1- LECTURE ASSESSMENT OF GROWTH AND DEVELOPMENT.pdf

ASSESSMENT OF GROWTH AND
DEVELOPMENT
Dr. Reyad Ahmed Abdu Mansoor
consultant pediatrician in university of Science & Technology Hospital ,
consultant pediatrician . in Al-sabeen Hospital
Associated Member Of The Arabic Board
3/23/2022 Dr. Reyad Ahmed Abdu Mansoor 1

INDEX
• DEFINITION
• DIFFERENCE BETWEEN GROWTH AND DEVELOPMENT
• FACTORS AFFECTING GROWTH
• STAGES OF HUMAN GROWTH AND DEVELOPMENT
• SCAMMON'S GROWTH CURVE
• NEURAL GROWTH
• LYMPHOID GROWTH
• REPRODUCTIVE GROWTH
• PHYSICAL/GENERAL
• EVALUATION OF GROWTH
• GROWTH MONITORING [GM]
• ANTHROPOMETRIC MEASURES
• NORMAL GROWTH
• WEIGHT
• LENGTH /HEIGHT
• MIDPARENTAL HEIGHT
• GROWTH VELOCITY
• BODY RATIOS
• WEIGHT-FOR-HEIGHT
• HEAD CIRCUMFERENCE
• CHEST CIRCUMFERENCE
• MID UPPER ARM CIRCUMFERENCE (MUAC)
• SKIN FOLD THICKNESS
• BODY MASS INDEX
• BODY PROPORTIONS
• DENTAL AGE
• FONTANELS
• BONE AGE
• GROWTH CHARTS (CURVES)

DEFINITION
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DEFINITION
• GROWTH
• increase in the size of the organism by
• simple increase in the size (physiological hypertrophy)
• Number of its cells (hyperplasia )
• Reflected by increase in body dimensions.
• IMPORTANCE
• Growth is an indicator of overall well-being, status of chronic disease and interpersonal
and psychologic stress.
• Essential feature that distinguishes a child from an adult.
• Indicates overall well-being of a child.
• Reflects the nation's economic status and public health System.
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DEFINITION
• DEVELOPMENT
• Development indicates maturation of functions.
• Acquisition of skills & maturation of already formed organs.
• Definition:
• Progressive, orderly, acquisition of the skills and abilities as a child grows, influenced by
genetic, neurological, physical, environmental and emotional factors.
• Term ‘child development’:
• Describe skills acquired by children from birth to about 5 years of age (rapid gains in mobility, speech,
language, communication and indepedence skills).
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DIFFERENCE BETWEEN
GROWTH AND
DEVELOPMEN
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GROWTH AND DEVELOPMEN
• What is Growth?
• Growth refers to the increase in size.
• Multiplication of cells and increase in the intracellular substance.
• Reflected by increase in body dimensions.
• Measure by Kg , meters
• What is Development?
• Development indicates maturation of functions.
• Acquisition of variety of skills for individual functions.
• Determine by Developmental Milestones
1. Gross Motor Development
2. Fine Motor and Vision Development
3. Language and Hearing Development
4. Social, Emotional and Behavioral Development
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TYPES OF GROWTH AND DEVELOPMENT:
Types
of
growth
and
development:
Types of growth:
Physical growth
Physiological growth
Types of
development:
Motor
Cognitive
Social
Affective/emotional
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FACTORS AFFECTING
GROWTH
FACTORS AFFECTING GROWTH & DEVELOPMENT
ADEQUATE & FAVORABLE FACTORS
OPTIMUM GROWTH & DEVELOPMENT
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Factors influencing growth & development
1. PREMARITAL
2.
PRECONCEPTIONAL
3. PRENATAL
4. PERINATAL
5. POSTNATAL
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FACTORS INFLUENCING GROWTH & DEVELOPMENT
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1. Premarital
1.Genetic factors
2. Parental traits
3. Chromosomal
disorders
4. Gene
mutations
5.Demographic
factors like race
2. Preconceptional
1.Maternal age.
2.Health /body built
3. Prenatal
1.Fetal factors (Fetal
diseases)
2.Maternal factors
1.Age
2.maternal infection
3.Anemia
4.Diseases of
Pregnancy
5.Obstetric diseases
(e.g. Placental
insurance
6.Obstetric
complications
7.Teratogens
8.Radiation ex
9.Hormonal factors
4. Perinatal
1.Perinatal Hypoxia.
2.Perinatal birth trauma.
3.delivery (R. Distress-
Jaundice , Cyanosis )
5. Postnatal
1.Biological factors like
1.Infections ; Tuberculosis
2.Chronic illness.
3.Hormonal factors
1.Thyroxine
2.Growth Hormone
3.Insulin
4.Insulin :ike growth factor
2.Nutritional factors
1.PEM
2.Anemia
3.Vitamin deficiency
3.Environmental factors and socio-
economic status
1.Poverty
2.Climate
3.Culture
4.Education
4.Emotional factors like mother and
infant bonding

FACTORS AFFECTING GROWTH
A. Race
• Growth differs in different races
B. Family:
• Height and body frame are inherited from parents (Genetic factors).
• Parental trait
• Tall parents have tall children
• Head size related to parents
C. SEX
1. Girls grow faster from the 7th month to 4 years and start puberty at a younger age.
2. Boys have greater growth potential than girls
3. Pubertal height gain is more in boys
D. GENETIC FACTOR
1. Chromosome defect
1. Short stature: Down syndrome, Turner syndrome
2. Tall stature: Klinefelter syndrome
2. Gene mutation
• Short stature: Prader-Wlli syndrome, Noonan
3. Syndrome
• Tall stature: Marfan syndrome
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FACTORS AFFECTING GROWTH
E. Chronic illness & infections:
• chronic renal, liver, chest diseases, cardiac and GIT-TB.
F. Developmental anomalies:
• as cleft palate, pyloric stenosis and renal anomalies.
G. FOOD, ENVIRONMENT.
1. PEM, Micronutrient deficiency
2. Infections
• Diarrhea, recurrent RTI,TB,HIV, Malaria, Kala-azar, Chronic giardiasis
3. Toxins
H. HORMONAL
1. Growth hormone deficiency
2. Hypothyroidism
3. Growth hormone resistance
I. SOCIAL FACTOR
1. Low socio-economic status: Poor diet, infections
2. Hot and humid climate
3. Poor emotional support: Broken family, orphans
4. Cultural factors: Religious taboos
5. Low parental education: Poor health promotion, poor nutrition.
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HORMONAL ROLE
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Intrauterine
1. Chorionic gonadotropins
2. Placental lactogen
3. Insulin
4. Thyroxin (skeletal growth)
Infancy & childhood
1. Thyroxin
2. Growth hormone
Adolescence
Sex hormones (Estrogen &
androgen) are responsible for
growth spurt during puberty

I. GENETIC FACTOR
• Most important deciding factor of growth.
• Up to certain extend , gene expression decides the height.
• Children of tall and heavy parents are likely to have the same stature.
• Some races are taller in comparison to others.
• Difference between male and female growth pattern, adolescent spurt appear to be
genetically controlled via the hypothalamus.
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2. NUTRITIONAL FACTOR
• For optimum growth , balanced diet is necessary.
• Balanced diet must be adequate not only in calories but also in proteins, carbohydrates,
fats, vitamins, minerals.
• Their requirements are increased during active periods of growth.
• Undernutrition and malnutrition in childhood is responsible for stunting of growth.
• If lack of nutrition is prolonged severe- stunting occurs which may be irreversible.
• If lack of nutrition is less severe & for short period- stunting may be reversible by restoring
normal diet leading to compensatory increase in rate of growth. This is called as Catch Up
growth.
• The mechanisms for catch up growth are unknown, but recent evidence suggests that it
may be related to the rate of stem cell differentiation within the growth plates.
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2. NUTRITIONAL FACTOR
• Undernutrition affects the growth of different organs and tissue unevenly
• Dietary deprivation affects muscles and fat more than bone.
• Skeletal maturation is less affected than skeletal growth.
• Total brain growth is inhibited more than myelination.
• At puberty malnutrition affects the genitals less commonly than other organs.
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3. Environmental Factors
PRENATAL
1.Maternal malnutrition
2.Maternal infection
3.Maternal substance abuse
4.Maternal illness
5.Hormones
6.Miscellaneous
Postnatal factors
1.Growth potential
2.Nutrition
3.Childhood illness
4.Physical environment
5.Psychological environment
6.Cultural influence
7.Socio economic status
8.Climate and season
9.Play and exercise
10.Birth order of the child
11.Intelligence
12.Hormonal influence
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4. HORMONAL FACTOR RETURN TO INDEX
HORMONES ACTIONS
GROWTH HORMONE Major stimulus of postnatal growth
1. Induces precursor cells to differentiate and secrete
2. Insulin-like growth factor 1 (IGF-1), which stimulates cell division.,
3. Stimulates protein synthesis.
INSULIN 1. Stimulates fetal growth
2. Stimulates postnatal growth by stimulating secretion of IGF-1.
3. Stimulates protein synthesis..
THYROID HORMONES
1. Permissive for growth hormone's secretion and actions.
2. Permissive for development of the central nervous system
SEX HORMONES A. Testosterone
1. Stimulates growth at puberty, in large part by stimulating the secretion of growth hormone.
2. Causes eventual epiphyseal closure.
3. Stimulates protein synthesis in male.
B. Estrogen
1. Stimulates the secretion of growth hormone at puberty.
2. Causes eventual epiphyseal closure
CORTISOL 1. Inhibits growth
2. Stimulates protein catabolism

METABOLIC GROWTH
• Growth is the balance between anabolism and catabolism.
• Growth is due to anabolism for which the energy is driven from catabolism.
• Protein anabolism is favoured by
1. Growth Hormone
2. Thyroid Hormone
3. Insulin
• Catabolism is favoured by
• Glucocorticoids secreted by adrenal cortex
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STAGES OF HUMAN
GROWTH AND
DEVELOPMENT
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STAGES OF HUMAN GROWTH AND DEVELOPMENT
• Intrauterine stage
• Prenatal
• Embryonic stage:
• First12 weeks of gestation(1st trimester
• It is the period of organogenesis.
• Fetal stage:
• From 12th to 40th week of gestation.
• It is a period of rapid growth and development
• Perinatal
• From 28th week of fetal life to 7th day after delivery
• Extrauterine stage
• Postnatal
• Neonate—From birth till 1 month.
• Infant— From 2nd month to 1 year.
• Toddler— 1 year to 3 years.
• Childhood
• Early Preschool — 3 years to 6 years.
• Late childhood — 6 to 12 years.
• Adolescence —13to 18 years.
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PREDOMINANT CONTROL IN EACH PHASE OF GROWTH
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Infancy
1. Nutrition
2. GH
3. Thyroxine
childhood
1. GH,
2. Thyroxine
Adolescence
1. Sex hormones
2. GH

PHASES OF LIFE
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Period duration
Ovum 0-14 days
Embryo 1 4ds-8 weeks
Fetus 8 wks- birth
Newborn Birth -28 days
Infancy Upto 1 year
Toddler 1 -3 years
Pre-school 3-6 yrs
School going child 6-10 /I 2years
Adolescence 1 0/1 2-1 8 years

POSTNATAL
• Neonatal period
• It is the most critical period during which
• The newborn adapts to extra-uterine environment
• It is mostly affected by;
• Prematurity
• Birth trauma
• Congenital anomalies
• Cross infections
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POSTNATAL
• Infancy
• It is the period of most rapid physical growth and mental development.
• Infectious diseases ‘immunizations are given during this period
• Nutritional disorders.
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POSTNATAL
• Toddlerhood
• It is the period during which the child is exploring what around him.
• Nutritional disorders
• Infections
• Accidents
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POSTNATAL
• Early childhood (preschool age):
• It is the period of exploring the outside world and starts learning.
• Child is thus exposed to:
1. Accidents and household poisons
2. Nutritional disorders
3. Infections
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POSTNATAL
• Late Childhood (School age):
• The School child starts studying and having exams.
• These children are mostly exposed to:
1. Accidents and infections
2. Cardiac diseases e.g. rheumatic fever and bacterial endocarditis
3. Malignancies [leukemia, lymphoma, etc
4. Psychological and emotional problems.
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POSTNATAL
• Adolescence
• It is the period of passage from childhood to puberty and adulthood.
• Puberty start and the velocity of pubertal
• changes are highly variable from person to person.
• This period exposing him/her to:
1. Psychological and behavioral problems
2. Acne, and sex hormones-related problems
3. Rheumatic heart diseases, DM, malignancies
4. Accidents.
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SCAMMON'S GROWTH CURVE
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DIFFERENTIAL GROWTH
DIFFERENT ORGANS
RATE AMOUNT TIME
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Human body doesn’t grow at the same rate throughout life.

LAWS OF GROWTH
• Growth pattern of every individual is unique.
• Cephalocaudal
• Distal to proximal
• Different tissues of the body grow at different rates
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LAWS OF GROWTH
1. Continuous and orderly process.
2. Growth pattern of every individual is unique.
3. Different tissues grow at different rates.
• General body growth
1. First two years of life.
2. steady gain during mid-childhood
3. rapid gain during the adolescent spurt
• Brain growth – 3rd trimester and 1st year of life.
• Lymphoid growth – Mid childhood
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Pattern of Growth & Development during childhood and adolescence
•Scammon's growth curve
• Growth of different tissues can be
summarized in 4 patterns or curves;
• Types of tissue growth patterns
1. PHYSICAL/GENERAL
2. NEURAL
3. LYMPHOID
4. REPRODUCTIVE
• Rate and timing of postnatal
maturation, measured as a proportion
of total adult size vary among major
systems of human body.
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II. NEURAL GROWTH
• Shows growth of brain, spinal cord and visual apparatus.
• grow rapidly after birth.
• At the end of 1st yr. of postnatal life brain growth is 60%.
• At the end of 2nd yr. brain growth is 80%.
• At the end of 5th yr. brain growth is almost 100% of adult
• Head circumference is important up to 3-5 years of age.
• Numbers of neurons are not increased.
• Increased in size of neurons, dendrite branching and number of synapses.
• Early age malnutrition can affects the growth of brain.
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III. LYMPHOID GROWTH
• Lymphoid organs
• Tonsils, adenoid, thymus, spleen, lymph nodes and lymphoid tissue of intestine
• Show rapid growth during infancy and childhood. Why?
• Reaches maximum by 10-12 years
• declines after that.
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IV. REPRODUCTIVE GROWTH
• Reproductive organs
• Gonads and accessary reproductive organs.
• Remain dormant in childhood.
• Grow at rapid rate around puberty.
• This rapid growth is due to secretion of GONADOTROPHINS.
• Gonadal growth pattern is opposite to that of neural growth
pattern.
• A different type of growth is shown by
• Adrenal Glands &
• Uterus
• They are relatively large at birth,
• then they lose weight rapidly and regain their birth weight
just before puberty.
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PHYSICAL/GENERAL
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PHASES OF PHYSICAL GROWTH
• Acceleration (fast)
• 1st Half of gestation,
• 2nd year of life.
• Puberty
• Deceleration- 2nd year
• Steady rate- 6-9 years of age
• two growth spurts
1. At infancy. Infantile growth spurt
2. At puberty. Pubertal growth spurt
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RAPID INCREASE GROWTH PHASE
• Occurs during infancy (Birth-3yrs)
• Infantile growth spurt.
• This rapid growth is characterized by
• Increase in birth weight to
• Weight increases from 3kg to 12kg.
• 2 times by 6th months of age.
• 3 times by 1 year of age.
• 4 times by 2 years of age.
• Increase in height by 2cm-2.5cm per month in the 1st year of postnatal life.
• 30% of the adult growth.
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SLOW PROGRESSIVE GROWTH
• Takes place from 3 to 10 years of age.
• Boys are slightly taller than girls.
• By the end of 10 years , 60% of adult growth is achieved.
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SECOND RAPID GROWTH
• Seen at 10-16 years.
• Pubertal growth spurt.
• Weight gain is about 3.5kgs/year between 12-16 years of age
• Height by 4-7cms/year.
• Average age for pubertal growth in
• Girls is 12-14 years. Between 8-14 yrs in girls
• Boys is 14-16 years. Between 9-14 yrs in boys
• It is due to secretion of-
• Sex hormones
• Growth hormone
• IGF-I
• Increase in weight in girls — due to fat deposition.
• in boys—due to muscular growth.
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EVALUATION OF
GROWTH
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EVALUATION OF GROWTH
GROWTH
ANTHROPOMETRIES
DENTALAGE
FONTANELLS
BONE AGE
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GROWTH MONITORING
[GM]
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GROWTH MONITORING [GM]
• What is growth monitoring
• Growth monitoring is the regular measurement of a child's size (weight, height or
length and head circumference) in order to document growth.
• The child's size measurements must then be plotted on a growth chart.
• This is extremely important as it can detect early changes in a child's growth.
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PARAMETERS OF ANTHROPOMETRY
Age dependent factors:-
1.Weight
2.Height
3.Head circumference
4.Chest circumference
Age independent factors:-
1.Mid-arm circumference (1-5
years)
2.Weight for height
3.Skinfold thickness
4.Mid upper arm/height ratio
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3/23/2022 Dr. Reyad Ahmed Abdu Mansoor

ASSESSMENT OF PHYSICAL GROWTH
• Anthropometric measurements
• ANTHRO Man
• POMETRY  Measure
• Means Measurement of The Human
• WEIGHT  Electronic weighing scale
• HEIGHT
• > 2 years  Stadiometer
• < 2 years
• Or Length  Infantometer
• BODY MASS INDEX
• BODY CIRCUMFERENCE
• HEAD CIRCUMFERENCE  A NON ELASTIC MEASURING TAPE
• MID UPPER ARM CIRCUMFERENCE  SPECIAL TAPE
• SKIN FOLD THICKNESS  Harpenden’s Skin fold calipers
• BODY PROPORTIONS
• ARM SPAN
• SITTING HEIGHT
• VELOCITY OF GROWTH
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EQUIPMENTS REQUIRED
STANDARD GROWTH CHARTS AND TABLES:
WHO GROWTH CHARTS
Weighing machines:
 Electronic weighing scales are preferred.
 Beam type weighing scale (Detecto scale) is also acceptable.
Infantometer for length measurement.
Anthropometer or stadiometer for height measurement.
Non-stretchable but flexible plastic tape.
Harpenden skin fold calliper.
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SCHEDULE OF GROWTH MONITORING
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WEIGHT LENGTH/ HEIGHT
HEAD
CIRCUMFERENCE
Birth + + After 4 day
First year MONTHLY Every 2 M MONTHLY
Second year Every 2 M Every 4 M Every 2 M till 18 M
3RD year Every 3 M Every 6 M
3 -8 years Every 6 M Yearly
9-18 years Annual assessment of height, weight, BMI & SMR
For simplicity child is checked when he coming for vaccination and during the month of his/her birth day(at 2nd ,4th .6th
.9th , 12th ,18th ,24th ,6th ,48th ,60th month).
SMR  Sexual maturity rating (Tanner staging)

Why do we Need to Perform Growth Measurements?
• Growth measurements are a proxy marker for:
1. Dietary adequacy
1. Energy, protein
2. Specific vitamins and minerals
2. Health
1. Chronic diseases (i.e. allergy, diabetes, cardiac disorders)
2. Acute diseases (i.e. diarrhea and vomiting)
3. General well being at home
1. Food security
2. Neglect
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Importance of GM
1. Early detected of growth flattering.
2. Prevent under nutrition.
3. Growth promotion
4. Decrease child mortality and morbidity.
5. Helps health workers to analyze the causes of a child's poor growth.
6. Helps demonstrate the child's condition to the caregiver.
7. involves caregivers in thinking through what actions can be done in the home to address causes
of poor growth.
8. Help in education of mother about normal growth.
9. It can help a health worker connect families to important community and nutrition
interventions.
10. It can help keep a child or family in regular contact with the clinic, or with other community
interventions.
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RED FLAGS FOR GROWTH PROBLEMS
1. No catch up after initial loss of birth weight
2. Plateau in weight
3. Pattern of weight gain & then loss
4. Failure to regain weight lost during an illness
5. A child's growth line crosses 2 major percentiles.
6. The child's growth line remains flat (stagnant); i.e. there is no gain in weight
7. Weight centile is 2 centiles less than height centile
8. Weight or height centiles are less than 2nd or 5th centile
9. Unexplained/unintentional weight gain
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3/23/2022 12:07 PM Dr. Reyad Ahmed Abdu Mansoor 55

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STEPS OF GROWTH MONITORING GM
Anthropometric measurements
Plotting
Interpretation
Investigate causes
Management to causes
Follow-up
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I. ANTHROPOMETRIC MEASURES
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Anthropometry: Introduction
•Anthropos - "man" and Metron "measurement”
•A branch of anthropology that involves the quantitative measurement of the
human body.
•Gold standard of nutritional assessment. It is the single most portable,
universally applicable, inexpensive and non-invasive technique for
assessing the size, proportions and composition of the human body.
•It is used to evaluate both under & over nutrition.
•The measured values reflects the current nutritional status & don’t
differentiate between acute & chronic changes
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• How can you assess anthropometric measures?
• Get an accurate body measurement e.g. weight, height, head circumference,
etc.
• Compare this measurement with growth standards obtained from normal
individuals of same age, sex, and community.
• This can be done by plotting this measurement on percentile or Z score growth
charts of the same age & sex
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• Parameters.
• Infants 0 to 2 years:
1. Weight
2. Length
3. Weight for length
4. Head circumference
• Children and adolescents 2 to 20 years:
1. Weight
2. Height
3. Body mass index (BMI)
• Mid Arm Circumference (MAC)
• Skin fold thickness
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Child Anthropometry
• Basic measurements in children include:
1.WEIGHT
• Clothing to be removed.
• Baby weighed on clean calibrated scale.
• The measurement is taken to at least 2 decimal places for accuracy in kg.
2.HEIGHT (LENGTH)
• An infantometer is used.
• The baby is placed supine with head against appropriate surface.
• The baby is held in a fully extended position with the heels at a 90º position.
• The measurement is taken to at least 3 time
• The measurement is taken to the nearest 0.1cm.
3.OFC (Occipitofrontal circumference)
• The OFC of the baby is measured to the nearest 0.1cm with a firm tape
measure placed appropriately.
• The measurement is taken to at least 3 time
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Components of Anthropometric Assessment:
• Height (Length )-for-age
• The maximum growth potential of an individual is decided by hereditary factors.
• Among the environmental factors, the most implicant being nutrition and morbidity.
• Is considered an index of chronic or long duration malnutrition (3).
• Weight-for-Height
• Weight-for-height is now considered more important than weight alone.
• helps to determine whether a child is within range of "normal" weight for his height (2)
• Mid-arm Circumference
• Yields a relatively reliable estimation of the body's muscle mass.
• The reduction of which is one of the most striking mechanisms by which the body adjusts to inadequate
energy intakes (2).
• Arm circumference cannot be used before the age of one year
• between ages one and five years, it hardly varies (2).
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NORMAL GROWTH
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AVERAGE GROWTH PARAMETERS AT BIRTH
• Weight: 3 Kg
• Length: 50 cm
• U/L ratio: 1.7
• HC: 35 cm
• CC: 33 cm
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Rules of Thumb for Growth
1.WEIGHT
• Weight loss in first few days: 5-10% of birthweight
• Return to birthweight: 7-10 days of age
• Double birthweight: 4-5 months
• Triple birthweight: 1 year
• Daily weight gain:
• 20-30 g for first 3-4 months
• 15-20 g for rest of the first year
2.HEIGHT
• Average length: 20 in. at birth, 30 in. at 1 year
• At age 4 years, the average child is double birth length or 40 in.
3.HEAD CIRCUMFERENCE (HC)
• Average HC: 35 cm at birth (13.5 in.)
• HC increases: 1 cm per month for first year (2 cm per month for first 3 months, then slower)
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WEIGHT
WEIGHT IS ONE OF THE BEST CRITERIA FOR ASSESSMENT
OF GROWTH AND A GOOD INDICATOR OF HEALTH AND
NUTRITIONAL STATUS OF CHILD.
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WEIGHT
At birth is 3 - 3.5 kg
1st week
Weight loss of 5-10 % during the first
3 to 4 days of life.
Weight regained by the
7th —10th day of life.
Daily weight gain during infancy:
• 20-30 g / day during the first 3- 4 months
• 15-20 g / day for the rest of the first year.
Daily weight gain during infancy
• 3/4 kg/ month for the first 4 months
• 1/2 kg/ month for the second 4 months
• 1/4 kg/ month for the third 4 months .
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1st Year
Double Birth Wt.
6 kq-4 month 8 kg- 8 month 9 ko- 12 month
Triple Birth Wt. Quadrable the weight at2years

Weight
• WEECH’S FORMULAcalculate the expected weight (KG)
a) 3 – 12 months
Expected weight(kg) = age (months) + 9 / 2
b) 1- 6 years
Expected weight(kg) = age (years) x 2 + 8
c) 7 – 12 years
Expected weight(kg) = (age (years) x 7) - 5 / 2
• The periodic recording of weight on a growth chart is essential for monitoring the growth of under-five
children.
• Presence of wastingalone indicates acute energy deficit.
• While stuntingimplies long-term energy deficit
• A combination of wasting/stuntingimplies an acute nutritional insult superimposed on long-
term energy deficit.
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Weight for age
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Nutritional status Wt for age (% of expected)
normal >90
1
st
degree PEM 75-90
2
nd
degree PEM 60-75
3
rd
degree PEM <60

LENGTH /HEIGHT
Increase in height indicates skeletal growth.
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Stadiometer
Infantometer

LENGTH /HEIGHT
• Height: > 2 years
• (standing length)
• Taken From children > 2 yrs.
• Scale: Stadiometer
• Length: < 2 years
• (recumbent supine length)
• Taken From infants and children < 2
• Scale: InFantometer
• If child less than 2 years cant lie down length =height +0.8
• Repeat this 2x and if 2 numbers > 0.5 cm different, repeat this again
• Repeat this 2x and if 2 numbers > 0.5 cm different, repeat this again
• The maximum growth potential of an individual is decided by
hereditary factors, (consider parental height)
• Is considered an index of chronic or long duration malnutrition .
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Stadiometer
Infantometer

LENGTH /HEIGHT
• First 3 months: increases 3 cm/ month.
• Second 3 months: increases 2 cm/ month
• From 7-12 months: increases 1.5 cm / month
• From 1/ 2 years: increases 0.5-1 cm / month
• After 2 years use the Following formula to calculate
height:
• Height in cm = (Age in years x 5) +80
• Height at 4 years = Birth length X 2
• Height at 12 years = Birth length X 3
• By 13 years of age, a child triples his birth length (about
150 cm).
RETURN TO INDEX
Birth length =50 cm
length at 6 Ms.= 65 cm
1st year

RETURN TO INDEX

MIDPARENTAL HEIGHT
• Prediction of adult height
• The calculation of mid-parental height is useful to evaluate the child's genetic
endowment for linear growth.
• The determination is made by using the following formulae:
• Boys = (Mother's height in cm) + (Father's height in cm) / 2 + 6.5 cm
• Girls = (Father's height in cm) + (Mother's height in cm) / 2 - 6.5 cm
• Draw the range in the growth chart
RETURN TO INDEX

PLOT MPH AND TARGET RANGE ON
GROWTH CHART
• Extend 10 cm above and below from
MPH point: Target range
• Extend an imaginary line backwards
from the lower end of the target range
till reaches the patient’s height
• If a short child’s height is above this
line then child is familial short stature
and if below then child is pathological
short stature
RETURN TO INDEX

GROWTH VELOCITY
80
RETURN TO INDEX

GROWTH VELOCITY
RETURN TO INDEX
• GROWTH VELOCITY
• Weight gain or height gain over a unit period of time
• it is a better indicator of growth.
• It reflects the effectiveness of any intervention

NORMAL GROWTH RATES IN CHILDREN
RETURN TO INDEX
Age group Height velocity Weight velocity
Infancy (0 to 12 months) 25 cm/y 7 kg/y
Toddler (12 to 24 months) 11 cm/y 2.5 kg/y
Preschool/school age 6 cm/y 2.5 kg/y
Adolescent 3-4 cm/6 mo 3 kg/6 mo

WEIGHT FOR HEIGHT
Absolute status
83
RETURN TO INDEX

WEIGHT FOR HEIGHT
RETURN TO INDEX
• Weight-for-height is now considered more important than weight alone.
• It helps to determine whether a child is within range of “normal" weight for his
height
• Weight-for-height =
Weight of the patient (kg)
Weight of normal child. same height
X 100
Weight for height Nutritional Status
>90% Normal
85-90% Borderline Malnutrition
75-80 % Moderate .Malnutrition
<75% Severe Malnutrition

Abnormalities of Height/length & Weight in
Children
RETURN TO INDEX
• Stunted: H/A < 2 SD: Chronic malnutrition
• Wasted: W/H < 2 SD- Acute malnutrition
• Stunted & Wasted: Both H/A & W/H is < 2 SD

RETURN TO INDEX

HEAD
CIRCUMFERENCE
It is related to brain growth and development of intracranial volume.
RETURN TO INDEX

HEAD CIRCUMFERENCE
•When to measure
• Occipitofrontal circumference (OFC) should be measured in all children at health maintenance visits
between birth and three years of age.
• OFC should also be measured at each visit in children of all ages with neurologic or developmental
complaints
•Brain growth takes place 70% during fetal life, 15% during infancy and remaining 10% during pre-school years.
•Measurement of OFC in the newborn may be unreliable until the third or fourth day of life since it may be
affected by caput succedaneum, cephalohematoma, or molding
•Measuring technique
• The head circumference is measured by placing the tape over the occipital protuberance at the back and just
over the supraorbital ridge and the glabella in front.
88
RETURN TO INDEX

Measurement
• OFC measurements may be inaccurate
until the 3-4th day of life due to:
• Caput succedaneum
• Cephalohematoma
• Molding
RETURN TO INDEX

HEAD CIRCUMFERENCE
• While measuring the head circumference
• the maximum occipitofrontal circumference is measured by placing non stretchable tape firmly over the
most prominent region of the occiput and fronto-orbital ridge.
• The approximate increase -
• During first year there is 12 cm increase in head circumference
• 2 cm /months in first 3 months
• 1 cm /month in next 3 months
• 0.5 cm /month in next 6 months
• 1 – 5 year age , only 5 cm gain occur in head size.
• Adult head size is achieved between 5 to 6 years .
• females head circumference = 55 cm
• Males head circumference = 57 cm
RETURN TO INDEX
At birth 35 cm in FT new-born
Till 3 months 2 cm/month
3 months – 6 months 1 cm /month
6 months -1 year 0.5 cm /month
1 – 3 year 1cm/ 6 month
3 – 5 year 1cm/ year
head circumference in the first year of life =
( length in cm + 9.5 ) ± 2.59
2

RETURN TO INDEX

HEAD CIRCUMFERENCE
• The marasmus children are seen to have relatively large head for their body size because brain growth is
minimally affected by malnutrition.
• During states of undernutrition of varying severity, weight, linear growth (height) & brain growth are affected in
that order.
• Macrocephaly
• (HC is > 2 SD above the mean for age and sex):
• Causes
• Megalencephalic:
• Benign familial
• Neurocutaneous syndromes
• Lysosomal storage disease
• Increased CSF: hydrocephalus
• Enlarged Vascular compartment:
• Arteriovenous malformation
• Intracranial hemorrhage
• Microcephaly (HC is 3 SD below the mean for age andsex
• Causes
1. Primary: genetic or as a part of syndromes
2. Secondary: to drugs, toxins, infections, perinatal insult
RETURN TO INDEX

CHEST
CIRCUMFERENCE
Chest circumference or thoracic diameters is an importance parameter
of assessment of growth and nutrition status
RETURN TO INDEX

CHEST CIRCUMFERENCE
• It is usually measured at the level of nipples, preferably in mid inspiration.
• Xiphisternum
• In children
• ≤ 5years - lying down position
• > 5 years - standing position
1. BIRTH: HC > CC
2. 1 YEAR: HC= CC
3. >1 YEAR: H C < CC
95
RETURN TO INDEX

MID UPPER ARM
CIRCUMFERENCE (MUAC)
This measurement helps to asses the nutritional status of younger
children.
RETURN TO INDEX

SHAKIR TAPE METHOD
• Measures Mid Upper Arm Circumference (MUAC)
• During 1-5 Yrs of age it remains reasonably static between 15-17cms
among healthy children
• used to diagnose undernutrition
RETURN TO INDEX
COLOR CM
Red :<11.5cm (Wasted)
YELLOW 12.5 - 13.5cm (Boderline)
Green >13.5cm (Normal)

MUAC cutoffs to classify nutritional status in
children 6 months to 14 years of age
RETURN TO INDEX
• Severe acute malnutrition (SAM)
• Moderate acute malnutrition (MAM)
• Normal nutritional status
Normal Mild-moderate malnutrition Severe malnutrition
6-59 months > 13.5 cm 11.5-12.5 cm < 11.5 cm
5-9 years > 14.5 cm > 13.5 to < 14.5 cm < 13.5 cm
10-14 years > 18.5 cm > 16 to < 18.5 cm < 16 cm

SKIN FOLD THICKNESS
RETURN TO INDEX

Skinfold thickness
• Definition: the amount of subcutaneous fat when the fold is lifted and
• Skin fold thickness gives estimation of fat.
• Can be measured by Lange’s of Harpenden’s Skin fold calipers.
• The triceps skinfold is necessary for calculating the upper arm muscle circumference.
• Its thickness gives information about the fat reserves of the body, whereas the
calculated muscle mass gives information about the protein reserves.
• In clinical practice, we can measure:
• Triceps skin fold (back side middle upper arm, normally about 13-14 MM
• Subscapular skinfold (under the lowest point of the shoulder blade)
• Triceps skin fold thickness is < 10 mm in malnutrition.
• Biceps skin fold thickness
RETURN TO INDEX

BODY MASS INDEX
RETURN TO INDEX

BODY MASS INDEX (BMI)
•A BMI-for-age of > 85th percentile is suggestive of Overweight.
•A BMI-for-age of > 95th percentile is or when it is associated with triceps or skinfold
thickness-for-age of > 90th percentile, it is diagnostic of Obesity.
104
RETURN TO INDEX
Body mass index for age WEIGHT / HEIGHT2 Nutritional status
■ < 5th percentile <18.5 kg/m2 > Underweight
■ 5th - 84th percentile 18.5-24.9 kg/m2 > Normal
■ 85th - 94th percentile 25-29.9 kg/m2 > Overweight
■ > 95th percentile >30 kg/m2 > Obese

BODY PROPORTIONS
RETURN TO INDEX

Body proportions
• Useful body proportions: that may help in understanding various growth
disturbances include:
• Upper Segment / Lower Segment ratio
• Arm span/ height.
• CC / HC ratio
• Upper segment (US} / lower segment ratio (LS)
• LS: is measured as the length between pubic symphysis and the heel while
the US is calculated by subtracting the lower segment length from stature.

• Normal US/LS ratio
• The ratio is 1.7:1 at birth.
• The ratio is 1.3:1 by 3-4 years
• The ratio is 1:1 by 7 to 10 years
• Diseases with abnormal US/LS ratio: Short stature with:
• High US/LS ratio (short limbs) as in achondroplasia, rickets...
• Decreased US/LS ratio (short trunk): as in mucopolysaccharidoses,
hypogonadism
• Norma} US/LS —^proportionate dwarfism as hypopituitarism, constitutional
RETURN TO INDEX
Age US/LS Ratio
Birth 1.7/1
3 years 1.3/1
5 years 1.25/1
Puberty 1/1

Arm span / height ratio
• Measurement
• Extend both hands outward (each arm abducted to 90)
• Measure finger tip to finger tip length.
• Interpretation: Normal results
• Children: arm span is 1-2 cm shorter than height.
• Adolescent: arm span is same length as height.
• Adult: arm span exceeds height by about 5 cm.
• Longer arm spans
• Boys
• African American descent
• Arm span as compared to the height is another useful index^
• As it can differentiate proportionate short stature from disproportionate o
RETURN TO INDEX
RETURN TO INDEX

Measurements Age groups Advantage Disadvantage
Weight all
Common in use Difficult in field;
Can’t tell body composition;
need accurate age;
Need proper scale
Height all
Common in use
Simple to do in field
Differs by day time:
Other factors play a role
Head
Circumference
0-4 yr simple Other factors play a role
MUAC all
Simple; age dependent; child need not to be
denuded; suitable for rapid survey
No limits for over nutrition & no
standard for adults
Skin-fold thickness
All
Measure body composition;
Detect obesity in adults
Need expensive callipers; difficult with
the child & in the field
Chest –head ratio 1-2 yr Simple; age independent For limited age; no classification
method
108
Summary
RETURN TO INDEX

• Water low classification
Anthropometry
(percentage of normal )
normal Wasted
(Acute malnutrition)
Stunted
(Chronic malnutrition )
Wt for Age 100 70 70
Wt for Ht 100 70 100
Ht for Age 100 100 84
RETURN TO INDEX

III. DENTAL AGE
RETURN TO INDEX

Teething
• Most infants have their first teeth erupt at age 6–8 months of Age.
• Two types of Tooth are
• Primary or Deciduous
• The deciduous teeth start erupting at age of 6 months.
• Secondary or Permanent Teeth
• The permanent teeth at age of 6 years.
• All the deciduous teeth are replaced by the permanent teeth by the age of 12 years.
RETURN TO INDEX

Primary or Deciduous
• Deciduous or Milky teeth
• Count : 20 teeth
• Teething starts at 6- 9 months and completed at 24 months.
• The teeth in the upper jaw erupt earlier than the lower jaw except lower central incisors
RETURN TO INDEX
Age Eruption
At birth Nil
6-8 months Central incisors
10 months Lateral incisors
12-15 months 1st molar
15-21 months Canine
21-24 months 2nd molar

SECONDARY (PERMANENT) TEETH
• Count : 32 teeth
• Teething start at the 6th years and completed at 22nd years
• Eruption follow exfoliation immediate or may lag 4-5 months
RETURN TO INDEX
Age Eruption
6 1st molar
7-8 Central and lateral incisors
9 First premolar
10-11 2nd Premolar
11-12 Canines
12-13 2nd molars
17-22 3rd molars

TEETHING
• Symptoms of primary tooth eruption include:
1. General irritability, sleep disturbances, crying.
2. Rhinorrhea and facial flushing
3. Low grade fever up to < 38.3.
4. Diarrhea, loss of appetite, drooling.
5. Inflammation of the gingiva overlying the tooth gum.
6. Increased biting, gum-rubbing and ear rubbing (on the affected side).
• FACTORS INFLUENCE THE ERUPTION:
1. Local: two rows of teeth, ectopic eruption, infected primary teeth
2. Systemic: primary failure of eruption, hypothyroidism
3. Congenital: Down’s Syndrome, Achondroplastic Dwarfism, Cleidocranial Dysplasia
RETURN TO INDEX

TEETHING ERUPTION ABNORMALITIES
A. Delayed teething: No eruption beyond 13 months of age.
• Causes :
1. Idiopathic : the commonest cause
2. Local: e.g. supernumerary tooth, cysts, rigid gums
3. Generalized: (DACRO H2); Down syndrome, Achondroplasia, Congenital hypothyroidism, Rickets,
Osteogenesis imperfecta, Hypopituitarism, Hypoparathyriodism
B. Premature teething is seen is:
1. Natal teeth (should be extracted to avoid aspiration).
2. Congenital syphilis
3. Ellis Van Creveld syndrome:
1. Disproportionate dwarfism (short stature with short limbs)
2. Post axial polydactyly
3. Ectodermal dysplasia(teeth and nail)
4. Congenital heart disease (ASD)
5. Narrow chest
C. Congenital missing or extra tooth
RETURN TO INDEX

III. FONTANELS
NUMBER 6
RETURN TO INDEX

POSTERIOR FONTANEL
• Normally:
• Closed at birth or
• Opened < 0.5 cm and closes within 2 months
• Abnormally: Opened > 1 cm or Not closed within 4 months
• Causes :
1. Prematurity
2. Increased intra cranial tension
3. Mongolism
4. Cretinism
RETURN TO INDEX

ANTERIOR FONTANEL
• Assessment of growth
1. At birth  3 fingers (= 3- 4 cm).
2. At 6 months  2 fingers.
3. At 12 months  1 finger.
4. At 18 months  closed.
• Closed by 12-18 month
• Size
A. Large fontanel (delayed closure) in: (DACRO HI)
1. Down syndrome
2. Achondroplasia
3. Congenital hypothyriodism
4. Rickets
5. Osteogenesis imperfecta
6. Hypopituitarism
7. Increased intra cranial tension
B. Small fontanel (premature closure; before 6 months) in: (2 C)
1. Craniosynostosis
2. Congenital hyperthyroidism
RETURN TO INDEX

ANTERIOR FONTANEL
• Surface :
• Normally it is smooth & continuous with the skull bones
A. Bulging: with  intra cranial tension e.g.
1. Intra cranial infections
2. Hydrocephalus
3. Intra cranial hemorrhage
B. Depressed : in dehydration
RETURN TO INDEX

IV. BONE AGE
Skeletal maturation or bone growth is an indicator of physiological
development and continue up to 25 years of age.
RETURN TO INDEX

Osseous Growth
• Bone age
• Bone age is a measure of the degree of skeletal maturity of a child
• It is measured in years by the radiographic examination of ossification centers; most
often using the Greulich-Pyle bone age scale
• At > 6 month onwards  by x-ray over the left wrist
• No. of ossification centres in wrist = Age(yrs)+1
• In late childhood  by assessing fusion of epiphysis
RETURN TO INDEX
Age X-ray
New born Knee, Ankle
3-9 months Shoulder
3 yrs Wrist
12-16 yrs Elbow, Hip

Osseous Growth
• Normally; there are 5 secondary ossific centers at birth in
1. Lower end of femur.
2. Upper end of tibia.
3. Calcaneus, talus & cuboid
• “X ray knee in newborn help assess intrauterine skeletal maturation ; it is a good screening
tool for congenital hypothyroidism”
• Carpal bones start ossification after birth as follow
• The 1st carpal bone  ossifies at about 2nd month of age.
• The 2nd carpal bone  ossifies by the end of the first year.
• Later on, one carpal bone ossifies approximately each year till the 6th year; the 8th bone usually
ossifies at the 12th year of age
RETURN TO INDEX

Skeletal (osseous) Maturation
Causes of delayed and advanced bone age
Delayed Advanced
1. Familial delayed maturation, i.e.a ‘slow grower’
2. Hypothyroidism
3. Growth hormone deficiency
4. Hypopituitarism
5. Delayed puberty.
6. Cushing syndrome
7. Chronic illness / under nutrition
1. Growth advance
2. Precocious puberty
3. Excessive androgen production
4. Hyperthyroidism
5. Hyperpituitarism
6. Androgen excess (e.g. congenital adrenal
hyperplasia)
7. Simple obesity

V. GROWTH CHARTS (CURVES)
RETURN TO INDEX

Definition: Growth Chart
• Definition
• Graphic method for assessment of physical growth
• By plotting various growth parameters against the age (e.g., Weight & height for age...)
• A growth chart is a graphic design of a growth reference presented as a visual display for clinical use.
• comprise growth curves which display both the size of the newborn at a series of ages, and at the same
time their growth rate or growth velocity overtime, based on the slope of the curve.
• the charts have become an important tool in child health screening and pediatric clinical workup.
• Each parameter separate for boys (Blue) & girls (pink)
• 0-5 years
• Height, weight, HC , Weight tor height
• 5-18 years
• Height, weight, BMI
RETURN TO INDEX

Types of Growth Curves
Types
of
Growth
Curves
Z scores
Percentiles
Velocity
RETURN TO INDEX

WHAT IS A Z-SCORE?
RETURN TO INDEX
• Z Score (or standardized value): the number of standard deviations that a
given value X is above or below the mean

What is the percentile?
• The lines on a growth chart are called
centile lines and are based on measurements
of many children.
• It describes the percentage of children
expected to be below that line; 50% below
50th centile
• Normal value lies between the 3rd and 97th
centile
• Percentiles explained
• 97th percentile
• 3 in approximately 100 children are above this line
• 3rd percentile
• 3 in approximately 100 children are below this line
• 50th percentile
• Half the children at any age are above this line and
half are below
RETURN TO INDEX

USES OF GROWTH CHARTS
• Rational (= Why should growth cures be used?)
• There is wide range of variation among normal children
• Growth curves are used to detect any abnormal growth pattern
• Values
1. Assess growth and normal growth variations among children
2. Early predictor of malnutrition (flattening of weight curve)
3. Monitor success of treatment of malnutrition
• Uses of growth charts
1. Growth monitoring
2. Diagnostic tool
3. Planning and policy making
4. Educational tool
5. Tool for action
6. Evaluation
7. Tool for teaching
RETURN TO INDEX

GROWTH CHARTS
ADVANTAGES OF ANTHROPOMETRY
1.Less expensive & need minimal training
2.Readings are reproducible.
3.Objective with high specificity &
sensitivity
4.Measures many variables of nutritional
significance (Ht, Wt, MAC, HC, skin
fold thickness, waist & hip ratio & BMI).
5.Readings are numerical & gradable on
standard growth charts
Limitations of Anthropometry
1.Inter-observers errors in measurement
2.Limited nutritional diagnosis
3.Problems with reference standards, i.e.
local versus international standards.
4.Arbitrary statistical cut-off levels for
what considered as abnormal values.
RETURN TO INDEX

PLOTTING MEASUREMENTS
• Select the appropriate chart for the age, sex & measurements
• Calculate the child’s age
• Plot the weight measurement on the growth chart appropriate for age
& sex
• Use a plotting aid such as a straightedge
• Use the information in the clinical assessment process
• Share the information with the family
RETURN TO INDEX

134
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