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normal growth,factors affecting growth,assessment and growth charts

Pediatrics <br>Dr.Mahishma.K

DrMahishma
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normal growth,factors affecting growth,assessment and growth charts

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  1. NORMAL GROWTH AND FACTORS AFFECTINGGROWTH IAP UG Teaching slides2015‐16

  2. DEFINITIONS • Growth:Netincreaseinthesizeormassoftissues which is largely due to multiplication of cells and increase in the intracellularsubstance. • Development: Maturation of functions associated withmaturationandmyelinationofnervoussystem. IAP UG Teaching slides2015‐16

  3. GROWTH:SIGNIFICANCE • Essentialfeaturethatdistinguishesachildfroman adult. • Indicates overall well‐being of achild. • Reflects the nation’s economic status andpublic healthsystem. IAP UG Teaching slides2015‐16

  4. FACTORS AFFECTINGGROWTH • Prenatalperiod • Fetal • Placental • Maternal • Postnatalperiod • Genetic • Environmental IAP UG Teaching slides2015‐16

  5. FACTORS AFFECTING PRENATALGROWTH • A. GeneticPotential • Parental trait ‐ Tall parents have tallchildren • ‐ Head size related toparents • Sex ‐ Boys larger thangirls • Race‐ Growth differs in differentraces IAP UG Teaching slides2015‐16

  6. FACTORS AFFECTING PRENATALGROWTH • B. Fetal GrowthFactors • GrowthPromotion • Insulin like growthfactors (IGF‐I and IGF‐II)(~70%) • Epidermal growthfactor • Transforminggrowth factor α (TGF‐α) • Platelet derivedgrowth factor • Fibroblast growthfactor • Nerve growth factoretc. • GrowthInhibition • Transforming growthfactor • β (TGF‐β) • Mullerianinhibiting substance(AMH) • Inhibin / Activin familyof proteins IAP UG Teaching slides2015‐16

  7. FACTORS AFFECTING PRENATALGROWTH • C. Fetalhormones • Have predominant role in lategestation • InsulinandThyroxine:Importantforaccretionand differentiation oftissues • Glucocorticoids : Required for maturation oforgans like lungs, liver and GItract • Note:InfluenceofGrowthhormoneonfetalgrowthis minimal. IAP UG Teaching slides2015‐16

  8. FACTORS AFFECTING PRENATALGROWTH • D. Placentalfactors • Placentaisessentialfornutritionoffetus • Fetal nutrition is enhancedby • Increased villous surfacearea • Decreased diffusiondistance • Increased dilatation of fetalcapillaries • Decreased resistance ofvasculature IAP UG Teaching slides2015‐16

  9. FACTORS AFFECTING PRENATALGROWTH E. Maternalfactors –Poornutrition –Anemia –Recentpregnancy –Highparity –Tobacco,drug, alcoholintake • PregnancyInduced Hypertension • Multiplepregnancy • Chronicsystemic diseases • TORCHinfections IAP UG Teaching slides2015‐16

  10. OVERALL REGULATION OF FETALGROWTH IAP UG Teaching slides2015‐16

  11. FACTORS AFFECTING POSTNATALGROWTH • A.Sex • Boys have greater growth potentialthan girls • Girls have early pubertal heightspurt thanboys • Pubertal height gainis more inboys IAP UG Teaching slides2015‐16

  12. FACTORS AFFECTING POSTNATALGROWTH • B.Genetic • Chromosomedefect • Short stature: Downsyndrome, Turner syndrome • Tall stature: Klinefeltersyndrome • Genemutation • short stature: Prader‐Willi syndrome,Noonan syndrome • Tall stature: Marfansyndrome IAP UG Teaching slides2015‐16

  13. FACTORS AFFECTING POSTNATALGROWTH • C.Environmental • Nutrition • – PEM, Micronutrient deficiency (Fe, Io, Ca, Zn, VitA, VitD) • Infections • – Diarrhea, recurrent RTI, TB, HIV, Malaria,Kala‐azar, Chronicgiardiasis • Toxins • – Food,environment. IAP UG Teaching slides2015‐16

  14. Factors affecting postnatalgrowth • D.Hormonal • Growth hormonedeficiency • Hypothyroidism • Growth hormoneresistance IAP UG Teaching slides2015‐16

  15. FACTORS AFFECTING POSTNATALGROWTH • E. Socialfactors • Low socio economic status: Poordiet, infections • Hot and humidclimate • Poor emotional support: Brokenfamily, orphans • Cultural factors: Religioustaboos • Low parental education: Poor healthpromotion, poornutrition. IAP UG Teaching slides2015‐16

  16. LATECONSEQUENCES OF POOR FETALGROWTH (NUTRITION) • Fetal origin hypothesis (Barker’shypothesis) • Alterationsinfetalnutritionandendocrinestatuslead toprogramming • Permanent changes in structure, physiologyand metabolism • IUGRinfantshaveincreasedriskofdiabetesmellitus, hypertension, hyperlipidemia and coronary artery disease IAP UG Teaching slides2015‐16

  17. LAWS OF GROWTH(I) • Growth is acontinuous and an orderlyprocess. • The rate of growth is not uniform –There are periodsofacceleration, deceleration and steadiness. IAP UG Teaching slides2015‐16

  18. PHASES OF GROWTHACCELERATION, DECELERATION ANDSTEADINESS Dotted line:Weight Solid line:Height • Accelerationv (fvast) ‐1st Half of gestation, 1st yearof life,Puberty • Deceleration‐ 2ndyear • Steady rate‐ 6‐9 years ofage IAP UG Teaching slides2015‐16

  19. ICP MODELFOR POSTNATAL GROWTH (KARLBERG) HEIGHTATTAINMENTDURING EACHPHASE • Infancy: Starts before birth andfallsoffbyage3to4years. Average total height gain is 45%. • Childhood: Begins at theend of the first year of life and continues to mature height. Average total height gain is 47%. • Puberty: This phase startswith initiation ofpuberty. • Average height gain is8% IAP UG Teaching slides2015‐16

  20. PREDOMINANT CONTROL INEACH PHASE OF GROWTH • Infancy:Nutrition, • GH,thyroxine • Childhood: GHand thyroxine • Puberty: Sexsteroid • andGH. IAP UG Teaching slides2015‐16

  21. LAWS OF GROWTH(II) • Growth pattern of every individual isunique. • Cephalocaudal • Distal toproximal IAP UG Teaching slides2015‐16

  22. LAWS OF GROWTH(III) • Different tissues of the body grow at differentrates • General growth: Rapid during fetal life, first 1‐2y and atpuberty • Brain and head: Rapid during late fetal andearly postnatallife • Atbirth70%,at2y90%of adult. IAP UG Teaching slides2015‐16

  23. LAWS OF GROWTH(II) 100% 100% age BrainGrowth years SomanicGrowth 100% 100% age LymphoidGrowth years GonadsGrowth • Lymphoid – maximum growth during mid‐ childhood (4‐8y) Large tonsils and lymphnodes • Gonads –grow at pubescence only IAP UG Teaching slides2015‐16

  24. PERIODS OFGROWTH Postnatal period Newborn: Birth to 28days Infancy: First year Toddler:2‐3y Preschool: 4‐6y School age: 7‐12y Adolescence:10‐18y Prenatalperiod • Ovum :0‐1w • Embryo :2‐8w • Fetus : 9w‐birth • Perinatal period :22wk of gestation to 7days afterbirth. IAP UG Teaching slides2015‐16

  25. PRENATALGROWTH • Embryonicperiod • 2wk: Bi‐laminarembryo • 3wk: Tri‐laminarembryo, Heart pumpingbegins • 4wk: 4cms, humanshape, arm‐legbuds • 5‐8wk: Major organsystem development • 9wk: 9g, 5cm. Fetalperiod begins. Fetalperiod 10wk: Externalgenitalia distinguishable 20wk: 460gm, 19cms,lower limit ofviability 24w – Primitive alveoli, surfactantproduction 25wk: 900gm, 25cm,3rd trimesterbegins 38wk: Term, weight triples, length doubles from thatof 25 w ofgestation IAP UG Teaching slides2015‐16

  26. PARAMETERS OFGROWTH • Weight. • Length<2yorHeight>2y. • Head circumference (HC), Chest circumference(CC). • Uppersegmenttolowersegment(U:L)ratio. • Arm span(AS). IAP UG Teaching slides2015‐16

  27. HOW TO MEASUREWEIGHT? • Weighingscales: • Lever/Electronic • Spring balance (lessaccurate) • Minimum unit100gm • Technique • In nude or minimalclothing • Weighing scale checked for zeroerror • Centertheinfantonthescaletray • Weighinfanttothenearest10gmandolder child to nearest 100gm. 27 IAP UG Teaching slides2015‐16

  28. MEASUREMENT OFLENGTH • After2‐3yearsofage,heightshould be measured bystadiometer. • Child should stand erect, withocciput, shoulders, buttocks, and heels touching theverticalbar. Look straight (Frankfort’s plane parallel to floor) • Horizontal bar is lowered to the vertexofthechildandtakereading IAP UG Teaching slides2015‐16 28

  29. MEASUREMENT OFLENGTH Lengthofchildren < 2‐3yare measured byinfantometer. IAP UG Teaching slides2015‐16 29

  30. MEASUREMENTOFHEADCIRCUMFERENCE(HC) • HC should be measured using non‐stretchabletapes (e.g..Steel) • Measure across most prominent points of superior orbital ridge (anterior) andexternal occipital protuberance (posterior) Should notbe measured within 24 hrs.after birth to avoid spurious values due tomoulding 30 IAP UG Teaching slides2015‐16 7

  31. MEASUREMENT OF ARMSPAN Distancebetweenthetipsofmiddlefingerswhenthe armsareoutstretchedparalleltothefloor. 31 IAP UG Teaching slides2015‐16 7

  32. AVERAGE GROWTH PARAMETERSAT BIRTH • Weight: 3Kg • Length: 50cm • U/L ratio:1.7 • HC: 35cm • CC: 33cm IAP UG Teaching slides2015‐16

  33. POSTNATAL GROWTH :WEIGHT Weight gain 25‐30g/day 400g/month Agegroup 0‐3 m 4m‐1yr. 2yr –Pubertal growth spurt* 2‐3Kg/y or • [Wt.inKg=(Ageinyears+4)X2] • Weightdoublesat5m,triplesat1y,quadruples at2y • *Boys12y,girls10y. IAP UG Teaching slides2015‐16

  34. POSTNATAL GROWTH:LENGTH/HEIGHT Agegroup 0‐3m 4‐6m 7‐9m 10‐12m 13‐24m 3‐10yr.* Heightvelocity 3.5cm/m 2cm/m 1.5cm/m 1.2cm/m 1cm/m 5‐6cm/y *Weech’s formula: Ht in cms = (Age in yearsX6) +77 IAP UG Teaching slides2015‐16

  35. POSTNATAL GROWTH:ADOLESCENCE *Sex maturity rating Meanpubertalheightgain:Boys‐27cm,girls‐25cm Meanpubertalweightgain:Boys29kg,girls24kg IAP UG Teaching slides2015‐16

  36. POSTNATALGROWTH UPPERSEGMENTTOLOWERSEGMENTRATIO >6m age U/L ratio = 1.6 (Age in yearsX0.1) IAP UG Teaching slides2015‐16

  37. POSTNATAL GROWTH HEAD CIRCUMFERENCE(HC) Age Birth‐3m 4m‐6m 7m‐12m 2ndy >2y By 12y Rate ofincrement 2cm/m 1cm/m 0.5cm/m 1cm/y 0.5cm/y 52cm IAP UG Teaching slides2015‐16

  38. POSTNATAL GROWTH CHEST CIRCUMFERENCE(CC) Birth:HC >CC 1 year: HC=CC >1year:HC<CC IAP UG Teaching slides2015‐16

  39. POSTNATAL GROWTH: ARMSPAN (AS) IAP UG Teaching slides2015‐16

  40. POSTNATAL GROWTH: SKELETALMATURATION • Steady in childhood, accelerates atpuberty • Closely correlates with sexualmaturation • Maturity indicated by epiphysealclosure • Completeinboysat22y,girlsat18y • Preferred areas for bone age estimationby radiography Birth‐3m 3‐9m 1‐13y 12‐14y knee andankle Shoulder Hands andwrists Elbow andhip IAP UG Teaching slides2015‐16

  41. POSTNATAL GROWTH –DENTITION Primary teeth(20) Central incisors Lateral incisors Canines I Molar IIMolar Age ateruption 5m to 8m 7m to 11m 16m to20m 10m to16m 20m to30m Approximateassessment Expectednumberofteeth=Ageinmonths‐6 IAP UG Teaching slides2015‐16

  42. POSTNATAL GROWTH –DENTITION Permanent teeth(32) Imolars Incisors Canines Premolars II Molar IIIMolar Age ateruption 6 to 7y 6 to 8y 9 to 12y 9 to 12y 12y ≥ 18y IAP UG Teaching slides2015‐16

  43. GROWTHSTANDARDS • Normsofgrowthrepresentedastablesorcharts • Derivedfromlargecohortofhealthychildrenby cross sectional or longitudinalstudies • Tablesareusefulaseasyreadyreferences IAP UG Teaching slides2015‐16

  44. GROWTHCHARTS • Superior to tablesto diagnose early deviations ingrowth • Distance growth charts reveal the growth acquired till the dateof lastevaluation IAP UG Teaching slides2015‐16

  45. HEIGHT VELOCITYCHARTS • Height velocity: Rate ofheight increment per unit timeand • Indicates periods of acceleration, decelerationand steadiness • Most useful for early identification ofgrowth faltering IAP UG Teaching slides2015‐16

  46. DISTANCE GROWTHCHARTS • Growthparameters are presented in graphicalmanner • Age along the X axis and measurementsin the Yaxis • Charts have 5 or 7 percentile curves representing the distribution of the growthparameters IAP UG Teaching slides2015‐16

  47. GROWTH PARAMETERS INGROWTH CHARTS • Weight forage • Height/length forage • Head circumference forage • Weight forlength/height • Body massindex • Eachparameterseparateforboys(Blue)&girls(pink) IAP UG Teaching slides2015‐16

  48. PLOTTING HEIGHT ONA GROWTH CHART • 8 years oldboy, • Height: 120cm, • Draw an imaginaryline along the X‐axis tillthe age (8y) of thechild. • Then extend the imaginary line along the Y‐axis till theheight (116 cm) of thechild • Mark thepoint IAP UG Teaching slides2015‐16

  49. RECOMMENDED GROWTHCHARTS WHO, derived fromMGRS study 0‐5years Revised IAP Growthcharts, 2015 Height, weight, HC for 0‐5y Weightforheightfor0‐5y Height, weight, BMIfor 5‐18 y IAP UG Teaching slides2015‐16

  50. WHOGROWTHCHARTS ‐2006 • Idealgrowthchartsthatprovidedataonhow children shouldgrow • Internationally usable standard growthcharts • Multi‐centerGrowthReferenceStudy(MGRS)from5 Continents. • Studysites–US,Brazil,Ghana,Oman,Norway,India. IAP UG Teaching slides2015‐16

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