Guide line for groth and development

GROWTH:
 It is the process of physical maturation resulting an
increase in size of the body and various organ.
 It occurs by multiplication of cells and increase in
intracellular substance
 It is a quantitative change in body
 Or refer to structural and physiological changes

DEVELOPMENT:
 It is a process of functional and physiological maturation
of the individual.
 It is a progressive increase in skill and capacity to
function.
 It is related to maturation and myelinisation of nervous
system.
 It include psychological emotional and social changes
 Qualitative aspects.

PRINCIPAL OF GROWTH AND
DEVELOPMENT:
Cephalocaudal direction
Proximodistal direction
General to specific

DEVELOPMENT:
Cephalocaudal direction:
 Improvement in structure and function come
first in the head region, then in trunk, and
last in the leg region.

DEVELOPMENT:
PROXIMODISTAL DIRECTION:
; The process in proximodistal
form centre or midline to
periphery direction.
Development proceed from near
to far
Out ward from central axis of
body to ward the extremities

Growth and development depend upon
multiple factor
They influence directly or indirectly by
promoting or hindering the process as
• Genetic factor
• Prenatal factor
• Post natal factor
FACTOR AFFECTING GROWTH AND
DEVELOPMENT:

FACTOR AFFECTING CONTI….
Genetic factor:
genetic predisposition is impartment factor
which affect the growth and development.
1) Sex
2) Race and nationality

FACTOR AFFECTING CONTI….
Prenatal factor:
Intrauterine environment is a important
factor of growth and development as
Malnutrition
Maternal infection
Maternal substance abuse
Hormones
Maternal illness

POST NATAL FACTOR:
Growth potential
Nutrition
Childhood illness
Psychological environment
Socioeconomic status
Birth order
Hormonal influences

AGE PERIODS:
Neonate:
 Birth to 1 month
Infant:
 1month-1yr
Early childhood:
 Toddler 1yr-3yrs
Preschool:
 3yrs-5yrs
Middle childhood:
 School age 6yrs-12yrs
Late childhood:(adolescent)
 13yr-18yr
image

ASSESSMENT OF GROWTH:
Assessment of growth
can be done by
anthropometric
measurement
Measurement of different
parameter is the
importance nursing
responsibility in child
care

WEIGHT:
Weight is one of the best
criteria of assessment
growth and good
indicator of health and
nutritional status of child.
Weight at full term
neonate at birth is
2.5-3.5kg
There is 10% loss
of weight first week
of life which regain
by 10 day of age.

WEIGHT:
 Weight gain about 20-30 gram/day for 1st three month
 Double at five month
 Trebled at one year
 Fourth time by two year
 Five time at three year
 Six time by five year
 Seven time by by seven years
 Ten time by ten years

LENGTH AND HEIGHT:
 Increase in height indicate skeletal growth, yearly
increment in height gradually diminished from birth to
maturity.
 At birth average length of a healthy new born is 50 cm.
 It increases to60 cm at 3month, 70cm at 9month and
75cm at 1year
 In second year increment approx 12cm
 Third year aprox 9 cm
 Fourth year 7cm and fifth year 6cm

LENGTH AND HEIGHT:
 So the child double the birth by 4-4.5yr of age
afterwards then is about 5cm increment in every yr
till puberty.

LENGTH AND HEIGHT:
PREREQUISITE:
Without footwear
Heels & back touching the wall
Looking straight ahead in frankfurt plane.
Gentle but firm pressure upwards applied to the mastoids from
underneath
Record to last 0.1cm

 It is an important criteria which help to asses the
normal growth or its deviation ie malnutrition or
obesity
BI more than 30 kg/m2 indicate obesity
and < 15kg/m2 indicate malnutrition
BODY MASS INDEX :

BODY MASS INDEX CATEGORIES:
Under weight <18.5
Normal=18.5-24.9
Over weight= 25-29.9
Obesity >30 or greater

HEAD CIRCUMFERENCE:
It is related to brain growth and development of intracranial
volume.
Average head circumference measured about 35cm at birth
Increase as
0-3month 2cm/m
3-6month 1cm/m
6-9month 0.5cm/m
9-12month 0.5cm/m
1-3yrs 0.2 cm/m

HEAD CIRCUMFERENCE:
If head circumference increase 1cm in two week during
first 3month of age then hydrocephalus is suspected.
Head circumference is measured by ordinal tape
it over occipital protuberance at the back,
above ear on side
just over the supra orbital ridges in front.

MEASUREMENT OF HEAD CIRCUMFERENCE:

FONTANELLES CLOSURE:
At birth anterior and posterior fontanelle generally
present
Posterior fontanelle close early few week 6-
8wk of life.
Anterior fontenelle closes by 12-18month of
age
Early closure of fontanelle indicate craniostenosis
due to premature closure of skull sutures.

CHEST CIRCUMFERENCE:
 Chest circumference or thoracic diameter is an
important parameter assessment of growth and nutrition
status.,
 At birth it is 2-3cm less than head circumference
 Become equal at 6-12month of age.
 After 1st year of age , chest circumference is greater
than head circumference by 2.5cm.
 about 5years, it is about 5cm larger than head
circumference

CHEST CIRCUMFERENCE:
 Chest circumference is measured by placing the
tap at level, around the nipple, in between
inspiration and expiration


MID UPPER ARM CIRCUMFERENCE:
Measurement help to asses nutritional status of younger
children
The average mid upper arm circumference at birth 11-12cm
At 1-5 year it is 16-17cm
At 12 year it is 18cm
At 15year it is 20-21cm

ERUPTION OF TEETH:
Their is the variation
in the eruption of
teeth , 1st teeth
appear is central
incision appear at
6-7 month of age.
Eruption
can be
delayed
up to
13month
Two
set of
teeth
Tempo
rary
perm
anent

ERUPTION OF TEETH:
Upper jaw teeth erupt earlier,
except the lower central incisor
1st molar >central & lateral incisor
>canines & premolar> 2nd molar> 3rd
molar

SKINFOLD THICKNESS:
 Skin fold consist of double fold of skin and
subcutaneous fat, excluding the under lying muscle.
 Used mainly in the estimation of fat content
 Common sites are triceps, subscapular.
Tools for measuring skinfolds:
Skinfold caliper:
1) Lange
2) Holtain
3) harpenden

UPPER AND LOWER SEGMENT LENGTH
&RATIO:
 Lower segment measured as the length between
pubic symphysis a and the heel.
 Upper segment is calculated by the subtracting
lower segment length from stature.
 Ratio of upper and lower segment is 1.7 at birth, at
3year 1.3, by 7-8 year upper segment equalizes the
lower segment.

UPPER AND LOWER SEGMENT LENGTH
&RATIO:
Increase:
 Rickets,
 achondroplasia,
 Untreated hypothyroidism
Decrease:
 spondyloepiphyseal
dysplasia,
 vertebral anomalies
By about 11 years of age, adult proportions are
reached

ARM SPAN:
 Distance between the tips to middle fingers of both
arms out stretched at right angle to the body &
measure across the back of child.
 < 10years 1-2cm less than the body height
 10-12years span equal to height
 Adult span greater than the height
Abnormally large span found in:
 Klinefelter’s syndrome
 Coarctation of aorta
 marfan’s syndrome

PUBERTAL ACHIEVEMENT:
Gonadal maturation
Secondary sexual characters
Adolescent growth spurt
Body composition and proportion
Skeletal maturity

Guide line for groth and development

AGE INDEPENDENT ANTHROPOMETRIC
INDICATORS:
Bangle test: If a bangle of 4 cm Internal diameter crosses elbow
Shakir’s tape: Plastic tape with color zones –Red if < 12.5 cm
Quac stick : Rod with markings for Height and Arm circumference.
Nabarrow’s thinness chart : Graphic chart for Wt/Ht
MAC:HC (Kanawati) ratio: 0.28-0.314 : Mild ; <0.249 : Severe
MAC : Height ratio : Normal if >0.32 ; Severe malnutrition if <0.29
Ponderal index : Weight (in kg)/ length 3(in cm) x 100 ; Normal if >2.5 ;
Symmetrical IUGR 2.0 -2.5 ; Asymmetric IUGR < 2.0
Dughadale ratio : Weight (in kg)/ height 1.6 ; Normal if >0.79 ;

Z- SCORE OR STANDARD DEVIATION
SCORE:
 The deviation of the value for an individual from the median value of
the reference population, divided by the standard Deviation for the
reference population
( Observed value) - (Median reference value)
Z- Score = --------------------------------------------------------
Standard deviation of reference population
 A fixed Z score interval implies a fixed height or weight difference for
children of a given age .
 Advantage:- Allows mean and SD calculation for a group of Z score
in population based applications.

PERCENTILE:
 The rank position of an individual on a given reference
distribution, stated in terms of what percentage of the group
the individual equals or exceeds .
Eg. A child of a given age whose weight falls in the 10th
percentile weighs the same or more than 10% of the reference
population of children of same age
 Towards the extremes of the reference distribution there is
little change in percentile values, when there is infact
substantial change in weight or height

STANDARD DEVIATION:
Denote the degree of dispersion or the scatter of observation away
from the mean
Approximately two third (68.3%) of observation lie within one standard
deviation above or below the mean value of the observation
95.4% value lie within 2SD
99.75 value lie within 3SD
Value beyond the 2SD are unusual in a normal population

CHARTS AND INTERPRETATION:
 x-axis:
In the Growth Record graphs, some x-axes show
age and some show length/height.
 y-axis:
In the Growth Record graphs, the y-axes show
length/height, weight, or BMI.
 plotted point– the point on a graph where a line
extended from a measurement on the x-axis (e.g.
age) intersects with a line extended from a
measurement on the y-axis (e.g. weight)

GROWTH PARAMETERS AND THEIR
INTERPRETATION FOR THE WORLD HEALTH
ORGANIZATION CHARTS:

 What are these growth charts?
 Growth charts are visible display of child’s physical
growth and development.
 Also called as “road-to-health" chart. It was first
designed by David Morley and was later modified
by WHO.
 A growth reference simply describes the growth of a
sample of individuals, whereas a standard
describes the growth of a healthy population and
suggests an aspirational model.

 WHO growth charts are growth standards. A
reference is representative of the existing growth
pattern of children and allows us to study the
secular trends in height, weight and obesity.
 On community and national level it helps identify
children at risk of morbidity and mortality. It thus
helps in implementation of national programmes for
nutritional and medical interventions like
supplementary feeding, foods to vulnerable group,

 Can reflect changes in morphological variation due
to inappropriate food intake or malnutrition
 There is no single permanent standard.
bcoz-Uniform growth pattern is not seen to occur
equally all over the world and also in subsequent
generations.
 50th percentile of Harvard Standards (1970s) is
considered 100% for Indian children. If a child is at
5thpercentile it means 5% children of that age have
less weight or growing less fast than this child.

 These growth charts are primarily designed for
longitudinal follow up of a child(growth monitoring),
to interpret the changes over time
 NCHS 1977 growth charts
 CDC 2000 growth charts
 WHO Growth Charts (2006)

 NCHS GROWTH CHART:(National Center for
Health Statistics ) 1977
 Using longitudinal-data from the Fels Research
Institute,
 collected in Yellow Springs and Ohio between
1929 and 1975
 Its sample was acknowledged to be quite limited
in geographic, cultural, socioeconomic and
genetic variability.

CDC 2000 GROWTH CHARTS
Two set of chart
 birth to 36 months of age
 2 to 20 years.
 BMI-for-age 2 to 20 years(not in NCHS )
1. National Health and Nutrition Examination Surveys
(NHANES),
2. National Natality Files
3. NatalityFiles in Wisconsin and-Missouri,
4. The CDC Pediatric Nutrition Surveillance System,
5. The Fels Research Institute child growth study
The primary source of data for the infant charts up
to age 6 months was NHANES III.

characteristic NCHS 1977(Fels
research institute)
CDC 2000( Third
National Health and
Nutrition Examination
survey)
Location Within a convenient
distance of Yellow
Springs, Ohio
U.S. nationwide, non-
institutionalized
Population
Study design Longitudinal follow up Cross sectional survey
Years of data collection 1929-1975 1988-1994
Exclusion criteria Triplets excluded VLBW(<1500g)
excluded
COMPARISON BETWEEN NCHS AND CDC
CHART:

characteristic NCHS 1977(Fels research
institute)
CDC 2000( Third National
Health and Nutrition
Examination survey)
Socio-economic
background
Middle class Representative of US
Racial/ethnic background Caucasian Representative of U.S. -
matches census
distribution for non-
Hispanic white, non-
Hispanic black, and
Mexican American,
Other racial groups subject
to random variation.
Ages Measurements made at
Birth, 1,3 and 6
month
Cross-section of population
spanning 2 to
6 months of age.

characteristic NCHS 1977(Fels
research institute)
CDC 2000( Third National Health and
Nutrition Examination survey)
Infant feeding
pattern
Nearly all formula fed Brest feed and
formula feed
Anthropometric
data quality
All measurements well-
standardized. Data
quality considered
high. Large
discrepancies between
length and stature data
have raised questions
about the quality of
the recumbent length
data
All measurements well-standardized
[Lohman et al. 1988] Data quality considered
high

ADVANTAGES OF CDC 2000 GROWTH CHART
 Most importantly the 2000 charts were representative, of all (non-VLBW)
infants in the U.S., not a select group of middle-class.white infants in a,
small US community
 Extent of breastfeeding in the NHANES III. sample was certainly greater
than was the case for the Fels study sample
Disadvantage of CDC 2000 Growth Charts
pooling of multiple datasets to construct the curves.
Though great care to ensure the comparability of the datasets
being pooled, we cannot rule out,the possibility that the shape of
the curves was affected by using different datasets at different
ages.

WHO GROWTH CHART:
 In 1993 the World Health Organization (WHO)
undertook a comprehensive review of the uses and
interpretation of anthropometric references
 Did not adequately represent early childhood growth
and that new growth curves were necessary.
 The World Health Assembly endorsed this
recommendation in 1994.
 In response WHO undertook the Multicentre Growth
Reference Study (MGRS) between 1997 and 2003 to
generate new curves for assessing the growth and
development of children the world over.

MGRS STUDY DESIGN YEAR
 Longitudinal (0-24 months)
 Cross-sectional (18-71 mo)
 WHO Multicentre Growth Reference Study (2006)After
the age of 5 years, the WHO extended the MGRS chart
till 18 yrs by appending NCHS data and extrapolating
the MGRS percentile lines.
 Many countries choose to use WHO charts only for
toddlers {upto 2 yrs in USA} [upto 4 yrs in UK] and their
own national charts for older children.

WHO GROWTH CHART:
 For the assessment WHO has provided charts for both
boys and girls.
 Growth indicators are used to assess growth
considering a child’s age and measurements together.
 length/height-for-age
 weight-for-age
 weight-for-length/height
 BMI (body mass index)-for-age

INTERPRET TRENDS ON GROWTH CHARTS:
When interpreting growth charts, be alert for the following
situations, which may indicate a problem or suggest risk:
 A child’s growth line crosses a z-score line.
 There is a sharp incline or decline in the child’s growth line.
 The child’s growth line remains flat (stagnant); i.e. there is no gain in
weight or length/height.

WHO GROWTH CHART BENEFITS:
 Seen as ‘gold standard’ of growth charts in terms of promoting
good health outcomes, including across cultures.
 Establishes breastfeeding as the biological norm.
 More suitable to the aboriginal population as the infants,
especially in remote communities, are predominantly
breastfed
 Have greater capacity to assist the early identification of
development of overweight

GROWTH CHART IN INDIA:
 The ICMR undertook a nationwide cross sectional study
during 1956-1965 to establish indian referance charts.
Irrelevant now as they were done on lower socio-economic
class.
 Indian context Multicenter study : Agarwalet al. (1992,1994);
Khadilkaret al. (2009);Marwahaet al. (2011)
 The growth charts compiled by Agarwal et al were based on
affluent urban children from all major zones of India measured
1989-1991. The data is now 20 years old.

 WHO recommends that each country should update its growth
references every decade and hence new growth references
were produced in 2009.
 Khadilkar et al have published the growth charts on affluent
children 5-18 years and have also compared the growth of 2-5
years old Indian children with the new WHO growth charts.
These are the most modern national growth references
available now at present.

 India has adopted the new WHO Child Growth
Standards (2006) in February 2009
 These standards are available for both boys and
girls below 5 years of age.

Guide line for groth and development

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