PAEDIATRICS.

Growth and Development.

ANA POCHKHUA
2024 YEAR
 PAEDIATRICS.

Pediatrics is the branch of medicine dealing with the health and

medical care of infants, children, and adolescents from birth up to
the age of 18. The word “paediatrics” means “healer of children”

Challenges:
• Small size
• Drugs.. Cannot be prescribed adult dosages
• We cant give all drugs… ciprofloxacin(arthropathy) or
tetracycline(can permanently stain teeth, also reduce the growth of
some bones)
• Common complaint is crying
• Genetics (down syndrome)
Objectives

 Learn key aspect of the newborn exam

 Focus on normal versus abnormal physical findings
 Where to start?
 When you enter the room, congratulate the family and introduce
yourself.
 Explain that you want to examen their baby and ask if you have come at
a convenient time
 If family agrees to an exam, carefully place the infant on her back and
unswaddle her from any blankets.
 Make a general observation of your patient. (Asleep or awake? Warm or
cool? Vital signs? Difficulty breathing? )

 If you note any signs of distress or illness end the physical exam here
and notify supervising resident or attending physician.
 If the baby looks well, but crying, console her. Proceed with the
individual aspects(from head to toe) of your exam.
 History and examination in pediatrics

H = History
E = Examination
L = Logical deduction
P = Plan of management
History and examination in pediatrics
Events of pregnancy completely connected with the newborn:

• Did pregnancy went well?

• Folic acids tablets 1st trimester (neural tube defects)
• Drugs – Lithium can cause heart defects
• TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes
simplex)
• Labor… if baby needed special care – f.e. resuscitation
• Birth and Age
• Immunizations, nutrition, allergies
• Development milestones
• Sleep
 Stages of Growth and Development

• Infancy
• Neonate • Middle Childhood
• School age
• Birth to 28 days
• 6 to 12 years
• Infancy
•
• 29 days to 1 year
•
Late Childhood
Early Childhood • Adolescent
• Toddler • 13 years to approximately 18 years
• 1-3 years
• Preschool

• 3-6 years
Physical Assessment/ vital signs

Temperature - 36.5 C - 37.5 C.

Heart Rate - 120 - 160 BPM.

Respirations- 40 - 60 breaths/min.

Blood Pressure - 85-65 / 45-35mmHg.

Posture of newborn
 Vernix Caseosa

Soft yellowish cream layer that

may thickly cover the skin of the
newborn, or it may be found only
in the body creases and between the
labia.
The debate on an issue wash it off
or to keep it.
Lanugo hair:

The more premature baby is, the

heavier the presence of lanugo is.-It
disappears during the first weeksof life
Mongolian spots

 Coloration on the lower back, buttocks, anterior trunk & around the wrist or ankle.
 They usually disappear during preschool yearswithout any treatment.
 Desquamation:
Peeling of the skin over the areas of bony prominence
that occurs within 2-4 weeks of life, because of
pressure and erosion of sheets.
Chapters

Head Groin
Face Extremities
Neck Back
Chest
Neurologic
Abdomen
 Head
Babies are born with five major bones of the skull: two frontal bones, two parietal bones, and one occipital
bone. Where these bones meet are called sutures.
Sutures allow the skull bones to move during birth to allow the head to fit through the birth canal. Also,
sutures allow the skull to grow quickly during the first few years of life in response to the rapidly growing
brain
 Fontanelle
6 fontanel: The sequence of fontanelle closure is a
follows:

 The Anterior fontanel – it is lozenge-shaped and

measures about 2,5-4cm. Generally the last to
close - 18 to 24 moth
 The posterior fontanel – is triangle-shaped,
measures about 0,5—1,0cm . Generally closes 2
to 3 moths after birth.
 The sphenoidal fontanel – is the next to close
around 6 -month after birth.
 The mastoid fontanel – closes next from 6 to 18
months after birth.
 Fontanelle
The posterior fontanelle usually closes first — within 2
months (6-8 weeks) of birth. Size- 0,5-1cm.

The anterior fontanelle will normally stay palpable and

open, sometimes up to 12 to 18 months of age. So the
fontanelle will normally be flat and it can be pulsatile, so
you can actually see some pulsations in the normal
fontanelle.

The average of anterior-posterior diameter (length) and

transverse diameter (width) is considered as the anterior
fontanel size. The anterior fontanel is considered to be
small if it is less than 0.6cm; normal if it is 0.6–3.6cm and
large fontanelle if it is greater than 3.6cm
 Pathological appearance of Fontanelle

A tense or bulging fontanelle occurs due of

increased intracranial pressure. Common Sunken fontanelle due of dehydration.
causes are hydrocephalus, meningitis, Common causes: diarrhea, vomiting, fever.
encephalitis, cancer.

 P.S. Remember, normal

fontanelle also dips in a bit.
It might look sunken but this
doesn't necessarily mean
your baby is dehydrated. If
your baby doesn't have any
symptoms of dehydration, is
nursing and feeding
regularly, and having 6-8 wet
nappies in a day you can be
assured this is normal.
Check the infant’s scull for bruising and swelling

 A bruise that doesn’t cross

the suture lines is called
cephalohematoma

 If the swelling crosses suture

lines – it’s Caput
Succedaneum
Check sutures for normal head structure or
abnormal facies (partial cranial synostosis)

 Coronal suture
 Lambdoid suture
 Anterior fontanelle
 Metopic suture
 Sagittal suture
What is Craniosynostosis?
 Craniosynostosis is an abnormal condition when a cranial suture fuses too early.
 Most babies with craniosynostosis are born with a fused suture, but occasionally, children may
develop craniosynostosis after birth.
 Craniosynostosis leads to two major problems. First, skull growth is limited at the site of a fused
suture. The remaining open sutures will attempt to compensate by growing faster. This can lead
to an abnormal head shape that takes on a specific pattern depending on the suture that is fused.
 Second, because sutures are important sites of skull growth in the first few years of life,
premature fusion of a cranial suture can increase a child’s risk of developing increased pressure
inside the skull (intracranial hypertension). This can lead to headaches, developmental delay, and
even blindness.
Sagittal craniosynostosis
 Metopic craniosynostosis
Most surgeons treat metopic craniosynostosis with an open surgery,
sometimes called a cranial vault raemodeling (CVR) or fronto-
orbital advancement (FOA). These operations are typically done
between 9–18 months of age and involve an ear-to-ear incision and a
multi-hour operation
Coronal craniosynostosis
Coronal craniosynostosis is when the suture on the
side of the head is closed. It runs from the side of
the eye up to the soft spot. The forehead will be flat
on that side and the eye socket may look further
back. The soft spot may be opened or closed.
Eyelid Edema
Eyes

 Usually edematous eyelids,

 Grey color (true color is not
determined until 3-6 month age)
 Pupil: react to light
 Absence of tears
 Blinking reflex is present in
response to touch
 Can not follow the object
(rudimentary fixation on objects)
Check the eyes and red reflex

Asymmetric red reflex

 Congenital cataract
Symmetric red reflex  Retinoblastoma
 Assess patency of nose if respiratory distress

Charge syndrome

 Coloboma of the eye

 Heart abnormalities
 Atresia of the choanae
 Retardation of
growth/development
 Genitourinary abnormalities
 Ear abnormalities
MILIA
 Check ears for pits, tags, malformation

Ear Formation

- Variation can be normal

- Minor variants may be
associated with genetic
conditions, hearing loss or
kidney anomalies
Check mouth for abnormalities
Dislocated Nasal Septum
Ankyloglossia (Lingual Frenulum)
Natal teeth

Natal teeth are teeth that are already present at birth.

Neck
A. Neck webbing (Turner syndrome)
B. Redundant skin (Noonan syndrome)
C. Extra skin around neck and back(Down’s syndrome)
 Palpate the clavicles for fracture

A clavicle fracture is a break in the

collar bone and occurs as a result of a
difficult delivery or trauma at birth.
Chest
 Flat? Cancave? Convex?
 Abdomen

After birth, the cord is clamped and cut.

Eventually between 1 to 3 weeks the cord will
become dry and will naturally fall off.

• Liver can be palpable up to 3 cm below costal margin

• Spleen and kidneys may be palpable
• Check for patent rectum
Normal male genitalia

 Urethral opening is at tip of

glans penis
 Testes are palpable in each
scrotum
 Scrotum is usually pigmented,
pendulous and covered with
rugae
Cryptorchidism
Female newborn genitalia

 Labia and clitoris are usually edematous.

 Urethral meatus is located behind the clitoris
 Vernix caseosa is present between labia
Hip dysplasia

 Congenital deformation or
misalignment
 More common if: family
history is positive.

All neonates with risk factors

should have a hip ultrasound at 4-
6 weeks of life, regardless of a
normal hip exam.
 Extremities
 Acrocyanosis is normal and common
 Look at all fingers and toes (polydactyly,
brachydactyly, arachnodactyly, a single transverse
palmar crease)
Back
Neurologic exam.

 High flexor tone

 Suck, root, grasp, moro reflex (it should be simetrical)
 DTRs(deep tendon reflex)
REFLEXES
REFLEXES
Growth

It is the process of physical maturation resulting an

increase in size of the body and various organs. It
occurs by multiplication of cells and increase in
intracellular substance. It is quantitative changes of
the body. ( physiological hypertrophy and
hyperplasia)
Assessment of growth

Assessment of physical growth can be done by anthropometric

measurement:

- Fontanelles
- Teething
- Osseous growth
- Anthropometrics (Weight, Height, Head circumference)
Types of Growth charts

According to age range (birth to 36 months or 2- 20yrs)

• Length for age

• Weight for length
• Weight for age
• Head Circumference for age
• BMI
Head circumference
Wrap a measuring tape in a circle – above eyebrows to the most prominent aspect of the
occiput and back again.
34-36 cm
Head circumference (HC)

• Average HC at birth - 34-36 cm

• During the first 3 months - it increases about 2 cm /month,

• During the 2nd 9 months of age – 1.5 cm/month.
• At age of 12 yr it is about 52 cm, almost same a adult
 Chest circumference

Measuring tape goes back – on the

inferior angle of scapula, in front –
on the nipple line.
The body of a normal newborn is
essentially cylindrical; head
circumference slightly exceeds
that of the chest.
The average circumference of the
chest is 30–33 cm (12–13 inches).
 Physical growth of normal infant/ weight

Normal Weight range = 2.700 – 4 kg

 Wt loss 5% -10% by 3-4 days after birth

 Wt regain by 10th-14th days of life

- Birth to 4 months → 800g /month

- 5 to 8 months → ½ kg / month
- 9 to 12 months → ¼ kg /month

Average weight: at birth - 3.5 kg

at 1 yr - 10 kg
at 5 yr - 20 kg
at 10 yr - 30 kg
 Physiological weight loss in newborns

They loose 5 % to 10 % of weight by 3-4

days after birth as result of :

• Withdrawal of hormones from

mother.
• Loss of excessive extra cellular fluid.
• Passage of meconium (feces) and
urine.
• Limited food intake.

Should regain by day 10-14

 Rules of Thumb for growth. Weight
Average weight at birth - 3.5 kg

Physiological Weight loss in first few days: 5-10% of birth weight

Return to birth weight(3.5kg): 10-14 days of age

Double birth weight: 4-5 month(7kg)

Triple birth weight: 1yr (10 kg )
Quadruple birth weight: 2 yr (14 kg)
at 5 yr - 20 kg
at 10 yr - 30 kg

Average annual weight gain: between 2 yr and puberty- 5 Lb (2.27kg)

 Calculating infant’s height
Normal range for both (47.5- 54 cm)
Boys average Ht = 50 cm
Girls average Ht = 49 cm

 Length during the first 3 months of age - increases about 3 cm/month,

 At age of 4-6 months - it increases 2 cm/month ,At 7–12 months - it increases 1,5 cm/month
 Rules of Thumb for growth.
Average length at birth 50cm
Average length at 1 yr:, 70 cm
At age 3 yr the average child is 75cm meter tall
At age 4 yr the average child is 100 cm tall (double birth length)
Average annual height increase: approx. 5 cm between age 4 yr and puberty
Body Mass Index- BMI
Weight in kg
BMI = ………………………………………..
(Height in meter) 2

It is an index for classifying adiposity and is recommended as a screening

tool for children and adolescents to determine if an individual is overweight
(BMI above 95th percentile for age) and If more than 30 kg/m2 indicates
obesity if less 15kg/m2 malnutrition
Red flags on Growth Charts

• Drop of two percentiles

• Gradual
• Sharp
• Less than 5 percentile- growth delay
• Failure to thrive -neglect
 Physical growth of toddler’s

Weight:
 The toddler's average weight gain is 1.8 to 2.7
kg/year.

Formula to calculate normal weight of children over 1

year of age is
 Age in years X 2+8 = ….. kg.
 e.g., The weight of a child aging 4 years = 4 X 2 +
8 = 16 kg
 Height of toddlers:

• During 1–2 years, the child's

height increases by 1cm/month.
•
The toddler's height increases
about 10 to 12.5cm/year.
Physical growth/ Pre-School age(3-6 year)

 Weight: The
preschooler gains
approximately
1.8kg/year.

 Height: He doubles
birth length by 4–5
years of age.
 Physical growth/ School–age child(6-12 year)

Weight:
School–age child gains about 3.8kg/year.
Boys tend to gain slightly more weight through 12 years.

Weight Formula for 7 - 12 yrs

= (age in yrs x 7 )– 5
2
Height:
• The child gains about 5cm/year.
 Body proportion during this period: Both boys and girls are long-legged.
Factor influencing growth and
development
• Genetic factors: genetic predisposition, sex, race and nationality
• Prenatal factors: maternal malnutrition, infection, abuse, illness, hormones
 Postnatal factors: growth potential, nutrition, childhood illness, climate and
season, hormonal influence, psychological environment.
Assessment of growth disorders

•History: exclude chronic illness, social pathology, malnutrition, drugs

•Examination: dysmorphic features, disproportion, nutritional status

•Growth velocity: using percentile charts

•Investigations
 Case Example 1: Excess Weight Gain
 Brady is an 18-month-old boy. Brady’s mother, Rae, works outside the home. Brady is cared
for by his grandmother during the day when Rae is working. Brady has been formula-fed since
birth. He was about 5 months old when he began eating solid foods.
 Brady has been seen by his health care provider regularly since birth (date of birth: April 8,
2009). His weight and length have been recorded and plotted on a growth chart at each visit.
 Brady’s measurements are as follows:
Age Weight kg Length cm
1 month 3.6 51
3 month 6 60
6 month 8 66
9 month 10 71
12 month 12 74
18 month 14 81
Normal development
Growth & Development proceed in
regular related directions :

- Cephalo-caudal (head down to toes)

- Proximodistal (center of the body to the peripheral)

- General to specific
Cephalocaudal direction

The process of cephalocaudal

direction from head down to toe.
This means that improvement in
structure and function come first in
the head region, then in the trunk
and last in the leg.
 Proximodistal direction

The process in proximodistal form

center or midline to periphery
direction. Development proceeds
from near to far outward from central
axis of the body toward the
extremities
 GROSS MOTOR SKILLS
The acquisition of gross motor skill precedes the development of fine motor skills. Both
processes occur in a cephalocaudal fashion
 Head control preceding arm and hand control
 Followed by leg and foot control.
21
3 head
Go
support up to
18 stairs

Run 24
6
Sitting G
o
15 Walk d
o
9 12 w
Crawl Stand n
KEY GROSS MOTOR DEVELOPMENT
MILESTONES
Age Milestone
3m Neck holding
5m Rolls over
6m Sits with own support
8m Sitting without support
9m Crawling, Standing holding on (with support)
12 m Crawl well, stand without support
15 m Walks alone, crawl upstairs
18 m Runs
2 yr Walks up and down stairs
3 yr Rides tricycle
4 yr Hops on one foot, alternate feet going downstairs
HEAD CONTROL

Newborn Age 3 months

 SITTING UP

5-6 months
Age 8
8 months
months
AMBULATION

13 month
old
9-12-months
KEY FINE MOTOR DEVELOPMENT
MILESTONE
Age Milestone
4m Reaching out for the objects with both hands
6m Reaching out for the objects with one hand
9m Immature pincer graps
12 m pincer graps mature
15 m Imitates scribbling tower of 2 blocks
18 m Scribbles tower of 3 blocks
2 yr Tower of 6 blocks, vertical and circular stroke
3 yr Tower of 9 blocks, copies circle
4 yr Copies cross, bridge with blocks
5 yr Copies triangles gate with blocks
 FINE MOTOR
DEVELOPMENT

4-month-old

12-month-old

6-month-old
LANGUAGE
DEVELOPMENT
Age Milestone
1m Alerts to sound
3m Coos (musical vowel sounds)
4m Laugh loud
6m Monosyllables ba da pa sound
9m Bisyllables mama baba dada sounds
12 m 1-2 words with meaning
18 m 8-10 words vocabulary
2 yr 2-3 word sentences, uses pronouns “I”, “Me”, You
3 yr Ask question
4 yr Says songs or poems tell stories
5 yr Asks meaning of words
PSYCHOSOCIAL DEVELOPMENT

Social smiling - 40 days

speech - 12 month
Laughing - 2 month

Mother recognition - 4
month

Drawing circle - 3 year

RED FLAGS IN INFANT
DEVELOPMENT
⮚Unable to sit alone by age 9 months
⮚Unable to transfer objects from hand to hand by age
1 year
⮚Abnormal pincer grip or grasp by age 15 months
⮚Unable to walk alone by 18 months
⮚Failure to speak recognizable words by 2 years
⮚ Loss of previously acquired skills (regression) is a red flag
and should prompt rapid referral for detailed assessment and
investigation
 HEARING

BAER(Brainstem Auditory Evoked Responce)

hearing test done at birth - detects electrical
activity in the cochlea and auditory pathways in
brain.
Ability to hear correlates with ability enunciate
words properly
Always ask about history of otitis media – ear
infection, placement of PET – tubes in ear
Early referral to MD to assess for possible fluid in
ears (effusion)
Repeat hearing screening test
Speech therapist as needed
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