Piyush Gupta with Devendra Mishra, Arpita Gupta, and Rachana Dubey (Development)
1.1 Definitions
GROWTH
Growth is defined as an increase in body size in terms of weight, height, and other measurable domains. It is also defined as a measurable change in physical size of body and its parts. It is used to designate all the quantitative changes brought about in structure and function of human anatomy and physiology. Growth reflects an increase in body dimensions and a resultant change in mass of body tissue like fat, muscle, and bone. Examples of growth include change in weight, height, bone density, and dental structure.
During the growth of a child, there is increase in both cell numbers (hyperplasia) and cell size (hypertrophy). The growth is not a steady process; the rate of growth varies with periods of rapid growth and slow growth. For instance, infancy and adolescence are characterized by periods of rapid growth.
DEVELOPMENT
Development is defined as a progressive series of orderly coherent changes that occur as a result of maturity and experience. It may also be defined as behavioral changes in skills and functional abilities. Development refers to gaining of skills in all aspects of child's life like physical development, social and emotional development, intellectual development, communication, and speech development. Hence, the development is not easily measurable. The terms “maturation” and “learning” are often used along with development.
- Maturation refers to process of become fully developed in terms of physiological and behavioral aspects toward attainment of his or her best physical, emotional, intellectual, and social potential.
- Learning refers to assimilation of information once the child is mature for a particular learning experience resulting in behavioral change.
The terms “growth” and “development” are conceptually different, and denote two altogether different aspects of the change; i.e., growth is quantitative while development is qualitative. However, both are interdependent. For instance, to learn to open a door, the child must be able to reach the doorknob (physical growth) and also must have a sufficient learning as to how to open the door knob (development).
CONCEPT OF EARLY CHILDHOOD DEVELOPMENT
Contrary to the traditional definitions as discussed above, it is now being recognized that the terms “Growth” and “Development” are inseparable and cannot be seen in isolation from each other. Realizing that the ultimate functional potential of humans is primarily dependent on brain growth that occurs in the first 2–3 years of life, the emphasis has shifted to growth and development in early childhood period.
Definition: Early childhood development (ECD) is a generic term that refers to a child's cognitive, social, emotional, language, and physical development. Implying that it includes both growth and development as per definitions given above. The early childhood starts from the time of conception and may span up to first 8 years of life.
Early childhood development is a relatively new term that represents the thrive agenda of the global strategy for women, children, and adolescent health and is also included in WHO agenda for action. Lancet, in 2017, reported that 250 million under-5 children (43%) are not able to achieve their optimal development potential. In India, 45% children under 5 years (70 million) are at risk.
Nurturing Care for Early Childhood Development (NC-ECD)
Nurturing care is the key to children in their formative years, i.e., between 0 and 3 years (because maximum brain growth occurs 2in this period) to achieve optimal development. The domains of nurturing care include: (1) good health, (2) appropriate nutrition, (3) ensuring safety and security, (4) promotion of responsive parenting, and (5) facilitating early learning opportunities (Fig. 1.1).
Fig. 1.1: Components of nurturing care for early childhood developmentSource: World Health Organization, United Nations Children's Fund, World Bank Group. Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. Geneva: World Health Organization; 2018
WHY STUDY GROWTH AND DEVELOPMENT?
It is important to study growth and development because of the following reasons:
- To know what is expected of a child at a given age, in terms of physical and mental ability, especially in high-risk babies.
- To identify children who may not look apparently sick but are having a disease process that is affecting growth. For example, a child with celiac disease may remain asymptomatic except for faltering of linear growth. This initial clue for diagnosis can prevent the long-term physical and emotional consequences of the disease (both for the child and the family). Growth charting also helps to monitor the effect of treatment/intervention modalities on the pattern of growth.
- Early identification of handicaps: Developmental assessment helps in early diagnosis of global developmental delay, intellectual disability, cerebral palsy, hearing and visual handicaps, neurological and metabolic disorders, disorders of muscle tone, and physical handicaps.
- To assess the general health and nutrition status of the community. Prevalence of wasting, underweight, and stunting in under-5 children serve as indirect indicators of health and nutritional status of the entire community, and may provide a launching pad for advocacy, and planning the most appropriate intervention.
- Evaluation of social action. Effectiveness of medical or social actions for promoting health of the community can be evaluated by comparing the growth data before and after the intervention, such as mid-day meal or preschool children feeding programs.
- To assess suitability of a baby for adoption. Parents may approach pediatrician before adopting a child to assess whether the child has a normal growth and to exclude developmental disabilities.
IN A NUTSHELL
Definitions
- Growth: Quantitative increase in structure of body (e.g., gain in weight or height).
- Development: Qualitative changes in body function leading to acquisition of skills in all aspects of child's life such as physical development, social and emotional development, intellectual development, communication, and speech development.
- Early childhood development: A holistic term that encompasses both growth and development. Starts from conception, continuing till 8 years of age. Of these, the antenatal period and up to 3 years are the most crucial as 90% of neuronal connections are formed in this period.
- Nurturing care: Caregivers need to provide nurturing care to their children to achieve ECD. Nurturing care has five components: good health, adequate nutrition, safety and security, responsive parenting, and early learning opportunities.
- Countdown to 2030. (2021). Women, Children and Adolescents health. India Country Profile. [online] Available from www.nurturing-care.org. [Last accessed November, 2022].
- Gupta P. President's Page. IAP Commitment to Nurturing Care for Early Childhood Development. Indian Pediatr. 2021;58(Suppl 1): S3.
- Mukherjee SB, Agrawal D, Mishra D, Shastri D, Dalwai SH, Chattopadhyay N, et al. Indian Academy of Pediatrics Position Paper on Nurturing Care for Early Childhood Development. Indian Pediatr. 2021;58(10): 962-9.
- World Health Organization. Operationalizing Nurturing Care for Early Childhood Development. Geneva: WHO; 2019.
INTRODUCTION
- Growth at birth is dependent on intrauterine factors that include various maternal, fetal, and placental factors.
- Postnatal growth is controlled by various genetic, environmental, and endocrine factors. These are broadly classified as intrinsic factors (genetic and endocrinal factors) and extrinsic factors (nutritional, sociocultural, psychological, and environmental factors).
- Poverty, broken homes, nutritional insults, and parental education mainly affect ECD. Imbalance between protective factors and triggers affects brain growth, physical health, and psychological development.
Box 1.1 summarizes the factors affecting growth and development.
FACTORS AFFECTING FETAL GROWTH
Maternal malnutrition: Undernutrition of the mother is identified with intrauterine growth retardation and consequently small size of the fetus. Fetal nutrition involves three stages: (1) intake of food by the pregnant woman, (2) placental transfer to fetus, (3) and utilization and metabolism of nutrients by the fetus. The fetal nutrition is affected when any of the maternal, placental, or fetal factors are affected. Adequacy of maternal nutrition is predicted by gestational weight gain and her past nutritional intake (reflected by her weight, height, body mass index, and hemoglobin).
Substance abuse: Maternal smoking, alcohol, and tobacco consumption leads to direct neurotoxic effect as well as resultant decreased placental blood flow which can adversely affect the fetal growth.
Teratogens: Maternal infections (e.g., toxoplasmosis, rubella, and syphilis), maternal medications (e.g., antiepileptic drugs, thalidomide, and ethanol) and maternal radiation exposure can adversely affect the fetal growth especially in early gestation which is the period of maximum growth and differentiation.
Maternal illness and obstetric disorders (preeclampsia, anemia, malnutrition, and heart disease): These could adversely affect the fetal growth leading to intrauterine growth retardation.
FACTORS AFFECTING POSTNATAL GROWTH
Genetic Factors
- Race: Genetic influences are responsible for marked variation in body size and structure among different races across the globe. Americans and Europeans are taller while Japanese and Chinese are shorter.
- Heredity: Genetic makeup of an individual is primarily determined by what has been inherited from previous generation. Final height of a child is influenced by paternal and maternal height. Daughters often reach menarche at a similar age as their mother.
- Sex: On an average, girls are lighter and shorter than boys. Boys tend to be ahead of girls in terms of weight and height till puberty. Girls achieve puberty earlier than boys hence in 12–14 years age group girls may become taller than boys. Shoulders are wider in boys while hips are broader in girls.
- Genetic disorders: Defect in chromosomes (Down syndrome), single gene, a group of gene or a defect in product of a gene can result in short stature (Turner syndrome) or failure to thrive (inborn errors of metabolism).
Hormonal Factors
Prenatal growth is primarily influenced by insulin and insulin-like growth factors (IGF); while growth hormone and thyroxine are the most important hormones responsible for postnatal growth.
- Growth hormone: It is secreted by anterior pituitary and induces production of IGF-1 in the liver and skeletal tissues. IGF-1 acts as the final mediator of growth. Thyroxine and cortisol may also influence the IGF plasma levels. The GH–IGF axis is also influenced by nutritional, systemic, and endocrine disorders.
- Thyroid hormones: These are crucial for epiphyseal development and growth.
- Gonadal hormones: They play an important role in inducing pubertal growth spurt. Gonadal steroids are responsible for pubertal growth, calcium accretion, and skeletal growth. Estrogens are responsible for epiphyseal closure in both boys and girls.
Nutritional Factors
Nutrition is the most important environmental factor influencing growth. Any imbalance in diet might result in either undernutrition or obesity.
- Undernutrition: Appropriate macronutrient (calorie, protein, fat, etc.) and micronutrient (vitamins and minerals) intake is essential for adequate growth. Indian Council of Medical Research (ICMR) has outlined estimated average 4requirement (EAR) of all nutrients for sustenance and maintenance of growth. Undernourished children lag in attainment of age-appropriate weight, height, head circumference, and intellectual scoring.
- Obesity: Introduction of JUNCS (Junk food high in fat, salt, sugar; Ultraprocessed, Nutritionally inappropriate, Colored/caffeinated/carbonated foods, and Sugar sweetened beverages), lack of physical activity, excessive and inappropriate dietary choices, and food fads could lead to inappropriately high body weight.
Sociocultural Factors
- Socioeconomic status: Children belonging to high socioeconomic status tend to be taller and heavier. Adolescents belonging to families of higher socioeconomic status are predisposed to developing obesity.
- Cultural beliefs: Culture influences every aspect of child rearing, nutrition, hygiene, health, and development. The culture, in turn, is influenced by ethnicity, religion, lifestyle, social class, and geographic location.
- Family size and structure: Number of children in a family and birth order might impact the food distribution in underprivileged households. Poverty, broken homes, nutritional insults, parental education, separated or divorced parents, family quarrels/conflicts, unemployment, and moving homes might deprive the emotional component to child's growth and development.
Environmental Factors
- Secular trends: India is following a secular trend of growth and puberty with subsequent generations having better height and early puberty, due to increasing industrialization and changing lifestyle.
- Geographic factors: Growth patterns differ between countries and climates. Iodine deficiency disorder, a widespread nutritional deficiency prevalent in children from mountainous Himalayan regions, may predispose to growth retardation.
- Environmental factors: Both indoor and outdoor air pollutants such as smoke, carbon monoxide, sulfur dioxide, and chlorofluorocarbons (CFCs) might influence the respiratory system and hence indirectly influence the growth and well-being. Similarly, sanitation, sewage treatment, waste disposal, and provision of safe water have impact on health.
- Access to healthcare: Ease of access to healthcare along with appropriate healthcare seeking behavior including well child visits during early childhood influence the growth in a positive direction.
Health Factors
Chronic ailments like congenital malformations and chronic infections; progressive renal, cardiac, gastrointestinal, and neurological illness; or malignancy could adversely affect the growth of child either directly or indirectly by interfering with the child's nutritional intake and metabolism.
Psychological Factors
Health and growth can be affected by the way the individuals feel about themselves (self-esteem and self-image). Stress may lead to decline of growth hormone levels leading to psychosocial dwarfism.
IN A NUTSHELL
Factors Affecting Growth and Development
- Growth at birth is mainly dependent on intrauterine factors.
- Postnatal growth is influenced by both genetic and environmental factors.
- Maternal malnutrition, illness, and teratogens are the main factors controlling size at birth.
- Race, heredity, and genetic disorders determine the basic framework of growth.
- Prenatal growth is primarily influenced by IGF-1, while thyroid and gonadal hormones are important for postnatal growth.
- Nutrition is the most important limiting or facilitating factor for postnatal growth.
- Early childhood development is hampered by poverty, broken, parental illiteracy, and nutritional insults.
- Ahmed SF, Phillip M, Grimberg A. The physiology and mechanism of growth. World Rev Nutr Diet. 2016;114:1-20.
- Cavallera V, Tomlinson M, Radner J, Coetzee B, Daelmans B, Hughes R, et al. Scaling early child development: what are the barriers and enablers? Arch Dis Child. 2019;104(Suppl 1):S43-S50.
- Hellström A, Ley D, Hansen-Pupp I, Hallberg B, Ramenghi LA, Löfqvist C, et al. Role of insulin like growth factor 1 in fetal development and in the early postnatal life of premature infants. Am J Perinatol. 2016;33(11): 1067-71.
- Prentice AM. Environmental and physiological barriers to child growth and development. Nestle Nutr Inst Workshop Ser. 2020;93:125-32.
1.3 Principles and Phases of Growth
PRINCIPLES OF GROWTH
- Growth and development are orderly and predictable. Every child goes through the same process. The growth is considered sequential with one stage leading to next stage.
- Growth progresses in a cephalocaudal and proximodistal manner. The process starts from the head to toe. Axial functions develop before functions of extremities. For example: Arm growth occurs before the finger growth.
- Growth is considered cyclic in the sense that the rate of growth is not constant. From birth to 2 years, there is a period of rapid growth. This is followed by a period of slow growth till puberty (10–12 years). This phase is followed by a phase of rapid growth again till 15–16 years of age. Periods of rapid growth are called critical periods and are most vulnerable to an external insult.
- Different tissues of body grow at different rates. Somatic growth follows a sigmoid curve with periods of rapid growth during infancy and puberty. The postnatal brain growth primarily occurs in the first year of life so that at 1 year infant has 90% adult brain size. In contrast to brain growth, lymphoid growth starts after 5 years of age. It peaks during 6–9 years of age and declines steadily, thereafter. Gonadal development resulting an increase in the size and function of reproductive organs starts after the onset of puberty (10–14 years) (Fig. 1.2).
- Growth is measurable both in terms of distance and velocity.
- Linear (distance) growth refers to overall growth at one point of time. Linear growth of a child can be compared to Growth Standards, and it can be interpreted whether the growth at the time of examination is within the normal range or not. But, linear growth does not predict the growth pattern in the recent past.
- Growth velocity or rate of growth is used to determine the growth pattern in recent past and it refers to increment of growth in a unit of time. Growth velocity can predict the ultimate growth potential and helps in early assessment of factors leading to growth retardation.
Fig. 1.2: Scammon's curves of systemic growth. Figure depicts the differential growth of body, brain, lymphoid organs, and genital organs, as the child passes through different phases of growth
PHASES OF GROWTH
It is amazing to realize the transformation of a fertilized egg to develop into an embryo and then into fetus and finally a complete human being. These phases of the growth can be classified into embryonic growth, fetal growth, somatic growth in infancy, preschool years, middle childhood, and adolescent (Table 1.1). A few authors have classified the phases of growth into two broad categories: Prenatal growth (before the birth) and postnatal growth (after birth).
- The prenatal period is characterized by three phases: Fertilized ovum or zygote (first 2 weeks), embryo (2–8 weeks), and fetus (9 weeks to birth).
- Postnatal growth also has three phases: Infancy, childhood, and adolescence.
Age of viability refers to the earliest age at which a fetus could survive, if they were born at that time, generally accepted as 23 weeks, or fetal weight of >400 g.
Conceptus is reserved for growing embryo or fetus and placental structure, throughout the pregnancy.
Puberty refers to that period of life when the ability to reproduce sexually begins. It is characterized by maturation of the genital organs, development of the secondary sex characteristics, and the onset of menstruation (menarche) in girls.
Prenatal Growth
Embryonic Period (0–8 Weeks)
Egg is fertilized by sperm to form a fertilized egg which gets transformed into a blastocyst and gets implanted in uterus with establishment of uteroplacental blood flow by 2 weeks of gestation. By 3 weeks of gestation, all the three germ layers are formed—endoderm, ectoderm, and mesoderm along with formation of primitive neural tube and blood vessels. By the end of embryonic period, rudiments of all major organs are formed. Times of intense development and rapid cell divisions are called critical period with development of each organ and tissue being most vulnerable to adverse influences during these periods. For example, critical period for neural tube development is 17–30 days; folate deficiency during this period could predispose to a neural tube defect.
Fetal Growth (9 Weeks to Birth)
During the fetal period starting from 9th week, there is consistent increase in cell number and cell size and differentiation of cells into tissues, organs, and systems. There is a rapid increase in fetal weight, length, and head circumference in the last half of gestation. Intrauterine fetal growth can be assessed by ultrasonography in terms of fetal weight, femur length, and biparietal diameter.
In human fetus in the early half of pregnancy, only 10–12% of body weight gain occurs. Early pregnancy is characterized by tissue differentiation, organ formation, and further development of fetal structures. However, there is a steady increase in weight 6at the rate of 15 g/day from 24 to 37 weeks of gestation. The weight gain declines in the last 2–3 weeks to 6 g/day. When the pregnancy proceeds beyond 42 weeks of gestation, the weight starts to decline. Similar reduction occurs in growth velocity for length, chest circumference, and head circumference after 37 weeks of gestation. The intrauterine growth curve for fetal body weight is S shaped or sigmoid in shape (See Annexures for fetal growth curves).
Fetal length (crown heel length) reaches to half of term length by 20 weeks of gestation. Rate of growth in fetal length reaches a peak of 1 cm/4 weeks by 20 weeks of gestation, and then it decreases. The growth curves for head and chest circumference resemble the fetal weight growth curve, but after 35 weeks of gestation, chest circumference appears to grow more rapidly reducing the difference between chest and head circumference. The normative curves for intrauterine growth have been constructed and any deviation or reduction in expected fetal growth pattern can result in intrauterine growth retardation (IUGR). These normative curves vary with ethnicity, socioeconomic status, parity, and multiple pregnancies. Hence, a caution needs to be exercised before labeling a fetus to be having IUGR.
Fetal Proportions
The embryo has gross anatomical features of human form. There is differential growth of body segments including the head, trunk, and lower extremity. At 2 months of gestation, the fetus has enormous head in proportion to body. By mid-gestation, growth of trunk and extremities occurs but still head looks proportionally larger. This differential growth continues in the postnatal period (Fig. 1.3).
Fetal Differentiation
Early weeks of pregnancy are characterized by differentiation and development of neurons and glial cells with neuronal migration. Major part of “brain growth spurt” is characterized by rapid multiplication of glial cells in early stages, followed by myelination of nerve fibers, extending from mid-gestation to 18 months of age. Normal pattern of fetal growth is determined by genetic potential, maternal nutrition, ability of placenta to transfer the nutrients, intrauterine hormones, and growth factors.
Fetal Growth Factors
Fetal growth in contrast to postnatal growth is not governed by growth hormones although the growth hormone levels in fetus are high. Hormones such as insulin, insulin-like growth factor (IGF), and thyroid hormones have an important role in late gestation for tissue differentiation and growth. Their growth promoting effect is primarily attributed to their anabolic effect on fetal metabolism. Glucocorticoids play an important role near term gestation for initiation and control of maturational events that occur in organs such as lung, liver, and gut.
POSTNATAL GROWTH
Normal growth pattern in children is shown in Figure 1.4.
Infancy (birth to 1 year): Infancy comprises of first year of life with maximum rate of growth. Physical, cognitive, and emotional 7development occurs in the first year of life. There is a rapid growth in most of the body systems and development of neuromuscular system.
Childhood (1–11 years): It consists of three broad groups: Toddler (1–2 years), Preschool (2–5 years), and school-going age group (5–11 years). This period is marked by steady progress in growth and maturation with a rapid progress in motor development. The phase of rapid growth in infancy is followed by slower growth rate after 1 year of age. Child attains to twice his birth length at the end of 2 years. Toddlers have relatively short leg, long torso, and exaggerated lumbar lordosis resulting in a protuberant abdomen. Growth at this stage depends on growth hormone and thyroid hormone. The deficiencies of growth hormone or thyroid hormone will typically present during this period with short stature.
Adolescence: The period of adolescence extends from age of 11 to 19 years. It is marked by hormonal influences leading to attainment of sexual maturity and adolescent growth spurt. This growth spurt differs by gender, with girls attaining it around 2 years prior to boys. Average age of adolescent growth spurt is 12–15 years in boys. This period is marked by alteration in relative proportion of muscle, fat, and bone resulting in change in body size and shape.
There is marked evolution of reproductive organs during adolescence. Sexual maturity is characterized by development of primary followed by secondary sexual characteristics. By the end of adolescence, boys acquire broader shoulder with deepening of voice; whereas girls acquire a broader pelvis and fat accumulation in buttock and breast region. During puberty, the child achieves almost 40% of peak bone mass. The average gain in height during adolescent period in boys is around 20–35 cm and in girls is around 15–25 cm.
IN A NUTSHELL
Principles and Phases of Growth
- Different tissues of the body grow at different rates. Maximum brain growth occurs in first year of life.
- Growth is described in two categories: Prenatal and postnatal.
- Prenatal growth is characterized by three phases (ovum, embryo, and fetus 9 weeks to birth).
- Postnatal growth is characterized by three phases (infancy 0–1 year, childhood 1–11 years; adolescence 11–19 years).
- Bernstein RM, O’Connor GK, Vance EA, Affara N, Drammeh S, Dunger DB, et al. Timing of the Infancy-Childhood Growth Transition in Rural Gambia. Front Endocrinol (Lausanne). 2020;11:142.
- Giglione E, Lapolla R, Cianfarani S, Faienza MF, Fintini D, Weber G, et al. Linear growth and puberty in childhood obesity: what is new? Minerva Pediatr (Torino). 2021;73(6):563-71.
- Hansen-Pupp I, Löfqvist C, Polberger S, Niklasson A, Fellman V, Hellström A, et al. Influence of insulin-like growth factor I and nutrition during phases of postnatal growth in very preterm infants. Pediatr Res. 2011;69(5 Pt 1):448-53.
- Rossavik IK, Brandenburg MA, Venkataraman PS. Understanding the different phases of fetal growth. Horm Res. 1992;38(5-6):203-7.
1.4 Normal Growth
SIZE AT BIRTH
Birth weight: The average birthweight of Indian infants is around 2.8–2.9 kg as compared to 3.4 kg in White Caucasian infants. The birthweight is influenced by the following factors:
- Maternal nutrition: Infants born to mothers who are short (height <145 cm), underweight (<45 kg prepregnancy weight), anemic (hemoglobin <8 g/dL), or hypoalbuminemic (serum albumin < 2.5 g/dL) are likely to be born low birthweight, i.e., <2.5 kg.
- Maternal infection, cigarette smoking, alcoholism or drug addiction, exposure to radiation, and living at high altitude also may lead to decreased birthweight.
- Fetal factors: Chromosomal anomalies, such as Down syndrome and gonadal dysgenesis, are associated with low birthweight.
- Singleton babies are heavier than infants of multiple births.
- Maternal toxemia, hypertension, and cardiac disease can result in low birthweight.
- Infants of diabetic mothers are generally heavier than average.
Length of a normal full-term male infant is around 50 cm.
Head circumference at birth is 35–37 cm.
Physical proportions: The head is large for body size, face is small and rounded, mandible is small, chest is rounded, and the abdomen is protuberant. Limbs are short and ratio of upper to lower segment is high (1.7:1).
GROWTH IN INFANCY (FIRST YEAR OF LIFE)
Weight: A term child loses 10% of his weight during first 3 days of life because of excretion of excess extravascular fluid and possibly poor intake. The birthweight is regained by 10 days of life. Subsequently, the weight gain occurs at a rate of 25–30 g/day for 8the first 3 months of life. Thereafter, about 400 g of weight gain occurs every month, for the remaining part of the first year. The consistent gain of weight during infancy provides a useful guide to nutritional status and health of the infant; it is not as sensitive a guide in the older child. Usually, the infant doubles his birthweight by 5 months and triples the birthweight by 1 year of age. The weight at 5 months, 1 year, and 2 years is approximately 6, 9, and 12 kg, respectively.
Length: The most dynamic linear growth spreads over during the first 2 years of life. A term newborn measures 50 cm at birth, 60 cm at 3 months, 70 cm at 9 months, and 75 cm at 1 year of age.
Head growth: It occurs in parallel to the rapid brain growth during this period. There is a 5–6 cm increase in head size during the first 3 months after birth and an additional 5–6 cm during the rest 9 months in the first year. Head circumference at 1 year of age is 45–47 cm. If the head growth exceeds 1 cm in 2 weeks during the first 3 months, hydrocephalus should be suspected.
Chest circumference: This is less than the head circumference at birth. The two equalizes by 6 months of age.
GROWTH AFTER INFANCY
Weight: The weight of a child at the age of 2 years is four times and at 3 years is usually five times that of the birthweight. The child gains, on an average, about 1.5–2.5 kg/year, from the age of 2 years till onset of adolescence. During the preschool years, between 2 and 5 years, the child gains on an average 2 kg (1.5–2.5 kg) in weight per year. Weight for age at a given age is more for boys as compared to girls. The adolescent acceleration in weight occurs earlier in girls (10–12 years) than boys (beginning 2 years later). The rapid weight gain is greatest in the year before menarche. Find below some formulae for a rough and quick calculation of expected weight between the ages of 3 months and 12 years. However, refer to the standard reference growth charts for exact values.
3–12 months | expected weight = (age in months + 9)/2 |
1–6 years | expected weight = 2 (age in years) + 8 |
7–12 years | expected weight = [7 (age in years) − 5]/2 |
Stature: The child usually reaches a length of approximately 88–90 cm by 2 years. Height at 4 years of age is 100 cm (which is double the length at birth). The child gains on an average about 4–5 cm/year from the age of 2 years till the onset of puberty. By 13 years of age, a child triples the birth length. Adolescent spurt of growth in height corresponds closely to weight gain. The following formula can be used for a rough and quick calculation of expected height, between the ages of 2 to 12 years.
Expected height = (age in years × 6) + 77
Head circumference: It increases less rapidly during the second year of life in accordance with the decreased growth of the brain. The head circumference increases by 2 cm in the second year of life (47–49 cm by 2 year) and then at a rate of 1 cm per year from 2–5 years of age. At 12 years of age, the average head size is 52 cm.
Mid-upper arm circumference: Normal mid-upper arm circumference of a term newborn is 9–11 cm. By 1 year of age, it grows to 16 cm. Mid-upper arm circumference (MUAC) increases by only 1.0 cm between the ages of 6 months and 5 years, therefore, it is also called an age-independent criterion between these ages. A child between 6 months and 5 years is termed undernourished, if the mid-arm circumference is <12.5 cm. Severe acute malnutrition is characterized by mid-arm circumference <11.5 cm (between 6 months and 5 years of age).
Velocity of growth in terms of both height and weight is most rapid during the first year of life and then falls rapidly. Weight velocity is 6 kg in the first year of life, and 2 kg/year in the preschool child, and 3 kg/year till puberty. Height velocity is 25 cm in the first year of life, 12 cm in the second year, followed by around 5–6 cm per year till puberty.
Body proportion: The ratio of upper segment (crown to pubic symphysis) and the lower segment (pubic symphysis to heel) is 1.7 at birth. Thus, sitting height represents 65–70% of total length in the newborn infant. After birth, limbs grow much faster than the trunk resulting in reduction of sitting height percentage. The ratio is 1.3 at 3 years of age. The upper segment equalizes the lower segment by 8–10 years of age (ratio 1:1).
Arm span is less than the stature by 1–2 cm by 10 years of age. Thereafter, arm span exceeds the height but the difference always stays <3–5 cm.
ERUPTION OF TEETH
The deciduous teeth start erupting at 6 months of age and the permanent teeth at about 6 years of age. All the deciduous teeth are replaced by the permanent teeth by the age of 12 years. A child between the age of 6 and 12 years has a mixed dentition. Ages of eruption and shedding of primary (deciduous) teeth are provided in Table 1.2.
Primary dentition: The lower central incisors appear between the ages of 5 and 8 months. The upper central incisors appear a month later and the lateral incisors usually within the next 3 months. The first molar teeth appear around the age of 12–15 months, preceding the eruption of canine teeth by 6 months, which appear between the age of 18 and 21 months. The second molars are out at the age of 21–24 months.
Permanent teeth erupt in the following order. 1st molar—6 years; central and lateral incisors—6–8 years; canines and premolars—9–12 years; second molars—12 years; third molars—18 years or later (Fig. 1.5).
| |||||||||||||||||||||||||||||||||||||||||||
Fig. 1.5: Timing of permanent tooth eruptionSource: Adapted from ADA Division of Communications; Journal of the American Dental Association; ADA Council on Scientific Affairs. For the dental patient. Tooth eruption: the permanent teeth. J Am Dent Assoc. 2006;137(1):127
IN A NUTSHELL
Normal Growth
- Average size at birth:
- Weight 2.8 kg; Length 50 cm, Head circumference 35–37 cm.
- Average size at 1 year:
- Weight 8–10 kg; Length 75 cm, Head circumference 45–47 cm.
- After 2 years, weight increases by 1.5–2.5 kg/year and height increases by 4–5 cm/year, till puberty.
- Mid-arm circumference is 9–11 cm at birth, increases to about 16 cm at 1 year. After 1 year, it increases @only 0.25 cm/year; thus called age-independent between 1 and 5 years of age.
- Deciduous teeth start erupting by 6 months, and permanent teeth by 6 years of age.
- ADA Division of Communications; Journal of the American Dental Association; ADA Council on Scientific Affairs. For the dental patient. Tooth eruption: The primary teeth. J Am Dent Assoc. 2005;136(11):1619.
- Cameron N. The biology of growth. Nestle Nutr Workshop Ser Pediatr Program. 2008;61:1-19.
- Fernández MA, Delchevalerie P, Van Herp M. Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards. Pediatrics. 2010;126:e195-201.
- Rogol AD, Roemmich JN, Clark PA. Growth at puberty. J Adolesc Health. 2002;31:192-200.
INTRODUCTION
Anthropometry (Greek anthropos—man and metron—measure) refers to the measurement of the human. Measurements that can be made on the body are almost limitless but weight and stature (height/length) are the most widely taken growth measurements. Commonly measured parameters are discussed below.
WEIGHT
Before the advent of digital electronic scales, two types of weighing scales were commonly used: Beam balance scales (with moving weights) and the spring balance scales. Of these, beam-balancing scales were more accurate.
The basket/pan type scale for infants can be used to weigh children up to 10.0 kg. Infants can be placed on the tray, which is supported on a reading frame calibrated for measuring a minimum of 10 g increment. The platform scale is for older children who can climb and stand up on the scale.
- Weigh the child in bare minimum of clothes and without shoes. Infants should be weighed naked (without diapers) and older children can be weighed with a vest and brief.
- Ensure that the scale is resting on firm, stable and even surface, or uncarpeted floor.
- Check the zero of the scale before weighing. Calibrate the weight scale at the beginning and at the end of each measurement.
- Infants: Place the infant in a manner so as to distribute the weight evenly about the center of the pan. If a diaper is worn, its weight should be subtracted from the observed weight; because the reference data for infants is based on nude weight.
- Children: Ask them to stand in the center of the platform, with bodyweight evenly distributed on both feet. Ensure that the child is not holding onto anything.
- A child on follow-up should preferably be weighed on the same scale.
- Read the weight by standing in front of the scale and not from the side.
STATURE
Stature is ascertained by measuring the length (in children <2 years old) or height (in older children).
Harpenden infantometer: It is used to measure the length of a newborn and infant. The tool consists of a horizontal wooden board limited by two vertical planks perpendicular to the two ends (Fig. 1.6). At one end, plank is fixed to the wooden board (headpiece); the other end has a movable vertical plank to adjust to the infant's length (foot piece). There is a calibrated reading strip in the middle of the board on which the length of the baby can be read directly. The infantometer is designed to measure lengths between 0 and 100 cm, with a precision of 1 mm.
Stadiometer: It is used for measuring standing height. The child stands on a wooden plank with his back against a wooden board that is calibrated in cm/inches. A flat board (wooden, metallic or cardboard) is placed at head end of the child to level off the height. Alternatively, the height can also be measured against a flat wall.
Length
- Place the child supine on the infant measuring board.
- Ask the assistant to hold the child's head in the Frankfort plane, while you steady the legs. The head is positioned in the Frankfort plane when the crown touches the headpiece and a vertical line from the ear canal to the lower border of the eye socket is perpendicular to the horizontal board (i.e., positioned vertically). Apply gentle traction to bring the head into contact with the fixed headpiece.
- Position the child's shoulders and hips at right angles to the long axis of the body. Apply gentle pressure on the knees to straighten the legs and prevent the knees from flexing.
- Bring the movable footboard to rest firmly against the child's feet with the soles flat on the board and the toes pointing directly upward.
- Record the measurement to the nearest 0.1 cm from the counter on the measuring board.
Height
- Remove the hair ornaments, undo the buns and braids, and take off the footwear.
- Ask the child to stand on the stadiometer with feet slightly apart at a 60° angle and confirm that the weight is evenly distributed on both feet. The arms hang freely by the sides of the trunk with palms facing the thighs.
- Ensure that the back of the head, shoulder blades, buttocks, calves, and heels are touching the vertical board/wall. This can be done by trying to insert a plastic rule at places where these points touch the wall. Inability to insert the rule implies good contact.
- Ask the child to look straight. Position the child's head so that a horizontal line drawn from the external auditory 11meatus to the lower edge of the eye socket runs parallel to the baseboard (i.e., the Frankfort plane positioned horizontally) (Fig. 1.7).
- The headpiece is moved down to rest firmly on top of the child's head, compressing the hair; keeping it perpendicular to the wall.
- Record the reading to the last completed 0.1 cm.
BODY CIRCUMFERENCES
Circumferences are measured to nearest 0.1 cm with a tape made up of a soft and nonshrinkable material.
Head Circumference
The head circumference is recorded between birth and 6 years of age (the period of brain growth) as the maximum circumference of the head with measuring tape overlying the occiput at back and supraorbital ridges in front.
- Anchor the tape just above the eyebrows.
- Ensure that the tape overlies the most prominent part of the occipital prominence at the back of the head.
- The tape should be perpendicular to the long axis of the face and should be pulled firmly to compress the hair, skin, and underlying soft tissues.
- Record measurement over the parietal eminence by cross-over technique (Fig. 1.8).
Chest Circumference
- Place the infant in the lap of the mother and stand in front. The chest should be bare.
- Abduct the arms of the infant slightly to permit passage of the tape around the chest.
- Pass the tape around the chest of the infant, at the level of nipples or 4th costosternal joints.
- Lower the arm to their natural position, once the tape is snugly in place.
- Record the circumference in a horizontal plane, midway between inspiration and expiration (Fig. 1.9).
Mid-upper Arm Circumference
Mid-upper arm circumference (MUAC) is recorded for children between 6 months and 5 years of age to nearest of 0.1 cm. A mid-upper arm circumference of <12.5 cm indicates malnutrition.
- Palpate and mark the two important bony landmarks, i.e., the acromion process and the olecranon. Forearm should be flexed while marking these points.
- Mark the mid-upper arm point. It is half the distance between the acromion process and the olecranon.
- Encircle the tape around the arm, over the marked midpoint, perpendicular to the long axis of the upper arm, with arm hanging freely in a relaxed position (Figs. 1.10A to C).
- Ensure that the tape lies flat around the arm, without compressing the skin or underlying tissue; there should be no gap or compression on the inner part of the arm.
SKINFOLD THICKNESS
Measurements of skinfold thickness may be useful in the estimation of muscle mass or of body fat content. The proportionate mass of subcutaneous tissue is greatest at about 9 months. It decreases steadily till about 6 years, when the increase begins again.
In clinical practice, however, measurements of triceps and subscapular skinfold thickness generally are sufficient. The thickness is expressed in millimeter and is taken using a skinfold caliper (Holtain or Harpenden).12
BODY PROPORTIONS
Useful body proportions that may help in understanding various growth disturbances include body mass index (BMI), sitting height for upper segment/lower segment ratio, and arm span.
Body mass index: It is calculated as weight in kg/(height in m2) and considered as the most important parameter used for assessment of growth in adolescents and adults. For Asian adults, the normal BMI lies between 18.5 and 23. Those having a BMI of between 23 and 28 are called overweight. Obesity is defined as a BMI of >28. Adults with BMI of <18.5 are termed to be having “chronic energy deficiency”.
Absolute cut-off values for defining chronic energy deficiency, overweight, and obesity are not applicable for children and adolescents. Therefore, evaluation of BMI in these age groups is carried out by comparison with age-related standard percentile charts. Obesity is defined as BMI greater than the 95th percentile for age whereas overweight refers to BMI between 85th and 95th percentile.
Sitting height: It denotes the upper segment length and represents 65–70% of total length in the newborn infant. After birth, limbs grow much faster than the trunk resulting in reduction of sitting height percentage. By the time of adolescence, the upper segment almost equals with the lower segment. High upper/lower segment ratio indicates short limb dwarfism.
Arm span: It is the physical measurement of the length from one end of an arm (measured at the fingertips) to the other when raised parallel to the ground at shoulder height at 180° angle. The arm span as compared to the total stature is a useful index. Usually, the difference between the two is not >3 cm. Longer arm span is seen in Marfan syndrome. For detailed description of methods of anthropometry and its interpretation, refer to “Clinical Methods in Pediatrics” by Piyush Gupta.
VELOCITY OF PHYSICAL GROWTH
Measurement of the velocity of growth or increment in a unit of time is a better tool for early identification of factors affecting growth. Velocity of growth can also help in predicting the ultimate adult height. The normal growth velocity curve for height is shown in Figure 1.11. The growth velocity is maximum during the first year of life. A second growth spurt occurs during puberty. This is known as the peak height/weight velocity. Maximum growth velocity occurs at sexual maturity rate (SMR) stage 3–4 in girls and SMR stage 4–5 in boys. Girls achieve pubertal growth spurt about 2 years prior to boys.
Fig. 1.11: Normal growth velocity in children (boys and girls). The figure shows that girls achieve pubertal growth spurt about 2 years prior to boys
BONE AGE ASSESSMENT
Bone age is a tool to evaluate skeletal maturation which in turn depends on hormonal influences. Assessment of bone age is thus used for diagnostic evaluation of children with growth failure, and advanced or delayed puberty. In healthy children, bone age corresponds to chronological age. A discrepancy between the two suggests a defect of the endocrine system. Characteristically, hypothyroidism slows the skeletal growth; ossification is delayed and bone age is less than the chronological age.
Ossification of skeleton begins in the intrauterine period—starting first in the clavicles followed by skull, long bones, and spine. Shaft ossifies earlier than the ends of the bone. The earliest epiphyseal centers to appear are those for os calcis and talus (22–26 weeks of gestation). At the time of birth in a full term 13newborn, the distal epiphyses of femur (age of appearance: 31–39 weeks of gestation) and the proximal epiphyses of tibia (age of appearance: 34 weeks of gestation to 5th postnatal week) are usually present. Two carpal bones are present at 1 year; and by 6 years, epiphyses of 7 carpal bones are present except pisiform, which ossifies later during puberty.
By convention, radiograph of the left limb is taken for computing bone age. At different chronological ages, radiographs of different parts of the body are required for correct assessment. For example, in the newborn period, radiographs of foot and knee are helpful. Between 3 and 9 months, radiographs of the shoulder is taken. X-ray of hands and wrists should be obtained between 1 and 12 years of age. For children between 12 and 14 years, radiographs of elbow and hip are helpful. A serial evaluation is always much more helpful than a single radiograph. Girls are more advanced than boys in skeletal development at all ages. Bone age corresponds more closely to SMR staging than to chronological age during puberty.
The two most widely used tools to assess bone age are the Greulich–Pyle Atlas method and the Tanner–Whitehouse 2 Individual Bones method (TW2 method). It is important to note that these methods are not always comparable and cannot be considered interchangeable. Readers are advised to refer to advanced text for more details.
IN A NUTSHELL
Assessment of Physical Growth: Anthropometry
- Commonly measured anthropometric parameters include weight, length, height, head and chest circumference, and midarm circumference.
- Weight and height/length are to be measured throughout childhood while body circumferences are important to be measured between birth and 5 years.
- Body mass index (BMI) is calculated as [weight in kg/height in m2] and considered as most important parameter to assess growth in older children and adolescents.
- Bone age is a tool to evaluate children with
- Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of Hand and Wrist. Stanford, CA: Stanford University Press; 1959.
- Gupta P. Clinical Methods in Pediatrics, 5th edition. New Delhi: CBS Publishers; 2022.
- Tanner JM, Whitehouse RH, Cameron N, Marshall WA, Healy MJR, Goldstein H. Assessment of Skeletal Maturity and Prediction of Adult Height (TW2 Method), 2nd edition. London: Academic Press; 1983.
1.6 Statistical Principles in Assessment of Growth
GAUSSIAN DISTRIBUTION
If measurements of any of the growth parameters (e.g., weight and height) are obtained in a large population of normal children and then arranged in a regular order starting from the lowest to the highest, a bell-shaped curve is formed (Fig. 1.12). This symmetrical curve illustrates a typical Gaussian (Normal) distribution, in which maximum values lie around the middle of the curve. The curve tapers off on the either side, with fewer observations at both the ends of the curve. Mean and median are equal in a Gaussian distribution.
MEAN AND STANDARD DEVIATION
Measurement of a parameter in a sample and its recording in a continuous numerical manner generates several measurements, the most important of them being mean and standard deviation (SD).
- Mean: It is obtained by dividing the sum of all observations by the number of observations. In a Gaussian distribution, the maximum number of values cluster around the average or mean.
- Standard deviation: It denotes the degree of dispersion or the scatter of observations away from the mean. It is estimated that 68.3% (approximately two-thirds) of the observations lie within 1 SD above or below the mean value of the observations. Values within the range of ±2 SD include 95.4% of all values. Values beyond 2 SD are unusual in a normal population. 3 SD around the mean includes 99.7% of all values.
MEDIAN AND PERCENT MEDIAN
When data are arranged in ascending or descending order of magnitude, half of the observations are above and the other half below a certain point. This point or value is known as the median. The median thus indicates that 50% of observations are above and 50% are below this point. In a typical Gaussian distribution, the median is expected to be equivalent to the arithmetic mean. Median, rather than the mean, is considered as the central value for most of the anthropometric parameters since the population data has a non-Gaussian (skewed) distribution.
PERCENTILES
Percentile indicates the position that a measurement would hold in a typical series of 100 arranged in ascending order. The median lies at the 50th percentile, on either side of which lie half the observations. Another example is the 85th percentile curve, which denotes that 15% of observations are expected to be above and 84% below it.
14Percentile location is used to designate where an individual stands with respect to other members of the population. The WHO growth standards show curves at 3rd, 15th, 50th, 85th and 97th percentiles, corresponding to distances from the average values. One standard deviation above or below the mean coincides with the 84th or 16th percentile curve, respectively.
Eighty percent of the weight/height measurements of healthy children at a given age are expected to lie between 10th and 90th percentiles. Further, 95% of the weight/height measurements of healthy children at a given age are expected to lie between 3rd and 97th percentile values. Thus, allowable normal range of variation in observations is between 3rd and 97th percentiles, which roughly corresponds to ±2 SD.
A healthy child normally remains and follows the same percentile curve during the entire period of his/her growth.
Z (SD)-SCORE
It represents the deviation of anthropometric measurement from the reference median and is calculated as follows:
Observed value – Median reference value standard deviation (SD) of the reference population
An SD score value of +1.5 means that the difference between the present (observed) and the expected (reference median value) is 1.5 times of the standard deviation of the reference population.
A negative value of Z-score means that the observed value is less than the expected; and vice versa. Similarly, a positive (+) value of Z-score indicates that the observed value of the measurement/index is more than the reference median.
Usually, −1, −2, and −3 Z-scores correspond to 15.8, 2.28, and 0.13th percentiles; while 1st, 3rd, and 10th percentiles correspond to −2.33, −1.88, and −1.29 Z-scores, respectively. Thus, the 3rd percentile roughly corresponds to −2SD.
Abnormal values usually refer to measurements below −2 Z-score (2.3rd percentile) or above +2 Z-score (97.7th percentile), relative to the reference median.
IN A NUTSHELL
Statistical Principles in Assessment of Growth
- Median, rather than mean is considered as the central value for most anthropometric parameters.
- Percentile indicates the position that a value will hold, arranged chronologically in a series of 100 values. Median is thus, the 50th percentile.
- Most normal children are expected to have their anthropometric measurements between 3rd and 97th percentiles.
- Z-score (also known as SD score) represents deviation from the central value.
- Usually, values between ±2 Z-score are considered normal.
- Curtis AE, Smith TA, Ziganshin BA, Elefteriades JA. The Mystery of the Z-Score. Aorta (Stamford). 2016;4(4):124-30.
1.7 Growth Charts, Growth References, and Growth Standards
GROWTH CHARTS
The growth charts comprise an X-axis that corresponds to the age in months or years; and Y-axis denoting the value of the anthropometric parameter, for example, weight (kg), height (cm), body mass index (kg/m2), etc. WHO growth charts are available for both percentiles and Z-score, separately.
- The WHO percentile charts depict 5 percentiles lines corresponding to 3rd, 15th, 50th, 85th, and 97th percentiles (from below to above) (Fig. 1.13A). Any child who is below the 3rd or above the 97th centile is likely to be abnormal.
- The WHO Z-score charts display curves for median, −2Z, −3Z, 2Z, and 3Z-scores (Fig. 1.13B). Abnormal is defined as any discrepancy of more than −2Z-scores. A deviation by more than −3Z-score denotes severe malnutrition. On the charts of growth velocity, the cut-off line for defining low-height velocity is below the 25th centile.
WHO growth standards for children <5 years have been adopted in many countries including India as the universal global standard, for monitoring growth in under-5 children. In 2015, Indian Academy of Pediatrics published new revised growth charts for Indian children 5–18 years of age in view of the changing trend in nutritional status of older children.
GROWTH REFERENCES VERSUS GROWTH STANDARDS
- Growth standards: These represent data on how a population of children should grow, under the given optimal nutritional and health conditions.
- Growth references: These are descriptive data that define how children in the population are growing under the best possible state of nutrition and health in a given community. They represent how children are actually growing rather than how they should be growing.
The WHO growth charts published in 2006, based on the WHO Multicenter Growth Reference Study (MGRS) for children under the age of 5 years, are an example of growth standards. Whereas the 2015 IAP growth charts are growth references which describe how children in India were actually growing at that point of time.
WHO GROWTH STANDARDS
The 2006 growth curves and charts developed by the World Health Organization (WHO) provide a single international standard that represents the best description of physiological growth for all children from birth to 5 years of age. These charts are based on the growth of exclusively breastfed infants. The second unique feature of these standards is that it is based on growth of children from many of the world's major regions: Brazil (South America), Ghana (Africa), India (Asia), Norway (Europe), Oman (the Middle East), and the USA (North America).
These standards show that all children of the world grow similarly till 5 years of age, provided the optimal environment, regardless of ethnicity and socioeconomic status. The standards show that nutrition, environment, and healthcare are stronger 15factors in determining growth and development than gender or ethnic background. The WHO standards differ from other existing growth charts in a number of innovative ways.
- WHO standards are based on longitudinally collected data as opposed to cross-sectional data in erstwhile NCHS reference (based on growth of North American Children). This is particularly useful in development of growth velocity standards.
- WHO standards describe “how children should grow,” as compared to earlier NCHS references which simply stated “how children are growing.”
- WHO standards make breastfeeding the biological “norm” and establishes the breastfed infant as the normative growth model. NCHS reference was based on the growth of artificially-fed children.
- WHO standards also include other growth indicators such as the skinfold thickness, and body mass index. These are useful to define obesity and overweight.
- MGRS also provide the Windows of Achievement standards for six motor development milestones including sitting, standing, and walking.
WHO charts have now replaced the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) Growth Charts for assessing the growth of children up to 5 years of age. The WHO growth charts are provided for weight-for-age (birth–5 years) (Figs. 1.13A to D); length/height-for-age (birth–5 years) (Figs. 1.14A to D); weight-for-length (birth–2 years) (Figs. 1.15A to D); and weight-for-height (2–5 years) (Figs. 1.16A to D). Corresponding tables are reproduced in the Annexures.
GROWTH REFERENCE FOR INDIAN CHILDREN 5–18 YEARS
Even though growth occurs in a similar manner among under-5 children throughout the world, but there do exist some regional variations among the pattern of growth of older children. The average adult weight and height are also different in different regions of the world because of the same reason. Thus for Indian children older than 5 years, the ideal reference standards would be the ones derived from Indian population itself.
In 2015, Indian Academy of Pediatrics (IAP) published the revised growth charts based on data collected from published studies on apparently healthy Indian children and adolescents in the past one decade. IAP recommends use of these charts as reference values for Indian children between 5 and 18 years of age. These reference curves are provided as Figures 1.17 and 1.18. We suggest using these charts as reference values for children above 5 years of age. Corresponding tables are reproduced in the Annexures.
GROWTH MONITORING
Growth monitoring is a screening tool used to diagnose nutritional discrepancies, chronic systemic illnesses, and endocrine disorders. Growth monitoring involves taking the same and multiple anthropometric measurements at regular intervals, approximately at the same time of the day and to see their changing trend. A single value only denotes the measurement at that point of time.
National Health Mission encourages growth monitoring of children <3 years of age. Children are monitored monthly in the Mother and Child Protection (MCP) Card (See below). The chart can detect whether a child is growing normally or having faltering in growth.16
Fig. 1.17: Indian Academy of Pediatrics (IAP) Growth Charts for height-for-age, and weight-for-age of boys (5–18 years)
Fig. 1.18: Indian Academy of Pediatrics (IAP) Growth Charts for height-for-age and weight-for-age of girls (5–18 years)
26A rising curve denotes “good” growth; a flattening curve is dangerous; and a downward curve calls for immediate management/referral. Green zone in the chart represents normally growing child; Yellow should be viewed with caution; and Orange represents undernutrition. The chart is to be used by all anganwadi workers (AWWs) and auxiliary nurse midwife (ANM).
IN A NUTSHELL
Growth Charts, Growth References, and Growth Standards
- WHO growth standards represent how children between 0 and 5 years should grow and show that all children of the world grow similarly till 5 years of age.
- WHO growth charts are available as (a) percentile curves (corresponding to 3rd, 15th, 50th, 85th, and 97th percentiles); and (b) Z-score curves (corresponding to 3Z, − 2Z, median, + 2Z, and + 3Z scores).
- Indian Academy of Pediatrics (IAP) growth charts (for weight, height, and BMI) are used as references for evaluating growth of children between 5 and 18 years of age.
- de Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr. 2007;137:144-8.
- de Onis M. 4.1 The WHO Child Growth Standards. World Rev Nutr Diet. 2015;113:278-94.
- Indian Academy of Pediatrics Growth Charts Committee. Revised IAP growth charts for height, weight and body mass index for 5- to 18-year-old Indian children. Indian Pediatr. 2015;52(1):47-55.
- Ong KK. WHO Growth standards: suitable for everyone? Yes. Paediatr Perinat Epidemiol. 2017;31(5):463-4.
- Singh P, Gandhi S, Malhotra RK, Seth A. Impact of using different growth references on interpretation of anthropometric parameters of children aged 8-15 Years. Indian Pediatr. 2020;57(2):124-8.
- van Dommelen P, van Buuren S. Methods to obtain referral criteria in growth monitoring. Stat Methods Med Res. 2014;23(4):369-89.
- WHO Multicentre Growth Reference Study Group. Relationship between physical growth and motor development in the WHO Child Growth Standards. Acta Paediatr Suppl. 2006;450:96-101.
- WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl. 2006;450:76-85.
- Ziegler EE, Nelson SE. The WHO growth standards: strengths and limitations. Curr Opin Clin Nutr Metab Care. 2012;15(3):298-302.
1.8 Normal Development
LAWS OF DEVELOPMENT
- Development is a continuous process from conception to maturity, and implies maturation of function, interaction with environment, communication, and independence in day-to-day activity. For example, at birth, a neonate is not able to roll over, sit, approach objects voluntarily, laugh, or interact with the help of language. In due course of time, sequentially, the infant acquires all such functions.
- Normal development requires an anatomically and functionally normal central nervous system, peripheral nervous system, musculoskeletal system, hearing and vision, supported by a suitable environment. A child with a morphologically abnormal central nervous system (e.g., anencephaly and meningomyelocele) or damaged neurons and pathways (e.g., following hypoxic or ischemic insult) is unlikely to have a normal development.Abnormal development may result from intrauterine and perinatal insults (perinatal asphyxia, kernicterus, etc., resulting in delayed development right from birth), or disease affecting neuronal pathways and myelination in later life (trauma, meningitis, CNS hemorrhage, etc. during first 6 years of life, while the brain is still growing).
- The sequence of development is same and predictable in all children but the rate may vary, e.g., head control always precedes sitting; however, the age of acquisition of these milestones may vary.
- Primitive reflexes are to be lost before voluntary functions are acquired. Primitive reflexes are group of motor reflexes found in neonates and infants; these are protective brainstem reflexes, which develop sequentially during late fetal life.These reflexes are essential for survival, feeding and movement while neonatal CNS is immature. For example, the grasp reflex should be lost (by 3–4 months) before the infant can learn to reach for objects and to grasp them voluntarily (by 4–5 months). Similarly, asymmetric tonic neck reflex should be lost before a child learns to turn over in bed (think, why?).Persistence of a primitive reflex, beyond the age at which it should have disappeared, indicates and predicts abnormal development. For example, Moro reflex should disappear by 4–6 months of age. A 6-month-old child with a positive Moro reflex is suggestive of abnormal development.
- Development always proceeds in a cephalocaudal manner, i.e., from head to toe. Thus, a child will learn to hold his head, followed by ability to sit and then be able to walk. This sequence will always remain the same; though, the age at which each function is achieved may differ within physiological range.The fine motor function of upper extremity develops in proximodistal manner, i.e., beginning at the shoulder girdle and progressing to fine movement of hands and fingers attaining important milestone of pincer grasp.
- Generalized mass activity is usually replaced by specific individual response, e.g., nonspecific, symmetric movements of arms and legs in infants are replaced by asymmetric precise grasping in older children, when presented with a toy.
DOMAINS OF DEVELOPMENT
Developmental milestones in first 5 years of life are categorized in five different domains for assessment and screening purpose:
- Cognition/problem solving: Refers to mental abilities of the child and includes imitation, simple problem solving, puzzles, drawings that eventually transform into reading, writing, and academic skills.
- Personal-social development: Child's reaction to other persons and his adjustment to domestic life, social groups, and community conventions. This includes social behavior, feeding, sphincter control, general understanding, play activity, and dressing.
- Language and speech development: Ability to communicate; including comprehension (receptive language) as well as expression of language (expressive language includes gestures, speech, and written language).
- Adaptive/activity of daily living: Development of skills needed by the child to initiate new experiences and to profit by past experiences. This adaptivity includes alertness, intelligence, and various forms of constructiveness and exploration. This subset majorly decides for self-help activities transforming into independent living in society in later life.
DEVELOPMENTAL MILESTONES
Children accomplish maturation of different biological functions (level of development or milestone) at an anticipated age, with a margin of a few months on either side. Milestones are like guideposts for various stages of development, through which every child passes in the normal trajectory at a particular age.
Motor Milestones
Gross motor development: It involves control of the child over his body and locomotion, i.e., head control, sitting, standing, walking, jumping, etc. Motor development depends on the maturation of muscular, skeletal, and nervous systems (Figs. 1.19 to 1.24). Ages of attainment of important gross motor milestones are provided in Table 1.3.
Fine motor development: It assesses the finer upper limb movements and coordination. This includes coordination of eyes, hand-eye coordination, hand-mouth coordination, and skills for manipulation with hands; i.e., grasping, fine hand movements (Figs. 1.25 to 1.29), making a tower, writing, etc. Ages of attainment of important fine motor milestones are provided in Table 1.4.
Adaptive/Cognitive Milestones
Adaptive/cognitive development is the ability to learn or deal with new situations. In initial few weeks of life, infant explores the environment visually. Initially, he follows faces and then objects. After gaining better control of arms and hands, he starts batting at and then reaching for objects. At first, objects are brought to the mouth for oral exploration. Later, the infant visually examines an object held in one hand while manipulating it with the other.
|
|
With maturation of vision, infant can focus on small objects 28by about 5 months of age. By 1 year, the child explores objects by poking and discovering how they work. The child learns to shift attention between two objects, learns how his actions produce certain effects, and how to repeat these actions to get the same effects, and later, how to vary the action to produce a novel effect. These skills need combined efforts of motor skills, normal vision, hearing, coordination, and cognitive skills. Ages of attainment of important adaptive/cognitive milestones are provided in Table 1.5.
Fig. 1.19: A 12-week-old infant. The child can lift the chin and shoulders bearing weight on forearms. Plane of face reaches 90° to couch, also can be noted here social smile and connect
Fig. 1.21: A 9-month-old infant with stable independent sitting, mouthing from right hand and radiodigital grasp on left hand
Personal Social Milestones
Personal social development is a very broad area that includes intellectual, moral, emotional, social, and spiritual development. Ages of attainment of important personal social milestones are provided in Table 1.6.
|
|
|
|
Language Milestones
Language is the expression of communication through which knowledge, belief, and behavior can be experienced, explained, and shared with others. Receptive language is the ability to understand what is being said. Expressive language refers to the ability to make thoughts, ideas known to others through speech, gestures, and facial expressions. Ages of attainment of important language milestones are provided in Table 1.7.
Table 1.8 provides a bird's eye view of achievement of various milestones at key ages.
Variations in Normal Development
There is no set age at which all children must acquire a particular milestone. One particular aspect, e.g., motor development or speech, may be delayed in the child without being abnormal or retarded. Due to wide variability in the ages of attainment 31of different milestones, it may be difficult to draw a strict line between normal and abnormal on single assessment.
Children who are at borderline may ultimately turn out to be abnormal or just a variant of the normal. For correct diagnosis, one should follow these children regularly with a screening test as described in the next section.
IN A NUTSHELL
Normal Development
- At birth, a child's sensory, motor, and neurologic capacities attribute to organizing experiences and interacting with the environment, resulting in development.
- The laws of development are universal, and every child goes through the same sequence although rate and character may vary.
- Development depends upon various mutually interactive factors which can be broadly divided into biological, social, and psychological factors.
- Development is usually defined and measured under five domains namely: (1) Motor development (Gross motor and Fine motor), (2) Cognition/problem solving, (3) Personal-social development, (4) Language and speech development, and (5) Adaptive functioning/activity of daily living.
- There may be variations in normal development which could manifest as developmental dissociation, developmental delay, and developmental deviance, and therefore development should be monitored over time.
Children who are ideal in all fields are not that common. Some are slow starters in a field and then catch up after a time-lag. Some children start well but may have a temporary cessation in development due to illness, protein energy malnutrition or other factors. Some may deteriorate after a point accounting to neurological or developmental regression. A few children with development delay may show unexpected improvement when placed in appropriate environment.
- Berk LE. Child Development, 9th edition. Boston, MA: Pearson; 2013.
- Bridgman A. Child Development. Child Dev. 2015;86(2):337-41.
- Cioni G, Sgandurra G. Normal psychomotor development. Handb Clin Neurol. 2013;111:3-15.
- Gupta P. Clinical Methods in Pediatrics, 5th edition. New Delhi: CBS Publishers; 2022.
- Illingworth RS. Child care in general practice. Normal development. Br Med J. 1964;2(5419):1245-8.
- Machado LR, da Silva CFR, Hadders-Algra M, et al. Psychometric properties of the Infant Motor Profile (IMP): A scoping review protocol. PLoS One. 2022;17(11):e0277755.
- Misirliyan SS, Huynh AP. Development Milestones. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2022.
- Sadaka Y, Sudry T, Zimmerman DR, et al. Assessing the Attainment Rates of Updated CDC Milestones Using a New Israeli Developmental Scale. Pediatrics. 2022:e2022057499.
- Scharf RJ, Scharf GJ, Stroustrup A. Developmental milestones. Pediatr Rev. 2016;37(1):25-47.
- Thompson RA. Development in the first years of life. Future Child. 2001; 11(1):20-33.
- Wilks T, Gerber RJ, Erdie-Lalena C. Developmental milestones: cognitive development. Pediatr Rev. 2010;31(9):364-7.
1.9 Developmental Assessment
TIMING OF ASSESSMENT
Developmental surveillance (an informal, more flexible, and ongoing assessment of development) should be a part of all well-baby clinic visits like immunization. During each visit the clinician should observe the normal milestones and presence of any red flags. Presence of any developmental red flag warrants an immediate referral and a detailed assessment. The list of developmental red flags are given in Table 1.9.
Developmental screening: Supported with culturally accepted tools, developmental screening is considered superior to developmental surveillance. Indian Academy of Pediatrics (IAP) recommends routine developmental screening using standardized screening tools at 9–12 months, 18–24 months of age, and at school entry and additionally at 4–6 months of age for high-risk infants. The age of routine screening coincides with the immunization visits. For autism, IAP recommends, children should be screened by standardized autism screening tools like Modified Checklist for Autism in Toddlers M-CHAT, and Trivandrum Autism Behavior Checklist (TABC) at 18 and 24 months of age.
DEVELOPMENTAL HISTORY
A detailed history is vital part of developmental assessment. History of prenatal and perinatal risk factors is highly relevant to mental and physical development. Additionally, history of important genetic conditions, degenerative disorders, and environmental factors (child abuse, parent child relations, etc.) that may lead to delayed development are important. Relevant illnesses such as rickets, malnutrition, and systemic disorders that may adversely affect development should be inquired about.
Assessment of chronology of development and age of achievement of milestones is the next step. This history should preferably be taken from the mother. There may be a family history of early or late motor, social, or language development. The developmental history should be asked in simple language and a precise manner. During inquiry about developing a new skill, the following questions should be asked: (i) when did it develop; (ii) how often it is practiced; and (iii) what is the degree of maturity with which this skill is performed.
DEVELOPMENTAL EXAMINATION
Prerequisites: Developmental examination in a young child is difficult. Therefore, it should preferably be performed before systemic examination and should be done when the child is well fed, not sleepy, happy and in a playful mood. The assessment should be performed in front of mother or primary caregiver and care should be taken to keep only relevant toys and objects so as not to distract the child. No rigid pattern should be followed while doing the assessment. Before performing the developmental assessment, the vision and hearing of the child should be checked as it may affect development and interpretation of assessment.32
|
Tools for developmental assessment: For a good developmental assessment, examiner should observe the child during free play and child's interaction with peers. For children till 5 years of age, tools required for developmental assessment include:
- A red ring (for visual fixation and tracking and reaching for objects)
- A small bell (for testing hearing; held 30 cm away from ear and away from the sight)
- Pellets made of cardboard, wool or paper; 8 mm size (pincer grasp)
- 10 cubes of 1 inch each (transfer of objects, different types of grasp, imitating/building tower/bridge)
- Crayon and paper (scribbling, imitating, and copying strokes/shapes, naming colors)
- A picture book of common objects (pointing, naming objects, fine motor skills of turning paper, joint interest)
- Doll (pretend play)
- Simple form board
- Colored and uncolored geometric forms
- Goddard's form board (for children >3 years of age)
PROCESS OF ASSESSMENT
Between 1 and 3 Months
- Observe the baby in the mother's lap; observe for any obvious abnormality such as fisting, tightness of body, etc.
- Notice, if the child watches the mother, smiles or produces sound. The child starts smiling at the mother from 6 to 8 weeks onward in response to visual/verbal contact.
- Note the shape and size of the head. Palpate sutures and anterior fontanel.
- Assess resistance to passive movement for tone. Loose limbs indicate hypotonia while stiff limbs indicate hypertonia.
- Place the child supine on the surface and observe the posture:
- Up to 8–10 weeks: Generally, flexed posture with symmetrical writhing. Arm extends on the same side, to which the head is turned (asymmetric tonic neck reflex) (Fig. 1.30).
- 12 weeks: No more appearance of asymmetric tonic neck reflex.
- Pull the child from supine position. Observe head lag and back:
- 4 weeks: Complete head lag, back completely rounded (Fig. 1.31A).
- 8 weeks: Able to hold up head momentarily, less rounding of back (Fig. 1.31B).
- 12 weeks: Head held up most of the time.
- Hold the child in standing position:
- Child should have some flexion at hips and knees and able to place sole on the surface (Fig. 1.32).
- In a hypotonic child, the arms and legs hang loosely; while in a spastic child, the two legs may cross each other in a scissoring position.
- Hold the child in ventral suspension as shown in Figures 1.33A to C by placing the child prone in air with hand under the abdomen. Watch for position of limbs and head control:
- 0–2 weeks: Curled up on ventral suspension. Note flexion of elbows, knees with some extension at hips (Fig. 1.33A).
- 4 weeks: The child holds up the head momentarily. There is some flexion at the knees and hip. Back is rounded (Fig. 1.33B).
- 6 weeks: Head held momentarily in plane of body.
- 8 weeks: Maintains head in the same plane as rest of the body (Fig. 1.33C).
- 12 weeks: The child holds the head up and above the plane of the body for considerable time.
Fig. 1.32: Child <12-week-old is able to place sole on surface while held in stand position. No weight bearingFigs. 1.33A to C: (A) Ventral suspension at 0–2 weeks. Child curled up; flexion of elbows and knees with some extension at hips; (B) Ventral suspension at 4 weeks. Child holds up the head momentarily. There is some flexion at the knees and hip. Back is rounded; (C) Ventral suspension at 8 weeks. Head is maintained in the same plane as rest of the body - Keep the child prone on an even surface. Observe the posture; especially chin, pelvis, and thighs (Figs. 1.34A to C):
- 340–2 weeks: The pelvis is high and the knees are drawn under the abdomen. Back is rounded, head remains on one side (Fig. 1.34A).
- 6 weeks: Knees are not under abdomen. Hips extended. Chin raised from the couch intermittently.
- 8 weeks: Head mostly in midline. Lifts chin off the couch up to 45°C (Fig. 1.34B).
- 12 weeks: Child can lift the chin as well as the shoulders off the surface or couch, up to 90°, bearing weight on the forearms. Pelvis is flat on the surface (Fig. 1.34C).
Figs. 1.34A to C: (A) Prone at 0–2 weeks: The pelvis is high and the knees are drawn under the abdomen. Back is rounded, head remains on one side; (B) Prone at 8 weeks: Knees are not under abdomen. Hips extended. Chin raised from the couch. Keeps head in midline; (C) Prone at 12 weeks: Child can lift the chin as well as the shoulders off the surface or couch, up to 90°, bearing eight on the forearms. Pelvis is flat on the surface
Between 4 and 6 Months
- Observe the child: Note facial expressions, vocalization, altertness, and interest in surroundings. Check vision and hearing.
- Place a rattle in the hand of the child. Observe, how he plays with it? At 4 months, the child plays with rattle placed in hand for long period; but cannot pick it up, if he drops it. At 5 months, he recovers the rattle, if dropped; and at 6 months, he looks for the dropped rattle.
- Place a 1-inch cube in front of the child. Observe whether he gets it (5 months) and if yes, whether he transfers it from one hand to the other (6 months).
- Watch for hand regards (normal between 3 and 5 months of age). It should disappear by 5 months of age.
- Place the child in prone position and observe:
- 4–5 months: Can lift the head and chest off the surface, bearing weight on forearms (Fig. 1.35).
- 5–6 months: Can lift the head and chest off the surface with weight bearing only on hands, may roll from prone to supine.
- Place the child supine and observe: The child lifts the head off the surface when about to be pulled up (6 months).
- Pull the child to sitting position. Look for head lag:
- If head lag is present, the development is <5 months. There may be a slight head lag at beginning of 4 months.
- If there is no head lag, watch for the support required for sitting:
- 4 months: Sits with both hands held (Fig. 1.36A).
- 5 months: Sits supported in a high chair or mother's lap.
- 6 months: Sits with his own hands on surface for support (Fig. 1.36B).
- Hold the child in standing position. By 5–6 months, the child is able to bear most of the weight on legs.
- Show a mirror: Smiles at mirror image by 6 months.
- Observe the speech:
- 4 months: Laughs aloud.
- 5 months: Speaks Ah-goo.
Fig. 1.35: Prone: A 4–5-month-old child can lift the head and chest off the surface, bearing weight on forearms
Figs. 1.36A and B: Pull the child to sitting position. (A) Sits with both hands held at 4 months; (B) Sits with hands on surface for support
Between 6 and 12 Months
- Observe the child's interest, alertness, and quality of vocalization/language as he sits or moves around. Does he differentiate between family and strangers? Also, notice interaction with mother, e.g., in peek-a-boo and pat-a-cake games.
- 35Offer a cube: With the child sitting in the mother's lap, place a cube on the table in front of the child. Observe, how the child approaches the cube and also observe what the child does with it:
- 6 months: Approaches cube with fingers and holds cube with the palm on the ulnar side (Fig. 1.25). Unidextrous approach.
- 7 months: Radial palmar grasp of cube.
- 8 months: Scissor grasp (using all four fingers against the thumb).
- 9–12 months: Approaches cube by index finger and holds cube steady with index finger and thumb (Fig. 1.26). This is mature grasp.
- As soon as the child takes one cube, offer the second cube:
- 5 months: Drops first cube when second is offered.
- 6 months: Retains the first cube in hand and takes the second cube also. Transfers from one hand to another.
- 9 months: Compares two cubes by bringing them together.
- Offer a pellet. Watch the approach and the grasp:
- 7–9 months: Approaches with all the fingers/hand (rakes). Not able to pick it up.
- 9–12 months: Able to pick up the pellet between tip of thumb and forefinger (Fig. 1.27).
- Place the child in the sitting posture and observe:
- 7 months: Can sit unsupported, momentarily.
- 8 months: Can sit steadily on floor without support.
- 10 months: Sits steadily without risk of imbalancing. Can pivot around to pick a toy from back/side.
- Place in the prone position and observe for creeping (9–10 months).
- Pull to the stand position, offer support of a table and observe. If the child can stand holding on to furniture and whether he can pull himself to standing position. Also watch, if he can walk around holding on to furniture.
- 9–10 months: Stands holding on to furniture, pulls to stand.
- 10–11 months: Can walk around holding onto the furniture.
- 12–13 months: Stands independently, takes a few independent steps.
Between 1 and 2 Years
- If child comes walking into the room, watch his gait and assess its maturity. Observe his interest in toys or pictures hanging in the room. Does he point at things to ask for them or show something interesting to parents?
- Offer 10 cubes: Show him how to build a tower and then let him do the same. This process is known as imitating. See how many cubes he can utilize in building a tower (Fig. 1.37).
- 15 months: Tower of 2 cubes.
- 18 months: Tower of 3–4 cubes.
- 2 years: Tower of 6–7 cubes.
Warning signs: The child should not take the cube to his mouth after the age of 15 months. Similarly, he should not be throwing cubes on the floor, one after another, after 18 months. - Train and chimney: Demonstrate, how to make a train of 9 cubes and place the 10th one on top of the first one (chimney). Ask him to do the same. A 2-year-old child can make the train, but fails to put the chimney.
- Picture identification and naming: Show picture cards or book, and ask to identify them in the following format “where is the cat”? At a later age, you may ask “what is that”? This is known as picture naming and more difficult (Fig. 1.38).
- 18 months: Identifies 1 object and names 1 object.
- 2 years: Identifies 5 objects; can name 3 objects.
- Give a picture book: See, how many pages of a book, he can turn at one time.
- 15 months: Turns 2–3 pages at a time.
- 18 months: Turns 1 page at a time.
- Offer pen and paper and notice any spontaneous scribbling.Ask to imitate (by showing how to do it by drawing in his/her sight) the drawing of a vertical stroke (|), horizontal stroke (—), and a circle. Interpret as follows:
- 12 months: Imitates scribbling.
- 15 months: Scribbles haphazardly.
- 18 months: Imitates vertical stroke.
- 2 years: Can imitate horizontal stroke and a circle.
- Offer simple form board (Fig. 1.39). First, offer only the round block.
- If a child can put in the round block, offer all three blocks. If the child puts all three correctly then ask to do it again, after you have rotated the Form board. If the child can correctly put in the blocks two to three times, he/she is at least 2 years of age.
Between 2 and 5 Years
- Notice the gait. At the end of the session, see how he climbs stairs, jumps/hops/skips.
- Can he throw a ball overhead? Undressing/buttoning-unbuttoning can be observed before the physical examination.Offer 10 cubes:
- Usually a child in this age group spontaneously begins to build a tower. Notice how many cubes he utilizes in making the tower.
- Ask the child to imitate/copy (depending on expected maturity level) a train, bridge, gate, and steps, one by one (Figs. 1.40 to 1.43). (Note: Imitation means building the model while the child is watching and then asking him to build the same; while Copying means building the model out of sight of child, shielding with a paper, and then showing him the final model and asking him to build the same.)
- 2½ years: Tower of eight cubes; imitates train with chimney.
- 3 years: Tower of 9–10 cubes, imitates bridge.
- 3½ years: Copies bridge.
- 4 years: Imitates gate.
- 5 years: Copies gate.
- 6 years: May copy steps.
While the child is handling cubes, observe minutely for any abnormal hand movements or disability. - Give a pencil and paper: Ask to imitate vertical and horizontal stroke, circle, cross, square, triangle, and diamond, in that order. If the child is able to imitate a task, ask to copy the same.
- 2 years: Imitates horizontal/circular stroke.
- 3 years: Copies circle and horizontal stroke. Imitates cross.
- 4½ years: Copies square.
- 5 years: Copies triangle.
- 6 years: Copies diamond.
- Show the picture cards and ask to identify or name the objects
- 2½ years: Identifies seven objects; names up to 5.
- 3 years: Names 8–10 objects.
- Offer simple form board and observe the ability of the child to insert the blocks and the accuracy with which he does that.
- If the child is successful with simple form board, he should be tried with the colored geometric forms followed by uncolored geometric forms. In each case, he is asked where the shapes fit, being given different forms one after the other. He is not told about his mistakes and is given another chance with those he has placed incorrectly.
- After developmental age (DA) of 3½ years, time his performance in Goddard Form board, the score being based on the best of 3 trials.
- Goodenough draw-a-man test: After DA of 3 years, ask the child to draw a man as completely as he knows. Child is given 1 point for each of the body parts added. For each 4 points, 1 year is added to the basal age which is 3 years. The test has 51 items, details of which can be found in textbooks. This test can be used for developmental assessment between 3 and 10 years of age.
- Gessel “Incomplete Man” test: In this test, picture of a man which is halfway complete is given to the child. The picture consists of a small circle for a head and below it a larger incomplete circle representing the trunk with one stick arm and one stick leg protruding. The head has one ear, half hair, a mouth and a nose but is missing eyes, one ear, half hair, one arm and one leg and various connecting elements. Child is asked to complete the man. Depending on how many and in what way the child adds the parts, DA is deciphered.
- Digit repetition: Child is asked to repeat digits, e.g., six, five, and seven. Initially, he is given two digits. If he can repeat them, ask him to repeat three and then four digits followed by five. In each case, he is given three trials with different numbers.
- Ask the child to identify colors in pictures.
Perform Relevant Physical Examination
Box 1.2 provides a list of risk factors that you need to look for. If present, they place the child at a higher risk of having abnormal development. Note that you have to take anthropometric measurements; look for major and minor congenital anomalies; examine carefully the skin, eye, ear, extremities in detail; and conduct a thorough neurological examination. Also look for the presence of hepatosplenomegaly. A few warning signs of developmental delay are listed in Box 1.3.
INTERPRETATION OF DEVELOPMENTAL ASSESSMENT
Based on the performance on developmental assessment a functional/developmental age (DA) is assigned to the child, on the basis of which developmental quotient (DQ) is obtained.
Development Quotient
Development quotient (DQ) is the numeric expression of a child's developmental level as measured by dividing the DA by the chronologic age (CA) and multiplying by 100. Ideally, CA should be equal to DA and the DQ should, therefore, be 100. A DQ of <70 is considered as delay. DQ should be estimated separately for each area of development, viz., motor, adaptive/cognitive, language, and personal/social. For preterm children till 2 years of age, corrected gestational age should be used instead of chronological age.
Presentation of Developmental Disorders
The age at which child presents with developmental delays varies with the domain of development in question and the severity of delay.
- Generally, disorders of greater severity present at early ages and those of lesser severity may present later.
- Severe motor delays present earliest, approximately between 6 and 12 months of life when the child fails to hold head, sit, or stand independently.
- Sensory deficits also present usually within the first 6 months when the child does not respond to sound or fails to fixate.
- Language and cognitive delays usually present after 24 months, when the child fails to demonstrate the expected expressive language.
- Social and behavioral delays present over wide range of ages depending upon the extent to which it is affecting the functioning of child or life of caregivers. Adaptive skill delays are usually not the presenting complaints but may be noted during the developmental history and examination of children who present with other concerns.38
IN A NUTSHELL
Developmental Assessment
- Developmental surveillance is an informal and ongoing method of assessing development whereas developmental screening and assessment use standardized tools at recommended age groups for diagnosing developmental delays.
- A good history and examination are the cornerstone for developmental assessment. Developmental examination should be performed with the age-appropriate toys in a comfortable and amiable setting.
- While assessing development of the child, care should be taken as not to miss any red flag which usually indicates an abnormal development and warrants immediate attention.
- Developmental quotient (DQ) is the numeric expression of a child's developmental level as measured by dividing the developmental age (DA) by the chronologic age (CA) multiplied by 100. DQ should be calculated for each domain separately. DQ <70 is considered delay.
- For preterm children till 2 years of age, corrected gestational age should be used instead of chronological age for calculating DQ.
- Berk LE. Child Development, 9th edition. Boston, MA: Pearson; 2013.
- Cairney DG, Kazmi A, Delahunty L, Marryat L, Wood R. The predictive value of universal preschool developmental assessment in identifying children with later educational difficulties: a systematic review. PLoS One. 2021;16(3):e0247299.
- Cheung YB, Gladstone M, Maleta K, Duan X, Ashorn P. Comparison of four statistical approaches to score child development: a study of Malawian children. Trop Med Int Health. 2008;13(8): 987-93.
- Del Rosario C, Slevin M, Molloy EJ, Quigley J, Nixon E. How to use the Bayley scales of infant and toddler development. Arch Dis Child Educ Pract Ed. 2021;106(2):108-12.
- Gupta P. Clinical Methods in Pediatrics, 5th edition. New Delhi: CBS Publishers; 2022.
- Hadders-Algra M, Tacke U, Pietz J, Rupp A, Philippi H. Standardized infant neurodevelopmental assessment developmental and socio-emotional scales: reliability and predictive value in an at-risk population. Dev Med Child Neurol. 2020;62(7):845-53.
- Lipkin PH, Macias MM; Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. Promoting Optimal Development: Identifying Infants and Young Children with Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics. 2020;145(1):e20193449.