Practical Mother, Newborn and Child Care in

Practical Mother and Child Health in Developing Countries
Book 1 Chapter 9 Growth and Development
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Chapter 9 Growth and Development
Chapter 9 Growth and Development .................................................................................................99
Growth and development .............................................................................................................100
Factors influencing growth ..........................................................................................................100
Methods of assessing growth .......................................................................................................101
Development ................................................................................................................................105
Figure 9.1 The Road to Health Chart...............................................................................................102
Figure 9.2 a-d. Charting weight .......................................................................................................104
Figure 9.3 Stages of development....................................................................................................105
Table 9.1 Ages for Key Abilities .....................................................................................................106
Table 9.2 Signals for Concern..........................................................................................................107
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Growth and development
Throughout childhood, the infant grows in size and the different physiological systems of the body
mature in function. At the same time, social and emotional development occurs and the individual
acquires several different skills of which the most important is language function. By growth is
meant an increase in size which may be due to an increase in the number of cells constituting the
various organs or an increase in the size of individual cells; by development is meant the acquisition
of functions and skills.
Growth does not occur by continuous and regular small increments but in a definite pattern. General
body growth takes place in two cycles, each with a speed-up and a slow-down phase. The first cycle
of growth begins in embryonic life in the uterus; by the time the baby is born he is already in the
decelerating phase even though increments in growth are more than at any other time in his life.
After the age of about two, growth is slow and regular until puberty is reached when the onset of a
growth spurt signals the beginning of the second cycle. Several body organs follow an individual
pattern separately from the general pattern mentioned above. Thus the nervous system grows
maximally in early life being one fourth of adult size at birth, and more than doubling in size in the
first two years of life; on the other hand the gonads, the genitals and the mammary glands do not
grow until puberty.
During any one cycle of growth, the different body parts do not grow symmetrically, and so
changes occur in the body proportions at different ages. In early life, because the nervous system is
growing rapidly, the head is large in proportion to the rest of the body; later the extremities grow
more rapidly than the trunk and both of them grow faster than the head. This gives the appearance
of growth progressing from head downwards and is called the cephalocaudal pattern of growth.
Factors influencing growth
A number of factors, both inborn as well as environmental, affect growth. These are:
1) Genetic factors. The size of the parents will influence the size of the child and this is
why children of tall parents are usually tall.
2) Nutrition. In most developing countries, inadequate nutrition is by far the most
common cause of growth retardation and as such constitutes a major public health
problem. In addition to sufficient calories, the diet should consist of proteins, vitamins
and minerals for optimum growth.
Of the protein portion, animal proteins are important because they contain all the essential aminoacids required by humans. However, a judicious combination of vegetable proteins of different
origins may also serve the same purpose and support adequate growth. A diet which is adequate in
calories may require much less protein than one with fewer calories, because the protein does not
get diverted for energy production and most of it is utilised for growth and maintenance.
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3) Infective illnesses. Illnesses, such as measles, whooping cough, diarrhoea and so on,
are important causes of slowing of growth. This is due to three reasons:
a) There is usually loss of appetite accompanying such illnesses and food intake is
diminished.
b) It is a very common practice to starve the child who has diarrhoea or fever. At the
most only liquid diet may be offered. Surprisingly some health workers also advise
the same.
c) During illness there is a breakdown of body tissues and loss of nutrients. There may
also be a diversion of nutrients for mounting a response to the illness.
Of all the above reasons for slowing of growth during an illness, the most serious and also
preventable is the withholding of food. Recent research shows that even with acute diarrhoea, up to
70 per cent of nutrients are still being absorbed by the gut. Hence there is no scientific basis for
starvation during an illness.
Because infective illness is more common in developing countries, especially amongst the
disadvantaged, it is often a more serious cause of growth retardation than deficient food intake. In
this respect measles and diarrhoea are the two big culprits.
4) Endocrines. Growth becomes distorted in the absence of a healthy endocrine system.
By far the most important hormone governing growth is the growth hormone produced
by the anterior pituitary. In the absence of the growth hormone, height is reduced and
infantile body proportions are retained in adult life. Thyroxine, the hormone produced
by the thyroid gland, not only helps growth and development but is also required for
maturation. Its deficiency leads to retardation of linear and intellectual growth as well
as bone maturation. The growth spurt at puberty is produced by the sex hormones,
which are secreted under the stimulation of the anterior pituitary.
5) Healthy body organs. Growth is affected in many disease states; every episode of
acute illness can cause slowing of growth but on recovery there is a phase of rapid
growth called 'catch up' growth, in which the lost ground is regained. However, in
cases of recurrent illnesses, especially when the individual is on marginal nutrition, the
cumulative effects of such recurrent illnesses may cause serious growth retardation.
Wherever community surveys have been carried out in the tropics, it has been found
that most children do not reach the average Western standard; inadequate nutrition in
addition to chronic ill health as well as life in a harsh environment combine to cause
suboptimal growth.
Methods of assessing growth
Measurements of height and weight are the commonly employed parameters for assessing growth.
Like all measurements these are of use only if carried out with meticulous care. The weighing
machine used should be sensitive and should be checked periodically for accuracy. Weighing
should not be delegated to the most junior member of the team as a job requiring little skill, but
should be done by an experienced person. The same comments also apply to measurements of
height.
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Serial measurements are more useful than a single reading; in this way any deviation from the
normal can be detected early and corrective measures can be applied in time. All readings obtained
are more informative if plotted on a graph which has the average weight curve or percentile curves
for comparison.
Weight charts, also called 'Road-to-Health' charts, are now in common use in most countries. (See
Fig. 9.1). The following features are common to all cards even though there may be some local
differences:
1) The horizontal line, or axis as it is called, is for age. It is usually divided into 12 boxes
for writing the month of the year. The first box for each year is in bold. At the child's
first visit to the clinic the month of birth and the year of birth are recorded in the first
box. The rest of the boxes are then filled in with the names of the following months.
2) The vertical axis is for recording the weight of the child.
3) There are two curves running across the chart. They denote the shape of the child's
growth curve when he is growing well. From experience we now know that the shape
of the growth curve is more important than the actual place on the chart where the
child's weight falls.
Figure 9.1 The Road to Health Chart
Note: a) The horizontal axis for age b) the vertical axis for weight c) The two lines running across the chart d) the
record of the child's weight
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4) At each visit, besides recording the weight of the child, important health events are
also recorded, for example, immunizations given, illnesses treated and so on.
Figure 9.1 is an example of a weight chart in common use. It shows that the child's growth was
satisfactory until the age of one year. After that a series of illnesses occurred, each causing a
faltering of growth, with the child ending up being underweight. Figures 9.2 (a-d) demonstrate how
to fill in the weight chart.
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Figure 9.2 a-d. Charting weight
In community surveys, other parameters besides height and weight are employed; these are the
circumference of the head and the chest, the arm circumference and skin-fold thickness. In routine
clinical practice these are hardly employed, except the circumference of the head and the chest
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expressed as a ratio to detect sub-clinical malnutrition. Serial measurement of the circumference of
the head in the first year of life is a useful method of assessing brain growth especially in the
follow-up care of babies born with a low birth-weight.
In a healthy child, centres of ossification in the skeleton appear at predictable times. In certain
clinical states, bone age is estimated and compared with the chronological age to assess growth
retardation. In the same way dentition may be employed for comparison with body growth.
Development
As body growth progresses, the child also passes through various stages of intellectual and social
development, learns motor skills of which the most important are walking and bladder control, and
acquires language function.
Arbitrarily, development process is divided into several stages.
1) The neonatal period is the first month of life in which the baby is adjusting to extra-uterine
life and an independent existence.
2) Infancy is the early year or two during which the child learns to walk and talk and is thus able
to explore his environment both physically and socially.
3) Pre-school period. The physical environment of the child is widened by being taken out of the
home more often, or by contact with adults or children of his own age. This is also the period
of weaning during which the child is being gradually brought onto an adult type of diet.
During this period the child acquires a number of skills the most important being language
function. (See Fig. 9.3)
Figure 9.3 Stages of development
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4) School age. The child has emerged from the first cycle of growth and has not yet entered the
second cycle. Both socially and educationally this is an important phase because the child now
enters the training and education system of society, from which he will emerge as a contributing
member.
5) Puberty. This stage is the stage of transition between childhood and adulthood. It is
characterized by the onset of the second growth cycle during which increases in height and
muscle mass occur, together with the appearance of sexual characteristics.
6)
For assessing whether development is progressing normally in the individual child key functions
may be looked for in a busy clinic. These are set out in tables 9.1 and 9.2.
Table 9.1 Ages for Key Abilities
Age (months)
Ability
1
Some indication of attention
2
Visual attention to faces and objects
3
Holds head. Smiles
4
Hand not kept fisted. Interest in people
5
Reaches for objects. No head lag.
6
Asymmetric tonic reflexes absent. Visual fixation and
follows objects
7
Holds objects using both hands
10
Sits independently on firm surface. Babbles. Chews
on lumpy foods
12
Pays attention to specific words
15
Releases held objects
18
Walks alone. Has stopped drooling
21
Says single words with meaning. Can kick a ball
27
Puts 2 to 3 words together
36
Talks in sentences
48
Uses fully intelligible speech
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Table 9.2 Signals for Concern
Age (months)
3
6
12
18
24
36
Signal
•
Does not react to sudden noise
•
Does not try to find a speaker’ face with his
eyes
•
Has not begun to vocalize sounds
•
Does not raise head when prone
•
Does not turn to the speaker
•
Never laughs or smiles
•
Does not reach for a toy
•
Is not imitating speech sounds
•
Is not saying two or three words
•
Does not respond to Peek-a-Boo
•
No speech or jargon
•
Not moving about to explore
•
No eye contact
•
Not naming familiar objects or using 2 or 3
word phrases
•
Not noticing animals, cars etc.
•
Not moving about vigorously
•
Avoids eye contact
•
Long periods of rocking or head banging.
•
Unaware of other children or people
•
No speech
•
Repeat behaviour
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