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September Board Review 2012 . Growth and development. Test Question . What Board Review Topic should we do next? Allergy & Immunology Adolescent Medicine and Gynecology. Normal Growth. Growth. Affected by: Prenatal factors: Maternal nutrition and uterine size Genetic growth potential

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September board review 2012

September Board Review 2012

Growth and development

Test question
Test Question

What Board Review Topic should we do next?

  • Allergy & Immunology

  • Adolescent Medicine and Gynecology


  • Affected by:

    • Prenatal factors:

      • Maternal nutrition and uterine size

    • Genetic growth potential

    • Nutrition throughout childhood

    • Multiple hormones

      • Growth, thyroid, insulin, sex hormones

  • Despite all these factors, growth is predictable

    • Carefully documented growth charts are powerful tool to measure health and well-being


  • Postnatal growth

    • Healthy term infants lose 10% of their birth weight in the first days after birth

      • Regain it back by 2-3 weeks of age

    • Normal: Gain 20-30g/day for first 3 months

    • This rapid phase of growth is influenced primarily by growth hormone (GH) and thyroid hormones

Question 1
Question #1

At what age to most healthy, term infants typically triple their birth weight?

  • 6 months

  • 12 months

  • 18months

  • 2 years

  • 3 years

Growth milestones
Growth Milestones

  • Birth weight triples by 1 year

  • Birth length doubles by 3-4 years

  • During puberty: sex hormones become significant factor

    • Slight deceleration of growth just prior to puberty

    • Followed by rapid acceleration of growth

      • Males later than females

      • Females BEFORE menarche

Accurate measurements
Accurate Measurements

  • Scales calibrated regularly

  • Weigh in underwear or diaper

  • Length/height should be measured supine in age <2 years

    • Legs fully extended, head resting on unmovable board, moveable footboard

  • Standing height for >2yrs

    • Wall-mounted stadiometer

    • If cannot stand: arm span is good substitute

Growth charts
Growth Charts

  • Growth charts from CDC or WHO

    • Specific charts for special populations

      • LBW and VLBW premies

      • Trisomy 21, Turner, Klinefelter, achondroplasia

  • Each child should be considered in terms of their genetic growth potential

    • Estimate with mid-parental height

      • Boys= [Father’s height(cm) + mother’s height(cm) +13]/2

      • Girls = [Father’s height(cm) + mother’s height(cm) -13]/2

Growth charts1
Growth Charts

  • Shifts across 2 or more percentile lines may indicate an abnormality in growth

    • Shifts in the early life can be normal

      • Birth size reflects maternal factors (uterine size, etc)

        • Genetic factors take over after birth

        • Small infant born to large parents catches up around 6mos

        • Large infant born to small parents slows down around 12 months

    • After age 3, shifts are uncommon and warrant investigation

Question 2

TH = target height


What is the most likely diagnosis?

  • Normal

  • Constitutional Growth Delay

  • Familial Short Stature

  • Hypothyroidism

  • Cushing syndrome

Abnormal growth
Abnormal growth

  • Malnourished

    • Drop in weight first, then height, then head circumference

  • Linear growth problems

    • Indicates congenital, genetic, or endocrine abnormality

      • Hypothyroidism or GH deficiency: normal or elevated weight with decreased height

Familial short stature
Familial short stature

  • Height and weight are normal for 2-3 years

  • Height then drifts downward across percentiles

  • Growth curve follows normal growth curve at lower percentile

  • After initial drop off, have normal growth velocity

Constitutional growth delay
ConstitutionalGrowth Delay

  • Variation of normal growth

  • Reduced tempo of development

    • Height and weight both cross percentiles

  • Normal or near normal growth rate during prepubertal years

  • Bone age is delayed

  • Delayed puberty

    • Fall further off curve

    • Complete pubertal growth in late teens/early 20’s

  • Achieve normal range height (might be slightly lower than MPH)

Growth and development

  • Begin plotting BMI for every patient at age 2

  • Weight (kg)/height(m)2

    • 85th-95th %ile = overweight

    • >95%ile = obseity

    • <5th%ile = underweight

  • Does not differentiate lean muscle from fat

Head size
Head size

  • Normal head circumference of full-term infant at birth

    • Range 32-38cm

    • Average 35cm

  • Microcephaly

    • 2 SDs below mean for age/sex (<2nd %ile)

  • Macrocephaly

    • 2 SDs above mean for age/sex (>98th %ile)


  • Congenital:

    • Trisomy 13, 18, 21

    • Cornelia de Lange, Smith-Lemli-Optiz, Rett

    • Inborn errors of metabolism, hypothyroidism

  • Acquired:

    • Normal head circumference at birth followed by development of microcephaly over months to years

      • Lack of brain development or growth

    • Causes: Stroke, meningitis, encephalitis, toxoplasmosis, rubella, CMV, teratogen exposure in utero, hypoxic-ischemic encephalopathy

  • MRI most helpful in head size <3SDs below mean and neurologic abnormalities

Question 3
Question #3

Which of the following is commonly associated with hydrocephalus?

  • Large parental head circumference

  • Increased amount of brain parenchyma

  • Normal CNS imaging

  • Developmental delay, hypertonia, hyperreflexia

  • Skeletal dysplasias

Macrocephaly vs hydrocephalus
Macrocephalyvs Hydrocephalus

  • Macrocephaly

    • Causes range in severity from benign to severe

    • Familial

      • Benign

      • Normal development

      • Parents with large heads

      • Accelerated rate of head growth which stabilizes by 12-18 months

  • Hydrocephalus

    • Excessive accumulation of CSF

    • Congenital: present at birth

    • Acquired: accelerated growth over several months

    • Irritability, vomiting, bulging fontanelle, upward gaze

Macrocephaly vs hydrocephaly
Macrocephalyvs Hydrocephaly

  • Can distinguish the two using clinical exam

    • Look for signs of increased ICP

    • Developmental delay, hypertonia, hyperreflexia

  • Imaging

    • Ultrasound: if fontanelle is open

    • CT: fast, available, does not always detect posterior fossa pathology

    • MRI: shows more specific detail, but is not always easily accessible

Question 4
Question #4

You are seeing an 18 month old child for the first time. She is developing well, and the parents have no concerns. Her growth chart reveals a weight at the 3%, height at the 25%, and HC between the 25-50%. What is the MOST likely cause of this patient’s poor weight gain?

  • Inborn error of metabolism

  • Congenital heart defect

  • Inadequate caloric intake

  • Growth hormone deficiency

  • Hypothyroidism


  • FTT is no longer viewed as simply nonorganic vs. organic syndrome

  • NOW…

    • It is a physical sign that a child is receiving inadequate nutrition for optimal growth and development

    • Causes of this may vary…and it is our job to figure that out

      • MOST cases are due to inadequate caloric intake (nutritional)

      • There are medical causes, too

Differential diagnosis
Differential Diagnosis

  • 3 mechanisms can cause under-nutrition

    • Inadequate intake (Ingesting insufficient nutrients for growth)

    • Malabsorption

    • Increased metabolic demands

Growth and development

  • Poor feeding techniques often cause FTT

  • May be a manifestation of parental neglect/inadequacy

  • Some clues to the cause may be elicited from simple observation

    • Oromotor problems

    • Food aversions

    • Poor parent/child interaction

Question 5
Question #5

A mom brings in her 2yo boy with Down syndrome. She is concerned that he is not gaining weight well. The nurse plotted him on a typical male growth chart at 5% for weight. He is a picky eater and often spits up after feeds. There is no history of cardiac or intestinal malformation, but he does have a history of frequent otitis media. Of the following, what is the most important next step?

  • Order an echo to look at his heart

  • Refer him to a nutritionist for dietary counseling

  • Send him to ENT for tympanostomy tubes

  • Plot his growth parameters on a different growth chart

  • Start Zantac for his reflux

Growth charts2
Growth Charts

  • Plotting the weight, length, and head circumference is an important step in assessing a child’s growth.

  • Remember subtle differences are important

    • Weight tends to fall 1st with poor caloric intake, then HC and length

    • For endocrine disorders, the patient is short (<50%) with relative sparing of weight

  • Special growth charts for certain genetic conditions (Down, Turner, Williams syndromes)


  • In the past, children underwent an extensive medical/lab evaluation for organic causes of FTT

  • Now…the majority of FTT work-ups are observational with dietary management and can be accomplished in the outpatient setting**

  • If outpatient management fails, then admission and laboratory evaluation may be needed**

    • CBC with RBC indices

    • CMP (test for renal and hepatic function)

    • Celiac screening

    • OTHER

Long term consequences
Long-Term Consequences

  • Many children who experience FTT in early life eventually seem to have normal function

  • However…the overall trend is worrisone

    • Persistent intellectual deficits

    • Behavioral problems

  • Conflicting evidence on emotional outcomes or future growth parameters

Gross motor
Gross Motor

  • Goal: to gain independent and volitional movement

  • Primitive reflexes develop during gestation

    • Prepare the infant for acquisition of skills

    • Disappear as CNS matures to allow infant to make purposeful movements

Question 6
Question #6

At what age should this reflex disappear?

  • 1 month

  • 2 months

  • 6 months

  • 9 months

  • 12 months


Protective Extension: emerges at 6 - 9mos

Moro reflex: Birth – 6 mos

Positive support: Birth - 4-6 months

Question 7
Question #7

A mother brings her child for a health supervision visit. He is able to pull to stand, take a few independent steps, and use his thumb and 2nd digit to grasp a piece of cereal. These milestones are MOST typical for a child who age is:

  • 6 months

  • 9 months

  • 12 months

  • 15 months

  • 18 months

Gross motor milestones
Gross Motor Milestones

  • 2 months: lifts head and chest while prone

  • 4 months: no head lag, steady head control while sitting, rolls front to back, props on wrists

  • 6 months: sits propped on hands, rolls over in both directions

  • 9 months: begins creeping, pulls to stand, walks on hands and feet

Gross motor milestones1
Gross Motor Milestones

  • 12 months: pulls to stand and cruises well, takes independent steps

  • 15 months: walks independently, stoops to floor/recovers to standing position

  • 18 months: walks up steps with hand held, throws ball

  • 24 months: runs well, kicks ball, jumps with 2 feet off the floor, throws ball overhand

Gross motor milestones2
Gross Motor Milestones

  • 3 years: broad jumps, stands momentarily on one foot, pedals tricycle

  • 4 years: balances on one foot for 3 seconds

  • 5 years: skips, alternating feet

  • 6 years: rides bicycle without training wheels, tandem walks

Question 8
Question #8

Of the following scenarios, which is the LEAST concerning?

  • An 18 month old who cannot walk independently

  • A 4 month old who lacks steady head control while sitting

  • A 9 month old who is unable to sit unassisted

  • A 30 month old who does not run

  • A 10 month old who does not crawl

Fine motor development
Fine Motor Development

  • Use of upper extremities to engage and manipulate the environment

    • Self-help tasks, play, do work

  • First play a role in balance and mobility

  • At birth – no voluntary use of hands

    • Due to primitive grasp reflex

    • Can’t hold or transfer objects until this goes away

  • Once gross motor development allows for stable upright position  hands for more free and purposeful exploration

Question 9
Question #9

You observe a child who is holding two blocks and bangs them together. Then she picks up a cheerio using an immature pincer grasp and feeds it to herself. These milestones are MOST consistent with a child who is:

  • 4 months

  • 6 months

  • 9 months

  • 12 months

  • 15 months

Development of pincer grasp
Development of pincer grasp

Raking Scissor Immature Inferior Fine

Fine motor milestones
Fine Motor Milestones

  • 2 months: regards object and follows 180 degrees, hands unfisted 50% of time, hands held together, hands to midline

  • 4 months: hands open, reaches for objects, clutches at clothes

  • 6 months: transfers object from one hand to another, reaches with one hand, raking grasp

  • 9 months: feeds self with fingers, plays gesture games (pat a cake) in imitation, bangs objects together, holds two objects at a time, immature pincer grasp

Question 10
Question #10

You observe a child as he walks into the exam room. He is holding a small ball. When you ask him to let you see the ball, he gives it to you. He stoops to the floor to pick up a crayon and recovers to a standing position. He uses the crayon to scribble on a piece of paper you gave him. When he sees a few blocks on the floor, he picks up two and stacks one on top of the other. These milestones are MOST typical for a child whose age is:

  • 9 months

  • 12 months

  • 15 months

  • 18 months

  • 24 months

Fine motor milestones1
Fine Motor Milestones

  • 12 months: fine pincer grasp, holds crayon, attempts to scribble after demonstration

  • 15 months: plays ball with examiner, gives and takes a toy, drinks from a cup, makes a line with a crayon, makes 2-3 cube tower

  • 18 months: feeds self with spoon, 3-4 cube tower

  • 24 months: washes and dries hands, removes clothing, 4-6 cube tower, feeds self with spoon and fork

Fine motor milestones2
Fine Motor Milestones

  • 3 years: independent eating, helps with dressing (unbuttons clothing, puts on shoes), 10 cube tower, copies circle

  • 4 years: brushes teeth, copies cross/square, draws simple figure of person (head plus 1 body part)

  • 5 years: dresses and undresses, cuts with scissors, draws person with 6 body parts, copies triangle, independent dressing

  • 6 years: , ties shoes, draws diamond, writes first and last name

Cognitive development1
Cognitive Development

  • The foundation of intelligence

  • Progression through developmental stages involves object permanence, causality, and symbolic thinking

  • Depends on two developmental domains

    • Language

      • Both an expressive and a receptive process

      • Language skills are the SINGLE best indication of intellectual ability

    • Problem-solving

      • The manipulation of objects to achieve a specific goal

The newborn
The Newborn

  • Alerts to sound

    • Bell

    • Voice

  • Visually fixates at 9-12”

  • Demonstrates visual preference for human face

Cognitive development2
Cognitive Development

  • 9-12 months: object permanence

  • 18 months: deduce location even if hidden

  • 18-24months: pretend play and symbolic thinking

  • School age: cognitive reasoning

Question 11
Question #11

You are examining a young boy during a health supervision visit. His mother reports that he says “mama,” “dada,” “bye,” “ball,” and “dog.” Following the exam, he sits on the floor in front of his mom while playing with a toy car. When he sees a jack-in-the-box on a shelf, he points to it. After his mom says (no gestures) “Bring me the Jack-in-the-box,” he brings it to her.

These developmental milestones suggest that the child is CLOSEST to

  • 12 months

  • 15 months

  • 18 months

  • 21 months

  • 24 months


  • 9 months

    • Understands own name

    • Says “mama” and “dada” nonspecifically

  • 2 months

    • Alerts to sound or voice

    • Coos, vowel-like noises

    • Reciprocal vocalizations, social smile (6 weeks)

  • 4 months

    • Orients head in direction of voice

    • Stops crying to soothing voice

    • Laughs out loud, squeals

  • 6 months

    • Turns directly to sound and voice

    • Stops briefly to “no”

    • Babbles consonants, imitates speech sounds


  • 1 year

    • Follows 1 step command with gesture

    • Points to get desired object

    • Says “mama” and “dada” with meaning and at least 1 other word

  • 15 months

    • Follows simple commands, identifies 1 body part

    • Uses 3 to 6 words

    • Mature jargoning with real words

  • 18 months

    • Identifies 3 body parts, points to self

    • Says 7-25 words, uses words for wants or needs

    • Understands “mine”

  • 2 years

    • 50+ words, 50% intelligible (2/4), 2-3 word sentences

    • Points to 5-10 pictures

    • Uses “I”, “me”, and “mine”


  • 3 years

    • Points to parts of pictures, names body parts with function

    • Knows meaning of simple adjectives (eg. tired, hungry, thirsty)

    • 200+ words, 5-8 word sentences

    • 75% intelligible (3/4), uses pronouns correctly

  • 4 years

    • Follows 3 step commands

    • 300-1000 words, speech fully intelligible (4/4)

    • Asks “when, why, how?”, tells stories

  • 5 years

    • 2,000 words

    • Defines simple words or asks questions about meaning of words

    • Responds to “why” questions

  • 6 years

    • 10,000 words, 8-10 word sentences

    • Describes events in order

Question 12
Question #12

I can count to 10, draw a person with 8-10 body parts, know 4-10 of my colors, and recognize my numbers and letters (even if they are out of order). How old am I???

  • 2 years

  • 3 years

  • 4 years

  • 5 years

  • 6 years

Problem solving1
Problem Solving

  • 2 months

    • Recognizes mother

    • Follows large, highly contrasting objects

    • *tracks objects in circle at 3 months*

  • 4 months

    • Stares longer at unfamiliar faces

    • Mouths objects

    • Reaches for ring/rattle, shakes rattle

  • 6 months

    • Touches reflection in mirror and vocalizes

    • Bangs and shakes toys

  • 9 months

    • Inspects and rings a bell

    • Pulls a string to obtain toy at the end

Problem solving2
Problem Solving

  • 1 year

    • Understands object permanence

    • Rattles spoon in a cup

    • Lifts box lid to find a toy

  • 15 months

    • Turns pages in a book

    • Places circle in a single-shape puzzle

  • 18 months

    • Matches pairs of objects

    • Imitates household tasks (cleaning, cooking, etc.)

  • 2 years

    • Sorts objects and matches objects to pictures

    • Shows how to use a familiar object

Problem solving3
Problem Solving

  • 3 years

    • Draws a 2-3 part person

    • Knows age and gender

  • 4 years

    • Draws a 4-6 part person

    • Counts 4 objects

    • Points to 5 or 6 colors and letters/numbers when named

  • 5 years

    • Counts to 10, names 4*-10 colors, 8-10 part person

    • Identifies letters and numbers

  • 6 years (*think of finishing kindergarten!)

    • Draws 12-14 part person

    • Writes name, reads (250 words by end of 1st grade)

    • Simple addition and subtraction

    • Knows left from right across midline

Question 13
Question #13

You have had multiple well child checks in clinic today, and all the developmental milestones are getting confusing!! You feel confident that at least you know the red flags to worry about! Which of the following DOES NOT concern you?

  • A 36 month old who can’t say a 4-word sentence

  • A 9 month old with no babbling

  • A 4 month old that doesn’t visually track

  • A 24 month old that doesn’t say any words

  • A 6 month old that doesn’t turn to sound/voice

Social emotional development
Social/Emotional Development

  • Most children are born with an inherent drive to connect with others and share feelings, thoughts, and actions

  • The earliest social milestone is bonding of the caregiver with an infant

  • Emotional development is influenced by a child’s temperament as well as the interactions between the care-giver and the child

Question 14
Question #14

How old are kids when they develop separation anxiety and stranger anxiety?

  • Stranger anxiety 6 months, separation anxiety 9 months

  • Stranger anxiety 9 months, separation anxiety 12 months

  • Stranger anxiety and separation anxiety at 6 months

  • Stranger anxiety and separation anxiety at 9 months

  • Stranger anxiety 6 months, separation anxiety 12 months

Social emotional1

  • 2 months

    • Reciprocal smiling

    • Responds to adult voice and smile

  • 4 months

    • Smiles spontaneously at pleasurable sights/sounds

    • Initiates social interactions

    • Alternating (to and fro) vocalizations

  • 6 months

    • Stranger anxiety

  • 9 months

    • Follows a point,”oh look at…”

    • Recognizes familiar people/objects

    • Separation anxiety

Social emotional2

  • 1 year

    • Shows object to parent to show interest

    • Points to get desired object (proto-imperative)

  • 15 months

    • Shows empathy (looks sad if someone else cries)

    • Points at object to express interest (proto-declarative)

  • 18 months

    • Engages in pretend play with other people

    • Shows embarrassment or possessiveness

  • 2 years

    • Parallel play

      • Best with one other kid, side by side but not cooperative!!

Social emotional3

  • 3 years

    • Starts to share, play become more cooperative

    • Fears imaginary things

    • Imaginative play

  • 4 years

    • Further development of pretend play, GROUP play

    • Deception: tricks others or are scared to be tricked

    • Has a preferred friend

  • 5 years

    • Plays board games or card games

    • Has group of friends

    • Apologizes for mistakes

  • 6 years

    • Has best friend of the same sex

    • Distinguishes fantasy from reality

    • Enjoys school

Question 15
Question #15

All of the following are social/emotional red flags EXCEPT…

  • A 12 month old who doesn’t respond to his name

  • A 15 month old who will not point to what he enjoys or finds interesting (proto-declarative)

  • A 2 year old who pointed for what he wanted 3 months ago but no longer does so

  • A 6 month old who doesn’t smile

  • A 15 month old who doesn’t engage in simple pretend play

Kindergarten readiness
Kindergarten Readiness

  • Able to separate from parents for several hours at a time

  • Plays well with other children

  • Takes turns

  • Follows directions in group activities

  • Able to relate personal experiences

  • Tells stories