NORMAL GROWTH AND DEVELOPMENT

NORMAL GROWTH
The term growth denotes a net increase in the size or mass of tissues. It is largely attributed to multiplication of
cells and increase in the intracellular substance. Hypertrophy or expansion of cell size contributes to a lesser extent
to the process of growth.
Development specifies maturation of functions. It is related to the maturation and myelination of the nervous
system and indicates acquisition of a variety of skills for optimal functioning of the individual.
Growth and development usually proceed concurrently. While they are discussed separately, both growth and
development are closely related; hence, factors affecting one also tend to have an impact on the other.

Fetal Growth Postnatal Period Social Factors

Genetic potential Genetic factors Socioeconomic level

Sex Intrauterine growth Poverty
Fetal hormones restriction (IUGR). Natural resources
Fetal growth factors Hormonal influence Climate
Placental factors Sex Emotional factors
Maternal factors Nutrition Cultural factors
Infections Parental education
Chemical agents
Trauma
Table 1. Factors affecting growth
Laws of Growth
• Growth and development of children is a continuous and orderly process
• Growth pattern of every individual is unique
• Different tissues grow at different rates
Assessment of physical growth
Weight. The weight of the child in the nude or minimal light clothing is recorded accurately on a lever or electronic
type of weighing scale. It is important that child be placed in the middle of weighing pan. The weighing scale
should be corrected for any zero error before measurement. Serial measurement should be done on the same
weighing scale.
Length. Length is recorded for children under 2 yr of age. Hairpins are removed and braids undone. Bulky diapers
should be removed. The child is placed supine on a rigid measuring table or an infantometer. The head is held
firmly in position against a fixed upright head board by one person. Legs are straightened, keeping feet at right
angles to legs, with toes pointing upward.
Standing height. For the standing height, the child stands upright. Heels are slightly separated and the weight is
borne evenly on both feet. Heels, buttocks, shoulder blades and back of head are brought in contact with a vertical
surface such as wall, height measuring rod or a stadiometer.
Head circumference. Hair ornaments are removed and braids undone. Using a nonstretchable tape, the maximum
circumference of the head from the occipital protuberance to the supraorbital ridges on the forehead is recorded.
The
crossed tape method, using firm pressure to compress the hair, is the preferred way to measure head circumference
Chest circumference. The chest circumference is measured at the level of the nipples, midway between inspiration
and expiration. The crossed tape method, as recommended for head circumference measurement, is used for
measuring chest circumference.
Mid upper arm circumference. To measure the mid upper arm circumference, first mark a point midway between
the tip of acromian process of scapula and the olecranon of ulna, while the child holds the left arm by his side.
Thereafter, the crossed tape method is used for measuring the circumference.
Normal Growth
It is difficult to precisely define the normal pattern of growth. Generally, it implies an average of readings obtained
in a group of healthy individuals, along with a permissible range of variation, i.e. between the third and ninety-
seventh percentiles.
Growth Charts
If the growth measurements are recorded in a child over a period of time and are plotted on a graph, the deviation
in the growth profile of the child from the normal pattern of growth for that age can be easily interpreted. This is a
satisfactory tool to diagnose deviation of growth from normal. Allowed normal range of variation in observations
is conventionally taken as values between 3rd and 97th percentile curves. Percentile curves represent frequency
distribution curves. For example, 25th percentile for height in a population would mean that height of 75% of
individuals is above and 24% are below this value. One standard deviation (SD) above the mean coincides with
84th percentile curve. Likewise 16th percentile curve represents one SD below the mean. Values between third and
97th percentile curve correspond to mean± 2 SD.

NORMAL DEVELOPMENT
Development refers to maturation of functions and acquisition of various skills for optimal functioning of an
individual. It is a global process reflected in new motor abilities and language, social and cognitive skills,
intelligence pertains to the part of the development dealing with cognitive or adaptive behavior.
Rules of Development
• Development is a continuous process, starting in utero and progressing in an orderly manner until maturity.
The child has to go through many developmental stages before a milestone is achieved.
• Development depends on the functional maturation of the nervous system. Maturity of the central nervous
system is essential for a child to learn a particular milestone or skill; no amount of practice can make a child
learn new skills in its absence. However, in absence of practice, the child may be unable to learn skills
despite neural maturation, since the capability to perform the skills remains dormant.
• The sequence of attainment of milestones is the same in all children. For example, all infants babble before
they speak in words and sit before they stand. Variations may exist in the time and manner of their
attainment.
• The process of development progresses in a cephalocaudal direction. Hence, head control precedes trunk
control, which precedes ability to use lower limbs. The control of limbs proceeds in a proximal to distal
manner, such that hand use is learnt before control over fingers.
• Certain primitive reflexes have to be lost before relevant milestones are attained. For example, palmar grasp
is lost before voluntary grasp is attained and the asymmetric tonic neck reflex has to disappear to allow the
child to turnover.
 • The initial disorganized mass activity is gradually replaced by specific and wilful actions. Hence, when
shown a bright toy, a 3-4 month old squeals loudly and excitedly moves all limbs, whereas a 3-4 yr old may
just smile and ask for it.

Factors Affecting Development

Development depends on a variety of mutually interactive factors such as hereditary potential, biological integrity,
physical and psychosocial environment and emotional stimulation. The brain matures through a dynamic interplay
of genetic, biological and psychosocial factors. Infancy and early childhood are the most crucial phases during
which development takes place. The factors that influence child development are listed below.

Prenatal Factors Neonatal Postneonatal Factors Psychosocial Factors Protective Factors

Risk Factors
Genetic factors Intrauterine Infant and child nutrition Parenting Breastfeeding
Maternal factors growth Iron deficiency Poverty Maternal
(maternal nutrition, restriction Iodine deficiency Lack of stimulation education
exposure to drugs Prematurity Infectious diseases Violence and abuse
and toxins, maternal Perinatal Environmental toxins Maternal depression
diseases and asphyxia Acquired insults to brain Institutionalization
infections) Associated
impairments
Table 2. Factors affecting development
Domains of Development
Normal development is a complex process and should be assessed under the following domains:
• Gross motor development
• Fine motor skill development
• Personal and social development and general understanding
• Language
• Vision and hearing
Age 1m 2m 3m 4m 5m 6m 7m 8m 9m 10 m 11 12 m 15 m 18 m 2y 3y 4y 5y
m
Gross MS Neck Rolls Sits in tripod Sitting Stands Creeps Walks Runs; Walks up Rides Hops on one
holding over fashion without holding on well; alone; explores and tricycle; foot; alternate
(sitting with support (with walks but creeps drawers downstairs alternate feet going
own support) falls; upstairs (2 feet going downstairs
support) stands feet/step); upstairs
without jumps
support
Fine MS Bidextrous Unidextrous Immature Pincer Imitates Scribbles; Tower of Tower of Copies cross; Copies
reach reach pincer grasp scribbling; tower of 3 6 blocks; 9 blocks; bridge with triangle;
(reaching (reaching out grasp; mature tower of 2 blocks vertical copies blocks gate with
out for for objects probes blocks and circle blocks
objects with one with circular
with both hand); forefinger stroke
hands) transfers
objects
Personal and Social Recognizes Recognizes Waves Comes Jargon. He follows Asks for Shares Plays Hel p s in
social smile mother; strangers, "bye bye" when He points simple food, toys; cooperatively household
development (smile anticipates stranger called; to objects orders and drink, knows in a group; tasks,
and general after feeds anxiety, plays in which indulges in toilet; full name goes to toilet dresses and
understanding being understand simple he domestic pulls and alone. undresses.
talked word "no". ball game. is mimicry people to gender. The left and Children
to) He can interested. (imitates show toys He begins right can
understand mother When to count, discrimination. follow 3
simple sweeping asked he identify Play activities step
questions, or can point 1-2 colors are also very commands,
such as cleaning). to 5-6 and sing imaginative identify
"where is familiar simple four colors
papa", objects, rhymes and repeat
"where is name at four digits
your ball" least 2-3
objects
and point
to 3--4
body parts
Language Alerts to Coos Laugh Monosyllables Bisyllables 1-2 words 8-10 word 2-3 word Asks Says song or Asks
sound (musical loud (ba, da, pa), (mama, with vocabulary sentences, questions; poem; tells meaning of
vowel ah-goo sounds baba, meaning uses knows stories words
sounds) dada) pronouns" full name
I", "me", and
"you" gender
Vision and At birth, a the child fixates intently the child he is By the the child
hearing baby can on an adjusts his able to age of 10 can follow
fixate and object shown to him(' position to localize months rapidly
follow a grasping with the eye') as follow objects sounds the child moving
moving if the child of interest. At made directly objects by
person or wants to reach for the 5 to 6 above looks at 1 yr
dangling object. Binocular vision is months the the the source
ring held well established by 4 child turns the level of of sound
8-10 months. head to one ears. diagonally
inches side and then
a way up downwards if
to a range By 3 to a sound is
of 45°. 4 months, the child turns made below
At around his head towards the the level of
1 month, source of ears.
the baby sound. Hearing, may be
can checked by producing
fixate on sound 11h
his feet away from the ear
mother as (out of field of vision),
she talks and a pattern
to him of evolving maturity of
hearing can be observed.
Newborns
respond
 to sounds
by startle,
blink,
cry,
quieting
or change
in
ongoing
activity

Table 3. Key milestones in developmental domains: average age of achievement

Developmental Assessment
• Developmental delay is estimated to be present in about 10% of children.
• Severe developmental disorders can be detected early in infancy.
• Speech impairment, hyperactivity and emotional disturbances are often not detected until the child is 3-4 yr
old.
• Learning disabilities are not picked up until the child starts schooling.

Prerequisites
• Developmental Assessment should be provided in a place which is free from distractions.
• The child should not be hungry, tired, ill or irritated at time of development assessment.
• Assess him when he is in a playful mood with his mother around.
• Adequate time should be spent in making the child and family comfortable.

Steps
1. History
• identify probable risk factors affecting development
• evaluate the rate of acquisition of skills and distinguish between delay and regression
• form a gross impression about the development age of the child
2. Examination
• assess physical growth and head circumference
• do a physical assessment, particularly for dysmorphism, stigmata of intrauterine infections and signs
of hypothyroidism
 • screen for vision and hearing
• conduct neurological examination
• examine for primitive reflexes (if required)
The annoying maneuvers, including assessment of reflexes, head circumference, ventral suspension and pull to sit
should be done at the end. It is preferable to perform the developmental assessment before the systemic
examination so that the child's cooperation is solicited.
The developmental quotient (DQ) for any developmental sphere is calculated as:
Average age at attainment
_______________________ X100

Observed age at attainment

A DQ below 70% is taken as delay and warrants detailed evaluation

Interpretation
In babies born preterm, corrected age rather than postnatal age is used for determining developmental status till two
years of age. For example, a child born at 32 weeks gestation (gestational age) seen at 12 weeks of age (postnatal
age) should be considered as a 4-week-old (corrected age) child for development assessment.
While drawing any conclusions about development, one should remember the wide variations in normality. For
example, let us consider the milestone of standing alone. The average age for attainment of this milestone in a
WHO survey was 10.8 months. However, the 3rd and 97th centiles for normal children were 7.7 and 15.2 months,
respectively. The same is true for many other milestones. The bars illustrate the age range for normal children to
attain that particular milestone. This range of normalcy should always be kept in mind while assessing
development.
Retardation
• should not be diagnosed or suggested on a single feature, repeat examination is desirable in any child who
does not have a gross delay.
 • recent illness, significant malnutrition, emotional deprivation, slow maturation, sensory deficits and
neuromuscular disorders should always be taken into account
• the opportunities provided to the child to achieve that milestone should be kept in mind. For example, a child
who has not been allowed to move around on the ground sufficiently by the apprehensive parents may have
delay in gross motor skills.
At times, there can be significant variations in attainment of milestones in individual fields, this is called
dissociation. For example, a 1-yr-old child who speaks 2-3 words with meaning and has finger thumb opposition
(10-12 months), may not be able to stand with support (less than 10 months). Such children require evaluation for
physical disorder affecting a particular domain of development. A child having normal development in all domains
except language may have hearing deficit.

Table 4. Upper limit of age for attainment of milestone