Dr. Venus G.

Saceda

GROWTH AND DEVELOPMENT

Growth

Development

Process by which a living being or any of its parts increases in size and mass, either by multiplication or by enlargement of component cells Quantitative

Maturation, function and skills are increased or enhanced. Usually synonymous with maturation or differentiation Qualitative

PERIODS OF GROWTH AND DEVELOPMENT

Growth period Prenatal Ovum Embryo Fetus early fetal life late fetal life premature infant Postnatal Infancy Neonate Nursling Toddler/run-about Childhood early childhood later childhood Adolescence Prepubescent Pubescent Puberty Postpuberty

Approximate age 0-280 days 0-14 days 14 days to 9 weeks 9 weeks to birth 2nd trimester 3rd trimester 23 to 37 weeks Birth 2 years 1st 4 weeks after birth first year 1-2 years

2-6 years 6-10 (girls) 10-18 (girls) 10-12 (girls) 12-14 (girls) 13 (girls) 14-18 (girls)

6-12 (boys) 12-20 (boys) 12-14 (boys) 14-16 (boys) 15 (boys) 16-20 (boys)

FACTORS AFFECTING GROWTH AND DEVELOPMENT

GENETIC FACTORS
Physique and intelligence quotient of children are usually similar to that of the parents Caucasians are usually taller and heavier than Asians. Infants of blacks usually develop motor skills faster than caucasians.

PRENATAL FACTORS

Illnesses
toxemias,

hypertension, anemia, and congestive heart failure result in hypoxia, and less oxygenation for the unborn infant. maternal malnutrition results in low birth weight infants and a high incidence of perinatal morbidity.

Infectious diseases
Viral,

protozoan and spirochetal infections affect growth and development during certain stages of pregnancy. Ex. Rubella, toxoplasmosis, syphilis Viral infections cause damage during the first trimester; protozoan and spirochetal infections are most feared during the last half of pregnancy.

CATARACTS IN CONGENITAL RUBELLA SYNDROME

Abnormal uterine conditions

may affect positioning of the fetus and its nutrition Amniotic bands may amputate extremities Uterine tumors may affect nutrition of the fetus in utero and result in growth retardation
Myomas

Actinic rays
Can

cause congenital malformations, particularly during early pregnancy Xrays during the first trimester of pregnancy have resulted in a higher incidence of congenital malformations Babies of parents with exposure to radar, space radiation and intensive exposure to medical xrays might also run a higher risk of congenital malformations

Drugs Alcohol, smoking and the effects of nicotine on the unborn fetus results in stunting

Drug Isotretinoin Adrenal corticosteroids Alcohol Aminopterin

Effect on the fetus Facial-ear anomalies, heart disease Cleft palate Congenital anomalies, IUGR Abortion

Dependability of evidence Suggestive Doubtful Conclusive Conclusive

Azathioprine
Busulfan

Abortion
Stunted growth, corneal opacities, cleft palate, hypoplasia of ovaries, thyroid and parathyroids

Suggestive
Doubtful

Caffeine
Chloroquine Chlorambucil

Spontaneous abortion, stillbirth, anomalies or premature birth

Deafness, bilateral vestibular paresis, abnormal retinal pigmentation Absent kidney and ureter

Doubtful
Suggestive Suggestive

Chlorpropramide
Cigarette smoking

Multiple defects
Low birth weight for gestational age

Doubtful
Suggestive

Maternal nutrition
Of

the utmost importance Studies have definitely shown that the effects on growth and development particularly of the brain are serious and may be permanent.

Endocrine problems
Diabetes

results in unusually large babies, give a high incidence of perinatal mortality and morbidity and congenital anomalies

POSTNATAL FACTORS

ORGAN DEVELOPMENT

Organ development proceeds according to a code system contained in the genetic blueprint of the growing individual. The genes of an individual can be altered only by mutation or chromosomal rearrangement, both of which are random events.

MUSCLES
Development takes place at premuscular mesodermic tissue. The largest part of increment of the body takes place from the 4th month of gestation to early maturity.

CUTANEOUS STRUCTURES
By the 3rd fetal month, the hair matrix, sebaceous and apocrine glands can be identified. By the 5th fetal month, the sweat glands appear. 1st 3 months of life, invasion of dendritic cells occur which later forms the melanin deposits in the skin.

3rd to 4th fetal month, dermis differentiates into connective tissue containing collagenous and elastic fibers. Newborn vernix caseosa and lanugo hair Puberty pubic and axillary hair, pimples; axillary and labial glands undergo cyclic change and the skin in the axillae, areolae and genitalia become hyperpigmented.

The subcutaneous fat appears during the last 3 months of gestation, increases during the 1st year of life, then it begins to diminish until adolescence, when it again increases in amount. More subcutaneous fat is found in girls than in boys

NERVOUS SYSTEM
Brain begins to develop at 4-6 weeks gestation, and grows rapidly during infancy and childhood. Differentiation continues on to the postnatal period where gyrations and convolutions increase with the development of white matter. Myelinization is completed by 6-12 months, and in some nerves up to 2 years

Relative size of the brain to total body weight:

2nd fetal month 50% At birth 10% At 5 years 5% Adult 2%
At

CSF amounts to 200 ml by 10 years, normally clear and colorless.

STAGES OF GROWTH RELATIVE PROPORTIONS OF HEAD, TRUNK AND EXTREMITIES

SENSORY DEVELOPMENT
Tactile sense starts in early prenatal life at the face, then spreads to the limbs and finally to the trunk in a cephalocaudal succession. Pain sensation is not developed in a newborn. This state of hypoesthesia lasts for a week. Visual sensation is not well developed at birth; clear vision is achieved only at 16 weeks of age; visual acuity of 20/20 is achieved at 7 yrs

Auditory system is functional from birth as soon as the external canal is cleaned. Hearing becomes acute soon after birth and at 6 months there is localization of sound and recognition of familiar voices.

Newborn can taste but is unable to distinguish flavors. At 3 months, acute taste discrimination is achieved.

CIRCULATORY SYSTEM
At birth, the ductus venosus and the foramen ovale become functionally closed. Ductus arteriosus closes after 8-12 weeks. Normal fetal heart = 140-160 bpm, with the females having higher HR than males. After 7 years old, the HR is below 100 bpm.

At birth, with the onset of breathing and ligature of the umbilical cord there is a rapid drop in the resistance of the pulmonary bed. the left atrial pressure exceeds that of the right atrium. This results in the functional closure of the foramen ovale.

LYMPHATIC SYSTEM
Great deal of lymphoid tissue including lymph nodes in the neonate, which increases regularly during childhood with peak at 6-7 years, undergoing a relative reduction after puberty and during adult life. Spleen relatively the largest lymphoid organ in proportion to the body at birth, increases in weight to 12x at adult life, and does not atrophy unlike the nodes.

BLOOD
In the beginning, all blood cells are nucleated. 10th fetal week 90% of cells are nonnucleated. Blood forming organs

Connective Liver

tissue or mesenchyme

Spleen
Mesonephros Bone

marrow

Fetal Hgb has close affinity for oxygen. 13th week of fetal life, the first adult Hgb appears At birth, the Hgb is lower in babies whose cords have been clamped early and higher among those whose cords have been clamped late.

In normal infants:
birth neutrophil is the predominant cell After 1 week of life lymphocytes predominate until 4 years of age when the neutrophils equal the lymphocytes 8 years leukocyte count concentration is similar to adults
At

IMMUNITY

Babies are born with passively transferred immune globulin from the mother. These antibodies protect the baby up to 6-9 months of age. Physical barriers: skin, mucus membranes and their secretions

Antitoxin and antiviral immunoglobulin are transferred better than antibacterial antibodies. Antiviral Igs diminish while antibacterial Ab rise by 2 months of age. The colostrum of human milk has a high titer of enteric antitoxins, hence E.coli fails to thrive in the intestinal lumen.

DIGESTIVE SYSTEM

From the 5th fetal week on there is elongation of the gut into the belly stalk and the organs of the digestive system begin to be formed.
Umbilical

hernia and omphalocoele are a result of abdominal wall deficiency and protrusion of the gut into the umbilical cord.

Meckels diverticulum occurs as a result of the persistence of the yolk stalk.

Malrotation is a result of reversed twisting of the small gut which ends up lying ventral instead of dorsal to the transverse colon

On the 2nd fetal month, there is profuse growth of the epithelial lining of the gut resulting in lumen occlusion. Failure to recanalize causes atresia; stenosis results from partial recanalization.

If 2 lumina are formed, duplication results. Capacity of the stomach:

At

birth One month One year Two years Later childhood

30-90 ml 90-150 ml 210-360 ml 500 ml 750-900 ml

RESPIRATORY SYSTEM
Arises as an outpouching from the pharyngeal pouch. The fetus and newborn are resistant to anoxia because a low cerebral metabolism, low and variable energy metabolism and an anaerobic source of energy

URINARY SYSTEM AND FLUID BALANCE

Internal homeostasis of the body is regulated mainly by the kidneys through:

Excretion

of nitrogenous waste mainly as urea Stabilization of osmotic pressure and chemical composition Regulation of extracellular fluid volume Maintenance of acid-base balance

In the early part of fetal life, growth is slow. Then, just before term, growth becomes rapid. The last renal tubules are completed from the 8th month of gestation to the 1st month of postnatal life. No new glomeruli are formed after birth and those already present may still be immature.

In the neonate, the urinary system, although relatively immature, functions sufficiently for the maintenance of fluid and electrolyte balance. The baby may not void 12-24 hours after birth. Mature function is achieved by 5-6 years of age.

SKELETAL SYSTEM
Calcification of bones begins at 8-9 weeks of age and establishes the end of embryonic period and the beginning of the fetal period. At birth, ossification has taken place in all long bones.

The amount of calcification in the newborn depends on maternal levels of calcium, phosphorus, vitamin D and proteins. (importance of pre-natal checks). At birth, the AP an lateral diameters of the chest are equal, the shoulders are elevated and the neck is hardly seen.

From 3-10 yrs, the chest becomes broader and flatter and the ribs slope down. The manubrium sterni also goes downs and the neck appears longer. The vertebral spine presents as 2 concavities at birth thoracic and sacral

GENITAL ORGANS
At birth, 90% of term infants have descended testes, in prematures, 70%. 50% of undescended testes undergo descent by one month of age. Puberty the testes undergo rapid enlargement and spermatogenesis occurs

At birth, the ovarian cortex is filled with primordial follicles. These mature with menarche, taking turns per ovulatory cycle.

TIME OF APPEARANCE OF SEXUAL CHARACTERISTICS

POSTNATAL GROWTH

NORMAL PATTERNS OF GROWTH

Growth and development has been found to proceed in a set pattern and any marked deviation from this might be considered abnormal. Although the term normal may be controversial, normal patterns of growth for a certain population have to be established before a particular childs growth status can be assessed.

The child has to be compared with his peers and with himself.

THE HUMAN GROWTH CURVE

3 basic components: 1st phase the rapid and rapidly decelerating growth of the first 3 years of life

THE HUMAN GROWTH CURVE

2nd phase the steady and slowly decelerating growth in middle childhood which is predominantly growth hormone dependent.

THE HUMAN GROWTH CURVE

3rd phase the pubertal growth spurt.

GROWTH MONITORING AND PROMOTION

2 main reasons for growth monitoring and promotion (GMP)

Assessment

and surveillance of nutritional

status Enhancement of health worker-mother interactions and nutrition education

Growth monitoring should lead to positive action resulting in improvement of child health and nutrition.

GMP AND NUTRITIONAL ASSESSMENT AND SURVEILLANCE

The need to monitor growth during the 1st 3 years is urgent:

effects of malnutrition during the 1st 3 years on growth and development are devastating particularly on brain growth and mental development After the age of 3, those who have been initially malnourished in the 1st 3 years remain smaller, shorter and lighter.
The

Growth monitoring is the essential step in eradicating child malnutrition.

The 1st 3 years of postnatal life are crucial. It has been repeatedly demonstrated that any setback during this period will mean poor growth which may persist. Frequent checks of stature and growth velocity during the 1st 3 years are essential for early detection of any deviation from the norm, prompt identification of adverse factors or conditions and immediate institution of therapy.

GMP AND HEALTH WORKER-MOTHER INTERACTION

Through growth monitoring, other means of protecting the childs growth may be shared with the parents, thus enhancing the childs health.

GROWTH MONITORING AND PROMOTION, PUBLIC HEALTH AND PRIMARY HEALTH CARE
Public health areas which have to be emphasized concerning growth monitoring are: (1) Full integration into primary health care (2) The need for political commitment (3) The importance of social mobilization or the level of community involvement and understanding

AIDS IN ASSESSING GROWTH

Anthropometrics head and chest circumference, length, height, upper midarm circumference, skinfold thickness Growth tables and charts

Weight is a simple, reproducible growth parameter which can serve as an index of acute nutritional depletion. Length or height is a reliable criterion of growth as this is not affected by excess fat or fluid. It reflects growth failure and chronic undernutrition especially in early childhood.

GROWTH VELOCITY
Height measurement is a more sensitive index of health particularly when 2 measurements are available at intervals of about 6 months. Weight-for-height measurement more accurately assesses body build and is particularly useful in identifying a child who is acutely malnourished.

SEXUAL MATURITY RATING

Pubertal changes have to be assessed in children. The most popular method for sexual maturity rating is that of Tanner.

BEHAVIOR
Numerous studies have shown that development proceeds in an orderly and predictable pattern. Areas of behavior:

Motor Adaptive Language Personal-Social

MOTOR BEHAVIOR
Of unusual interest because of its neurologic implications. Divided into gross and fine motors

Factors which may influence the degree to which motor ability is perfected or delayed in its utilization:
Environmental

influences and opportunities to

practice a skill; Childs physical size; Childs health condition; Childs nutritional state; Childs mental status; Adult attitudes

ADAPTIVE BEHAVIOR
Considered the most significant among the 4 areas and has been found to be most closely related to intelligence. Ex. Ability to utilize and manipulate objects, the use of motor and sensory coordination in the solution of practical problems and the resourcefulness in utilizing past experience in adjusting to new situation.

LANGUAGE DEVELOPMENT
Language has been defined as the art of communication or the ability to understand another person and to be able to make oneself understood Stages of language development: (1) Reflex sound (2) Babbling sound (3) Gestures (4) Word usage

PERSONAL-SOCIAL BEHAVIOR
This area is very much affected by environment and culture but it may also demonstrate the state of neuromuscular coordination. Ex. Habits affecting feeding, sleeping, bowel and bladder control and the ability to get along with other people

EVALUATION METHODS

Denver Developmental Screening Test Gessel Developmental Test The GoodenoughHarris Draw-a-Person Test

INTELLECTUAL DEVELOPMENT

Mental operations which constitute intelligence

Recognition Attention

span Retention and recall Inductive and deductive reasoning Abstraction and generalization Organization

2 types of intelligence
Formal

intelligence or academic learning

Measured

by intelligence tests resulting in what is known as the intelligence quotient

Contentional
May

intelligence

manifest as common sense or astuteness

Intelligence tests are inaccurate before the age of 5 years but may have a good predictive value afterwards. Ex. Bayley Scale of Infant Development, Cattell Test for Measurement of Intelligence of Infants and Young Children, Minnesota Preschool test, etc.

THANK YOU!