GROWTH/DEVELOPMENT/PUBERTY😊

GROWTH/DEVELOPMENT/PUBERTY

Growth

Ponderal Index (PI)

• Formula:

• Interpretation:
• > 2: Normal growth / symmetric growth retardation
• < 2: Asymmetric growth retardation

Weight

• Average birth weight of an Indian baby - 2.9kg.

• Birth Weight:
• Doubles at: 5 months.
• Triples at: 1 year.
• Quadruples at: 2 years.

• Rate of weight gain:
• 1-3 months: 30g/day.
• 3-6 months: 20g/day.
• 6-9 months: 15g/day.
• 9-12 months: 12g/day.
• 1-3 years: 8g/day.

• Formula for calculating expected weight of a child:
• < 1 year: (x+9)/2,
• where x is the age in months.
• 2-6 years: 2x+8,
• where x is the age in years.
• 7-12 years: (7x-5)/2,
• where x is the age in years.

Length/Height

• Length < 2 years of age
• measured by an Infantometer.

• Height > 2 years of age
• measured using a stadiometer.
• Precautions:
• Remove footwear.
• Remove headgear.
• Stand erect so that eyes are parallel to the Frankfurt plane.
• Occiput, back of the shoulder, buttocks, heel should be touching the vertical wall behind.
• Standing length is always 0.7 cm less than the recumbent length (due to gravity).

• Usual length or height:
• At birth: 50 cms.
• At 1 year: 75 cms.
• At 2 years: 90 cms.
• At 4-4.5 years: 100 cms.

• Length of a child increases by:
• 50% in the 1st year.
• Maximum growth
• 1st year of life f/b puberty.
• 100% in 4-4.5 years
• doubles Length

• Increase in length with age:
• 3 → 2 → 1.5 → 1
• 1-3 months: 3.5 cm/month.
• 3-6 months: 2 cm/month.
• 6-9 months: 1.5 cm/month.
• 9-12 months: 1.2 cm/month.
• 1-3 years: 0.8-1 cm/month.

Head Circumference

• At birth: 33-35cm.

• Normal rate of increase in HC:
• 1-3 months: 2 cm/month.
• Next 3 months: 1 cm/month.
• Next 6 months: 0.5 cm/month.
• Next 2 years: 0.2 cm/month.

• In any given single month
• if the HC increases at a rate > 2 cm/month
• It is abnormal.
• Underlying causes such as tumor, hydrocephalus should be ruled out.

Formula for calculating expected height of a child:

• 0.6x+77, where x is the age in years.
• 75 cm = ht at 1 year of age

Arm span:

• Distance between
• middle finger of one arm to another
• when arms are outstretched

• < 10 years:
• 1-2 cms less than the height.

• > 10 years:
• 1-2 cms more than the height.

• Normally, difference between the arm span and the height is 3 cms.

At what age is the child's height half of adult height?

• Average height of an Indian adult: 160-170 cms.

• Age at which the child will be half the adult height:
• 20-24 months.
• Approx: 80-85 cms.

Upper Segment: Lower Segment Ratio:

• Upper segment: Part of the body above symphysis pubis.

• Lower segment: Part of the body below symphysis pubis.

• Normally,:
• At birth:
• 1.7 - 1.9 : 1.
• 3 years:
• 1.3 : 1.
• 7-10 years:
• 1 : 1.

Interpretation of height of a child:

• < 5 years: WHO growth charts.

• > 5 years: IAP growth charts.

• At 2 years of age
• if the height of the child is 70cms
• falls below the third percentile
• short stature.

WHO Growth Charts:

 

• Based on: MGRS (Multicentre Growth Reference Study).

• Children from 6 countries were studied:
• Brazil.
• Oman.
• Norway.
• Ghana.
• USA.
• India.

• Came to use first in 2006.

• Used in exclusively breastfed children.

• Excluded:
• Maternal alcohol.
• Smoking.

• Underweight: Less than 5th percentile

• Healthy weight: 5th percentile to less than 85th percentile

• Overweight:
• 85th to 95th percentile

• Obese:
• ≥ 95th percentile

Short Stature

Definition:

• If the height of a child is
• < 3rd percentile or
• < 2 Z score
• of expected according to the age and sex of the child.

Etiology of Proportionate Short Stature:

• Normal variants:
• Familial short stature.
• Constitutional delay in growth and puberty.

• Intrauterine causes:
• IUGR.
• Infection by TORCH.
• Genetic syndromes:
• Turner's syndrome,
• Down's syndrome,
• Seckel syndrome.

• Postnatal/acquired causes:
• Chronic malnutrition.
• Any chronic systemic illness.
• Celiac disease.
• Maternal deprivation.
• Psychosocial.
• Endocrine: Growth hormone deficiency.

• Note:
• Acute malnutrition
• affects weight
• Chronic malnutrition
• affects height

Morphological IUGR

• Definition: Babies with clinical features of malnutrition.

• Birth weight: Between 10th–25th percentile for gestational age.

• Classification:
• Considered as IUGR
• Not SGA

• IUGR: Clinical diagnosis → based on growth pattern and clinical features.

SGA:

• Birth weight <10th percentile for gestational age.

• Asymmetrical IUGR, Symmetrical IUGR

Case scenario:

• A 7-year-old otherwise well child presents with short stature. His weight is appropriate as per his age. His bone age is less than chronological age. The height of his parents is normal. What is the diagnosis?
• Height of parents normal - rules out familial short stature.
• Bone age < chronological age
• delay in bone maturation
• Constitutional delay in growth and puberty (CDGP).

X-ray for bone age of:

• INfants:
• X-ray of knees.

• CHildren:
• X-ray left hand and wrist.

• Older children:
• X-ray of shoulders.

CDGP vs Familial Short Stature:

Mid parental height:

• For males:
• Average height of parents + 6.5

• For females:
• Average height of parents - 6.5

• In the above image, stature/height is plotted.

• During childhood, the child's height is running almost parallel to the 3rd percentile line.

• But ultimately a catch up growth happens and the final height achieved is normal.

• Seen in CDGP.

Growth hormone deficiency:

• Type of Proportionate short stature.

• US:LS ratio: Normal.

• Bone age < Chronological age.

• Investigations:
• Growth hormone stimulation test.
• Insulin, Clonidine can be used.

• Management:
• Recombinant growth hormone Inj..
• Side effect:
• Pseudotumor cerebri.

Laron Dwarfism (Growth Hormone Insensitivity Syndrome)

Mnemonic:

• Laron dwarfism → Large GH but dwarfism

Cause:

• Mutation in
• growth hormone receptor gene or
• post-receptor signaling pathway genes.

Hormone levels:

• ↑ Growth hormone

• ↓ IGF-1 (Insulin-like Growth Factor 1)

Pathophysiology:

• Body cannot respond to growth hormone.

• GH fails to stimulate IGF-1 production.
• IGF-1 is essential for GH-mediated growth.

Clinical result:

• Impaired growth

• Short stature

Disproportionate Short Stature:

• Short trunk: US:LS ratio - Decreases.
• Mnemonic - Short Man Climbs High:
• Upper limb short due to vertebral causes
• Spondyloepiphyseal dysplasia.
• Mucopolysaccharidosis.
• Caries spine/ Potts' disease.
• Hemivertebrae/ Butterfly vertebra.

• Short limbs: US:LS ratio - Increases.
• Thyroid, Bone, Cartilage, vitamin D
• Congenital hypothyroidism.
• Rickets.
• Osteogenesis imperfecta.
• Achondroplasia.

Microcephaly

• Definition:
• HC < 3 Z score of expected according to the age and sex.

Etiology of primary microcephaly:

• Genetic syndromes:
• Mnemonic: Cannot see PGFR in child
• Cri du chat syndrome (5p-).
• Patau syndrome: Trisomy 13.
• Edward syndrome: Trisomy 18.
• Familial.
• Smith Lemli Opitz syndrome:
• Mnemonic: Smith Lemli Optiz → S (semen → gonad) L (L → cLeft Lip) O (Optics → eye or hOlOprOsencephaly)
• Midline defects:
• Cleft lip,
• Cleft palate,
• holoprosencephaly,
• gonadal abnormalities.
• Cholesterol metabolism defects,
• accumulation of 7-dehydrocholesterol.
• Rubinstein Taybi syndrome
• deviated (Z like) thumb.
• Mnemonic: Taybe → Thumb gone
• Cornelia de syndrome



• long eyelashes.
• Mnemonic: Cornea → eye lashes

Etiology of secondary microcephaly:

• Maternal:
• Alcohol intake.
• Smoking.
• Phenytoin.
• Radiation exposure.
• Metabolic disorder - Phenylketonuria.
• TORCH infections.

• Baby:
• Severe malnutrition.
• Perinatal asphyxia/ HIE.
• Any CNS infection in the first year of life - Meningoencephalitis.

• Acquired causes:
• Rett syndrome - X linked dominant inheritance.
• Angelman syndrome.
• Seckel syndrome.

Rett Syndrome:

• Inheritance: X linked dominant inheritance.

• M/c in: Females.

• M/c gene affected: MECP2 gene.

• HC at birth: Normal.

• C/f:
• Gradual developmental delay.
• Acquired microcephaly.
• Loss of purposeful hand movements.
• Stereotypic hand wringing movements.

• FDA approved drug: Trofinetide

• Mnemonic:
• Female singer → has Mike (MEC P2)
• To make writing Fine (Trofine) and give trophy (Trofine)

Macrocephaly

• HC > + 2SD

• Increased thickness of cranial bones:
• Rickets.
• Osteogenesis imperfecta.
• Chronic hemolytic anemia - thalassemia.
• Mnemonic: ROT → Rotting thala

• Subdural Effusion or empyema
• usually a sequelae of meningitis

• Megalencephaly:
• size of the brain ↑↑
• due to accumulation of abnormal substance.

• Hydranencephaly:
• cerebral hemispheres are absent
• replaced by fluid filled sac
• Transillumination +.
• Midbrain and brain stem are intact.

• Hydrocephalus:
• enlargement of ventricles
• either due to
• increased production or
• impaired drainage of CSF.

Etiology of Megalencephaly:

• Benign familial megalencephaly.

• Amino acid disorders:
• Glutaric aciduria.

• Lysosomal storage disorders:
• Mucopolysaccharidosis.

• Weavers syndrome.

• Achondroplasia.

• Neurodegenerative diseases:
• Alexander disease
• deposition of GFAP, Rosenthal fibers.
• Demyelinating disease
• T2 MRI
• Hyperintensity in frontal white matter
• B/L symmetrical involvement
• Canavan disease
• deficiency of asparto acylase
• leads to deposition of N asparto acetic acid (NAA) in the brain.
• Spongiform leukodystrophy
• Extensive vacuolation of subcortical white matter

• Soto syndrome.

• Neurofibromatosis.

• Galactosemia.

• Mnemonic: Alexander () Fap (GFAP) with Rose (Rosenthal) → From Caravan (Canavan) a NAA (NAA dep) sound came → Achondroplasia () olla child was born → She fed him milk (Galactosemia) → she weaved () and glued (Glutaric acid) amino acid → Sought to (Soto) Nurture him (NF1)

Craniosynostosis

• Abnormal head shape due to premature fusion of one or more cranial sutures.

• dolichocephaly (m.c)
• Anteroposteriorly
• oblong head
• premature fusion of sagittal suture.

A/w Craniosynostosis:

• Crouzon syndrome:
• Maxillary hypoplasia
• Prominent eyes,
• mid facial hypoplasia,
• bulging eyes,
• small mandible.

• Pfeiffer syndrome:
• Clover leaf shape of the skull.

• Carpenter syndrome.
• Autosomal Recessive

• Apert syndrome:
• Syndactyly - Mitten hands and toes.

• Aperture (Apert) → Carpenter () → Cruize (Crouzen) → Phineus and fer (Pfeifer)

Patterns of Growth

• brain growth
• Maximum growth in first 2 years, then stagnant
• Parabolic

• lymphoid growth
• Maximum growth between 4–9 years
• physiologic lymphoid hyperplasia

• somatic growth
• Sigmoid curve:
• accelerated growth from birth to 2 years,
• then slowed
• then picks up again
• signifies
• two periods of accelerated growth:
• infancy
• puberty

• gonadal growth
• Minimal growth rate in first 10 years, then picks up
• Corresponds with skeletal growth

Dentition

• Primary dentition - Milk teeth.

• Secondary dentition - Permanent teeth.

Primary vs Secondary Dentition:

• Period of mixed dentition: 6 to 12 years.

Delayed dentition:

• Definition:
• When no teeth erupts by 13 months of age.

Etiology:

• Familial.

• Rickets.

• Idiopathic.

• Endocrine:
• Hypopituitarism.
• Hypothyroidism.
• Hypoparathyroidism.

• Down's syndrome.

Cleidocranial dysostosis:

• Complete or partial absence of clavicles.

• Autosomal dominant inheritance.

• Large anterior fontanelle.

• Supernumerary teeth.

Hutchinson's Triad (Mnemonic: ENT):

• Late manifestation of congenital syphilis.

• E (Eye):
• Interstitial Keratitis.

• N (Nerve):
• 8th Nerve Deafness.
• SNHL

• T (Teeth):
• Hutchinson's Teeth.
• Notching of incisors

• Others features include:
• Saddle nose (Olympic brow)
• Mulberry molars.
• Running nose.
• Clutton's joints.

 

Hutchinson's

• H → Herpes Zoster Ophthalmicus

• U → subUngual Melanoma (superficial spreading melanoma)
• Hutchinson sign

• T → Triad → congenital syphillis
• Peg shaped teeth
• Interstitial Keratitis (IK + SNHL)
• SNHL

• CH → Chauffeur's Fracture/Backfire Fracture
• Intra articular #

• Son → looking older → Hutchison Gilford
• LMN A gene defect (laminopathy).
• Progeria (onset: Child)

• PUPIL → Hutchinson Pupil
• Herniation of uncus (medial temporal lobe) → compresses ipsilateral CN III → same side pupillary dilatation.
• Kernohan’s notch phenomenon:
• False localizing sign
• Ipsilateral pupil dilatation
• Ipsilateral UMN palsy

Development

Gross Motor Milestones

• Neck Holding
• Partial: 3 months
• Complete: 5 months

• Rolls Over:
• 5–6 months

• Sitting
• With support (Tripod position):
• 6 months



• Without support: 8 months

• Crawling



• 8 months

• Pivoting, Cruising, Creeping:



• 10–11 months

• Standing
• With support: 9 months
• Without support: 12 months

• Walking without support: 15 months

• Stair Climbing
• Up and down: 2 years
• Upstairs with alternate feet + downstairs with two feet/step: 3 years
• Alternate feet up & down: 4 years

Image Interpretations

• Upper Left Corner:
• Child looking at hands intently → Hand regard → 3 months

• Upper Right Corner:
• Lifting head above body → Partial neck control → 3–4 months

• Lower Left Corner:
• Holding small objects using thumb + index finger → Pincer grasp → 9 months

• Lower Right Corner:
• Child riding a tricycle → 3 years

Major Fine Motor Milestones

• Hand regard: 3 months.

• Reaches out for objects: 4 months.

• Bidextrous grasp:
• 5 months.

• Unidextrous → Immature Palmar grasp:
• 6 months.

• Transfers objects:
• 7 months - compare objects.

• Pincer grasp:



• Immature: 9 months.
• Mature: 12 months.

• Casting (drops everything down):
• 13 months.

• Tower of Cubes:
• Number of cubes put on top of each other = Age x 3.
• 2 years: Tower of 6 cubes.
• 3 years: Tower of 9-10 cubes.

• Train
• without chimney: 2 years.
• with chimney: 2.5 years.

• Bridge: 3 years.

• Gate: 4 years.

• Steps: 5-6 years.

• At 2 years:
• Copies a straight line.
• Turns door knob.
• Unscrews a lid.

• At 3 years:
• Copies a circle.
• Handedness gets established.
• Dress and undress by self - Except buttons.

• At 4 years:
• Copies a rectangle or a cross.
• Buttons and unbuttons.

• At 5 years:
• Copies a triangle/a tilted cross.
• Ties shoelaces.

Social Milestones

• Social smile: 2 months.

• Mirror play:
• 6 months.

• Stranger anxiety:
• 7 months.

• Waving bye bye: 9 months.

• Plays peek-a-boo: 10 months.

• Kisses/plays a simple ball game: 12 months.

• Points to objects: 15 months.

• Domestic mimicry and dry during day time: 18 months.

• Parallel play: 2 years.

• Joins in play and night time continence: 3 years.

• tying shoe lace is seen - 5 years.

Piaget’s Theory – Sensory-Motor Stage

• Here and now
• Focus on immediate sensory experience
• what is seen, touched, heard

• Out of sight, out of mind
• No mental representation of objects not currently perceived
• lack of object permanence

• Preference for familiar objects and people.

• No association with absent objects or people.

• Example:
• Infant is comforted by mother’s touch, upset when she leaves, without understanding she will return.

Nocturnal Enuresis:

• Involuntary urination at night beyond 5 years of age.

Management:

• 1st line:
• Lifestyle and behavioral modifications
• like early dinner,
• limitation of fluids in the evening.
• Positive reinforcement/ motivational therapy/ Star chart.

• 2nd line:
• Conditioning: subcortical dementia
• Bell and alarm technique
1. a moisture sensing alarm in underwear
2. child voids → alarm rings → child wakes up → goes to the washroom and voids.

• 3rd line:
• Pharmacological:
• Oral Desmopressin.
• Imipramine.
• Relapse rates are high.

Important Language Milestones

• Vocalizes: 2 months.

• Cooing: 3 months.

• Monosyllables: 6 months.

• Bisyllables: 9 months.

• Two to three words with meaning: 1 year.

• Jargon speech: 15 months.

• Vocabulary of 10 words: 18 months.

• Vocabulary of 50 - 100 words: 2 years.

• Two words sentences and use of pronouns: 2 years.

• Three words sentences and repeats three digits: 3 years.

• Tells a poem/story/sings a song: 4 years.

Developmental Quotient (DQ)

• DQ = Developmental age/ Chronological age x 100.

• Q. If a 6-year-old child can do milestones only of a 3-year-old child and not beyond that, what is the DQ?
• Ans. DQ = 3/6 x 100 = 50.

• If there is a delay (DQ<70%) in more than 2 domains,
• ↳ global developmental delay (GDD)

Criteria for Mental Health (IQ)

• Wechsler intelligence scale

• IQ formula: (Mental age / Chronological age) × 100

• Average for child = 90

Red flag signs of developmental delay

Developmental Implications (Important)

• Hand regard: Self discovery of hands.

• Transfers objects: Comparison of objects.

• Points to objects: Interactive communication.

• Uncovers hidden toys: Object permanence.

• Pretends to drink from cup: Symbolic thought.

Puberty

• Precocious Puberty
• Puberty < 8 years

Girls: TPM

1. Thelarche

2. Pubarche

3. Menarche

Boys: TPAM

1. Testicular enlargement

2. Pubarche

3. Adrenarche

4. Moustache and Beard

First sign of puberty in:

• Girls:
1. Thelarche - breast development.
2. Pubarche (development of pubic and axillary hair).
3. Growth spurt (period of exaggerated growth/ peak increase in growth velocity).
4. Menarche.

Tanner's Staging or Sexual Maturity Rating (SMR) in females:

• Based on development of breast and pubic hair.

• Stage 1: Prepubertal.

• Stage 2: Pubic hair sparse and located along the medial border of labia.

• Stage 3: Pubic hair thicker and curled.

• Stage 4: Pubic hair is coarse and spreads along the mons pubis.

• Stage 5: Mature adult.
• Pubic hair extends to the medical part of the thigh.

First sign of puberty in boys:

• Testicular enlargement.
• (assessed using Orchidometer).

• Penile enlargement.

• Pubic hair.

• Peak increase in growth velocity.

• Axillary hair.

• Facial hair.

• Deepening of voice takes place in the later part of puberty.

SMR assessment in males:

• Based on testes, penis and pubic hair.

• Stage 1:
• Prepubertal.
• Testicular volume < 4c.c.
• Long axis < 2.5cms.

• Stage 2:
• Testicular volume > 4 c.c.
• Minimal sparse hair at the root penis and scrotum.

• Stage 3:
• Scrotum reddens.
• Penis increases in length.
• Coarser pubic hair.

• Stage 4:
• Penis increases in length and breadth.
• Testicular enlargement continues.
• Pubic hair spreads mons pubis.

• Stage 5:
• Mature adult.
• Pubic hair is coarse and curly in the male pattern.
• Spreads across medial thigh.

Hypothalamic Hamartoma

• Pedunculated mass in floor of 3rd ventricle

• C/F
• central precocious puberty.
• TOC: GnRH agonists (long-acting depot or implant)
• Intractable gelastic / psychomotor seizures:
• Gamma Knife surgery

Adolescent Age Group

• WHO Definition: 10-19 years of age.
• Early: 10-13 years.
• Mid: 14-16 years.
• Late: 17-19 years.

Growth spurt occurs in:

• Females - SMR stage 3.

• Males - SMR stage 4.
• Occurs later and lasts longer in males.
• Pubertal gynecomastia in males
• During puberty
• self limiting and no management is required.

HEAD-SS Assessment

• It is a non judgemental assessment.

• Assess about:
• Home.
• Education.
• Activities/ alcohol.
• Diet/ drugs.
• Self esteem/ sexuality.
• Safety/suicidal tendencies.

• Helps to identify adolescent problems.