Growth and Development

Dr.Yahya A.Shoole
MBBS, Msc Pediatrics

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 Growth and development is an essential
part of the examination of children.
 No matter which system is involved,
assessment of growth and development
will provide insight into the general well
being of the child.

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GROWTH IN CHILDREN

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growth can assessed in various ways
• 1. Assessment of physical growth –
anthropometric measurements of parameters
like weight, length/height, head, chest and
midarm circumferences (age dependent
variables).
• 2. Skeletal assessment – radiography of
centers of ossification and bone growth.

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 3. Tissue growth assessment—
• a. subcutaneous fat – by skinfold callipers or
by soft tissue radiography
• b. muscle mass – using soft tissue
radiography to distinguish muscle mass from
subcutaneous fat and bone width.
 4. Assessment of dental development –
by counting the number of teeth erupted

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Measuring Growth in Length
and Stature

 Recumbent length (Crown-heel length) is

measured from birth until a child is able to stand
• Measured from the vertex (highest point on skull) to
the soles of the feet

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Measuring Growth in Length
and Stature

 Stature or standing
height is measured
between the vertex and
the floor
 Preferred measurement
of body length

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Growth in Length and Stature
 Zygote ~ 0.14 mm in diameter
 Birth
• Boys ~ 50.5 cm
• Girls ~ 49.9 cm
 Year 1
• Boys ~ 76.1 cm
• Girls ~ 75 cm

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Growth in Length and Stature
 At birth: 50 cm
6 months: 68 cm
1 year : 75 cm
2 years: 87 cm
3 years: 94 cm
4 years: 100 cm (2 times birth length).
 Between 4-8 years, the height increases about 7 cm/year.
5 years: 107 cm
6 years: 114 cm
7 years: 121 cm
8 years: 128 cm
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 Between 8 -12 years, it is about 5
cm/year.
 9 years: 135 cm
 10 years: 140 cm
 11 years: 145 cm
 12 years: 150 cm (3 times birth length).

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Formula for average height
 For a quick estimation of height/length,
• length from 2-12 year = (age in years × 6) +77
cm.

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Stem Length (crown rump
length)

 This denotes the

upper body length.
 Stem length is
measured using
the same
measuring board
used to measure
crown heel length.

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Sitting Height

 The sitting height is the equivalent of

the crown rump length in the
cooperative child over 5 years of age.
 Sitting height is useful to assess body
proportions particularly in those with
short stature due to skeletal dysplasias
(for example achondroplasia)

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Subischial Leg Length

 Subischial leg length is another way to

assess body proportions.
 One may record subischial leg length as
per the following equation:
 subischial leg length = total length/height
– crown rump length/sitting height.

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Symphisis Pubis Height
 The symphisis pubis height is also
another useful measure of body
proportions.
 The child is made to stand as for
measuring height and the symphisis
pubis is marked.
 The total height minus the symphisis
pubic height gives us the length of the
upper body segment.
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Changes in Sitting Height
 Birth – sitting height = 85% of total
length
 Age 6 – sitting height = 55% of total
length
 Adult – sitting height = 50% of total
length

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Changes in Stature
 55-60% of stature increase due to leg
growth
 Ratio between sitting height and stature
• Describes the contribution of the legs and
trunk to total height

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Changes in Body Proportions

 Sitting
height/stature
ratio

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 Growth in Length and Stature

 Plots accumulative
growth over time

Typical distance
curve for stature

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 Measuring Body Weight

•Electronic digital scales, calibrated

in metric units are recommended
•Chair scales are available for those
who are not capable of standing

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Growth in Body Weight
 Conception ~ ovum weighs 0.005 mg
 Median Birth Weight
• Boys ~ 3.3 kgs
• Girls ~ 3.1 kgs
• Day 1-3 postnatal, infant may lose up to 10% of
body weight
 Year 1
• Boys ~ 10.2 kgs
• Girls ~ 9.5 kgs
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 Growth in Body Weight
Average weight for age
 At birth: 3 kg
 During the first 4 months, weight gain is
about 750 gm/month.
 1 month 3.750 kg

 2 months: 4.500 kg

 3 months: 5.250 kg

 4 months. 6.000 kg (2 times birth weight)

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 During the second 4 months, weight
gain is about 500 gm/month.
 5 months: 6.500 kg
 6 months: 7.000 kg
 7 months: 7.500 kg
 8 months: 8.000 kg'.

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 During the third 4 months, weight gain
is about 250 gm/month.
 9 months: 8.250 kg
 10 months: 8.500 kg
 11 months: 8.750 kg
 12 months: 9.000 kg (3 times birth
weight)

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 During early childhood, weight gain is
about 2 kg/year.
 2 years: 12 kg
 3 years: 14 kg
 4 years: 16 kg
 5 years: 18 kg
 6 years: 20 kg

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 During late childhood, weight gain is
about 2.5 kg/year.
 7 years: 22.5 kg
 8 years: 25 kg
 9 Years: 27.5 kg
 10 years: 30 kg. (10 times birth weight)

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 Formula for average weight

Age Weight

3-12 mon [age(mo)+9]/2

1-6 yr Age(y) X 2+8

7-12 yr [age(y) X 7-5]/2

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Growth in Body Weight

 Peak weight velocity = maximum rate of

growth in body weight
• Occurs after peak height velocity

 Mature body weight is approximately 20x

that of birth weight

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 Growth in Body Weight

Typical distance
curve for body
weight

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Body Mass Index (BMI)

 Calculating BMI
 Healthy adult = 18.5-24.9
 Underweight = <18.5
 Overweight = 25-29.9
 Obese = >30

wt (kg)
BMI  2
ht (m )

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BMI-for-Age
 In children and adolescents, BMI-for-age
is best used as a guide to determine
individual nutritional status
 BMI-for-age between 85th percentile and
95th percentile is classified as risk for
becoming overweight
 BMI-for-age greater than 95th percentile,
overweight is a concern

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BMI-for-Age
 Adiposity rebound: upward trend
occurring after the low point on the BMI
percentile curve
• The earlier the adiposity rebound occurs in a
child, the more likely BMI will be high in
adulthood

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Growth Spurts
 Although broadly a continuous process,
growth occurs in spurts, or periods of
acceleration.
 There are three growth spurts in the post
natal period of life:
• 1. infantile growth spurt (0-1 years).
• 2. mid-growth spurt (6-8 years).
• 3. adolescent growth spurt (puberty till young
adult life).

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Adolescent Growth Spurt
 Estimated age for boys = 13.7 yr
 Estimated age for girls = 11.8 yr
 The phenomenon is not universal

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Head Circumference

 The head circumference is measured by

the tape, and is passed over the supra-
orbital ridges in front and that part of the
occiput which gives the maximum
diameter.

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Changes in Head Circumference
 Ratio of head size to overall body length
• Head contributes 25% to body length
 Head circumference
• Indicative of brain development

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Measuring Head Circumference

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Changes in Head Circumference
 Birth – head is ¼ of total body length
• Head circumference is greater than chest circumference
• Head circumference ~ 35 cm
 First 3 months Growth 2 cm/month
 Second 3 months Growth 1 cm/month
 Next 6 months Growth 0.5 cm/month
 6 months: 43 cm (8 cm more)
 1 year : 47 cm (4 cm more)

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 2 years: 49 cm (2 cm more)
 4 years: 51 cm (2 cm more)
 6 years: 51 cm
 11 years: 52 cm (1 cm more)
 12 years: 53 cm (2 cm more)

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Changes in Body Configuration

 Changes in body proportions with age

 Notice the great changes in the relative size of the head and lower
limbs

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Chest Circumference
 The tape is passed through the xiphi-
sternal junction and surrounds the chest
in that plane.
 The measurement is done midway
between inspiration and expiration and
recorded nearest to 0.1 cm.
 The tape should not be passed through
the nipple line.

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Changes in Shoulder and Hip
Width
 Ratio between biacromial and bicristal
breadths
• Shoulder width to hip width

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Changes in Shoulder and Hip
Width

 Mean biacromial
and bicristal
breadth
 Males – wide at
shoulders
 Females – wide at
hips

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Changes in Shoulder and Hip
Width %

 Bicristal/biacromial
breadth x 100

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Tissue Growth
 The hand and wrist X-ray is used to
assess tissue differentiation in growth.
 In the next figure (a) represents
subcutaneous fat width and (b) the bone
width.
 The muscle width may be obtained by
subtracting the sum of subcutaneous
and bone widths from the total width.

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 Subcutaneous fat
under the skin of
triceps, and
infrascapular area
can be measured
with Harpenden
Skin-fold Calipers.

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Infracapsular Triceps

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Physique
 Overall body form
 W.H. Sheldon (1940) rated physique by
three components
• Endomorphic (round)
• Mesomorphic (muscle)
• Ectomorphic (thin)

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Endomorph Mesomorph Ectomorph
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Skeletal Development
 Appositional growth
• Long bones grow in width by bone apposition
on the outer surface of the bone
• Short, flat, and irregular bones increase size
by this method
 Endochondral growth
• Involves the interstitial growth of cartilage
followed by calcification of this cartilage
• The result is increased bone length

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Skeletal Development
 In utero
• Intramembranous bone formation
• Embryonic membranes begin to ossify
 All long bones begin to ossify by birth
 Bone remodeling
• Occurs throughout the lifespan
• Osteoblasts (building)
• Osteoclasts (chewing)

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Skeletal Development
 From birth to 35 yr – osteoblast activity >
osteoclast activity
• Gaining bone
 After 35 yr, osteoclast activity >
osteoblast activity
• Exercise and stress on the bones becomes
important

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Skeletal Development
 Endochondral growth occurs at the
epiphyseal plate (growth plate)
 Bone growth in length occurs when the
epiphyseal plate becomes ossified and
forms the epiphyseal line
• Osteoblastic (bone building cell) activity

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Exercise and Skeletal Health
 Interaction among activity, nutrition,
genetics, and lifestyle
 Exercise increases bone density
 Inactivity is associated with bone
decalcification (bone loss)
 Long periods in space reduce bone
mass unless a vigorous exercise
program is followed (treadmill)

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Exercise and Skeletal Health
 Female athlete triad
• Amenorrhea
• Eating disorders
• Bone mineral loss
 These problems are interrelated and this
interrelationship is not completely
understood in young women athletes

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Female Athlete Triad -
Interrelationships
Eating Disorder
•Restrictive dieting
•Overexercising
•Loss of weight

Bone Mineral Loss Amenorrhea

Diminished
Osteoporosis
hormones

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Maturation & Developmental
Age
 Chronological age
• Often used to denote maturity, but is a poor
indicator
 Bone age
• Much better indicator of maturity
• e.g., adolescence
• Addresses variations in rate of maturation

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 Bone age tells us the rate at which
bones mature in ossification.
 It should be the same as the
chronological age if the child
progresses “normally”.

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 In conditions such as hypothyroidism,
malnutrition, constitutional delay of
growth and puberty and growth hormone
deficiency, bone age is delayed.
 bone age may be advanced in
thyrotoxicosis and precocious puberty.

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Skeletal Maturity
3-year-old

14-year-old
5-year-old

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 For a rough estimate of bone age from
the left hand X-ray, the following appear
as centers of ossification:
 Capitate, hamate – 1 year
 Lower end of radius – 2 years
 Triquetral – 3 years
 Lunate – 4 years

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 Scaphoid – 5 years
 Lower end of ulna, trapezium, trapezoid–
6 years
 Pisiform – 12 years

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Dental Growth

 Dental maturation
• Count the number of teeth that have emerged
 Dental age
• Radiographs determine stage of bone
calcification
• Technique of choice
• Can compare developmental stages

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 Permanent teeth
6y：First molar
7～8y：primary
teeth are
exfoliated
instead by
permanent teeth
according to the
eruption order.
12y：Second molar
>18y：Third molar
Totally：32
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Genitalia Maturity
 Stages of pubertal development

 Girls
• Assess pubic hair and breast development
• Age of menarche
 Boys
• Assess pubic hair and reproductive organ
development

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Boys
 the first sign of puberty is an acceleration
of growth of the testis (4 ml at beginning
of puberty; 12 ml – minimum adult size)
and scrotum with thinning, reddening
and wrinkling of the scrotal skin.

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 This is soon followed (after about 1 year)
by height spurt and penile growth.
 The acceleration of penile growth begins
at about 12.5 years of age.
 The size of the testes can be estimated
clinically by comparing with standard
known volumes using ‘Prader
Orchidometer’

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 Girls : The first sign of puberty is an
increase of height velocity and is
manifested shortly afterward by
appearance of the breast bud.
 Menarche is a late event, and occurs
after the height spurt has passed (the
majority of girls menstruate when their
breasts are in stage 4, although 25
percent do so in stage 3).
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Maturation and Motor
Performance

 The level of maturation can affect motor

performance
 Postpubescent boys initially outperform
prepubescent boys
 Once the late-maturing boys reach
adolescence, the advantage is no longer
evident

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Maturation and Motor
Performance
 Early maturation is not associated with
superior motor performance in girls,
except in swimming
 Late-maturing girls have superior motor
performance
• Longer arms and legs
• Narrower hips

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WHO Child Growth Standards
A growth
A growth
chart for
chart for
st
the 21 st
the 21
century
1 year 2 years 3 years 4 years 5 years
century
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WHO growth charts show that all
children across all regions can attain a
similar standard of height and weight
and development with correct feeding
practices, good health care and a
healthy environment.

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 WHO Growth Charts

Length/height-for-age
Weight-for-age
Weight-for-length
Weight-for-height
Body mass index-for-age (BMI-for-age)
Motor development milestones.

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A second set of growth standards will be
available later for the following
indicators:
• Arm circumference-for-age
• Head circumference-for-age
• Subscapular skinfold-for-age
• Triceps skinfold-for-age

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Subsequently, child growth velocity
standards will be developed for:
• Length/height
• Weight
• BMI
• Arm circumference
• Head circumference

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Uses for WHO charts
 Health practitioners- effective screening tool to
assess growth of children in their care, ensure timely
and adequate treatment if necessary.
 Nutritionists- assess nutritional status of individuals
or populations and monitor child growth and
development.
 Child and health advocates- promote and protect the
right of children to grow normally.
 Also advocate for protection, promotion and support
of breastfeeding and adequate complementary
feeding

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Uses ….
 Governments and UN agencies- formulating
health and related policies, planning
intervention and monitoring their
effectiveness.
 Parents / caregivers- monitor growth of their
child, understand and follow nutritional
recommendations and seek timely health
care for their child.

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WHO Child Growth Standards

Child survival

Physical growth

Child
development

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THANKS FOR YOUR ATTENTION
 ANY QUESTIONS
 ANY COMMENTS

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