1. . Copyright © 2015 by Mosby, an imprint of Elsevier Inc. CHAPTER 6 GROWTH AND MEASUREMENT

2. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. "Who in the world am I? Ah, that's the great puzzle." --Lewis Carroll

3. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. GROWTH AND MEASUREMENT Weight and body composition offer much information about an individual’s health status and often provide a clue to the presence of disease when they are out of balance Focus is on the evaluation of individual’s anthropometric parameters and the examination for growth, gestational age, and pubertal development 3

4. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PHYSICAL EXAMINATION PREVIEW From the history, assess the patient’s size, including the following:  Recent growth, weight gain, or weight loss  Chronic illnesses affecting weight gain or loss 4

5. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PHYSICAL EXAMINATION PREVIEW (CONT.) Obtain the following anthropometric measurements, and compare them to those in standardized tables:  Standing height  Weight  Frame size  Calculate the body mass index. 5

6. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ANATOMY AND PHYSIOLOGY Growth is the increase in size of an organ or person. Growth depends on sequence of endocrine, genetic, constitutional, environmental, and nutritional influences. Through the biologic process of development and maturation, individual organ systems acquire function. 6

7. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. GROWTH DIFFERENCES BY ORGAN SYSTEM Brain: peak fetus, early infancy Skeleton: peak fetus, infancy, adolescence Muscle: peak fetus, adolescence Adipose: peak infancy, adolescence Lymphoid: peak age 10 to 12 years Neural: peak age 4 to 14 years Genital: peak adolescence 7

8. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. INFANTS AND CHILDREN Fetus  Head growth predominates Infant  Trunk growth predominates  Weight gain at rapid but decelerating rate Child  Legs are fastest growing  Weight gained at steady rate 8

9. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 9 Figure 6-03. Changes in body proportions from 8 weeks of gestation through adulthood.

10. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ADOLESCENCE Trunk and legs elongate. 50% of ideal weight is gained.  Of adults who become obese  30% are obese during childhood  70% are obese during adolescence Skeletal mass and organ systems double in size. 10

11. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PREGNANT WOMAN Progressive weight gain is expected. Fetus is 6 to 8 lb of weight gained. Rest of gain is from increase in maternal tissue and fluids.  Weight gain is slow in first trimester and rapid in second trimester and slows in third trimester. 11

12. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. OLDER ADULT Stature declines in older adult, beginning at 50 years of age.  Thinning intervertebral discs  Development of kyphosis with osteoporotic vertebral compression An increase in overweight and obese older adults has been documented over the past 15 to 20 years. A decrease in weight for height and body mass index has been found in longitudinal studies among individuals over age 60. 12

13. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. OLDER ADULT (CONT.) A loss of 5% body weight over several years often occurs.  Accompanied by an increase in body fat as skeletal muscle declines  Most likely due to decreased exercise and reduced anabolic steroid secretion An age-associated reduction in the size and weight of various organs has been identified.  Liver  Lungs  Kidneys 13

14. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. HISTORY OF PRESENT ILLNESS Weight loss and weight gain  Undesired weight loss, anorexia, vomiting or diarrhea, difficulty swallowing, excessive thirst, frequent urination, change in lifestyle, activity and stress levels  Medications: chemotherapy, diuretics, insulin, fluoxetine, diet pills, laxatives, steroids, oral contraceptives Changes in body proportions  Coarsening facial features, enlarging hands/feet, moon facies  Change in fat distribution  Medication: steroids 14

15. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PAST MEDICAL HISTORY Chronic illness  Gastrointestinal  Renal  Pulmonary  Cardiac  Cancer  HIV or other infections  Allergies Previous weight loss or gain efforts  Weight at 21  Maximum body weight 15

16. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. FAMILY HISTORY Obesity Constitutionally short or tall stature  Precocious or delayed puberty Genetic or metabolic disorder  Cystic fibrosis  Dwarfism 16

17. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PERSONAL AND SOCIAL HISTORY Usual weight and height Activity and exercise pattern Use of alcohol Use of recreational drugs 17

18. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. INFANTS Estimated gestational age, birth weight, length, head circumference Following an established percentile growth curve Development: achieving milestones at appropriate ages Congenital anomaly or chronic illness 18

19. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. CHILDREN AND ADOLESCENTS Sexual maturation of girls: early (before 7 years) or delayed (beyond 13 years); signs of breast development and pubic hair, age at menarche Sexual maturation of boys: early (before 9 years) or delayed (beyond 14 years); signs of genital development and pubic hair Short or tall stature Medications: steroids, growth hormones 19

20. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PREGNANT WOMEN Pregnancy weight, dietary intake Age at menarche Date of last menstrual period, weight gain pattern, following established weight gain curve for gestational course Eating disorders History of pica (eating laundry starch, ice, clay, raw rice) Nausea and vomiting 20

21. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. OLDER ADULTS Chronic debilitating illness  Problems with meal preparation  Difficulty feeding self, chewing, swallowing, poorly fitting dentures  Ability to follow prescribed diet  Difficulty with digestion 21

22. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. EQUIPMENT Standing platform scale with height attachment Skinfold thickness calipers Measuring tape Infant scale Recumbent measuring device (for infants) Stature-measuring device (for children) 22

23. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. WEIGHT AND STANDING HEIGHT Weight Height Frame size  Determined to assess the appropriateness of a person’s weight for age, height, and gender when using weight tables 23

24. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. BODY MASS INDEX The most common method used to assess nutritional status and total body fat For adult men and women, the following are classifications of weight for height by BMI values (kg/m 2 ):  Undernutrition―under 18.5  Appropriate weight for height―18.5 to 24.9  Overweight―25 to 29.9  Obese―30 to 39.9  Extreme obesity―40 and higher 24

25. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. CALCULATING THE BMI The formula to calculate the BMI using pounds (be sure to convert ounces to a decimal) and inches:  [weight in pounds ÷ (height in inches)2 ] × 703 The formula to calculate the BMI using kilograms and centimeters:  weight in kg ÷ [height in meters] 2 25

26. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. INFANTS Recumbent length Weight Head circumference Chest circumference Gestational age Size for gestational age  Classification Weight Percentiles  Appropriate for gestational age (AG) 10th to 90th  Small for gestational age (SGA) Less than 10th  Large for gestational age (LGA) Greater than 90th 26

27. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. CHILDREN Stature and weight  BMI is now standardized for use in children and adolescents, and it is calculated the same way as for adults  Underweight ‒ BMI for age under the 5th percentile  At risk of overweight ‒ BMI for age greater than the 85th percentile  Overweight ‒ BMI for age greater than the 95th percentile 27

28. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. CHILDREN (CONT.) Upper/lower segment ratio  A higher upper-to-lower body segment ratio than expected may be associated with dwarfism or bone disorders Arm span  Arm span that exceeds height is associated with Marfan syndrome 28

29. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. SEXUAL MATURATION Assessing growth and development of the older child and adolescent includes evaluating the patient’s sexual maturation. The height growth spurt and timing of other physiologic events are associated with the stage of secondary sexual characteristic development. Sexual maturation  Girls: breast, pubic hair, menarche  Boys: genital development, pubic hair, ejaculation 29

30. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Sexual Maturation – Male and Female Sexual maturation  Female: breast, pubic hair, menarche  Male: genital development, pubic hair, ejaculation 30

31. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 31 Figure 6-09. Five stages of breast development in females. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.) Sexual Maturation - Females

32. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 32 Figure 6-10. Six stages of pubic hair development in females. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)

33. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. SEXUAL MATURATION - MALES 33 Figure 6-11. Five stages of penis and testes/scrotum development in males. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)

34. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 34 Figure 6-12. Six stages of pubic hair development in males. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)

35. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PREGNANT WOMEN Weight gain  Weight gain during pregnancy should be calculated from the woman’s prepregnancy weight.  To provide guidance in weight gain during pregnancy, first determine the prepregnancy body mass index (BMI). 35

36. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. PREGNANT WOMEN (CONT.) Weight gain  Monitor the woman’s weight throughout pregnancy using the BMI weight gain curve guidelines on the prenatal weight gain chart. 36

37. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. OLDER ADULTS Measurement procedures for the older adult are the same as those used for the general population. Compare the individual’s weight for height, and triceps skinfold thickness by gender and age. Approximately 60% of adults over age 65 years are overweight with a BMI greater than 25, and 20% are obese with a BMI greater than 29. 37

38. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES Acromegaly  A rare disease of excessive growth and distorted proportions caused by hypersecretion of growth hormone and insulin-like growth factor after closure of the epiphyses 38

39. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES (CONT.) Cushing Syndrome  A disorder associated with a prolonged and excessively high exposure to glucocorticoids 39

40. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES (CONT.) Turner syndrome  A genetic disorder in which there is partial or complete absence of a second X chromosome 40

41. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES (CONT.) Hydrocephalus  An excess volume of cerebrospinal fluid (CSF) in the brain leading to an enlarged head circumference 41

42. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES (CONT.) Failure to thrive  Growth in an infant or child below the 3rd to 5th percentiles on a growth chart, or  Slower than normal rate of growth in a short period of time (e.g., from the 50th percentile to below the 10th percentile on the growth chart) 42

43. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES (CONT.) Growth hormone deficiency  Failure of the anterior pituitary to secrete adequate growth hormone to support growth in stature 43

44. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. ABNORMALITIES (CONT.) Precocious puberty  The onset of secondary sexual characteristics before 7 years of age in girls and 9 years of age in boys with progressive sexual maturity 44