1. GROWTH AND DEVELOPMENT Dr. Tee/Yu

2. Growth  The act or process or a manner of growing Merriam Webster  Indicator of overall well being, status of chronic disease and interpersonal and psychologic stress

3. Models of Development  Biopsychosocial Model

4. Freud (psychosexual) Erickson (psychosocial) Piaget (cognitive) Kohlberg (Moral) Infancy (0-1yr) OralBasic trust vs mistrust Sensorimotor-------- Toddler (1-3yr) AnalAutonomy vs shame and doubt SensorimotorPreconventional: avoid punishment/obtain rewards Preschool (3-6yr) Phallic/ oedipalInitiative and guiltPreoperationalConventional: conformity School Age (6-12yr) LatencyIndustry and inferiority Concrete operations Conventional: law and order Adolescent (12-20yr) GenitalIdentity vs role diffusion Formal operations Postconventional: moral principles

7. The Newborn  Begins at birth and includes 1 st month of life  Physical Examination  Ave wt ~3.4kg  Ave lt 50cm  Ave HC 35cm  assess vigor, alertness, tone

8. As pediatricians…  Assess potential threats to bonding  1 st office visit: during 1 st 2 wks after discharge  babies who are discharged early, those who are breastfeeding, those who are at risk for jaundice seen 1 to 3 days after discharge

9. Infants

10. 0 - 2 months PhysicalCognitiveEmotional weight decreases 10% in the 1 st wk regains or exceeds BW by 2 wks wt gain – 30 gm/day in 1 st mo recognize human faces and smiles increased attention when stimulus changes Basic trust vs mistrust Crying peaks at 6 wks then decreases by 3 mos

11. 2 - 6 months PhysicalCognitiveEmotional By 3-4 mos - rate of growth = 20 gm/day Early reflexes disappear Voluntary movements appear Regular sleep wake cycle 4 mos – interested in a wider world Explore their own bodies, vocalizing, blowing bubbles Starts to have emotions of fear, anger, joy

12. 6 - 12 months PhysicalCognitiveEmotional Communication 1 st yr – BW doubled, Lt increased by 50 %, HC increased by 10cm Motor improvemen t Tooth eruption Complex play Object permanence – 9 mos Stranger and separation anxiety Demand for autonomy Syllables or language development

13. Second Year

14. 12 - 18 months PhysicalCognitiveEmotional Communication Short legs and long torso Exaggerate d lumbar lordosis and protruding abdomen Genu varus Exploration of environment Symbolic play Temperament depends on comfort given by parents Speak 1 st words – 12mos Receptive language Polysyllabic jargoning

15. 18 - 24 months PhysicalCognitiveEmotional Communication Ht and wt increase at a steady state Improveme nt in balance and agility Object permanence firmly established Flexibility in problem solving rapproachme nt Understand 2 step commands Vocab 50- 100

16. Preschool Years

17. 2 – 5 years PhysicalCognitive Increases of ~2kg in wt; 7-8 cm in Ht/ yr Somatic and brain growth slows Knock- knee and flatfoot VA 20/30 – 3yrs; 20/20 – 4yrs All 20 primary teeth erupted Handedness Bowel and bladder control Magical thinking Egocentricism perception cooperative play

18. 2 – 5 years EmotionalLanguage Tantrums peak between 2-4 yrs Vocabulary increases to 2000 can count Use future tense

19. Developmental Milestones

20. Newborn:  lies in flex attitude  turns head from side to side  head lags on pull  can fixate face or light in line with vision  Moro, grasp, stepping reflexes  Visual preference to a human face

21. At 1 month:  Holds head up momentarily  Tonic neck posture predominates  head lags when pulled to sitting  Follows moving object  Reflex smile  Body movements in cadence with voice of others in social contact

22. At 2 months:  Head sustained on ventral suspension  Tonic neck posture predominates  Follows moving objects past midline- 180 degrees  Smiles on social contact (social smile)  Listens to voice and coos

23. At 4 months:  Symmetric posture  No head lag  When held erect, pushes with feet  Reaches & grasps objects and brings them to mouth  Laughs out aloud  Shows displeasure when social contact is broken

24. At 7 months:  Rolls over; crawls or creeps  Sits briefly with support  Rolls over  Transfers objects from hand to hand  Polysyllabic vowel sounds  Prefers mother  babbles

25. At 10 months:  Sits alone; pulls to stand  Cruises; walks holding on to furniture  Pincer grasp; looks for hidden toy  Repetitive consonant sounds( mama, dada)  Responds to sound of name  Waves bye-bye; plays peek-a-boo

26. At 12 months  Walks with 1 hand held  Obeys simple commands on request or gesture  Speaks few words besides mama, dada  Makes postural adjustment to dressing  Plays simple ball game

27. At 15 months:  Walks alone  crawls up stairs  Makes a line  Makes tower of 3 cubes  Jargon  follows simple commands  May name a familiar object (ball)  Indicates needs by pointing

28. At 18 months:  Runs stiffly  walks up stairs with 1 hand held  Imitates scribbling and vertical stroke  Makes tower of 4 cubes  Names pictures; identifies 1 or more body parts  Average of 10 words  Feeds self  Seeks help when in trouble

29. At 24 months (2 yrs):  Runs well  walks up & down stairs one step at a time  Jumps  Makes tower of 7 cubes  Circular scribbling, imitate horizontal line  Puts 3 words together ( subject-verb-object)  Handles spoon well;  listens to stories with pictures  Helps to undress

30. At 30 months:  Goes upstairs with alternating feet Imitates circular stroke  Makes tower of 9 cubes  Knows full name; refers to self as “I”  Helps put things away; pretends in play

31. At 36 months (3 yrs):  Rides tricycle  Stands momentarily on one month  Copies a circle; imitates a cross  Knows age and sex  counts 3 objects correctly  Plays simple games with other children  helps in dressing

32. At 48 months (4yrs):  Hops on one foot  Throws ball overhand  Copies cross and square  draws a man with 2 to 4 parts besides the head  Tells a story  Role playing  Goes to toilet alone

33. At 60 months:  Skips  Copies a triangle  Names 4 colors  Dresses and undresses  Asks questions about meaning of words  Domestic role-playing

34. MIDDLE CHILDHOOD  6-11 yr of age  previously referred to as latency  period during which children increasingly separate from parents and seek acceptance from teachers, other adults, and peers  self-esteem becomes a central issue  develop the cognitive ability to consider their own self- evaluations and their perception of how others see them  judged according to their ability to produce socially valued outputs

35. MIDDLE CHILDHOOD  Physical Development  growth averages 3-3.5 kg (7 lb) and 6-7 cm (2.5 in) per year  growth occurs discontinuously, in 3-6 irregularly timed spurts each year,  head grows only 2-3 cm, reflecting a slowing of brain growth.  myelinization is complete by 7 yr of age.  body habitus is more erect than previously, with long legs compared with the torso  growth of the midface, lower face occurs gradually

36. MIDDLE CHILDHOOD  Physical Development  loss of deciduous (baby) teeth is a more dramatic sign of maturation, beginning around 6 yr of age  replacement with adult teeth occurs at 4 per year  by age 9 yr, children will have 8 permanent incisors & 4 permanent molars  premolars erupt by 11-12 yr of age  lymphoid tissues hypertrophy, often giving rise to impressive tonsils and adenoids  muscular strength, coordination, and stamina increase progressively,  sedentary habits at this age are associated with increased lifetime risk of obesity and cardiovascular disease

37. MIDDLE CHILDHOOD  Cognitive Development  increasingly apply rules based on observable phenomena, factor in multiple dimensions and points of view, and interpret their perceptions using physical laws  Piaget documented this shift from “preoperational” to “concrete logical operations.”  the concept of “school readiness” is controversial  there is no consensus on whether there is a defined set of skills needed for success on school entry  by age 5 yr, most children have the ability to learn in a school setting, as long as the setting is sufficiently flexible to support children with a variety of developmental achievements

38. MIDDLE CHILDHOOD  Social, Emotional and Moral Development  energy is directed toward creativity and productivity  central Ericksonian psychosocial issue, the crisis between industry and inferiority, guides social and emotional development  changes occur in three spheres: the home, the school, and the neighborhood  increasing independence is marked by the 1st sleepover at a friend's house and the 1st time at overnight camp  the beginning of school coincides with a child's further separation from the family and the increasing importance of teacher and peer relationships  social groups tend to be same-sex  popularity, a central ingredient of self-esteem, may be won through possessions as well as through personal attractiveness, accomplishments, and actual social skills.

39. MIDDLE CHILDHOOD  Social, Emotional and Moral Development  by age of 5 or 6 yr, the child has developed a conscience  has internalized the rules of the society.  can distinguish right from wrong  will adopt family and community values, seeking approval of peers, parents, and other adult role models

40. ADOLESCENCE  consists of 3 distinct periods—early, middle, and late—each marked by a characteristic set of biologic, psychological, and social issues  in girls, the 1st visible sign of puberty and the hallmark of SMR2 is the appearance of breast buds, between 8 and 12 yr of age.  menses typically begins 2 to 2 ½ yr later, during SMR3-4 (median age, 12 yr; normal range, 9-16 yr)  less obvious changes include enlargement of the ovaries, uterus, labia, and clitoris, and thickening of the endometrium and vaginal mucosa.  in boys, the 1st visible sign of puberty and the hallmark of SMR2 is testicular enlargement, beginning as early as 9 ½ yr  followed by penile growth during SMR3  peak growth occurs when testis volumes reach approximately 9-10 cm 3 during SMR4\  under the influence of LH and testosterone, the seminiferous tubules, epididymis, seminal vesicles, and prostate enlarge

41. ADOLESCENCE  Growth acceleration begins in early adolescence for both sexes, but peak growth velocities are not reached until SMR3-4  Boys typically peak 2-3 yr later than girls, begin this growth at a later SMR stage and continue their linear growth for approximately 2-3 yr after girls have stopped.  asymmetric growth spurt begins distally, with enlargement of the hands and feet, followed by the arms and legs, and finally, the trunk and chest  rapid enlargement of the larynx, pharynx, and lungs  elongation of the optic globe often results in nearsightedness  dental changes include jaw growth, loss of the final deciduous teeth, and eruption of the permanent cuspids, premolars, and finally, molars

42. ASSESSMENT OF GROWTH  critical component of pediatric health surveillance is the assessment of a child's growth  growth results from the interaction of genetics, health, and nutrition  many biophysiologic and psychosocial problems can adversely affect growth, and aberrant growth may be the first sign of an underlying problem  most powerful tool in growth assessment is the growth chart

43. ASSESSMENT OF GROWTH  accurate measurement is a critical component of growth assessment  for infants and toddlers, weight, length, and head circumference are obtained  performed with the infant naked  head circumference is determined using a flexible tape measure run from the supraorbital ridge to the occiput in the path that leads to the largest possible measurement.  length is most accurately measured by two examiners (one to position the child)  with the child supine on a measuring board  for older children, the measure is stature or height, taken without shoes, using a stadiometer

44. ASSESSMENT OF GROWTH  body mass index for age complements the standard growth charts for children over 2 yr of age  BMI can be calculated as weight in kilograms/(height in meters) 2 or weight in pounds/(height in inches)  BMI percentile varies with age over childhood: a 6 yr old girl with a BMI of 21 is overweight, whereas a 16 yr old girl with the same BMI is just above the 50th percentile.  height velocity charts, which evaluate the rate of growth per yr, are considered by many to give a more sensitive and specific indicator of abnormal growth.  used primarily by pediatric endocrinologists.

46. ASSESSMENT OF GROWTH  between 6 and 18 mo of age, infants may shift percentiles upward or downward toward their genetic potential.  thereafter, most children will track along a growth percentile  tracking often represents the mid-parental height and a corresponding weight, where mid-parental height is calculated in inches as follows:  Boys: [(maternal height + 5) + paternal height]/2 Girls: [maternal height + (paternal height − 5)]/2 13 cm (instead of ? 5 in) if using metric units

47. ASSESSMENT OF GROWTH  diagnosis of failure to thrive usually a diagnosis of children under 3 yr of age, is considered if a child's weight is below the 5th percentile, if it drops down more than 2 major percentile lines, or if weight for height is less than the 5th percentile  weight for height below the 5th percentile remains the single best growth chart indicator of acute undernutrition.  BMI less than the 5th percentile also indicates that a child is underweight  low weight for age or height or weight loss may be referred to as wasting

48. ASSESSMENT OF GROWTH  another way to evaluate weight is to determine the ideal body weight for height and compare the current weight to the ideal body weight for length or height

49. ASSESSMENT OF GROWTH  Linear growth deficiency (stunting) is more likely to be due to congenital, constitutional, familial, or endocrine causes than to nutritional deficiency  in endocrine disorders, length or height declines first or at the same time as weight; weight for height is normal or elevated  in nutritional insufficiency, weight declines before length, and weight for height is low (unless there has been chronic stunting)  in congenital pathologic short stature, an infant is born small and growth gradually tapers off throughout infancy  in constitutional growth delay, weight and height decrease near the end of infancy, parallel the norm through middle childhood, and accelerate toward the end of adolescence. Adult size is normal  in familial short stature, both the infant and the parents are small; growth runs parallel to and just below the normal curves.

51. ASSESSMENT OF GROWTH  Obesity  weight for height exceeds 120% of the standard (median) weight for height  BMI over the 95th percentile indicates obesity and a BMI between the 85th and 95th percentiles indicates overweight  BMI may not provide an accurate index of adiposity, because it does not differentiate lean tissue and bone from fat  Measurement of the triceps, subscapular, and suprailiac skinfold thickness can be used to estimate adiposity;

52. OTHER INDICES OF GROWTH  Body proportions  lower body segment is defined as the length from the symphysis pubis to the floor,  upper body segment is the height minus the lower body segment  ratio of upper body segment divided by lower body segment (U/L ratio)  equals approximately 1.7 at birth  1.3 at 3 yr of age\  1.0 after 7 yr of age  Higher U/L ratios are characteristic of short-limb dwarfism or bone disorders, such as rickets.

53. OTHER INDICES OF GROWTH  Bone Maturation  bone age correlates well with stage of pubertal development and can be helpful in predicting adult height in early- or late- maturing adolescents  in familial short stature, the bone age is normal (comparable to chronological age)  in constitutional delay, endocrinologic short stature, and undernutrition, the bone age is low and comparable to the height age  skeletal maturation is linked more closely to sexual maturity rating than to chronological age  it is more rapid and less variable in girls than in boys

56. OTHER INDICES OF GROWTH  dental development includes mineralization, eruption, and exfoliation  initial mineralization begins as early as the 2nd trimester (mean age for central incisors, 14 wk) and continues through 3 yr of age for the primary (deciduous) teeth and 25 yr of age for the permanent teeth  eruption begins with the central incisors and progresses laterally  begins at about 6 yr of age and continues through 12 yr of age  eruption of the permanent teeth may follow exfoliation immediately or may lag by 4-5 mo  delayed eruption is usually considered when there are no teeth by approximately 13 mo of age  common causes include hypothyroid, hypoparathyroid, familial, and (the most common) idiopathic  causes of early exfoliation include histiocytosis X, cyclic neutropenia, leukemia, trauma, and idiopathic factors  nutritional and metabolic disturbances, prolonged illness, and certain medications (tetracycline) commonly result in discoloration or malformations of the dental enamel.

58. End