Growth and development

GROWTH AND DEVELOPMENT

September Board Review 2012

Test QuestionWhat Board Review Topic should we do

next?A. Allergy & ImmunologyB. Adolescent Medicine and Gynecology

NORMAL GROWTH

Growth Affected by:

Prenatal factors: Maternal nutrition and uterine size

Genetic growth potential Nutrition throughout childhood Multiple hormones

Growth, thyroid, insulin, sex hormones Despite all these factors, growth is

predictable Carefully documented growth charts are

powerful tool to measure health and well-being

Growth

Postnatal growth Healthy term infants lose 10% of their birth

weight in the first days after birth Regain it back by 2-3 weeks of age

Normal: Gain 20-30g/day for first 3 months This rapid phase of growth is influenced

primarily by growth hormone (GH) and thyroid hormones

Question #1At what age to most healthy, term infants

typically triple their birth weight?A. 6 monthsB. 12 monthsC. 18monthsD. 2 yearsE. 3 years

Growth Milestones Birth weight triples by 1 year Birth length doubles by 3-4 years

During puberty: sex hormones become significant factor Slight deceleration of growth just prior to

puberty Followed by rapid acceleration of growth

Males later than females Females BEFORE menarche

Accurate Measurements Scales calibrated regularly Weigh in underwear or

diaper Length/height should be

measured supine in age <2 years Legs fully extended, head

resting on unmovable board, moveable footboard

Standing height for >2yrs Wall-mounted stadiometer If cannot stand: arm span is

good substitute

Growth Charts Growth charts from CDC or WHO

Specific charts for special populations LBW and VLBW premies Trisomy 21, Turner, Klinefelter, achondroplasia

Each child should be considered in terms of their genetic growth potential Estimate with mid-parental height

Boys= [Father’s height(cm) + mother’s height(cm) +13]/2

Girls = [Father’s height(cm) + mother’s height(cm) -13]/2

Growth Charts Shifts across 2 or more percentile lines

may indicate an abnormality in growth Shifts in the early life can be normal

Birth size reflects maternal factors (uterine size, etc) Genetic factors take over after birth Small infant born to large parents catches up

around 6mos Large infant born to small parents slows down

around 12 months After age 3, shifts are uncommon and

warrant investigation

Question#2

What is the most likely diagnosis?

A. NormalB. Constitutional

Growth DelayC. Familial Short

StatureD. HypothyroidismE. Cushing syndrome

TH = target height

Abnormal growth Malnourished

Drop in weight first, then height, then head circumference

Linear growth problems Indicates congenital,

genetic, or endocrine abnormality Hypothyroidism or GH

deficiency: normal or elevated weight with decreased height

Familial short stature Height and weight

are normal for 2-3 years

Height then drifts downward across percentiles

Growth curve follows normal growth curve at lower percentile

After initial drop off, have normal growth velocity

ConstitutionalGrowth Delay Variation of normal growth Reduced tempo of

development Height and weight both cross

percentiles Normal or near normal

growth rate during prepubertal years

Bone age is delayed Delayed puberty

Fall further off curve Complete pubertal growth in

late teens/early 20’s Achieve normal range

height (might be slightly lower than MPH)

BMI Begin plotting BMI for every patient at

age 2 Weight (kg)/height(m)2

85th-95th %ile = overweight >95%ile = obseity <5th%ile = underweight

Does not differentiate lean muscle from fat

HEAD GROWTH

Head size Normal head

circumference of full-term infant at birth Range 32-38cm Average 35cm

Microcephaly 2 SDs below mean for

age/sex (<2nd %ile) Macrocephaly

2 SDs above mean for age/sex (>98th %ile)

Microcephaly Congenital:

Trisomy 13, 18, 21 Cornelia de Lange, Smith-Lemli-Optiz, Rett Inborn errors of metabolism, hypothyroidism

Acquired: Normal head circumference at birth followed by

development of microcephaly over months to years Lack of brain development or growth

Causes: Stroke, meningitis, encephalitis, toxoplasmosis, rubella, CMV, teratogen exposure in utero, hypoxic-ischemic encephalopathy

MRI most helpful in head size <3SDs below mean and neurologic abnormalities

Question #3Which of the following is commonly

associated with hydrocephalus?A. Large parental head circumferenceB. Increased amount of brain parenchymaC. Normal CNS imagingD. Developmental delay, hypertonia,

hyperreflexiaE. Skeletal dysplasias

Macrocephaly vs Hydrocephalus

Macrocephaly Causes range in

severity from benign to severe

Familial Benign Normal development Parents with large

heads Accelerated rate of

head growth which stabilizes by 12-18 months

Hydrocephalus Excessive

accumulation of CSF Congenital: present

at birth Acquired:

accelerated growth over several months

Irritability, vomiting, bulging fontanelle, upward gaze

Macrocephaly vs Hydrocephaly Can distinguish the two using clinical

exam Look for signs of increased ICP Developmental delay, hypertonia,

hyperreflexia Imaging

Ultrasound: if fontanelle is open CT: fast, available, does not always detect

posterior fossa pathology MRI: shows more specific detail, but is not

always easily accessible

FAILURE TO THRIVE

Question #4You are seeing an 18 month old child for the first

time. She is developing well, and the parents have no concerns. Her growth chart reveals a weight at the 3%, height at the 25%, and HC between the 25-50%. What is the MOST likely cause of this patient’s poor weight gain?

A. Inborn error of metabolismB. Congenital heart defectC. Inadequate caloric intakeD. Growth hormone deficiencyE. Hypothyroidism

Definition FTT is no longer viewed as simply

nonorganic vs. organic syndrome NOW…

It is a physical sign that a child is receiving inadequate nutrition for optimal growth and development

Causes of this may vary…and it is our job to figure that out MOST cases are due to inadequate caloric

intake (nutritional) There are medical causes, too

Differential Diagnosis 3 mechanisms can cause under-

nutrition

Inadequate intake (Ingesting insufficient nutrients for growth)

Malabsorption

Increased metabolic demands

Poor feeding techniques often cause FTT

May be a manifestation of parental neglect/inadequacy

Some clues to the cause may be elicited from simple observation Oromotor problems Food aversions Poor parent/child

interaction

Question #5A mom brings in her 2yo boy with Down syndrome.

She is concerned that he is not gaining weight well. The nurse plotted him on a typical male growth chart at 5% for weight. He is a picky eater and often spits up after feeds. There is no history of cardiac or intestinal malformation, but he does have a history of frequent otitis media. Of the following, what is the most important next step?

A. Order an echo to look at his heartB. Refer him to a nutritionist for dietary counselingC. Send him to ENT for tympanostomy tubesD. Plot his growth parameters on a different growth

chartE. Start Zantac for his reflux

Growth Charts

Plotting the weight, length, and head circumference is an important step in assessing a child’s growth.

Remember subtle differences are important Weight tends to fall 1st with poor caloric intake,

then HC and length For endocrine disorders, the patient is short

(<50%) with relative sparing of weight Special growth charts for certain genetic

conditions (Down, Turner, Williams syndromes)

Evaluation In the past, children underwent an extensive

medical/lab evaluation for organic causes of FTT Now…the majority of FTT work-ups are

observational with dietary management and can be accomplished in the outpatient setting**

If outpatient management fails, then admission and laboratory evaluation may be needed** CBC with RBC indices CMP (test for renal and hepatic function) Celiac screening OTHER

Long-Term Consequences

Many children who experience FTT in early life eventually seem to have normal function

However…the overall trend is worrisone Persistent intellectual deficits Behavioral problems

Conflicting evidence on emotional outcomes or future growth parameters

MOTOR DEVELOPMENT

Gross Motor Goal: to gain independent and volitional

movement Primitive reflexes develop during

gestation Prepare the infant for acquisition of skills Disappear as CNS matures to allow infant to

make purposeful movements

Question #6At what age should this reflex disappear?A. 1 monthB. 2 monthsC. 6 monthsD. 9 monthsE. 12 months

Reflexes

Moro reflex: Birth – 6 mos

Protective Extension: emerges at 6 - 9mos

Positive support: Birth - 4-6 months

Gross Motor Milestones

Question #7A mother brings her child for a health

supervision visit. He is able to pull to stand, take a few independent steps, and use his thumb and 2nd digit to grasp a piece of cereal. These milestones are MOST typical for a child who age is:

A. 6 monthsB. 9 monthsC. 12 monthsD. 15 monthsE. 18 months

Gross Motor Milestones 2 months: lifts head

and chest while prone 4 months: no head lag,

steady head control while sitting, rolls front to back, props on wrists

6 months: sits propped on hands, rolls over in both directions

9 months: begins creeping, pulls to stand, walks on hands and feet

Gross Motor Milestones 12 months: pulls to

stand and cruises well, takes independent steps

15 months: walks independently, stoops to floor/recovers to standing position

18 months: walks up steps with hand held, throws ball

24 months: runs well, kicks ball, jumps with 2 feet off the floor, throws ball overhand

Gross Motor Milestones 3 years: broad jumps,

stands momentarily on one foot, pedals tricycle

4 years: balances on one foot for 3 seconds

5 years: skips, alternating feet

6 years: rides bicycle without training wheels, tandem walks

Question #8Of the following scenarios, which is the LEAST

concerning?A. An 18 month old who cannot walk

independently B. A 4 month old who lacks steady head

control while sittingC. A 9 month old who is unable to sit

unassistedD. A 30 month old who does not runE. A 10 month old who does not crawl

Fine Motor Development Use of upper extremities to engage and

manipulate the environment Self-help tasks, play, do work

First play a role in balance and mobility At birth – no voluntary use of hands

Due to primitive grasp reflex Can’t hold or transfer objects until this goes

away Once gross motor development allows for

stable upright position hands for more free and purposeful exploration

Question #9You observe a child who is holding two blocks

and bangs them together. Then she picks up a cheerio using an immature pincer grasp and feeds it to herself. These milestones are MOST consistent with a child who is:


Development of pincer grasp

Raking Scissor Immature Inferior Fine

Fine Motor Milestones 2 months: regards object and

follows 180 degrees, hands unfisted 50% of time, hands held together, hands to midline

4 months: hands open, reaches for objects, clutches at clothes

6 months: transfers object from one hand to another, reaches with one hand, raking grasp

9 months: feeds self with fingers, plays gesture games (pat a cake) in imitation, bangs objects together, holds two objects at a time, immature pincer grasp

Question #10You observe a child as he walks into the exam room. He

is holding a small ball. When you ask him to let you see the ball, he gives it to you. He stoops to the floor to pick up a crayon and recovers to a standing position. He uses the crayon to scribble on a piece of paper you gave him. When he sees a few blocks on the floor, he picks up two and stacks one on top of the other. These milestones are MOST typical for a child whose age is:


Fine Motor Milestones 12 months: fine pincer

grasp, holds crayon, attempts to scribble after demonstration

15 months: plays ball with examiner, gives and takes a toy, drinks from a cup, makes a line with a crayon, makes 2-3 cube tower

18 months: feeds self with spoon, 3-4 cube tower

24 months: washes and dries hands, removes clothing, 4-6 cube tower, feeds self with spoon and fork

Fine Motor Milestones 3 years: independent eating,

helps with dressing (unbuttons clothing, puts on shoes), 10 cube tower, copies circle

4 years: brushes teeth, copies cross/square, draws simple figure of person (head plus 1 body part)

5 years: dresses and undresses, cuts with scissors, draws person with 6 body parts, copies triangle, independent dressing

6 years: , ties shoes, draws diamond, writes first and last name

COGNITIVE DEVELOPMENT

Cognitive Development The foundation of intelligence Progression through developmental stages

involves object permanence, causality, and symbolic thinking

Depends on two developmental domains Language

Both an expressive and a receptive process Language skills are the SINGLE best indication of

intellectual ability Problem-solving

The manipulation of objects to achieve a specific goal

The Newborn

Alerts to sound Bell Voice

Visually fixates at 9-12”

Demonstrates visual preference for human face

Cognitive Development 9-12 months: object

permanence

18 months: deduce location even if hidden

18-24months: pretend play and symbolic thinking

School age: cognitive reasoning

Question #11You are examining a young boy during a health supervision

visit. His mother reports that he says “mama,” “dada,” “bye,” “ball,” and “dog.” Following the exam, he sits on the floor in front of his mom while playing with a toy car. When he sees a jack-in-the-box on a shelf, he points to it. After his mom says (no gestures) “Bring me the Jack-in-the-box,” he brings it to her.

These developmental milestones suggest that the child is CLOSEST to


LANGUAGE

2 months Alerts to sound or voice Coos, vowel-like noises Reciprocal vocalizations,

social smile (6 weeks) 4 months

Orients head in direction of voice

Stops crying to soothing voice Laughs out loud, squeals

6 months Turns directly to sound and

voice Stops briefly to “no” Babbles consonants, imitates

speech sounds

9 months Understands own name Says “mama” and “dada”

nonspecifically

Language

1 year Follows 1 step command with gesture Points to get desired object Says “mama” and “dada” with meaning and at least 1 other word

15 months Follows simple commands, identifies 1 body part Uses 3 to 6 words Mature jargoning with real words

18 months Identifies 3 body parts, points to self Says 7-25 words, uses words for wants or needs Understands “mine”

2 years 50+ words, 50% intelligible (2/4), 2-3 word sentences Points to 5-10 pictures Uses “I”, “me”, and “mine”

Language

3 years Points to parts of pictures, names body parts with function Knows meaning of simple adjectives (eg. tired, hungry, thirsty) 200+ words, 5-8 word sentences 75% intelligible (3/4), uses pronouns correctly

4 years Follows 3 step commands 300-1000 words, speech fully intelligible (4/4) Asks “when, why, how?”, tells stories

5 years 2,000 words Defines simple words or asks questions about meaning of words Responds to “why” questions

6 years 10,000 words, 8-10 word sentences Describes events in order

Language

PROBLEM SOLVING

Question #12I can count to 10, draw a person with 8-10

body parts, know 4-10 of my colors, and recognize my numbers and letters (even if they are out of order). How old am I???

A. 2 yearsB. 3 yearsC. 4 yearsD. 5 yearsE. 6 years

2 months Recognizes mother Follows large, highly contrasting objects *tracks objects in circle at 3 months*

4 months Stares longer at unfamiliar faces Mouths objects Reaches for ring/rattle, shakes rattle

6 months Touches reflection in mirror and vocalizes Bangs and shakes toys

9 months Inspects and rings a bell Pulls a string to obtain toy at the end

Problem Solving

1 year Understands object permanence Rattles spoon in a cup Lifts box lid to find a toy

15 months Turns pages in a book Places circle in a single-shape puzzle

18 months Matches pairs of objects Imitates household tasks (cleaning, cooking, etc.)

2 years Sorts objects and matches objects to pictures Shows how to use a familiar object

Problem Solving

3 years Draws a 2-3 part person Knows age and gender

4 years Draws a 4-6 part person Counts 4 objects Points to 5 or 6 colors and letters/numbers when named

5 years Counts to 10, names 4*-10 colors, 8-10 part person Identifies letters and numbers

6 years (*think of finishing kindergarten!) Draws 12-14 part person Writes name, reads (250 words by end of 1st grade) Simple addition and subtraction Knows left from right across midline

Problem Solving

Question #13You have had multiple well child checks in clinic

today, and all the developmental milestones are getting confusing!! You feel confident that at least you know the red flags to worry about! Which of the following DOES NOT concern you?

A. A 36 month old who can’t say a 4-word sentence

B. A 9 month old with no babblingC. A 4 month old that doesn’t visually trackD. A 24 month old that doesn’t say any wordsE. A 6 month old that doesn’t turn to sound/voice

Red Flags

SOCIAL/EMOTIONAL

Social/Emotional Development

Most children are born with an inherent drive to connect with others and share feelings, thoughts, and actions

The earliest social milestone is bonding of the caregiver with an infant

Emotional development is influenced by a child’s temperament as well as the interactions between the care-giver and the child

Question #14How old are kids when they develop separation

anxiety and stranger anxiety?

A. Stranger anxiety 6 months, separation anxiety 9 months

B. Stranger anxiety 9 months, separation anxiety 12 months

C. Stranger anxiety and separation anxiety at 6 months

D. Stranger anxiety and separation anxiety at 9 months

E. Stranger anxiety 6 months, separation anxiety 12 months

2 months Reciprocal smiling Responds to adult voice and smile

4 months Smiles spontaneously at pleasurable sights/sounds Initiates social interactions Alternating (to and fro) vocalizations

6 months Stranger anxiety

9 months Follows a point,”oh look at…” Recognizes familiar people/objects Separation anxiety

Social/Emotional

1 year Shows object to parent to show interest Points to get desired object (proto-imperative)

15 months Shows empathy (looks sad if someone else cries) Points at object to express interest (proto-declarative)

18 months Engages in pretend play with other people Shows embarrassment or possessiveness

2 years Parallel play

Best with one other kid, side by side but not cooperative!!

Social/Emotional

3 years Starts to share, play become more cooperative Fears imaginary things Imaginative play

4 years Further development of pretend play, GROUP play Deception: tricks others or are scared to be tricked Has a preferred friend

5 years Plays board games or card games Has group of friends Apologizes for mistakes

6 years Has best friend of the same sex Distinguishes fantasy from reality Enjoys school

Social/Emotional

Question #15All of the following are social/emotional red flags

EXCEPT…

A. A 12 month old who doesn’t respond to his name

B. A 15 month old who will not point to what he enjoys or finds interesting (proto-declarative)

C. A 2 year old who pointed for what he wanted 3 months ago but no longer does so

D. A 6 month old who doesn’t smileE. A 15 month old who doesn’t engage in simple

pretend play

Red Flags

Able to separate from parents for several hours at a time

Plays well with other children

Takes turns

Follows directions in group activities

Able to relate personal experiences

Tells stories

Kindergarten Readiness

THANKS

Documents

Growth and development