Growth and Development Self-Study

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1 Growth and Development Self-Study Attached is a self-directed learning module for the FIM-2 Growth and Development section. The content here will be included in the Human Behavior block. You will be responsible for this material on the corresponding exam. Section 1 - Growth Refer to module pages Educational objectives: 1. Be able to discuss the normal growth patterns of the neonate & infant, child, and adolescent 2. List the correct order of tooth eruption for the human child 3. Be able to use the bone age assessment 4. Know the sexual maturity rating scales for both genders and the sequence of pubertal events in both genders Section 2 - Development Refer to module pages See also: Milestones handout (module pages 18-20) Learning objectives: 1. List the 5 domains of development 2. Discuss the 4 principles of development 3. Discuss characteristics of primitive reflexes 4. Be able to state the age of a child when given a list of descriptive developmental milestones the child demonstrates Section 3 - Case Studies Case study 1: Developmental Delay (module page 2) Case study 2: Delayed Puberty (module page 3) Case study 3: Failure to thrive (module page 4) 1

2 Case study 1: Developmental Delay The case can be accessed at the following website: Educational objectives: 1. To be able to outline the importance of developmental surveillance and assessment. 2. To be able to review an approach to assessing child development for medical students. 3. To be able to describe, define and provide examples of milestones in the 5 major sectors of development. 4. To be able to review the use of naturalistic clinical observation. 5. To be able to review important questions to ask about babies, toddlers and older children. 6. To be able to discuss the importance of regression. 2

3 Case study 2: Delayed Puberty The case can be accessed at the following website: Educational objectives: 1. To be able to define delayed puberty in a boy. 2. To be able to develop an approach to the history and physical exam in delayed puberty. 3. To be able to know the most common cause of delayed puberty in boys and list other causes of delayed puberty. 4. To be able to list baseline investigations in delayed puberty. 5. To be able to list further investigations that may be appropriate based on the clinical presentation. 6. To be able to gain learning objectives from podcast 7. To be able to define short stature. 8. To be able to define a normal childhood growth pattern. 9. To be able to develop an approach to the history and physical examination of a child with short stature. 10.To be able to list common investigations, with a basic understanding of their usefulness. 11.To be able to briefly describe some specific causes of short stature including constitutional delay of growth and puberty, familial short stature, endocrine diseases, chromosomal abnormalities or syndromes, skeletal dysplasias and chronic diseases or malnutrition. 3

4 Case study 3: Failure to thrive The case can be accessed at the following website: Educational objectives: 1. To be able to define failure to thrive. 2. To be able to understand the three basic problems that can cause failure to thrive. 3. To be able to develop an approach to history-taking for failure to thrive 4. To be able to develop an approach to physical examination of a child with failure to thrive. 5. To be able to know the investigations required for a child with failure to thrive. 4

5 Growth: Overview Infant Childhood Teen Sexual maturity Growth: Objec0ves Objective 1: be able to discuss the normal growth patterns of the neonate & infant, child, and adolescent Objective 2: List the correct order of tooth eruption for the human child Objective 3: be able to use the bone age assessment Objective 4: know the sexual maturity rating scales for both genders and the sequence of pubertal events in both genders 5

6 Growth: Newborn At birth: average weight: 3.4 kg or 7 ½ pounds 95% of newborns weigh between kg (5 ½- 10 pounds) Length average 50 cm (20 inches) 95% are between cm (18-22 inches) Head circumference: 35 cm (13.8 inches) range: cm ( inches) Growth: Infancy Proportions: head relatively larger, chest rounded, abdomen prominent & extremities relatively short 6

Cruising Growth requirements 1 st 6 mo 110 cal/kg/day Breastmilk 20-22 cal/30 ml (1 ounce) About 1

7 Cruising Growth requirements 1 st 6 mo 110 cal/kg/day Breastmilk cal/30 ml (1 ounce) About 1 liter/day: 630 cal E.g. 3.5 kg baby would get 180 cal/day! Usually gain about 1 ounce/day in first 6 months of life 7

8 Growth Aphorisms Babies regain their birth weight by 10 days old Full term infants double their birth weight by 5 months old and triple it by 12 months old A baby will grow 10 inches the first year (25 cm) Head circumference will grow 3 cm the first month, about 1 cm per month until 6 months old, & ½ cm per month until 12 months old. Humans achieve 90% of their ultimate head size by 3 years of age. 2 nd year of life Deceleration of growth is normal Average child gains 4-6 pounds over this year and grows 5 inches Often parents note a big decrease in appetite around months old, which can last well into the 2 nd year of life Body habitus changes 8

9 Body habitus changes: Lordosis & protuberant abdomen Physiologic bowing of the legs 9

Growth Charts Ubiquitous in pediatric practice Very useful for both snapshot and long term assessment of growth At 2 groupings of age: 0-36 months old &

10 Growth Charts Ubiquitous in pediatric practice Very useful for both snapshot and long term assessment of growth At 2 groupings of age: 0-36 months old & 2-20 years old (recumbent vs. standing) One for each gender as well Link to CDC.gov blackboard under the growth & development tab Growth Chart Example 10

11 Preschool years (3,4, & 5 years) Grow about 2-3 inches per year and gain 4 pounds per year Lose the belly and the fat pads that hide the arches of the feet Physiologic bowing has resolved Early School Years Relatively steady growth ending with the preadolescent growth spurt 7 pounds/yr, 2.5 inches per yr Head circumference grows about 1 inch from 5-12 years Bodies are very supple, children are able to achieve postures that are quite flexible Knock- knee and flat foot self correct Abundance of lymphoid tissue persists 11

12 Flat feet progression over 0me Adolescence Early, middle & late Early adolescence: gains in wt & ht are similar to early school (elementary) In females, increased body fat deposition Males, more musculature Sexual Maturity Rating (SMR) 1 & 2 12

13 Middle Adolescence Corresponds to SMR 3 & 4 Most dramatic growth & changes; peak of height velocity and weight velocity curves Growth spurt in females on average is 8 cm/yr, in males, 10 cm/yr Orderly progression of skeletal growth from distal to proximal, starting with the feet and hands, hence the clumsiness of adolescence Late Adolescence Body approximates proportions of young adults Little additional linear growth occurs Remaining epiphyses close (femur, humerus, sternoclavicular junction) but some as late as the early 20 s SMR 5 is achieved 13

Sexual Maturity Ra0ng Girls (old term = Tanner stage 1. Prepubertal 2. Breast buds appear 3. Enlargement of entire breast; no protrusion of papilla of nipple 4.

14 Sexual Maturity Ra0ng Girls (old term = Tanner stage 1. Prepubertal 2. Breast buds appear 3. Enlargement of entire breast; no protrusion of papilla of nipple 4. Enlargement of breast and projection of areola and papilla as a secondary mound 5. Adult configuration with recession of the areola back into the contour of the breast Sexual Maturity Ra0ng (SMR): Girls 1. No pubic hair 2. Straight hair extending along labia majora, none on pubis 3. Pubic hair increased in quantity, darker, curled, typical triangle 4. Pubic hair more dense, curled, adult in distribution 5. Abundant adult type pattern, may extend onto medial thighs 14

Sexual Maturity Ra0ng (SMR): Boys 1. No pubic hair; testes less than 4 ml volume 2. Light down hair laterally, later darker. Penis & testes slightly larger; scrotum more textured. 3.

15 Sexual Maturity Ra0ng (SMR): Boys 1. No pubic hair; testes less than 4 ml volume 2. Light down hair laterally, later darker. Penis & testes slightly larger; scrotum more textured. 3. Pubic hair extends across pubis, testes & scrotum further enlarged, penis longer 4. More abundant p.h., curling, glans larger and broader, scrotum darker 5. Adult. Pubic hair spreads to thighs Sequence of Pubertal Events: Average male At about 11 years, the testicles begin enlarging and producing more testosterone; this is the first sign of puberty Maximal height spurt peaks between SMR 4-5 Maximal testicular enlargement at about the end of the height spurt, 15 ½ years old 15

Gynecomas0a Occurs in 30-50% boys Peaks in mid- puberty SMR 3-5 Does not last more than 2 years Can be tender reassurance Other male matura0onal events By SMR 3: Spermarche, acne, axillary

16 Gynecomas0a Occurs in 30-50% boys Peaks in mid- puberty SMR 3-5 Does not last more than 2 years Can be tender reassurance Other male matura0onal events By SMR 3: Spermarche, acne, axillary perspiration 13.9 years old (+/- 1 year) Axillary hair 14.3 years old (+/- 1 year) Facial hair 14.5 years old (+/- 1 year) Voice change complete 15.1 years old (range 14.3 to 15.1 plus years) 16

17 Sequence of Pubertal Events: Average Female The height spurt may begin before or just at the breast bud development, but peaks at SMR 3 Breast buds considered to be first sign of puberty (FSH stimulates ovarian growth which produces estrogen, which stimulates breast growth) Peak height spurt ends just about SMR 4 Menarche occurs between SMR 4-5 of breast and pubic hair stage (90% of girls have menarche at SMR 4) Other female matura0onal events Acne 12.4 years old (+/- 1.1 years) Axillary perspiration years old (+/- 1.1 years) Axillary hair 12.9 years old (+/- 1.1 years) 17

18 Growth and Development Milestones (90% of children passing) Personal-Social: Smile Clap hands (pat a cake) Wave bye-bye Put on clothes 2 months 12 months 14 months 2.5 years Fine Motor-Adaptive Follow past midline Hands together Reaches for objects Thumb-finger grasp (pincher) Copy a circle 3 months 4 months 5 months 10 months 4 years Language Laughs Squeals Dada/Mama (nonspecific) One word Speech (! understandable) Names one color Speech all understandable 3 month 4 months 9 months 15 months 2.75 years 3.75 years 4 years Gross Motor Head up 45 degrees when prone 3 months 18

19 Roll over 5! months Sit-no support Stand alone 14 months Walks well Runs 19 months Jump in place Hops 4 years Heel to toe walk 5! years 5.5 months 7 months 14 months 15 months (median 11.5 months) 19 months 28 months 4 years 5.5 years 19

20 20

21 Development Objec/ves List the 5 domains of development Discuss the 4 principles of development Discuss characteristics of primitive reflexes Be able to state the age of a child when given a list of descriptive developmental milestones the child demonstrates Discuss the effects on healthcare issues at different stages of adolescent development Development The acquisition of motor and cognitive skills during childhood. 5 domains: gross motor, fine motor/adaptive (self- help), personal/social (emotional), language, and cognitive (problem- solving) 4 principles 21

22 Development Principle #1 It is a continuous process that proceeds in a cephalocaudal direction, and parallels neuronal myelination Therefore, developmental milestones reflect maturation of the nervous system Development Principle #2 The sequence of development is the same in all children. The rate of development varies from child to child. For example, all children walk before they run, but they may start walking at different ages. 22

23 Development Principle #3 The rate of attainment of milestones in one area may not parallel another. A child may be walking well by 9 months, but not say a word until 15 months. Development Principle #4 Certain primitive reflexes must be lost before corresponding voluntary movements can be attained. The asymmetric tonic neck reflex (fencer s pose) must be lost before rolling from stomach to back is attained. 23

24 Influences on Development Biological prematurity Exposure to drugs in utero Chronic disease in mother in utero Physical characteristics temperament Environmental Parental attitudes Parental actions Sociodemographic factors Cultural influences Societal influences Quality of parental stimulation siblings poverty Primi/ve Reflexes Mediated by brainstem Involuntary motor responses elicited by appropriate peripheral stimuli Present at birth & disappear by 6 months old Persistence or reappearance may indicate brain damage 24

25 Some primi/ve reflexes Moro Rooting Sucking Grasp Placing Stepping Asymmetrical tonic neck reflex Primi/ve Reflexes 25

26 Postural reac/ons Appear between 2 & 9 months of age Help maintain orientation of body in space righting reactions parachute reactions parachute 26

27 Developmental Assessment Includes evaluation of milestones in each of the 5 categories The Denver II is a commonly used tool Gross Motor Overall movements of large muscles (sitting, walking, running) Primary goal: walking, independent & volitional movement 1 st step: head control, initial 1 mo; by 4 months no head lag when pulled to sitting from supine By 6 mo sit for a few seconds, no support 9-10 months pull to stand months walking (range 8 mo- 16 mo) Then run, climbing stairs, jump, hop, skip in that order 27

28 Gross Motor Tasks over the subsequent years consists of refinements in balance, coordination, speed and strength Gait reaches the adult pattern by 3 years old 3years: pedal a tricycle; by 5 years, a bicycle 28

29 Fine Motor/Adap/ve Skills Small muscles of the hands, manipulating small objects, problem solving skills, eye- hand coordination 1 st year major goal: pincer grasp: 9 months old Unfisted > 50% of time Hands to mouth, rakes objects, transfers (by 6 mo) 14 mo: scribbles (also indicates object use) Copy shapes by 3-5 years (2 y vertical line, 3 y circle, 3.5 year +, 5 y square, 6 y triangle) Handedness appearing at age 3, established by 4-5 y Fine Motor/Adap/ve Skills Upper extremities Self- help tasks, play, accomplish work At first, to support the upper body Then, exploration Sequence: 4 mo reach & attain clutch, palmar grasp. 5 mo transfer hand- mouth- hand. 6 mo hand to hand transfer. 7 mo radial palmar grasp. 9 mo radial digital grasp. 10 mo inferior pincer. 12 mo fine pincer. 29

30 Fine motor Mature pincer grasp 30

31 Fine Motor: 2 nd year of life Using objects as tools The infant knows what s/he wants to do and how to accomplish it Voluntary release improves Fine Motor: subsequent years Draw, explore, problem- solve, create, self- help tasks 3 years Copies circle, cuts w/scissors, strings small beads 4 years Copies square, ties single knot, writes first name 5 years Copies triangle, cuts w scissors, spreads w/ knife, independent dressing, bathes independently 31

32 Developmental Red Flags Absence of certain milestones should raise concern These are specific to the gross motor domain By 4 months, lack of steady head control while sitting By 9 months, inability to sit By 18 months, inability to walk independently Personal/Social Skills 1 mo: sucks well 2 mo: opens mouth at sight of breast 3 mo: brings hands to mouth 4 mo: briefly holds onto breast 5 mo: gums/mouths pureed food 6 mo: feeds self crackers 7 mo: refuses excess food 8 mo: finger feeds oat ring shaped cereal 32

33 Personal/Social Skills 11 mo: cooperates with dressing 12 mo: finger feeds part of meal; takes off hat 14 mo: removes socks/shoes 15 mo: uses spoon; tries to brush own hair 16 mo: fetches and carries objects (same room) 18 mo: gets onto adult chair unaided 22 mo: uses spoon well; unzips 24 mo: opens door using knob 33 mo: toilet trained (highly variable) Personal/Social Skills 3 years independent eating, puts on shoes w/o laces, unbuttons 4 years toilets alone, wipes after b.m. (but not well), washes face/hands, brushes teeth, buttons, uses fork well 5 years spreads w/ knife, independent dressing, bathes independently 6 years Ties shoes, combs hair, looks both ways crossing street, remembers to bring belongings 33

34 Language Speech is the production of sounds Language is both comprehension & expression Normal hearing is essential for the development of speech & language Recep/ve Language Milestones Newborn: alerts to sound by startling, widening eyes, crying 4 mo: orients to sound, responds to own name 6 mo: gestures for up 9 mo: understands no 12 mo: understands 1- step commands accompanied by gesture 34

35 Recep/ve Language Milestones 14 mo: follows 1- step commands w/o gesture 17 mo: can point to several body parts 24 mo: can follow 2- step commands 36 mo: listens to stories Expressive Language Milestones 2 mo: cooing (vowel sounds) 4 mo: laughs, ah- goo 6 mo: babbling (consonants added to vowel sounds) 8 mo: indiscriminate use of mama & dada 12 mo: discriminate use of mama & dada ; 3-5 word vocabulary; one word utterances; immature jargoning (nonsense sounds with rhythm & cadence of speech) 35

36 Expressive Language Milestones 16 mo: mature jargoning: nonsense sounds w/ occasional intelligible words 24 mo: 50 word vocabulary; 2 word sentences; indiscriminate pronouns; 50% of speech intelligible to strangers 36 mo: 250 word vocabulary; 3 word sentences; discriminate use of pronouns; 75% of speech intelligible to strangers Danger Signals in Language Development Inconsistent or lack of response to auditory stimuli at any age No babbling by 9 mo old No intelligible speech by 18 mo old Inability to respond to simple commands by 24 mo old Speech predominantly unintelligible at 36 mo old Dysfluency (stuttering) of speech noticeable after 5 years old Hypernasality, inappropriate vocal quality, pitch or intensity at any age 36

37 Causes of delayed language development Hearing impairment Mental retardation Autism Disorders of articulation Presence of anatomic abnormalities Environmental deprivation Cogni/on Assessment depends on progression through 2 developmental domains: Problem solving Language 37

38 Cogni/on Advancement is through learning Infants are not passive learners Fundamental concepts in the current understanding of cognitive development include: Object permanence Causality Symbolic thinking Cogni/on Problem solving: the manipulation of objects to achieve a goal. Sequence: Visual tracking, leading to: Reaction to a visual threat Batting at objects & reaching Inspection of objects held in hands, visually and orally Holding objects in one hand & manipulating it with the other Attempts to pick up develop the pincer grasp The index finger is used to explore objects 38

39 Problem- Solving 12 mo: lifts a box lid to find a toy 18 mo: recognizes self in mirror 24 mo: sorts objects 3 years: knows some comparisons: long/short, big/ small; knows own gender, knows own age 4 years: simple analogies; points to 5 or 6 colors; points to letters 5 years: identifies coins; rote counts to 10 or 20; names 10 colors; reads 25 words Cogni/ve Red Flags 2 mo: lack of fixation 4 mo: lack of visual tracking 6 mo: failure to turn to sound or voice 9 mo: lack of babbling consonant sounds 24 mo: failure to use single words 36 mo: failure to speak in 3 word sentences 39

40 Social & Emo/onal Development 1 mo: knows mother s voice 2 mo: social smile 3 mo: visually tracks a person around a room 4 mo: to & fro alternating vocalizations 6 mo: separation anxiety w/ familiar/unfamiliar persons 9 mo: uses sounds to get attention; recognizes familiar people 12 mo: shows object to parent to show interest; points to get a desired object Social & Emo/onal Development 15 mo: shows empathy if someone else is sad; hugs adult back 18 mo: kisses by touching lips to skin; self conscious; pretend play 21 mo: watches other children intently 24 mo: parallel play 40

41 Social & Emo/onal Development 2 ½ years: imitates adult activities 3 years: starts to share w/o prompt; imaginative play 4 years: has a preferred friend 5 years: apologizes for mistakes 6 years: best friend of same sex; board games; enjoys school Adolescent Developmental Milestones First review Piaget s theory: recall that concrete operational thought ranges from 6-11 years, and formal operational thought ranges from 11- adult Different ranges of pubertal development, therefore Thought processes may be concrete to formal, with variations depending on the situation, at different SMR Could have a girl at SMR 4 who is still in concrete thought, whereas another girl at SMR 2 could be at formal operations. 41

42 Early Adolescents SMR 1 & 2 In the family arena, the teen begins independence from the family Onset of puberty initiates desire for privacy Unspoken wish for limit setting coupled with the need for autonomy Usually prefers the same- sex peer group Friendships involve joint activities rather than the relationship itself (devoid of depth or mutuality) High degree of conformity Early Adolescents In school, synchrony of pubertal development with the peers is important in adjustment Boys who lag in development perform less well academically & have lower expectations & aspirations Girls who mature earlier have poorer self- image & lower GPAs The gender differences in spatial ability and verbal ability appears now 42

43 Middle Adolescence SMR 3 & 4 School & peer groups are more important Sex differences in peer relationships more apparent For boys, needs for achievement & independence are best worked thru in groups For girls, developing interpersonal skills thru dyadic relationships Social groups may extend to include both genders Most teenagers in middle adolescence do not have sexual intercourse Middle Adolescence Vocational and educational decisions are often made Physical effects of pubertal development are incorporated into the self- image Trying on & experimenting with different social roles Development of an identity occurs Solidification of sexual identity(which may be suppressed or denied if homosexual) and a sense of sexual adequacy is developed. Sometimes exploitive, narcissistic relationships 43

44 Late Adolescence SMR 5 Neurophysiologic structures are complete Cognitive, social, & moral development continues to evolve throughout life Career decisions are faced Return to family on a new footing Still frequently moralistic & absolute in their thinking but can dialogue with parents Deeper relationships that are more intimate and empathetic ; loyalty, trust, & support are most valued Best way to learn child development? Play with kids Ask them questions and listen to what they say 44

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