Pediatric

Growth and Development

Objectives

Growth vs Development
Growth: Weight, Height, Head Circumference
Discrepancies in Measurement
Normal Development & Psychosocial Assessment
Developmental Screening
Milestones
Language Screening and Speech Delays
Adolescence

Growth vs Development
Growth:
in size of the body
Normal growth pattern:
between 3rd and 97th percentiles
Body Mass Index (ages 2y-20y)
Wt(kg)/ht(cm)2 x 10,000
Overweight is >95th percentiles
Risk of being overweight is in 85-95 percentiles

Development: in function of
processes related to body and
mind

Rule of Thumb :Weight

Wt loss in 1st few days of life:
5-10% of BW
Return to BW at 7-10 days of
age

Daily wt gain
20-30g/day for 3-4mo
15-20g/day for rest of 1st yr
Avg Annual Wt gain
5 lbs between 2yr-puberty

Double BW at 4-5mo
Triple BW at 1 yr
Quadruple BW at 2 yr

Average Wts
Birth: 3.5 Kg
1 yr: 10 Kg
5 yr: 20 Kg
10 yr: 30 Kg

Rule of Thumb : Height

Birth length increases by 50% by age 1y
Birth length doubles by age 4y
Birth length triples by age 13y
Avg lengths

Birth: 20 in
1 yr: 30 in
3yrs: 3ft
4 yrs: 40 in (double birth length)

Avg annual ht increase: 2-3 in between 4yrs and

puberty

Rule of Thumb : Head Circumference

Avg HC at birth: 35 cm (13.5in)
HC increases:
- 1cm/month for 1st 6months
(fastest in 1st 3 months)
- 0.5 cm/month for 6-12months
Plot HC until 3 years of age
Re-Check HC

 Large shifts in percentiles warrant attention,

as do large discrepancies among height,
weight, and head circumference percentiles.
Children growing <5cm/yr should be
evaluated for GH deficiency or
hypothyroidism
Inadequate caloric intake
Weight Height Head Circumference

Discrepancies

Normal Development
Newborn Period
Primitive neonatal reflexes are consequence of
continued development of the CNS
Growth of the nervous system is the most rapid
in the first 2 years
Normal reflexes:
Moro
Rooting
Sucking
Grasp
Tonic neck

Reflexes in the Newborn Period

Moro: Allowing head to gently
move back suddenly results in
abduction and upward
movement of the arms
followed by adduction and
flexion

- Disappears at 4-6 mo

Rooting: Touching the corner

of the mouth results in
lowering of the lip and
tongue movement towards
the stimulus.
Disappears at 4-6 mo

Reflexes in the Newborn Period

Sucking: Put an object in the
mouth and the baby responds
with vigorous sucking.
Replaced by voluntary sucking

Grasp: Palmar disappears at 3-4 mo

Plantar disappears at 6-8 mo

Asymmetric tonic neck

reflex: In supine position,
baby, turns head to the
side ipsilateral extension
of the arm and leg with
contralateral flexion
Diappears at 2-3 mo

Later in Infancy
Control of posture
Proximal (1st) and then distal musculature

Check for ortho deformities

Fixed deformities warrant a consult

Evaluation of vision and ocular

movements to prevent outcomes
of strabismus
Check cover test and light reflex

Late School Age - Early Adolescent Child

Comprehensive sports physical exam and evaluation
of the Cardiovascular system
Worrisome signs/ symptoms/ history:
Hx of heart disease or murmur
Dyspnea, CP on exertion, Irregular HR, Syncope, Seizure
Fam Hx of atherosclerosis < 50 yrs or sudden death

Contact sports: assess for vulnerabilities (ex. WPW,

kidney disease/damage)
Assess vision

Adolescence

Show sensitivity
Scoliosis
Obesity
Trauma Ortho probs
Sexual Maturity Rating
Menstrual cycles, Dysmenorrhea
Gynecomastia

Psychosocial Assessment
Bonding - occurs shortly after birth and reflects the
feelings of the parent toward the newborn
(unidirectional)
Attachment - involves reciprocal feelings
(bidirectional) between parent and infant and
develops gradually over the first year (*postpartum)
Stranger Anxiety- between 9 and 18 mo
Autonomy ages 2-3 yrs
School Readiness depends on autonomy and the
ability of the parent and child to separate for hours at
a time.

Psychosocial Assessment
Preacademic Skills: colors, counts to 10, knows age,
names, address, phone number, copies shapes, stands on
1 foot, skips, bounces a ball and can dress him or herself.
At 3-4 years, Preschool helps develops socialization,,
improve language, increase skill buidling and problem
solving.
Kindergarten helps develop emotional maturity, social
skills, cognitive abilities, and fine and gross motor skills.
Children do better in kindergarten if their 5th b-day is at
least 4-6 months before starting school. Girls are usually
ready earlier than boys.

Development
18% of children in the US have
Developmental and Behavior disabilities
25% have Psychosocial Problems

Developmental Screening
Compares the developmental skills of a child
with the skills of a population of children to
identify delays and who will need further
testing.
<= 6y : Assess achievement of milestones
> 6y : Ask about academic achievement and
behavior

Denver Developmental
Screening Test II
Age birth to 6 years
Testing Four Domains:

1.
2.
3.
4.

Gross motor
Fine motor-adaptive
Personal-social
Language

Other Screening Tests

Ages and Stages Questionnaires
Child Development Inventories
Parents Evaluations of Developmental Status
Parent reported screenings have good validity
compared with office based screenings

Age
Newborn
- 2w
1m
2m
4m
6m
9m
12m
1y
15m
18m

Age

Motor

Full Term (+)Moro

Infant Reflex

Cognitive
Behavioral

Language

Alert to sound
of Voice

Social
Fixates on face
and briefly
follows

2m

-Follows objects past

midline
-Lifts head and
shoulders off bed
when placed in prone
position

Coos

4m

*Head lag and Moro

disappear*
-Bears weight on
forearms when
prone
-Rolls back to front
-Bears weight while
held standing
-Holds hands open
predominantly

Laughs
outloud
Squeals!

Imitates
social
interaction

Age

Motor

Cognitive
Behavioral

Language

Social

6m

-Transfers objects from hand to hand

-Reaches/rakes for objects
-Sits with support
-Rolls over both ways
-Bangs/shakes toys

Turns directly to
sound/voice

- Babbles
consonant sounds
- Imitates speech

9m

-Bangs two blocks together

-Sits without
support!
-Inferior pincer grasp

-Turns when
name is called
-Plays peekaboo
-Plays pattycake

Mama-Dada
(nonspecific)

-Stranger anxiety
-Recognizes
common objects
and people

12m

-Pulls to stand/cruises
-Takes a few steps
-Walks with one hand held
-Waves bye-bye
-Fine pincer grasp
-Drinks from cup held by
another person

Assists with
dressing

-Mama- Dada
(specific)
-One additional
word

Follows a single
step command
with a gesture

Age

Motor

15m

-Gives and takes ball

-Drinks from a cup
-Puts cube into a cup
-Walks independently
-Stoops to floor and recovers to standing

18m

-Self feeding with a spoon

-Stacks 2-3 cube tower
-Throws a ball
-Walks upstairs while holding hand
-Climbs into and sits on chair
-Spontaneous scribbling

24m

-Builds a 6 cube tower

-Washes and dries hands
-Throws a ball overhand
-Removes clothing
-Kicks a ball
-Jumps with 2ft

Cognitive
Behavioral

Language

-3-6 additional words

- Points to one body
part

Imitates
household chores

Social

Follows a single step

command without
gesture

10-20 words

>50words
-Pronouns
-Speech 50%
intelligible to stranger

Follows 2step
commands

Age

Motor

Cognitive
Behavioral

Language

3y

- Copies a circle
-Puts on shirt/shorts
-Builds a 8 cube tower
-Balances on 1ft for 1-2s
-Pedals tricycle
-Goes up stairs with
alternating feet
-Hops once

- Knows the name

of a friend
- Understands
basic adjectives

-5-8word sentences
-Uses pronouns
correctly
-Speech
75%intelligible to
strangers
-Starts using what
and who

4y

- Hops on one foot several

times
-Walks up and down stair
-Balances on 1ft or 4s
-Draws a person with 4
body parts

-Dresses and
brushes teeth
without help
-Names 4 colors
-Can identify
opposites
-Counts to 4

-Asks questions
- Speech 100%
intelligible to
stranger

Social

Pretend
plays

Age

Motor

Cognitive
Behavioral

Language

5y

- Draws a person with 6 body

parts
-Skips
-Walks backwards
-Prepares a bowl for food
-Holds pencil correct way
-Ties a knot
-Prints letters

-Plays board games -Defines words

-Counts to 5
-Names all primary
colors

6y

-Ties Shoelaces
-Rides bike

-Writes name
-Knows left from
right
-Counts to 10

Social

Milestones

Language Screening
Age (y)

1y

2y

3y

4y

Divide by
4

1/4

2/4

3/ 4

4/4

25%

50%

75%

100%

Language Delay
Consider hearing deficit

S ensorineural
P sychomotor
E nvironment
A utism
K inetics

High Risk Conditions:

Hyperbilirubinemia (Bili > 19; exchange transfusion)
Infection (congenital rubella, meningitis)
Structural anomalies
Hypoxemia (apnea, persistent fetal circulation)
Ototoxic drug exposure (aminoglycosides, loop diuretics)

Dysfluency (aka stuttering) is common is 3-4 yr olds, transient

Physical Growth and Development

of Adolescents
Sexual Maturity Rating (SMR) aka Tanner Stages
Stages I-V
Biological maturation can be related to specific lab
values and physical conditions
Higher hematocrit values in adolescent boys are the result
of greater androgenic stimulation of the BM
Alkaline phosphatase levels increase during puberty
because of rapid bone turnover, especially during a
growth spurt

Girls
Average age for puberty: 11 yrs (range: 8-13 yrs)
SMR Stage II
Thelarche: Breast budding under the areola. Mean age 9y
Adrenarche/Pubarche:
Mean age of adrenarche 10y.
Mean age of menarche 12y
Peak growth spurt occurs 1 yr after thelarche
Interval from thelarche to onset of menarche: 2 yrs
Precocious puberty = pubertal changes before 6 -7 yo

Tanner Stages for Girls

Stage I: Breasts are
preadolescent. Elevation of the
papilla only
Stage II: Breast bud stage.
Areolar diameter increases
Stage III: further enlargement of
breast and areola
Stage IV: Projection of the areola
and papilla to form a secondary
mound
Stage V: Mature female, areola
has recessed to the general
contour of the breast

Tanner Stages for Girls

Boys
Adrenarche: Followed by pubic hair
development at the base of the penis
Growth spurt occurs 10-16 yrs (late event)
Deepening of the voice, facial hair, acne
indicate early stages of puberty

Tanner Stages for Boys

Stage I: penis, testes, and

scrotum are of childhood size
Stage II: enlargement of the
scrotum and testes only,
scrotal skin reddens
Stage III: further growth of
testes and scrotum,
enlargement of the penis in
length
Stage IV: Increased size of
the penis in breadth
Stage V: Adult in size and

Objectives

Growth vs Development
Growth: Weight, Height, Head Circumference
Discrepancies in Measurement
Normal Development & Psychosocial Assessment
Developmental Screening
Milestones
Language Screening and Speech Delays
Adolescence

I am a child, I last a while . . .

You cant conceive of
the pleasure in my smile.
-Neil Young

References
Frankenburg, W.K., et al. (1992). The Denver II: A Major
Revision and Restandardization of the Denver Developmental
Screening Test. Pediatrics, 89 (1), 91-97.
Kliegman, R.M., Marcdante, K.J., Jenson, H.B., Behrman, R.E.
(2006). Nelson essentials of pediatrics (5th ed.).
Pennsylvania: Elsevier Saunders.
LaRosa, A., Glascoe, F.P. Developmental Surveillance and
Screening in Primary Care. Up to Date (1997). Online.
Internet. Available: www.uptodate.com
Robertson, J., & Shilkofski, N. (Eds). (2005). The Harriet Lane
Handbook (17th ed.). Pennsylvania: Elsevier Saunders.