Overview of growth and development in children

Growth and development is a very important aspect of childcare. understanding growth and development enhances the ability of the child healthcare provider to properly attend to the needs of the children under his/her care. The concept of growth and development helps with early detection of both medical, social and psychological problems in a child. it makes for early intervention in child healthcare.

1. GROWTH AND DEVELOPEMENT BY DR C.D. NZEDUBA

2. OUTLINE Objectives Definitions Differences between growth and developement Principles of growth and developement Factors influencing growth and developement Stages of growth and developement Monitoring of growth and developement Growth assessment Assessment of developement

3. OBJECTIVES By the end of this session, you are expected to: Define growth and development Identify the importance of growth and development assessments . Mention the principles of growth and development. List factors affecting growth and development. Mention types of growth and development. Describe the stages of development. Be able to do developmental and growth assessment.

4. DEFINITIONS Growth refers to an increase in physical size of the whole body or any of its parts. It is simply a quantitative change in a child’s body. It can be measured in Kg, pounds, meters, inches etc. Development refers to a progressive increase in skill and capacity of function. It includes psychological, emotional and social changes. It is qualitative aspects. It is a qualitative change in a child’s functioning. It can be measured through observation.

5. Differences between growth and developement GROWTH DEVELOPEMENT It generally refers to increase in size, length. Development implies overall change in shape, form or structure resulting in improved working or functioning. Changes in the quantitative aspects come into the domain of Growth Changes in the quality or character rather than the quantitative aspects comes in this domain. It is a part of developmental process It is a comprehensive and wider term and refers to overall changes in the individual. Growth does not continue throughout life It continues throughout life and is progressive. The changes produced by growth are the subject of measurement. Development implies improvement in functioning and behavior and hence bring qualitative changes which are difficult to be measured It takes place due to the multiplication of cells. Development is organizational. It is organization of all the parts which growth and differentiation have produced. Growth may or may not bring development. Development is also possible without growth.

6. Importance of Growth and Development Assessment Knowing what to expect of a particular child at any given age. Gaining better understanding of the reasons behind illnesses. Helping in formulating the plan of care. Helping in parents’ education in order to achieve optimal growth & development at each stage .

7. PRINCIPLES OF GROWTH AND DEVELOPEMENT

8. •Cephalocaudal direction •Proximodistal direction •General to Specific

9. Cephalocaudal direction The process of cephalocaudal direction from head down to toe. This means that improvement in structure and function come first in the head region, then in the trunk, and last in the leg region.

10. Proximodistal direction The process in proximodistal from center or midline to periphery direction. development proceeds from near to far - outward from central axis of the body toward the extremities

11. General to Specific • Children use their cognitive and language skills to reason and solve problems. • Children at first are able hold the big things by using both arms, In the next part able to hold things in a single hand, then only able to pick small objects like peas, cereals etc. • Children when able to hold pencil, first starts draw circles then squares then only letters after that the words.

12. • Development proceeds from general to specific responses

13. Factors influencing Growth and Development

14. • Growth and development depend upon multiple factors or determinants. • They influence directly or indirectly by promoting or hindering the process.

15. • Genetic factors • Prenatal factors • Postnatal factors

16. Genetic factors • Genetic predisposition is the important factors which influence the growth and development of children. • Sex • Race and Nationality

17. Prenatal factors • Intrauterine environment is an important predominant factor of growth and development. Various conditions influence the fetal growth in utero.

18. Cont… • Maternal malnutrition • Maternal infection • Maternal substance abuse • Maternal illness • Hormones • Miscellaneous

19. Postnatal factors • Growth potential • Nutrition • Childhood illness • Physical environment • Psychological environment • Cultural influence • Socio economic status • Climate and season • Play and exercise • Birth order of the child • Intelligence • Hormonal influence

20. GROWTH AND &DEVELOPMENTAL AGE PERIODS • Infancy –Neonate •Birth to 1 month –Infancy •1 month to 1 year

21. • Early Childhood –Toddler •1-3 years –Preschool •3-6 years

22. • Middle Childhood – School age – 6 to 12 years • Late Childhood • Adolescent – 13 years to approximately 18 years

23. Growth and Development Monitoring

24. Assessment of growth Assessment of physical growth can be done by anthropometric measurement and the study of velocity of physical growth. Measurement of different growth parameters is an important nursing responsibility in child care.

25. Weight Weight is one of the best criteria for assessment of growth and a good indicator of health and nutritional status of child. According to WHO, weight of the full terms neonate at birth is approximately 2.5 kg to 4.0kg. There is about 10% loss of weight first week of life, which the baby regains by 10 days of age.

26. Cont… • Then, weight gain is about 25- 30 gm per day for 1st 3 month and 400gm/ month till one year of age. • The infants double weight gain their birth weight by 5month of age, trebled by one year, four times by two years, five times by three year, six times by five year, seven times by seven year and ten times by ten year. • Then weight increases rapidly during puberty followed by weight increase to adult size.

27. Length and height • Increase in height indicates skeletal growth. Yearly increments in height gradually diminished from birth to maturity. • At birth average length of a healthy newborn baby is 50 cm. • it increases to 60 cm at 3 months, 70 cm at 9 month and 75 cm at one year of age.

28. Cont… • In second year, there is 12 cm increase, third year it is 9 cm, fourth year it is 7 cm and in fifth year it is 6 cm. • So the child doubles the birth length by 4 years of age afterwards there is about 5 cm increase in every year till onset of puberty

29. Body Mass index (BMI) • It is an important criteria which helps to assess the normal growth or its deviations i.e. malnutrition or obesity. Weight in Kg BMI = -------------------------------- (Height in meter) 2 • If the BMI is more than 30kg/m2, it indicates obesity and if it is less then 18.5Kg/m2, it indicates malnutrition.

30. BMI Categories:- – Underweight = <18.5 – Normal weight = 18.5–24.9 – Overweight = 25–29.9 – Obesity = BMI of 30 or greater

31. Head circumference It is related to brain growth and development of intracranial volume. Average head circumference measured about 35+/-2 cm at birth. At 3 months it is about 40 cm, at 6 month 43 cm, at one year 45cm, at 2 years 48 cm, at 7 year 50 cm and at 12 years of age it is about 52 cm, almost same a adult.

32. Cont… If head circumference increase more than 1 cm in two weeks during the first 3 month of age then hydrocephalus should be suspected. Head circumference is measured by an inelastic measuring tape, placing it over the occipital protuberance at the back, above the ear on the side and just over the supraorbital ridges (glabella) in front measuring the point of highest circumference.

33. Fontanelle Closure At birth, anterior and posterior fontanelle are usually present. Posterior fontanelle closes early few weeks(6-8week) of age. The anterior fontanelle normally closes by 12-18 months of age. Early closure of fontanelle indicates craniostenosis due to premature closure of skull sutures.

34. Chest Circumference Chest circumference or thoracic diameters is an importance parameter of assessment of growth and nutritional; status. At birth it is 2-3cm less than head circumference. At 6 to 12 months of age both become equal. After first year of age, chest circumference is greater than head circumference by 2.5 cm and by the age of 5 year, it is about 5 cm larger than head circumference.

35. Cont… Chest circumference is measured by placing the tape measure around the chest at the level of the nipple, at maximal inspiration.

36. Mid Arm Circumference(MAC) This measurement helps to asses the nutritional status of younger children. The average MAC at birth is 11 to 12 cm, at one year of age it is 12 to 16 cm, at 1 to 5 years it is 16 to 17 cm, at 12 years it is 17 to 18 cm and at 15 years it is 20 to 21cm.

37. Eruption of teeth There is a variation for the time of eruption of teeth. First teeth commonly the lower central incision may appear in 6 to 7 months of age. • It can be delayed even up to 15 months, which also can be considered within the normal range of time for teething. • So dentition is not a dependable parameter for assessment of growth. • There are ‘two sets of teeth, temporary teeth and permanent teeth.

38. Age Type Total number of teeth Temporary teething 6 – 12 months Incisors(central and lateral) 2-8 12 – 15 months First molar 8- 12 15 – 24 months Canines( cuspids) 12 – 16 24 – 30 months Secondary molar 16 - 20 Permanent teething 6 -7 years First permanent molars 24 7 -10 years Replacement of temporary 10 -12 years Replacement of temporary molar by premolars 12 – 15 years Secondary permanent molars 28 16 years Third permanent molars 32

39. Assessment of Development Normal development is a complex process & has a multitude of facets. However, it is convenient to understand & assess development under the following domains.

40. Gross motor development Motor development progress in an orderly sequence to ultimate attainment of locomotion & more complex motor tasks thereafter. In an infant it is assessed & observed as follows:-

41. Fine motor skill development Fine motor development depen upon neural tract maturation. Fine motor development promotes adaptive activities with fine sensorimotor adjustments and include eye coordination, hand eye coordination, hand to mouth coordination, hand skill as finger thumb apposition, grasping, dressing ect.

42. Key fine motor development milestone Age Milestone 4m reaching out for the objects with both hands 6m Reaching out for the objects with one hand 9m Immature pincer graps 12m Pincer graps mature 15m Imitates scribbling, tower of 2 blocks 18m Scribbles, tower of 3 blocks 2yr Tower of 6 blocks, vertical and circular stroke 3 yr Tower of 9 blocks, copies circle 4yr Copies cross, bridge with blocks 5yr Copies triangle, gate with blocks

43. Personal & social development Personal and social development includes personal reactions to his own social and cultural situations with neuromotor maturity and environment stimulation. It is related to interpersonal and social skill as social smile, recognition of mother, use of toys.

44. Key social and adaptive milestones Age 2m Social smile 3m Recognizes mother 6m Recognizes strangers, stranger anxiety 9m Waves “bye bye” 12m Comes when called, plays simple ball game 15m Jargon 18m Copies parents in tasks 2yr Asks for food, drink, toilet 3yr Shares toys, knows full name and gender 4yr Plays cooperatively in a group, goes to toilet alone. 5yr Helps in household tasks, dressing and undressing

45. Key gross motor development milestones Age Milestone 3m Neck holding 5m Rolls over 6m Sits with own support 8m Sitting without support 9m Standing holding on (with support) 12m Creep well, stand without support 15m Walks alone creeps upstairs 18m Runs 2 yr Walks up and down stairs 3 yr Rides tricycle, 4yr Hops on one foot, alternate feet going downstairs.

46. Language development Age Milestone 1m Alerts to sound 3m Coos ( musical vowel sounds) 4m Laugh loud 6m Monosyllables (ba, da, pa) sound 9m Bisyllables ( mama, baba, dada) sound 12m 1-2 words with meaning 18m 8 -10 words vocabulary 2yr 2-3 word sentences, uses pronouns “I”, “Me”, “you” 3yr Ask question 4yr Says songs or poem, tell stories 5yr Asks meaning of words

47. Assessment of Development Healthy development, in all forms, particularly social/emotional, communication, and behavior, should be monitored by parents and physicians through screenings at each well visit.

48. Cont… • The Denver Developmental screening test • Denver articulation screening examination(DASE) • Baroda screening test • Trivandrum development screening test • Other test – Woodside DST – Cognitive adaptive test – Early language milestone etc.

49. AGE SPECIFIC MILESTONES

50. 0-2 months 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 month ▫ This is the period of fastest postnatal growth

51. Cont… 2. LANGUAGE AND SOCIAL - Cries - Protrudes tongue - Hearing is well developed & prefers high pitched sound - Near sighted - Spontaneous smile 3. COGNITIVE/ BEHAVIOURAL DEVELOPEMENT - Regards on face

52. INFANCY 1. PHYSICAL GROWTH Weight Birth weight doubles by 5th mn and triples by11-12mn 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 o.5cm/mn 6-12mn

53. 2. DENTITION starts at age 5-6mn no teeth at age 4mn then erupts 4 teeth every 4 month till 20 teeth. milk/ temporary/ deciduous teeth

54. 3. MOTOR DEVELOPEMENT Gross motor • At 2 months • Hold head erects in mid-position • Turn from side back • At 3 months • Hold head erects and steady • Open or close hand loosely • Hold object put in hand

55. 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

56. 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

57. At 6 months • Sit alone briefly • Turn completely over(abdomen to abdomen) • Lift chest and upper abdomen when prone • Hold own bottle

58. 7 months • Sit alone • Hold cup • Imitate simple acts of others 8 months • Sit alone steadily • Drink from cup with assistance • Eat finger food that can be held in one hand

59. 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

60. 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

61. FINE MOTOR - 6-7 mn Transfers object from one hand to the other - 9-10 mn pincer grasp

62. 2. LANGUAGE • 1-2 months: coos • 2-6 months: laughs and squeals • 8-9 months babbles: mama/dada as sounds • 10-12 months: “mama/dada specific 3. SOCIAL DEVELOPEMENT • He learns that crying brings attention • The infant smiles in response to smile of others • 7mn shows fear of stranger (stranger anxiety). • He responds socially to his name

63. TODDLER 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/mn (Age in yrs X 5) +80 ▫ Head circumference increases 10cm from 1yr till adulthood ▫ HC increases 2cm from 1st -2 nd year

64. MOTOR DEVELOPEMENT Gross motor 15 months • Walk alone • Creep upstairs • Assume standing position without falling 18 months • Runs stiffly, walks up stairs with one hand held 24 months  Runs well, walks up and down stairs, one step at a time, jumps

65. 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

66. 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

67. SOCIAL DEVELOPEMENT ▫ 15mn hugs parents ▫ 18mn Feeds self ▫ 24mn Handles spoon well, helps to undress

68. 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)

69. PRESCHOOL AGE PHYSICAL GROWTH ▫ Weight: - 2 kg per year, ▫ Wt gain in the age 2-5 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

70. MOTOR DEVELOPEMENT 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

71. SOCIAL/LANGUAGE - language dev’t is rapid during the age of 2-3y - From 100 to 2,000 words - From 3 word to complex sentences

72. Summary of Stages of Gross motor

73. Summary of stages of Fine Motor

74. Cont…….

75. SCHOOL AGE ▫ Age between 6-12 years referred as middle child hood or latency ▫ Self esteem becomes a central issue - Able to evaluate themselves - perceive others’ evaluation of them

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

77. 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 DEVELOPEMENT ▫ 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.

78. MOTOR DEVELOPEMENT Gross motor 6-8 ride bicycle, sporty Fine motor 6th year copies a diamond & draws a man with 12 details At 7th yr draw a man with 16 detail 9-10yr draw man with many details Typing skill Musical instrument

79. SOCIAL/LANGUAGE ▫ Receptive language ▫ Expressive language ▫ Identify with same sex parents adopting them as role models ▫ Further separation from the family

80. ADOLESCENCE ▫ The age group of 10 -18 years ▫ Growth spurt occurs here - Height increase by 6-7 cm ▫ 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

81. PHYSICAL GROWTH Weight: • Growth spurt begins earlier in girls (10–14 years, while it is 12–16 in boys) • Males gain 7 to 30kg, while female gains 7 to 25kg

82. 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

83. SECONDARY SEXUAL CHARACTERISTICS Male • Genital changes • Appearance of pubic, axillary, and facial hair • Voice change Female • Breast changes, pelvic diameter widens • Growth of pubic and axillary hair • Onset of menarche

84. Classification of sexual maturity states in girls

85. RED FLAGS • It is a quick reference guide for assessing development. • It outlines a range of functional indicators or domains commonly used to monitor healthy child development. • It will assist in identifying when a child could be at risk of not meeting developmental milestones, triggering an alert for the need for further investigation. • It can be used in conjunction with validated developmental screening tools.

86. Social- Emotional Red Flags Age Red flags 6 months Lack of smile or other joyful expressions 9 months Lack of reciprocal vocalizations, smiles , or other facial expressions 12 months Failure to respond to name when called Absence of babbling Lack of reciprocal gestures( showing, reaching, waving) 15 months Lack of single words Lack of proto-declarative pointing or other showing gestures 18 months Lack of simple pretend play Lack of spoken language/gesture combinations 24 months Lack of two-word meaningful phrases(without imitating or repeating) Any age Loss of previously acquired babbling, speech or social skills

87. Motor Red flags Age Red flags 4 months Lack of steady head control while sitting 9 months Inability to sit 12 months Inability to transfer objects from hand to hand 15 months Abnormal pincer grasp 18 months Inability to walk independently

88. IMMUNIZATION SCHEDULE IN NIGERIA

89. BABY COLIC

90. DEFINITION Baby colic, also known as infantile colic, is defined as episodes of crying for more than three hours a day, for more than three days a week, for three weeks in an otherwise healthy child. Often crying occurs in the evening. It typically does not result in long-term problems.

91. DEFINITION CONTD Colic affects 10–40% of babies. It is most common at six weeks of age and typically goes away by six months of age. It rarely lasts up to one year of age. It occurs at the same rate in boys and in girls. The first detailed medical description of the problem occurred in 1954

92. SYMPTOMS legs pulled up to the stomach a flushed face clenched hands wrinkled brow the cry is often high pitched (piercing).

93. EFFECT ON FAMILY frustration of the parents depression following delivery excess visits to the doctor child abuse eg. Shaken Baby Syndrome severe marital discord postpartum depression early termination of breastfeeding

94. IT IS NOT COLIC Concerning findings include: a fever poor activity swollen abdomen Fewer than 5% of infants with excess crying have an underlying organic disease.

95. TREATMENT Treatment is generally conservative, with little to no role for either medications or alternative therapies. Extra support for the parents may be useful. Tentative evidence supports certain probiotics for the baby and a low-allergen diet by the mother in those who are breastfed. Hydrolyzed formula may be useful in those who are bottlefed

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