1. GROWTH AND DEVELOPMENT

2. Growth means natural increase in size or dimensions i. e
Growth means natural increase in size or dimensions i.e. weight and length as well as the size of different organs, not necessarily associated with functional maturation. This is achieved by cell multiplication and by increase in the intercellular substances.
Development means functional maturation gaining or acquisition of skills.
In the normal human being growth and development run parallel to each other.

3. STAGES OF GROWTH AND DEVELOPMENT
I) Prenatal or intra uterine stage
II) Postnatal or Extra uterine stage

4. I) Prenatal or intra uterine stage
1- Embryonic period (1st 8 weeks)
During this period the fertilized ovum divides and differentiates rapidly to form most of the organs of the body. So it is called period of organogenesis.
Any abnormal event in this period will disturb the normal pattern of organs formation and result in either congenital anatomical malformation or abortion.

5. 2- Fetal period (9th – 40th weeks) It is characterized by increase in size (growth) as well as (development) of the already organized (formed) fetus. Placenta gets formed and takes its role in fetal nutrition. Sometimes it is called placental period. Any abnormal event in this period will not affect organogenesis but fetal growth and development might be greatly disturbed miscarriage, premature delivery, still birth or intra uterine growth retardation.

6. Fetal period is divided into:- Early fetal period (9th – 28th w) Late fetal period (28th – 40th w) **Early fetal period (9th – 28th w): More growth in length than in weight (35 cm, 1 kg). Fetus is pre-viable because of incomplete development of pulmonary alveolar system.

7. **Late fetal period (28th – 40th w) More growth in weight than length (50 cm, 3.35 kg). Fetus is viable. Important substances pass from the mother to the fetus through placenta during that period e.g. calcium, iron, vit D, vit K, coagulation factors and gamma globulins (formation of body stores).

8. II) Postnatal or Extra-uterine stage
It is characterized by full activity and self responsibility of the developing organism.
It is divided into:-
A. Neonatal period (1st 4 weeks)
It is characterized by physiological adaptation and adjustment to the new extra uterine environment.

9. B. Infancy period (1st 2 years) It is characterized by:- 1- Feeding and weaning. 2- Higher rate of growth & development. 3- Eruption of all milk teeth. 4- Immunity against many of the infectious diseases. 5- Development of most of milestones.

10. C. Childhood period (2 -12 years) It is characterized by social and educational maturation.
D. Adolescence It is characterized by sexual and psychosomatic maturation as well as another spurt of physical growth.

11. FACTORS AFFECTING GROWTH AND DEVELOPMENT
1- Herido-constitutional factors
2- Maternal factors during pregnancy
3- Endocrinal factors
4- Nutritional factors

12. 1- Herido-constitutional factors:-
e.g. sex, race, familial factors, certain congenital anomalies or familial diseases which interfere with prenatal or postnatal growth.

13. 2- Maternal factors during pregnancy:-
Non-infections e.g. hypertension, D.M., eclampsia.
Maternal infection e.g. german measles, toxoplasmosis…..
Maternal drug intake, smoking
Maternal exposure to hypoxia.
Nutritional status of the mother during pregnancy.

14. 3- Endocrinal factors:-
During fetal period: chorionic gonadotropins & placental growth factors.
Infancy & childhood:
Growth hormone: for linear growth
Thyroxine hormone: for skeletal maturation
Adolescence: sex hormones (androgens and estrogens) share.

15. 4- Nutritional factors:-
Malnutrition and under nutrition growth retardation.

16. ASSESSMENT OF GROWTH AND DEVELOPMENT
A) Physical growth
B) Development

17. Physical growth A) Anthropometric measures: 1) Weight
a) Birth weight kg.
b) Physiological weight loss about 6 – 10 % of birth weight.
It occurs during 1st few days and regained by 10th day.
It is due to:
1- Scanty milk and fluids intake.
2-Natural loss of body fluids in urine & stool.

18. c) During 1st 4 months weight increases by 3/4 kg / month.
During 2nd4 months weight increases by 1/2 kg / month.
During 3rd 4 months weight increases by 1/4 kg / month.
d) Thus: body weight at 4 months: 6 kg, at 8 months: 8 kg, at one year: 9 kg.
e) After the 1st year:- Weight in kg = (Age in years X 2)+ 8

19. 2- Linear growth
Length is crown to heal measurement in recumbent position.
Height is the same measurement in standing position.
Length is measured in recumbent position in children up to 4 years.
Height is measured while child is standing (stature).

20. Height is measured while child is standing (stature).
Length is measured in recumbent position in children up to 4 years.
Height is measured while child is standing (stature).
= +4 (in Length is more than height by 0.5 – 1 cm due to relaxation of ligaments during lying down and compression of the spine during standing.
Normal length at birth is 50 cm, at 1 year 75 cm, at 2 years 87.5 cm.
After 2 years, length in cm = (Age in years X 5) + 80

21. Proportion of upper to lower segment:
At birth 1.7 : 1, at 3 years 1.3 : 1, in adult 1 : 1.
Arm - span and height:
Arm span – height = -3 at 1 – 7 years
= 0 at 8 – 12 years
males) & +1 (in female)

22. 3-Head circumference
It gives an idea about brain growth.
At birth head circumference = 35 cm.
At 1 year : 45 cm - At 2 year : 47 cm
At 5 years : 50 cm - At 12 years : 55 cm.

23. 4- Mid-arm circumference
It is about cm in normal child between 1 – 4 years
It gives an idea about muscles mass, and it is best and early predictor of malnutrition.

24. Premature closure: microcephaly and craniosynostosis.
B) Skull fontanelles:
There are 6 fontanelles : 4 lateral, clinically insignificant, one anterior and one posterior.
Anterior fontanelle is 3 fingers in transverse diameter at birth, 2 fingers at 6 months,1 finger at 1 year, close at 18 months .
Premature closure: microcephaly and craniosynostosis.

25. Bulging ant. fontanelle: intracranial tension e. g
Bulging ant. fontanelle: intracranial tension e.g. intracranial hemorrhage, meningitis, encephalitis and hydrocephalus.
Depressed ant. fontanelle: collapse of extracellular fluid in shock and dehydration.
Delayed closure of ant. fontanelle: rickets, Down's syndrome, hypothyroidism (cretinism), hydrocephalous, achondroplasia, osteogenesis imperfecta.

26. C) Teething: Deciduous teeth (milk teeth): 20 in number.
6 – 9 months central incisors appear.
9 – 12 months lateral incisors
12 – 18 months 1st molar.
18 – 24 months canine.
24 months 2nd molar.
Age in months = number of teeth + 6.

27. Permanent teeth: 32 in number.
Eruption of the permanent teeth:
First molars – 7 years.
Central incisors – 8 years.
Lateral incisors – 9 years.
Canines – 10 years.
First premolars – 11 years.
Second premolars – 12 years.
Second molars – 13 years.
Third molars (wisdom tooth)17 – 22 years.

28. D) Appearance of ossific centers:
In the fetus:
5-6th month: calcanum, 7-8th month: cuboid, 10th month: talus.
At birth: lower end of femur: 1 cm smooth, regular, well defined, and upper end of tibia.
Two carpal bones appear after 2 months, then
Carpal bones appear at a rate of one ossific center for every year.

29. Carpal bones appear at a rate of one ossific center for every year.
Chronic illness. At 6 years child has 7 carpal centers .
The 8th carpal center (pisiform) appears by age 12.
Ossesous development is retarded in:
- Congenital hypothyroidism.
- Male hypogonadism.
- Delayed adolescence.
- Malnutrition
It is accelerated in obesity, adrenogenital syndrome and sexual precocity.

30. 35 – 50 % trainable (imbicil).
B) Development
A) Development of mentality :
This can be assisted by:
Disappearance of neonatal reflexes.
Development of locomotor system.
Development of speech, hearing & vision.
Development of sphincters control.
Social adaptation as recognition of mother, relatives, smiling, recognition of surrounding and others.
Learning ability in school.
Also by I.Q. :
50 – 75 % educable (morror).
35 – 50 % trainable (imbicil).
0 – 35% idiot.

31. In normal child:
2nd month: Social smile appears.
4th month: Recognizing mother.
9th month: Recognizing father.
1 year: Speaking 2 – 3 words.
2 years: Speaking 2 – 3 phrases.
3 years: Can draw a circle.
4 years: Can draw a triangle.

32. B) Development of Locomotor system:
It depends on:
1- Development of C.N.S.
2- Environmental factor which is training.
3- Development of peripheral locomotor system, bones, joints and muscles:
4th month: head support, sitting support.
6th month: sitting freely.
9th month: crawling, standing supported.
12th month: standing freely.
15th month: walk freely.
18-24th month: run freely, up and down stairs.
3 years: ride a tricycle.

33. C) Development of speech:
It occurs in 3 successive stages:
1- Stage of vocalization (1st 2 months)
Simple production of sounds by the vocal cords, no meaning , no purpose.
2- Stage of babbling (2 – 6 months)
Simple production of sounds by lips.

34. 3) Stage of vocal verbal play
Production of sounds which have meaning & purpose.
Development of speech depend s on 3 integral function units:-
Reception, i.e. good hearing.
Memorization, i.e. good mentality.
Production, i.e. proper peripheral articulation.

35. D) Development of hearing:
At birth: impaired, tympanic cavity is filled with amniotic fluid.
1st & 2nd months: responds to sound by Moro reflex.
3rd & 4th months: responds to sound by cessation of movement and stopping crying.
5th &6th months: the infant turns his head to sound.
At 1 year: hearing ability becomes very fine.

36. E) Development of vision:
In the neonatal period infant cannot fixate, since the maculate are not well developed.
During the second month, the infant can fixate on a steady source of light.
At 3 months, he can follow slowly moving objects with his eyes.
At 6 months, he can follow rapidly moving objects.

37. F) Development of sphincteric control:
It occurs at variable age from 1 – 4 years
It depend upon maturation of the pyramidal tract, training & psychological status.
Sphincteric disturbance after a period of normal control is considered pathological

38. G) Puberty: It means beginning of sexual maturation.
The mean age for onset of puberty is 11.4 years & 12 years in boys.
It begins in girls breast development & in boys with testicular growth.

39. Girls
Boys
Breast development
Testicular growth
Pubic hair development
Public hair development
Maturation of external genitalia
Growth of penis & scrotum
Female body habitus
Muscle bulk increases
Axillary hair
Bread, axillary & body hair
Oil secretion & acne
Menstruation
First seminal discharge

40. ASSESSMENT OF GROWTH
Assessment of growth is undertaken by a combination of accurate measurement and plotting on suitable growth charts.
a) Percentile growth charts
b) Road to health charts (Morly's chart)

41. A) Percentile growth charts:
The word percentile means ranking (or arranging) a particular child compared to normal children of the same age and sex using a percentile chart .
There are separate charts for boys and girls and for each age group.
At the right end of each curve in a chart is a number starting from above 95, 90, 50, 25, 10, 5 percentile.
Children above 95th or below the 5th percentiles are most likely abnormal and need thorough evaluation.

42. B) Road to health charts (Morly's chart):
Used for 1st 3 – 5 years of life only, for both sexes.
Only 2 curves on the chart, no percentile figures.
Used for early detection of PEM flat curve, success treatment weight increases. i.e. for comprehensive care and follow up at health centers.

43. GROWTH RETARDATION
Normal growth is the aggregate expression of normal environmental, nutritional and genetic factors.
Failure to thrive: weight or height at least two standard deviation below the mean for children of the same age.
Short stature: subnormal height relative to other children of the same sex, age and ethnic background. Height is below the 3rd percentile for sex and age.

44. Stunting: height is less than 90% of the 50th percentile for age.
Dwarfism: indicates small size.
Infantilism: dwarfism as well as sexual retardation when the individual has passed the expected age of puberty.

45. CAUSES OF GROWTH RETARDATION
Normal variants
Pathologic G.R.

46. I) Normal variants: A) Familial short stature (Genetic):
Either the parents or other healthy close relatives are short, bone age is normal, birth size tends to be small, history and physical examination are normal.

47. B) Constitutional growth delay:
It represents the lower end of the normal range of skeletal and pubertal development. Birth size is normal, and infants grow normally for few months, then linear growth and weight gain slow down. Bone age remains roughly equivalent to height age.

48. The adolescent growth spurt does not come until after the age of 14 years in girls and 16 years in boys, but final adult height and sexual development are normal. There is history of delay growth and sexual development in other family members.

49. II) Pathologic G.R. A) Disproportionate:
Measuring U/L segments and arm span minus height is useful in identifying this group. The most common causes of this type are:
Rickets and skeletal dysphasia e.g. achondroplasia and hypothyroidism.

50. I) Prenatal: B) Proportionate:
Intrauterine growth retardation due to intrauterine infections, cytomegalovirus, toxoplasmosis, rubella, herps simplex, syphilis and AIDS.
2. Chromosomal anomalies: Down's syndrome, Turner's syndrome.

51. 3. Placental diseases, uterine tumors, twins, maternal vascular diseases and malnutrition (usually only restrict growth in utero).
4. Dysmorphic syndromes:-
Syndromes of unknown etiology, identified by their unique clinical and radiological features. Bones age is not retarded. There is no treatable underlying cause of short stature.

52. II) Postnatal: Endocrine disorders:-
Hypopituitarism, either panhypopituitarism or isolated growth hormone deficiency. There is deceleration of linear growth beginning in infancy, immature facies, trunkal obesity, microphallus, bone maturation is retarded, puberty is delayed.

53. Diabetes Mellitus (DM): severe growth retardation occurs in poorly controlled DM, even children with fairly well controlled DM may sustain decrease of adult height if the disease appears before puberty.
Glucocorticoid excess: Cushing's disease or excess adrenal glucocorticoid intake. Affected children show moon facies, plethoric complexion, trunkal obesity, cervical dorsal fat bad, and cutaneous striae.

54. 2. Psychosocial dwarfism:-
Hypogonadism: sex hormones deficiency becomes a cause of G.R after age of 10 years in female and 12 years in male.
2. Psychosocial dwarfism:-
Factors include maternal depression and family disturbances. It is diagnosed by family and dietary history. It is due to suppression of hypothalamus by higher cortical centers.

55. 4. Gastrointestinal disease:-
3. Malnutrition:-
Decrease intake of proteins, calories, zinc and iron.
4. Gastrointestinal disease:-
Cystic fibrosis, chronic infections, malabsorption, parasitic infestation.
5. Chronic anemias:-
B-thalassemia, sickle cell anemia, iron deficiency anemia.

56. 6. Cardiopulmonary diseases:-
Chronic upper airway obstruction.
Congenital heart diseases, acquired heart diseases.
Chronic lung diseases, asthma, bronchiectasis, bronchopulmonary dysplasia, cystic fibrosis.
7.Renal diseases:-
UT infections – Chronic renal failure – Renal tubular acidosis – Diabetes insipidus – Malformation or cystic disease.

57. 8. Chronic infections and inflammatory conditions:-
Tuberculosis, parasites, collagen diseases, immune deficiency diseases.
9. Metabolic disorders:-
Galactosemia, hypercalcemia, mucopolysaccharidosis, glycogen storage disease.

58. ASSESSMENT OF GROWTH RETARDATION
History
Examination
Growth velocity
Investigation of children with growth retardation

59. A) History: to exclude:
1- Social pathology & similar conditions.
2- Chronic illness (e.g. heart, chest, renal).
3- Malnutrition.
4- Drugs (e.g. steroid).

60. B) Examination: Dysmorphic features. Disproportion e.g. short limbs.
Fundus exam (papilledema, optic atrophy).
Evidence of systemic disease.
Assessment of nutritional status.
C) Growth velocity: using percentile growth charts.

61. D) Investigation of children with growth retardation:
Condition
Investigation
Malabsorption / anemia
CBC, reticulocytes & folate
Electrolyte imbalance & renal failure
Urea, creatinine & electrolytes
Renal tubular acidosis
HCO3
Asthma or T.B
X-rays for chest & heart
Rheumatoid arthritis
ESR, rheumatoid factor

62. Condition
Investigation
Hepatitis, chronic liver diseases
Liver function tests
Giardiasis and other parasites
Stool analysis
Urinary tract infection
Urine culture
Hypothyroidism
Thyroid function
Turner's syndrome
Buccal smear for Barr body
Vit. D resistant rickets
Ca, Ph, alkaline phosphates
Craniopharyngioma
Skull x-ray / CT head

63. DISORDEDS OF PUBERTY
Early Puberty
Delayed Puberty

64. A) Early Puberty:
Early puberty is defined as development of secondary sexual characteristics in girls before 7 years and in boys before 9 years. It is commoner in girls.

65. Characteristics of the precocious puberty and virilization
True precocious puberty
Characteristics
Present (Hirsutism ++)
Present
Secondary sexual characteristics
Absent
Breast development (female)

66. Virilization
True precocious puberty
Characteristics
Penis only
Both enlarge
Penis & testis
Excessive enlargement
Normal development
Clitoris (female)
Absent
Present
Spermatogenesis / ovulation
Frequent
Familial history

67. B) Delayed Puberty
Delayed puberty is defined as no sexual development by the age of 15 years in boys and 14 years in girls.
Chromosome karyotype is needed to exclude Turner syndrome (in females) and Klinfilter syndrome (in males).

68. MENTAL RETARDATION
It is a state of impairment of intelligence from early life due to inadequate mental development throughout the growth period.
Etiology:
In many cases the cause is unknown.

69. l) Non organic
Genetic factors: intelligence, like height and weight, is inherited.
Socio-cultural factors: low socio-economic state, lack of stimulating environment, high blood lead level, nutritional deficiency, smoking.
Emotional disturbances.

70. II) Organic 1) Prenatal: A) Genetic:-
Chromosomal abnormalities: Down's syndrome, triple X syndrome, hermaphroditism.
Inborn errors of metabolism: phenylketonuria, galactosemia, cerebral lipidosis.
Cerebral demyelinating disease, congenital ectodermosis e.g. neurofibromatosis, tuberus sclerosis.
Cranial anomalies: primary microcephaly, craniostenosis and congenital hydrocephalus.

71. 2) Natal B) Maternal infections:-
C) Maternal irradiation or drug intake, toxemia of pregnancy.
D) Kernicterus.
E) Cretinism.
2) Natal
Birth injuries, anoxia, hypoglycemia, hemorrhage.

72. 3) Postnatal Cerebral infections: meningitis, encephalitis.
Cerebral trauma.
Cerebro-vascular accidents: occlusion and hemorrhage from congenital defect or of unknown cause.
Post vaccination encephalitis.

73. MANIFESTATION OF MR Slow and incomplete maturation:-
- Delay onset of milestones and development retardation.
- Delay sphincteric control.
- Impaired learning ability and school performance.
- Poor social adjustment.

74. Degrees of MR
According to the Intelligence Quotient (IQ), mentally retarded children are classified into:
Incidence
Prognosis IQ
Degree
85 – 90 %
Educable
50 – 75 %
Mild
5 – 10 %
Trainable
35 – 50 %
Moderate
5 %
Non
trainable
20 – 35 %
Severe
Below20%
profound