Normal growth,assessment ,charts

NORMAL GROWTH AND
FACTORS AFFECTINGGROWTH
1
IAP UG Teaching slides2015‐16

DEFINITIONS
• Growth: Net increase in the size or mass of tissues
which is largely due to multiplication of cells and
increase in the intracellularsubstance.
• Development: Maturation of functions associated
with maturation and myelination of nervous system.
2

GROWTH: SIGNIFICANCE
• Essential feature that distinguishes a child from an
adult.
• Indicates overall well‐being of achild.
• Reflects the nation’s economic status andpublic
health system.
3

FACTORS AFFECTINGGROWTH
• Prenatal period
– Fetal
– Placental
– Maternal
• Postnatal period
– Genetic
– Environmental
4

FACTORS AFFECTING PRENATALGROWTH
A. Genetic Potential
• Parental trait ‐ Tall parents have tallchildren
‐ Head size related toparents
• Sex ‐ Boys larger thangirls
• Race‐ Growth differs in differentraces
5

B. Fetal GrowthFactors
Growth Promotion
• Insulin like growthfactors
(IGF‐I and IGF‐II)(~70%)
• Epidermal growthfactor
• Transforming growth
factor α (TGF‐α)
• Platelet derived growth
factor
• Fibroblast growth factor
• Nerve growth factoretc.
Growth Inhibition
• Transforming growthfactor
β (TGF‐β)
• Mullerian inhibiting
substance (AMH)
• Inhibin /Activin familyof
proteins
6

C.Fetal hormones
•Have predominant role in lategestation
•Insulin and Thyroxine :Important for accretion and
differentiation of tissues
•Glucocorticoids :Required for maturation oforgans
like lungs, liver and GItract
•Note :Influence of Growth hormone on fetal growth is
minimal.
7

D. Placental factors
•Placenta is essential for nutrition of fetus
•Fetal nutrition is enhancedby
– Increased villous surfacearea
– Decreased diffusion distance
– Increased dilatation of fetalcapillaries
– Decreased resistance ofvasculature
8

E.Maternal factors
–Poor nutrition
–Anemia
–Recent pregnancy
–High parity
–Tobacco, drug,
alcohol intake
– Pregnancy Induced
Hypertension
– Multiple pregnancy
– Chronic systemic
diseases
– TORCH infections
9

OVERALL REGULATION OF FETALGROWTH
10

FACTORS AFFECTING POSTNATAL GROWTH
A. Sex
• Boys have greater
growth potentialthan
girls
• Girls have early
pubertal heightspurt
than boys
• Pubertal height gainis
more inboys
11

B. Genetic
• Chromosome defect
– Short stature: Downsyndrome, Turner syndrome
– Tall stature: Klinefelter syndrome
• Gene mutation
– short stature: Prader‐Willi syndrome,Noonan
syndrome
– Tall stature: Marfan syndrome
12

C.Environmental
• Nutrition
– PEM, Micronutrient deficiency (Fe, Io, Ca, Zn, VitA,
VitD)
• Infections
– Diarrhea, recurrent RTI,TB, HIV, Malaria,Kala‐azar
,
Chronic giardiasis
• Toxins
– Food,environment.
13

Factors affecting postnatal growth
D. Hormonal
•Growth hormone deficiency
•Hypothyroidism
•Growth hormone resistance
14

E.Social factors
• Low socio economic status: Poordiet, infections
• Hot and humidclimate
• Poor emotional support: Brokenfamily, orphans
• Cultural factors: Religioustaboos
• Low parental education: Poor healthpromotion,
poor nutrition.
15

16
LATE CONSEQUENCES OF POOR FETALGROWTH
(NUTRITION)
Fetal origin hypothesis (Barker’shypothesis)
•Alterations in fetal nutrition and endocrine status lead
to programming
•Permanent changes in structure, physiologyand
metabolism
•IUGR infants have increased risk of diabetes mellitus,
hypertension, hyperlipidemia and coronary artery
disease

LAWS OF GROWTH(I)
• Growth is acontinuous
and an orderlyprocess.
• The rate of growth is
not uniform – There are
periods of acceleration,
deceleration and
steadiness.
17

PHASES OF GROWTHACCELERATION,
DECELERATION AND STEADINESS
• Accelerationv(fv
ast)‐1st Half of gestation, 1st yearof
life, Puberty
• Deceleration‐ 2nd year
• Steady rate‐ 6‐9 years ofage
Dotted
line:
Weight
Solid
line:
Height
18

ICP MODELFOR POSTNATAL GROWTH (KARLBERG)
HEIGHTATTAINMENT DURING EACH PHASE
• Infancy: Starts before birth
and falls off by age 3 to 4 years.
Average total height gain is
45%.
• Childhood: Begins at theend
of the first year of life and
continues to mature height.
Average total height gain is
47%.
• Puberty: This phase startswith
initiation of puberty.
Average height gain is8%
19

PREDOMINANT CONTROL
INEACH PHASE OF GROWTH
• Infancy: Nutrition,
GH, thyroxine
• Childhood: GHand
thyroxine
• Puberty: Sexsteroid
and GH.
20

LAWS OF GROWTH(II)
Growth pattern of every individual isunique.
• Cephalocaudal
• Distal to proximal
21

LAWS OF GROWTH(III)
•Different tissues of the
body grow at differentrates
•General growth: Rapid
during fetal life, first 1‐2y
and atpuberty
•Brain and head: Rapid
during late fetal andearly
postnatal life
At birth 70%, at 2 y 90% of
adult.
22

LAWS OF GROWTH(II)
• Lymphoid – maximum growth during mid‐
childhood (4‐8y) Large tonsils and lymphnodes
• Gonads – grow at pubescence only
1 0 0 % 1 0 0 %
y e a r s
S o m a n i c G r o w t h
a g e
B r a i n G r o w t h
1 0 0 % 1 0 0 %
y e a r s
G o n a d s G r o w t h
a g e
L y m p h o i d G r o w t h
23

PERIODS OFGROWTH
Prenatal period
• Ovum :0‐1w
• Embryo :2‐8w
• Fetus :9w ‐birth
• Perinatal period :22wk
of gestation to 7days
after birth.
Postnatal period
Newborn: Birth to 28days
Infancy: First year
Toddler: 2‐3y
Preschool: 4‐6y
School age: 7‐12y
Adolescence:10‐18y
24

PRENATAL GROWTH
Embryonic period
• 2wk: Bi‐laminarembryo
• 3wk: Tri‐laminarembryo,
Heart pumpingbegins
• 4wk: 4cms, humanshape,
arm‐leg buds
• 5‐8wk: Major organsystem
development
• 9wk: 9g, 5cm. Fetalperiod
begins.
Fetal period
10wk: Externalgenitalia
distinguishable
20wk: 460gm, 19cms,lower
limit of viability
24w – Primitive alveoli,
surfactant production
25wk: 900gm, 25cm,3rd
trimester begins
38wk: Term, weight triples,
length doubles from thatof
25 w ofgestation
25

PARAMETERS OFGROWTH
• Weight.
• Length <2 y or Height >2 y
.
• Head circumference (HC), Chest circumference(CC).
• Upper segment to lower segment (U:L) ratio.
• Arm span (AS).
26

HOW TO MEASUREWEIGHT?
Weighing scales:
•Lever/Electronic
•Spring balance (lessaccurate)
•Minimum unit100gm
Technique
• In nude or minimalclothing
• Weighing scale checked for zeroerror
• Center the infant on the scale tray
• Weigh infant to the nearest 10 gm and older
child to nearest 100gm.
2
7

MEASUREMENT OFLENGTH
• After2‐3yearsofage,height
should bemeasuredby
stadiometer.
• Childshouldstanderect,with
occiput, shoulders,buttocks,
andheels touching thevertical
bar.
Look straight(Frankfort’splane
parallelto floor)
• Horizontalbarislowered
tothe vertexofthechild
andtakereading
IAP UG Teaching slides2015‐16 2
8

MEASUREMENT OFLENGTH
Length of children < 2‐3yare
measured byinfantometer.
9

MEASUREMENT OF HEAD CIRCUMFERENCE (HC)
• HC should be measured
using non‐stretchabletapes
(e.g..Steel)
• Measure across most
prominent points of
superior orbital ridge
(anterior) and external
occipital protuberance
(posterior)
Should notbe
measured
within 24 hrs.after
birth to avoid spurious
values due tomoulding
3
0

MEASUREMENT OF ARMSPAN
Distance between the tips of middle fingers when the
arms are out stretched parallel to the floor.
3
1

AVERAGE GROWTH PARAMETERSAT BIRTH
• Weight: 3 Kg
• Length: 50 cm
• U/Lratio: 1.7
• HC: 35 cm
• CC: 33 cm
32

POSTNATAL GROWTH :WEIGHT
Age group
0‐3 m
4m‐1 yr.
2yr – Pubertal growth spurt*
2‐3 Kg/y
or
Weight gain
25‐30g/day
400g/month
[Wt. in Kg = (Age in years +4) X 2]
• Weight doubles at 5m, triples at 1 y
,quadruples
at 2y
* Boys 12 y
, girls 10 y
.
33

POSTNATAL GROWTH: LENGTH/HEIGHT
Age group
0‐3 m
4‐6m
7‐9m
10‐12m
13‐24m
3‐10 yr.*
Height velocity
3.5cm/m
2cm/m
1.5cm/m
1.2cm/m
1cm/m
5‐6cm/y
* Weech’s formula: Ht in cms = (Age in
years X6)
+ 77 34

POSTNATAL GROWTH:ADOLESCENCE
PARAMETER EARLY MIDDLE LATE
Age (years) 9-13 14-16 17-20
Weight gain/Year 2Kg 3.5kg 1kg
Height gain/year 6-8cms 8-10 cm 2-3 cm
SMR* stages 1,2 3,4 5
35
* Sex maturity rating
Mean pubertal height gain :Boys‐27 cm, girls‐25 cm
Mean pubertal weight gain :Boys 29kg, girls 24 kg

POSTNATAL GROWTH
UPPER SEGMENT TO LOWER SEGMENT RATIO
Age Ratio
Birth 1.7
6m 1.6
2yr 1.4
3yr 1.3
4yr 1.2
6yr 1.1
10yr 1.0
Adults 0.9
>6m age U/L ratio = 1.6 (Age in years
X0.1)
36

POSTNATAL GROWTH
HEAD CIRCUMFERENCE(HC)
Age
Birth‐3m
4m‐6m
7m‐12m
2nd y
>2y
By 12 y
Rate ofincrement
2cm/m
1cm/m
0.5cm/m
1cm/y
0.5cm/y
52 cm
37

POSTNATAL GROWTH
CHEST CIRCUMFERENCE (CC)
Birth: HC > CC
1 year: HC=CC
> 1 year: HC < CC
38

POSTNATAL GROWTH: ARMSPAN (AS)
Birth to 5y Ht 2cm > armspan
5‐10 y Ht 1cm > armspan
10 y Ht = armspan
Adults Ht 2cm < armspan
39

POSTNATAL GROWTH: SKELETALMATURATION
•Steady in childhood, accelerates atpuberty
•Closely correlates with sexualmaturation
•Maturity indicated by epiphysealclosure
•Complete in boys at 22 y
, girls at 18 y
Preferred areas for bone age estimationby
radiography
Birth‐3m
3‐9 m
1‐13 y
12‐14 y
knee andankle
Shoulder
Hands andwrists
Elbow and hip
40

POSTNATAL GROWTH – DENTITION
Primary teeth(20)
Central incisors
Lateral incisors
Canines
I Molar
II Molar
Age ateruption
5m to 8m
7m to 11m
16m to20m
10m to16m
20m to30m
Approximate assessment
Expected number of teeth = Age in months ‐ 6
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POSTNATAL GROWTH – DENTITION
Permanent teeth(32)
I molars
Incisors
Canines
Premolars
II Molar
III Molar
Age ateruption
6 to 7y
6 to 8y
9 to 12y
9 to 12y
12 y
≥ 18 y
42

GROWTH STANDARDS
• Norms of growth represented as tables or charts
• Derived from large cohort of healthy children by
cross sectional or longitudinalstudies
• Tables are useful as easy ready references
43

GROWTH CHARTS
• Superior to tablesto
diagnose early
deviations ingrowth
• Distance growth charts
reveal the growth
acquired till the dateof
last evaluation
44

HEIGHT VELOCITYCHARTS
• Height velocity: Rate ofheight
increment per unit timeand
• Indicates periods of
acceleration, decelerationand
steadiness
• Most useful for early
identification of growth
faltering
45

DISTANCE GROWTH CHARTS
• Growth parameters
are presented in
graphical manner
• Age along the X axis
and measurementsin
the Yaxis
• Charts have 5 or 7
percentile curves
representing the
distribution of the
growth parameters
46

GROWTH PARAMETERS INGROWTH CHARTS
• Weight forage
• Height/length for age
• Head circumference forage
• Weight forlength/height
• Body mass index
Each parameter separate for boys (Blue) & girls (pink)
47

PLOTTING HEIGHT ONA GROWTH CHART
• 8 years oldboy,
• Height: 120 cm,
• Draw an imaginary line
along the X‐axis till the
age (8y) of thechild.
• Then extend the
imaginary line along
the Y‐axis till theheight
(116 cm) of thechild
• Mark thepoint
48

RECOMMENDED GROWTHCHARTS
Revised IAP Growthcharts,
2015
WHO, derived fromMGRS
study 0‐5 years
Height, weight, HC for 0‐5y
Weight for height for 0‐5 y
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Height, weight, BMIfor 5‐18 y

WHO GROWTH CHARTS ‐2006
• Ideal growth charts that provide data on how
children should grow
• Internationally usable standard growthcharts
• Multi‐center Growth Reference Study (MGRS) from 5
Continents.
• Study sites – US, Brazil, Ghana, Oman, Norway, India.
50

WHO GROWTH CHARTS‐ 2006
• Derived from children raised underoptimal
conditions for growth suchas:
– Exclusive breast feeding
– Healthy environment
– Minimal infection
– Nonsmoking mothers
51

STATISTICS USED IN DESCRIBINGGROWTH
• Normal: Healthy.
• Median: Value above and below which 50% of
observations lie.
• Mode: Value having highest number of observations
• Mean:The average value of observations.
• Standard deviation or Zscore: The extent to which
observed values cluster near themean.
52

NORMAL DISTRIBUTION (GAUSSIAN)CURVE
• Symmetrical bell shaped curve in which 50% of the
observations lie above & 50% below a central line
which is the 50th percentile ormedian
• Values below 3rd (‐2SD) and above97th (+2SD)
percentile are abnormal.
53

THANK YOU
54

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