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Factors affecting growth

1. Prenatal factors
o Familial (genetic);children inherit their height pattern from their parents
o Racial; some races are shorter than others e.g. Chinese
o Constitutional
2. Factors operating during pregnancy (In Utero Exposures)
o Maternal diseases e.g. diabetes mellitus, hypertension
o Maternal exposures: Teratogens, infections e.g. TORCH, irradiations
o Maternal nutritional state.
3. After birth
a. Age: Growth rate is more during infancy and adolescence.
b. Sex:
- Growth rate is nearly equal in males & females from birth till 11 years
- Girls grow faster between 11 14 years (due to earlier puberty)
- Boys grow faster than girls beyond 14 years (due to later puberty)
c. Nutritional status Chronic under nutrition & malnutrition retard growth
d. Psychological and socioeconomic status
e. Health status chronic diseases retard growth
4. Hormonal role: growth is controlled by hormones depending on the stage
Intrauterine
Infancy & childhood
1. Chorionic gonadotropines 1. Thyroxin
2. Placental lactogen
2. Growth hormone
3. Insulin
4. Thyroxin (skeletal growth)

Adolescence
Sex hormones
(Estrogen & androgen)
are responsible for
growth spurt during
puberty

So

o Newborns of diabetic mothers whose mothers have hyper glycemia during

pregnancy usually have hyperinsulinemia and eventual macrosomia at
birth
o Newborns with congenital hypothyroidism usually have delayed bone age
detected by plain radiograph on their knees that shows absent tibial and
femoral epiphyseal centers
o Newborns with growth hormone deficiency usually have normal size at
birth simply because growth hormone actions operates after birth onwards

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Assessment of Growth
I. Anthropometric measures
1. Weight
* At birth
3 - 3.5 kg
st
* During the 1 year:
- 1st 4 months
Weight by kg per month.
So, weight at 4 months = 6 kg double birth weight
- Next 4 months Weight by kg per month
- Last 4 months Weight by kg per month.
So, weight at 1 year = 9 kg triple birth weight
st
* Beyond the 1 year Weight is calculated as: weight = age (in years) 2 + 8
Physiologic weight loss:
* Initial weight loss usually occur during the first 3-4 days of life
* The baby loses about 10% of his birth weight due to:
- Scanty milk flow
- Poor suckling capacity
- Passage of meconium & urine
* This weight loss is usually regained by the 10th day of life

2. Length/Height
* At birth
* At 6 months
* At 1 year
* At 2 years
* After the 2nd year

50 cm
68 cm
75 cm
87.5 cm
Height = age in years 5 + 80

How to measure?
o Under 2 years: Length is measured in supine position
o Over 2 years: Height is measured in standing position

3. Occipto Frontal head circumference (OFC)

Clinical value
- OFC reflects the rate of brain growth.
- Maximum rate of brain growth & OFC is during the 1st year
* At birth

35 cm.
* At 6 month

43 cm
* At 1 year

45 cm
* At 12 years

55 cm

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4. OFC & chest circumference (CC) ratio
Chest circumference is measured at level of xiphiod process in mid inspiration
Age
OFC/CC ratio
* At birth
>1
* At 6 months
Equal 1
* at 1 year
<1
th
* At 5 year
<1
Clinical value: Suspect malnutrition if OFC/C.C > 1 beyond 6 months

5. Mid arm circumference (MAC)

* In a baby 1- 4 years

MAC is > 14 cm
* In border line malnutrition
MAC is 12 14 cm
* In severe malnutrition

MAC is < 12.5 cm

Clinical value
o Early indicator of malnutrition; and is not affected by edema.
o Often used for screening for malnutrition in lieu of weight for height
o MUAC divided by OFC classify malnutrition into; Mild < 0.31 , moderate
<0.28 , and severe < 0.25 ( Kanawati classification of malnutrition)

6. Skin fold thickness

Clinical value: Estimate total body fat;
* Measured by skin fold calipers
* Measured at left triceps or left subscapular regions
* Normal values: - 10 mm at 1 year
- 14 mm at 1- 4 years

8. The Arm span - Height relationship

* Span is shorter than height by 3 cm at 1-7 years.
* Span equals height at 8-12 years.

7. Proportions of upper segment & lower segment

* Upper segment (US) is measured from crown to symphysis pubis.
* Lower segment (LS) is measured from symphysis pubis to the floor.
* Proportions of US/LS:
o At birth
1.7 /1
o At 3 years
1.3 /1
o After 7 years 1
/1
Clinical value: Help evaluation of short stature

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II. Teething
Primary = Deciduous or Milky teeth
Tooth
Age (months)
- Central incisor 6 - 9
- Lateral incisor
9 - 12
st
- 1 molar
12- 18
- Canine
18- 24
nd
- 2 molar
24

* Count : 20 teeth
* Teething start at 6- 9 months and
completed at 24 months.
* The lower jaw incisors precedes the
upper jaw by one month

Secondary (permanent) Teeth

Tooth
Age (years)
- Central incisor
7
- Lateral incisor
8
- Canine
10
st
- 1 premolar
11
nd
- 2 premolar
12
st
- 1 molar
6
nd
- 2 molar
13
- Wisdom tooth
22
* Count : 32 teeth
* Teething start at the 6th years and
completed at 22nd years
* Eruption follow exfoliation immediate or
may lag 4-5 months

Teething Eruption Abnormalities

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

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III. Fontanels
Posterior fontanel

Normally: Closed at birth or opened < 0.5 cm and closes within 2 months

Abnormally: Opened > 1 cm or Not closed within 4 months
Causes :
- Prematurity
- Increased intra cranial tension
- Mongolism
- Cretinism
Anterior fontanel: Clinical value
1. Assessment of growth
- At birth 3 fingers ( 3- 4 cm).
- At 6 months 2 fingers.
- At 12 months 1 finger.
- At 18 months closed.
2. Size
A- Large fontanel (delayed closure) in: (DACRO HI)
- Down syndrome
- Achondroplasia
- Congenital hypothyriodism
- Rickets
- Osteogenesis imperfecta
- Hypopituitarism
- Increased intra cranial tension
B- Small fontanel (premature closure; before 6 months) in: (2 C)
- Craniosynostosis
- Congenital hyperthyroidism
3. Surface : Normally it is smooth & continuous with the skull bones.
A- Bulging: with intra cranial tension e.g. B- Depressed : in dehydration
- Intra cranial infections
- Hydrocephalus
- Intra cranial hemorrhage

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IV. Osseous Growth
Normally; there are 5 secondary ossific centers at birth in
o Lower end of femur.
o Upper end of tibia.
o Calcaneus, talus & cuboid
X ray knee in newborn help assess intrauterine
skeletal maturation ; it is a good screening
tool for congenital hypothyroidism
Carpal bones start ossification after birth as follow
o The 1st carpal bone ossifies at about 2nd month of age.
o The 2nd carpal bone ossifies by the end of the first year.
o Later on, one carpal bone ossifies approximately each year till the 6th year;
the 8th bone usually ossifies at the 12th year of age.
Bone age is determined radiologically by
Bone age is a measure of the degree of skeletal maturity of a child
It is measured in years by the radiographic examination of ossification
centers, most often using the Greulich-Pyle bone age scale
At > 6 month onwards by x-ray over the left wrist
In late childhood by assessing fusion of epiphysis
Causes of Delayed Bone Age
1- Hypothyroidism
2- Hypopituitarism
3- Delayed puberty.
4- Cushing syndrome
5- Chronic illness / under nutrition

Causes of Advanced Bone Age

1- Hyperthyriodism
2- Hyper pituitarism
3- Androgen excess (e.g. congenital
adrenal hyperplasia)
4- Simple obesity.

Example for bone age estimation by Greulich-Pyle bone age scale

Average bone age 1 year

Average bone age 2 years

Average bone age 3 years

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V. Growth Charts (Curves)
Values

1- Assess growth and normal growth variations among children

2- Early predictor of malnutrition (flattening of weight curve)
3- Monitor success of treatment of malnutrition
Examples
1. Percentile growth curves
Each chart is composed of 7 curves
- 97th percentile Highest normal.
- 90th percentile High normal.
- 75th percentile Above average.
- 50th percentile Average.
- 25th percentile Below average.
- 10th percentile Low normal.
- 3rd percentile Lowest normal.
Normal child on percentile curves
o Should lie between the 3rd & 97th
percentile curves. So, values < 3rd or
above 97th are abnormal.
o On serial measurement deviation of the
child from his own percentile curve is abnormal.
o Not all the child growth parameters necessarily fall into the same
percentile.
2. Growth velocity curves
Rate of growth is maximal in infancy and during pubertal spurt
N.B
Weight for height below the 5th percentile remains the single best growth
chart indicator of acute under nutrition
Decreased height for age with normal weight for age indicate nutritional
disorder in the past
Decreased both weight for height with normal height for age indicate both
recent and past nutritional disorder
Specialized charts have been developed for children with :
o Very low birth weight and prematurity
o Down
o Turner
o Klinefelter syndromes
o Achondroplasia

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Assessment Of Development
Motor Milestones : (Locomotor development)

Head support ; no head lag

Sit without support

Crawls

3 months

6 months

9 months

Stands

Walks
10 months

Climbs stairs

Runs

12 months

Rides a tricycle

2 years

18 months

Dresses himself
3 years

Mental milestones
A. Social development

Social smile on
social contact

2 months

Recognizes mother
Recognizes father
Excited at sight of food Stranger awareness

4 months

9 months

Finger feeds
Waves bye bye

12 months

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B. Fine motor

Play with hands in midline

Grasp offered rattle

4 months

Outreaches objects,

Pincer grip

mouth it and transfers it

6 months

9 months

Tower of two cubes

Casting

Scribbles

12 months

15 months

Turn pages in 2-3 pages

18 months

Cut with scissors

Copies a cross & square Copies a triangle

Copies a circle

Recognize 3 colors

3 years

4 years

Draws man with six parts

5 years

C. Speech development
Says Mama or Dada
At - 10 months
- 1 year

Speaks first real 3 words

- 19 months
Speaks 2-word sentences (e.g., Mommy shoe)
- 2 years

Says 3 word sentences (phrases).

- 3 years

Says his name & age

- 5 years

Says clear speech

Criteria of speech delay
- No first words by 15 months.
- No real words by 18 months.
- No word combinations by 2 yrs
- Speech is difficult for others to understand at 3 years
D. School achievement

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Self Assessment Clinical Cases
Case 1
A 3-month-old girl, comes in for her checkup with her mother .her mother complains that
her baby is not active, sleeps much and cries little with persistence of the yellow tinge of
skin and sclera since the first week of life. You requested a plain radiograph for her knees
a. What does the x ray show?
b. What is the expected diagnosis?
c. What do you expect from examining her fontanels?

Case 2
Bone age will be advanced in short stature caused by which of the following?
a. Environmental deprivation syndrome
b. Hypopituitarism
c. Hypothyroidism
d. Congenital adrenal hyperplasia
e. Chronic administration of glucocorticoids in high doses

Case 3
An infant can lift his head from a prone position 45 off the examining table,
smiles when encouraged, and makes cooing sounds. He cannot maintain a
seated position. The most likely age of the infant is
a. 1 month
b. 3 months
c. 6 months
d. 9 months
e. 12 months
Case 4
A child is brought to your clinic for a routine examine. She can dress
with help, can ride a tricycle, knows her own age, and can speak in short
sentences. She had difficulty in copying a square. The age of this child is
most likely
a. 1 year
b. 2 years
c. 3 years
d. 4 years
e. 5 years
(Source: Pretest Pediatrics for USMLE )