESI TA (FWACP)31 FACTORS AFFECTING GROWTH Growth rate is the outcome of the interaction between genetic & environmental factors. Genetics determine the rate of growth & the final attainable size. Environmental factors influence these two.

32 OGUNLESI TA (FWACP)32 FACTORS AFFECTING GROWTH The phenomenon of “CATCH-UP GROWTH” is a natural compensatory mechanism. When the rate of growth is slowed down by environmental factors (eg infections) and these have been promptly addressed (by way of therapy), CATCH-UP GROWTH occurs to ensure that the final size programmed by genetics is eventually attained.

33 OGUNLESI TA (FWACP)33 FACTORS AFFECTING GROWTH GENETICS – Inheritance of the age at attainment of menarche; correlation for height between siblings or between parent and child. NUTRITION  Poor growth is prevalent in places where diet is deficient in calories & proteins.  When diet is poor, energy that should be used for growth is diverted to other metabolic processes required to maintain life.  Hence growth failure is a constant feature of PEM.

34 OGUNLESI TA (FWACP)34 FACTORS AFFECTING GROWTH DISEASES especially infections  Diarrhoea, measles, tuberculosis, pertussis and malaria are important infective causes of growth failure  Food is culturally withheld during infections  Food refusal & anorexia occur commonly during infections  Infections are highly catabolic

35 OGUNLESI TA (FWACP)35 FACTORS AFFECTING GROWTH HORMONES  Human Growth Hormone (Somatotrophin) is the most important in somatic growth.  Gonadal Hormones (Testosterone, FSH & LH) and adrenal androgens are required for pubertal growth spurt.  Insulin only influences intra-uterine growth (hence, IDM are usually LGA).  Thyroxine affects bone growth and not general somatic growth.

36 OGUNLESI TA (FWACP)36 FACTORS AFFECTING GROWTH PSYCHO-SOCIAL Children who are loved & cared for usually show better growth pattern compared to those who are deprived of love. Psychological factors greatly influence the Higher Centers (cerebrum & hypothalamus) with indirect effect on the above-mentioned hormones. Children in High SEC grow better than those in Low SEC (better home situation etc)

37 OGUNLESI TA (FWACP)37 NCHS/WHO GROWTH CHART NCHS/WHO Growth Chart for children aged 0 to 20 years displaying:  Weight-for-Age  Height-for-age  Weight-for-Height  Body Mass Index

38 OGUNLESI TA (FWACP)38 NCHS/WHO GROWTH CHART Parameters are expressed in percentiles (3 rd, 5 th, 25 th, 50 th, 75 th, 95 th, 97 th ) WA < 3 rd centile = Wasting HA < 3 rd centile = Stunting WH < 3 rd centile = Underweight

39 OGUNLESI TA (FWACP)39 COMMON DISORDERS OF GROWTH Failure-to-Thrive Short Stature Tall Stature

40 OGUNLESI TA (FWACP)40 FAILURE-TO-THRIVE Defined as body weights or rates of weight gain significantly below the expected for the age & sex.  WA< 3 rd centile on NCHS chart  WH < 5 th centile on NCHS chart  Weight gain < 20g/d from 0 to 3mo  Weight gain <15g/day for 3 to 6 mo  Downward crossing of > 2 centiles on growth chart.

41 OGUNLESI TA (FWACP)41 CAUSES OF FAILURE-TO- THRIVE INADEQUATE INTAKE  Feeding disorders (Starvation, wrong feeding technique, wrong food for age)  Neurological problems (CP, myopathies)  Craniofacial abnormalities (cleft deformities, choanal atresia)  Chronic dyspnea (CHD, Pulmonary diseases)  Tracheo-esophageal fistula

42 OGUNLESI TA (FWACP)42 CAUSES OF FAILURE-TO- THRIVE CALORIE WASTING  Excessive/protracted vomiting (↑intracranial pressure, pyloric stenosis, esophageal reflux, metabolic disorders)  Malabsorption (Helminthiases, Enzymatic deficiencies, food sensitivity, Biliary atresia, Immunologic deficiency)  Renal Losses (Diabetes mellitus, RTA)

43 OGUNLESI TA (FWACP)43 CAUSES OF FAILURE-TO- THRIVE ↑CALORIC REQUIREMENTS  Chronic anaemia  Chronic Heart Diseases  Chronic/recurrent infections (TB, HIV)  Endocrine (Hyperthyroidism, Hyperaldosternism)  Malignancies

44 OGUNLESI TA (FWACP)44 CAUSES OF FAILURE-TO- THRIVE Altered Growth Potential  Prenatal Insults  Chromosomal abnormalities  Genetic syndromes  Psychosocial  Maternal Deprivation Syndrome  Child abuse/neglect

45 OGUNLESI TA (FWACP)45 NEUROLOGICAL DEVELOPMENT NEUROLOGICAL DEVELOPMENT

46 OGUNLESI TA (FWACP)46 NEUROLOGICAL DEVELOPMENT Development refers to increase in the complexity of functions of an organ/system. It involves acquisition of the following skills required for adaptation to life:  PSYCHO-MOTOR  SPECIAL SENSE  INTELLECTUAL  SOCIAL It is a continuous process from conception to maturity.

47 OGUNLESI TA (FWACP)47 NEUROLOGICAL DEVELOPMENT Nervous system maturation is a basic requirement for development. Neuronal complement is fully developed well before birth (no new neurones are formed after birth). After birth: major events include: (1) SYNAPTIC BRANCHING (2) AXONAL MYELINATION These are required for adaptation & learning.

48 OGUNLESI TA (FWACP)48 NEUROLOGICAL DEVELOPMENT Development progresses in a cephalocaudal pattern. The sequence of development is similar in all normal children. Every normal child must be skilled in maintaining a balance of the trunk before sitting can be achieved. On the other hand, the rate varies greatly due to genetic influences (a.k.a constitutional factors). A normal child may walk at 11 months while another normal child may not walk until 16 months of age.

49 OGUNLESI TA (FWACP)49 NEUROLOGICAL DEVELOPMENT Development consists of 2 parts: PHYSICAL & COGNITIVE/EMOTIONAL Development is best described under FOUR areas (Details as contained in the Appendix):  GROSS MOTOR  FINE MOTOR  SPEECH & LANGUAGE  PSYCHO-SOCIAL

50 OGUNLESI TA (FWACP)50 NEUROLOGICAL DEVELOPMENT Delay in all the 4 areas strongly suggest MENTAL RETARDATION. Isolated delay in only one area may not be abnormal particularly in the absence of an obvious cause. Delay in walking is the commonest isolated developmental delay (may run in families). Delay in speech may occur when infants are exposed to more than one language at the same time.

51 OGUNLESI TA (FWACP)51 PRIMITIVE REFLEXES These are reflexes with which the infant is born. They are required for the earliest adaptation to extra-uterine life. They originate from the brain stem. They are inhibitory and so, must disappear before normal motor development can occur. Their persistence indicates severe neurological abnormality which may be congenital or acquired.

52 OGUNLESI TA (FWACP)52 PRIMITIVE REFLEXES Moro Reflex Rooting reflex Sucking Reflex Tonic Neck Reflex Grasp Reflex (Palmar & Plantar) Walking Reflex Placing Reflex

53 OGUNLESI TA (FWACP)53 SOCIAL INTERACTION & DEVELOPMENT (0 – 2 M) Adaptation to state of arousal begins. Sleep and waking cycles emerge and this is influenced by mother’s routine as well. Longest period of sleep occurs at night. Highly alert when awake and attracted by the human face & spoken words. Interacts with the mother by facial contact during feeding.

54 OGUNLESI TA (FWACP)54 SOCIAL INTERACTION & DEVELOPMENT (2 – 5 M) Visual development is the most prominent feature at this age. Can sustain eye contact & use stares to catch the attention of the mother. Beginning of vocalization. Speech is described as “Cooing” & mother responds to this by ‘questioning’ or ‘talking’. The absence of such response may cause the infant to withdraw from further interaction.

55 OGUNLESI TA (FWACP)55 SOCIAL INTERACTION & DEVELOPMENT (5 – 8 M) Infant transfers attention from the mother to objects in the environment. Spends 2/3 of his time paying attention to the environment unlike at the age of 6 weeks when ¾ of time is spent paying attention to the mother. Exploration begins by reaching out for objects & pointing at objects. Infant understands he shares the world with other people and objects.

56 OGUNLESI TA (FWACP)56 SOCIAL INTERACTION & DEVELOPMENT (8 – 18 M) Infant becomes highly mobile leaving the safety of his mother to interact with the environment. Begins to initiate contact and reciprocate. So, can play games. Can manipulate objects to attract the attention of adults. Learns to associate his cry with response from the mother. Cries to get attention. Takes up interest in other children from 12 to 18 months. Side-by-side play till 18 months. Starts to play together from age 18 months.

57 OGUNLESI TA (FWACP)57 SOCIAL INTERACTION & DEVELOPMENT (>18M) Infant becomes highly integrated individual capable of verbal communication. Understands communicative use of speech, hence, begins naming of objects. Understands symbolic play eg using a doll to represent a baby to be fed. Begins to learn social adaptation (toilet training etc). Parents have to direct him away from socially unacceptable activities.

58 OGUNLESI TA (FWACP)58 ABNORMALITIES OF NEUROLOGICAL DEVELOPMENT Usually a cause of concern for the anxious parent and the physician. May occur either in form of DELAYED DEVELOPMENT or REGRESSED DEVELOPMENT. If a child who developed social smile at 3m, controlled the neck at 5m, sat without support at 9m could only stand with support at 15m, that development was DELAYED.

59 OGUNLESI TA (FWACP)59 ABNORMALITIES OF NEUROLOGICAL DEVELOPMENT If the same 15m old child who had been able to walk became unable to sit without support following an illness, that development was REGRESSED. Developmental delay may start from soon after birth (when the cause is congenital, prenatal or perinatal) or later in life.

60 OGUNLESI TA (FWACP)60 ABNORMALITIES OF NEUROLOGICAL DEVELOPMENT For the latter, the present developmental attainment of a child may be used to predict the onset of his neurological problem. If a previously normal child presented with inability to crawl at the age of 14m, the illness which retarded his development probably occurred at about the age 6m.

61 OGUNLESI TA (FWACP)61 ABNORMALITIES OF NEUROLOGICAL DEVELOPMENT Neurodevelopmental problems result in impaired educational attainment & inadequate social integration.  GROSS MOTOR DEFICTS eg Cerebral Palsy  COGNITION DEFICIT eg Mental Retardation  SPEECH DEFICITS eg Aphasia, Dysphasia, Dyslexia, Dysgraphia.  SOCIAL INTEARCTION IMPAIRMENTS eg ADHD, Autism

62 OGUNLESI TA (FWACP)62 INDICATIONS FOR NEURO- DEVELOPMENTAL ASSESSMENT Lack of visual attention at 2m. Inability to smile at mother or hold the head erect without a lag at 3m. Fisting and lack of interest in people at 4m. Inability to reach out for objects at 5m. Persistence of primitive reflexes at 5m. No midline hand play at 7m.

63 OGUNLESI TA (FWACP)63 INDICATIONS FOR NEURO- DEVELOPMENTAL ASSESSMENT Inability to sit unsupported & babble at 10m. Lack of attention to specific words like ‘no’, ‘stop’ at 12m. Inability to release held objects at 15m. Inability to walk alone & drooling at 18m. Inability to say a single word with a clear meaning at 22m. Inability to talk in sentences at 36m.


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