Stages of Growth

1-Intrauterine stage :

)from the time of fertilization to the time of birth(

1-Embryonic period (the first 8 weeks of gestation): By the end of wk. 8, the gross structure of all
major organ systems have developed.

2-Fetal period (9-40 weeks of gestation)

a) Early fetal period(9-24 weeks of gestation): By 24wk, primitive alveoli have formed and lung
surfactant production has begun; the newborn delivered before that time cannot survive.
b) Late fetal period(25-40 weeks of gestation)

2- Extra uterine (postnatal) period :

1-Newborn period (the first 28 days of life)

2-Period of infancy (the first 2 years of life)

)a) Early infancy period (1-12 mo. of age)

)b) Late infancy period (the 2nd year of age)

3-Period of childhood (2-12 years of age)

a) Early childhood or preschool years (2-5 years of age)

b) Late childhood or school-aged children (6-12 years of age)

4-Period of adolescence (10-20 years of age)

Normal Embryonic Sexual Differentiation

 During the first, 6 weeks of the embryonic period:
a. The gonads: They are undifferentiated (ovotestis(.
b. The internal sex organs: Two sets of primitive duct system are present:
1. The Wollfian (male).
2. Mullerian (female) duct systems.
c. The external genitalia:
1. A knob-like genital tubercle (that forms penis or clitoris(.
2. Urogenital groove flanked by urethral folds and labio-scrotal
swellings.

 The normal sexual differentiation occurs between the 6th -14th weeks of gestation.
Sexual Development
Development of the male phenotype (genotype 46, XY)

 Maleness requires a Y chromosome which directs the undifferentiated gonads to become a

testis (at ~6th wk. gestation).
 The testis secretes testosterone by Leydig cells and antimullerian hormone (AMH) by Sertoli
cells.
 The testosterone initiates the development of the Wollfian duct into the internal sex organs
(1.epididymis, 2.vas deferens and seminal vesicle) and is responsible for the differentiation
of the external genitalia to develop as penis ،fusion of urethral folds to form penile urethra)
and scrotum (fusion of the labio-scrotal folds(.

The AMH causes the Mullerian ducts to regress at 6th-7th wk. of gestation.

Development of the female phenotype (genotype 46, XX)

i. In the absence of ¥ chromosome, the undifferentiated gonads develop into ovaries.

ii. In the absence of ¥ chromosome, and testosterone, the Wollfian duct system will regress,
and the external genitalia remain without virilization.
iii. In the absence of AMH, the Mullerian duct system Develops into:
 Two fallopian tubes
 Uterus
 Vagina

Physiology of puberty
 The pre-pubertal stage: Between early childhood and approximately 9 yrs. of age, the
hypothalamic-pituitary-gonadal axis is dormant as reflected by undetectable serum
concentrations of LH and sex hormones (estradiol in girls and testosterones in boys.
 FSH is detectable in most children
 The peri-pubertal period: 1-3 yrs. before the onset of puberty becomes clinically evident:

1. FSH and LH levels are low but measurable.

LH secretion occurs in pulsatile fashion during sleep due to episodic discharge of
gonadotropin-releasing hormone.
2. Adrenarche: Adrenal cortical androgens are responsible for the appearance of sexual
hairs (axillary and pubic hairs).
The androgens begin to rise before the earliest physical changes of puberty.

 With the onset of puberty (after the age of 8yrs. in girls and 9 yrs. in boys) LH and FSH
increase progressively in the blood and they act synergistically to promote enlargement and
maturation of the gonads and the secretion of sex hormones.
Signs of puberty
Girls: The first visible sign of puberty is the:

b) Appearance of Breast buds (8-13 yrs.) and breasts increase gradually in Size with the
development of the areola and nipples.
c) Menses typically begin 2 yr. later (the mean age of Menarche is about 12 yrs.)

Boys: The first visible sign of puberty is the enlargement of testes which begins as early as 9 ½ yrs.

 The pre-pubertal testicular volume is 1, 2, or 3 mL in volume or less than 2.5 cm in longest

diameter
 The testicular volume increases during the pubertal period gradually from 4mL to the adult
size
 This is followed by pigmentation and thinning of the scrotum and growth of penis.

Boys typically begin their linear growth acceleration(the height)2-3 yrs. later than girls and continue
their linear growth for ~2-3 yrs. after girls have stopped.

The growth accelerates up to 6-7 cm per year in boys and may continue beyond 18 yrs. of age,
whereas it is up to 8 cm per year in girls and then slows to a stop at 16 yrs.

The pubic hair in both sexes starts to appear as scanty, straight, and slightly pigmented hairs and
then it becomes darker and starts to curl. The adult distribution is triangular and spreads to the
medial surface of thigh.

Development of speech
It occurs in 3 successive stages:

I. Vocalization
II. Babbling
III. True verbal articulation

Vocalization stage (the first 6 mo. of age): Simple production of sounds by The vocal cords. Crying .
and sounds of no meaning are examples of this Stage.

Babbling stage (7-10 mo. of age): Babbling begins with many syllable (ba-da-ma), and then repetitive
consonant sounds (mama, dada) are articulated at the age of 10 mo.

True verbal articulation (words, proper speech). The development of proper speech depends on 3
integral functional units:

a) Good hearing ability

b) Memorization (good mentality)
c) Production of sounds that requires peripheral articulation (by the lips, tongue, larynx .etc..)
Disturbances in any one of these will prolong the babbling stage and delay the verbal
communication.

Development of sphincter control

The development of sphincter control requires

i. Central nervous system maturation

ii. Training
iii. Encourage the child to go to the bathroom whenever he feels the urge to urinate or
defecate.
iv. Should not try to postpone this urge.
v. Avoid punishment and reward child for being dry (notification and smiles, hugs, and
kisses from everyone in the family when the child is dry)
vi. Refusal to defecate in the toilet or potty is relatively common:
• Defusing the issue by a temporary cessation of training (and return to diapers) often
allows toilet mastery to proceed.
• Bladder and bowel control emerge during the preschool years(average age 2 ½ yr.)
• Day time bladder control typical precedes bowel control, and girls precede boys.
• Bed wetting is normal up to the age 4 yr. in girls and 5yr in boys.

Bony Maturation
Bone age equals to the chronologic age of the normal individuals.

Bone age is determined by the time of appearance of the ossific centers and the time of complete
fusion. Reference standards for bone maturation facilitate estimation of bone age.

Time of ossific centers appearance in the X-ray

1) At birth: The ossific centers at the lower end of femur and the upper end of tibia are usually
present at birth.
2) At the age of 3 weeks: The ossific center appears in the head of humerus.
3) At the age of~2 mo.- 6 yr.: The ossific centers of the carpal bones in the wrist appear
successively, approximately one center per year.

Bone age in years may be calculated as 1 + number of ossific centers in the wrist.
Assessment of Physical Growth
Growth assessment is an essential component of pediatric health surveillance. The most powerful
tool in growth assessment is the growth charts.

Growth curves: Curves demonstrating the different parameters of growth (height, weight, and head
circumference) of the same person in the successive years.

percentile growth curves: They are designed because of the wide range of normal variations in
growth parameters and the requirement to compare these parameters to those of healthy children
of the same age ,sex, race, and environment.

percentile growth curves are available for height, weight, and head circumference for boys and
others for girls.

How to create a percentile growth curve (an example is demonstrated):

1-Bring 100 normal healthy children at the age of 6 yrs. (from the same school), measure their
heights, and categorize them in the following 7 groups (levels or percentiles on the chart).

 50th percentile (the average = the median): The level at which 50% of these heights are
below it and 50% are above it.
 25th percentile (below average): The level at which 25% of these heights are below it and
75% are above.
 10th percentile (low normal): The level at which 10% of these heights are below it and 90%
are above it.
 5th percentile (lowest normal): The level at which 5% of these heights are below it and 95%
are above it.
 75th percentile (above average): The level at which 75% of these heights are below it and
25% are above it.
 90th percentile (high normal): The level at which 90% of these heights are below it and 10%
are above it.
 95th percentile (highest normal): The level at which 95% of these height are below it and 5%
are above it.

The percentile growth curves measure the height, weight, and head circumference of normal
healthy children of the same age, sex, race, and environment.
Carbohydrate Requirement
The carbohydrates are the main source of energy.

The minimal daily requirement of carbohydrates sufficient to prevent ketosis and hypoglycemia is
about 5g/kg/24 hr. About (10g/kg/ 24 hr.) or more is usually consumed.

An infant should receive daily no less than 1% of his body weight of carbohydrates.

Types of breast milk

1-Colostrum (day 2-to-4)

2-Transitional breast milk (day 5-to-20)

3-Mature breast milk (the 4th week onwards)

Compare between Colostrum and Mature breast milk

Type of breast milk Colostrum Mature breast milk

Color Greyish yellow White
Consistency Thick Thin
Reaction Alkaline Neutral
Amount 40-60 ml/day Up to 1-2 liters/day
Caloric value 1,500 calories/day 67 calories/100 mL
Composition Protein : 4-8g/100 mL (very Protein: 1.2 g/l00 mL
high) Lactalbumin and lactglobulin
Fats: 3g/100 mL (low) (why):casein is 80:20
Carbohydrates: 4g/ 100mL Fats : 3.8 g/ 100 mL
(high) (triglycerides, linoleic acid,
Minerals : 4 g/100 mL (high) and a-linolenic acid)
Carbohydrates : 7 g/100 mL
(beta lactose is the main
carbohydrate)
Minerals : 7 g/100 mL
Water :0.5 g/100 mp (low)
90 mp/100 mp
Contents of breast milk

1-Proteins: The amount of soluble proteins (lactalbumin and lactglobulin) is much more than the
amount of insoluble protein (casein). This factor renders the protein of breast milk easily broken
down and digested.

2-Fat

The fat globules are of small size, this renders them easily acted upon by the digestive enzymes.

High content of lipase enzyme helps the intestinal impolitic enzyme in digesting fat.

It contains small amounts of volatile fatty acids (not irritant to GIT).

Carbohydrates

Beta lactose facilitates the growth of lactobacilli which prevent the growth of pathogenic organisms
they synthesize vitamins K and B complex.

Minerals content

Although small amounts of calcium and phosphorus are present, optimal Ca/P ratio (2:1) is very
suitable for their complete absorption and utilization.

N.B : Although human milk contains less iron than most infant formulas, iron deficiency is less
common in breast-fed infants because of its higher bioavailability.

Adequate amounts of vitamins A and B complex

Reaction

It is neutral and this fits very well with the weak acidity (hypoacidity) of the infant’s stomach.

Rickets
Causes of Tetany in Rickets (Commonest) Hypocalcaemia occurs in rickets in the following conditions:

1. Sever cases of rickets.

2. Failure of the parathyroid gland.

3. Shock therapy with vit. D (600,000Unit), if calcium was not given.

4. In primary hypocalcaemic rickets (vit-D dependent rickets).

Contraindications for Vaccinations
Compulsory vaccination

 T.B immunization (B.C.G vaccine)

Contraindications: Immunodeficiency or in patients on immune-suppressive drugs.
 Diphtheria-tenatus-pertussis vaccine (D.P.T vaccine)
Contraindications: During acute illness, during convalescence from diseases, C.N.S. damage
and epilepsy and sever reaction.
 Measles vaccine
Contraindications: Before the age of eight months of life, during febrile illness or during
convalescence from diseases. It is also contraindicated in diseases as leukemia or immune
deficiencies and with corticosteroids and immunosuppressive therapy.

Hepatosplenomegaly