Child Healthcare: Growth and development


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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

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Child Healthcare: Growth and development

  1. 1. 3 Growth and development • Size compared to other children of the Objectives same age • Growth curve When you have completed this unit you • Growth pattern should be able to: • Measure the size of a child to assess growth. MEASURING BODY SIZE • Know the value of growth monitoring. • Use centile charts and growth curves. • Understand different growth patterns. 3-2 How is body size determined in • Identify obese children. children? • Use the growth chart on the Road-to- The following 3 measurements of body size are Health Card. commonly used in children: • Assess neurodevelopment. 1. Weight: This is the most commonly used measure of body size as it is easy and accurate to weigh a child.INTRODUCTION 2. Height or length: This is a very useful measure of size, especially in older children. However, it is more difficult to3-1 What is growth? measure accurately. Height is measuredGrowth is the increase in body size over a with the child standing. In infants theperiod of time. In order to assess growth, some measurement is taken lying down and ismeasure of body size has to be accurately then called length. A child’s length andmeasured on two or more occasions. height are the same. 3. Head circumference: This is also a useful measure of size but must be measured Growth is the increase of body size over a period correctly. of time.Growth is best assessed by determining the Weight is the most common way of assessingchild’s: body size in children.
  2. 2. 50 GROWTH AND DEVELOPMENT3-3 How is weight measured? For convenience, height is used in this unit. However, whatever is said about the height ofYoung children are weighed when lying on older children, applies equally to the length ofa scale. Wait until the child lies still before infants and young children.recording the weight to the nearest 10 g. Alwaysweigh the child undressed or wearing only avest. Always remove the nappy before weighing. 3-5 How should head circumference be measured?Older children are weighed standing up.Record the weight to the nearest 100 g (0.1 It can be difficult to the measure headkg). Remove all the child’s clothes, except the circumference accurately. Use a measuringunderpants, before weighing. tape and record to the nearest 1 mm. Measure the largest circumference of the headBefore weighing a child, always check that the (occipito-frontal circumference) with the tapescale reads zero. Scales should be calibrated across the forehead and then around to theweekly. back of the head (occiput). NOTE When weighing an infant on a spring scale, or an older child on a bathroom scale, you are 3-6 How often should the size of children measuring weight. A balance scale measures be measured? mass. Both are equal and expressed in kilograms. Weight should be measured and recorded3-4 How are height and length measured? every month for the first year of life, as young children grow fast.Height must be measured with the childstanding barefoot. Keep both heels on the floor • Children should be weighed every 6with the child’s back pressed against a wall. months between 1 and 5 years.The child should stretch as tall as possible with • Height should be measured every year.the arms kept at the side while looking straight • Head circumference is not routinelyahead. Move a square block of wood or a book measured unless there is a good reason.down against the wall until it touches the top In addition, a child’s weight should also beof the child’s head. Then measure the distance measured and recorded every time the childfrom the floor to the block of wood, to the is seen at a clinic, hospital or by a generalnearest 1 mm, to get the correct height. Ideally, practitioner.a special measuring device should be used,with a fixed tape or ruler on the wall and a 3-7 How is a child’s size used to assesssliding head board. growth?Under 2 years: It is difficult to measure an The best method to assess growth is toinfant’s standing height. Therefore, the lying measure the child’s size (e.g. weight) and thenlength is measured. If possible, a measuring to repeat the measurements a few monthsboard should be used. The infant is laid down later. The increase in size is due to growth.on his/her back with legs fully extended. One The greater the increase, the faster the childperson holds the infant’s head against the top is growing. If there is no increase, the child isboard while another person gently stretches not growing. For this reason it is important tothe infant’s legs, keeping the knees flat and record a child’s size and plot the measurementspressing the heels of the infant’s feet against on a growth chart at every clinic visit.the bottom board. Measuring the distance, tothe nearest 1 mm, between the boards givesthe length of the infant. It is inaccurate tosimply measure length with a tape measure.
  3. 3. GROWTH AND DEVELOPMENT 51THE IMPORTANCE OF Head circumference can be used to assess brain growth in children under 2 years.GROWTH MONITORING During this period brain growth is fast and, therefore, head circumference increases rapidly. A small head (microcephaly) suggests3-8 What is growth monitoring? a small brain, while a large head suggestsGrowth monitoring is the regular hydrocephaly. Head circumference is lessmeasurement of a child’s size in order accurate in assessing brain growth over 2 yearsto document growth. The child’s size of age.measurements must then be plotted on a Therefore, measuring head circumference isgrowth chart. This is extremely important as most useful in young children, and height init can detect early changes in a child’s growth. older children.Both growing too slowly or too fast mayindicate a nutritional or other health problem. If a child’s weight gain is normal, the heightTherefore, growth monitoring is an essential and head circumference is usually alsopart of primary health care in children. normal. However, it is particularly importantMeasuring a child’s size is of very little value to measure height and head circumference inunless it is used for growth monitoring. children who are not gaining weight normally. Growth monitoring is an essential part of primary Height is an important measure of growth, health care in children. especially in older children.3-9 What is the value of weight in growth 3-11 Can an infant’s growth be determinedmonitoring? at a single clinic visit?Weight-for-age is usually used to monitor No, as the definition of growth is a change ingrowth. It is particularly useful in small infants body size over a period of time. Therefore,who normally gain weight fast. Normal weight some other form of assessment of growth isgain suggests that the infant is healthy and needed when you cannot wait a few weeks orgrowing normally. Failure to gain weight months to decide whether the child is growingnormally is often the earliest sign of illness or normally or not. An assessment of growth canmalnutrition (i.e. undernutrition). Therefore, be made if the size of a child is compared toa child’s weight should be measured at every the size of other children of the same age. Inclinic visit in order to monitor growth. order to do this, the normal (i.e. average size) range of children of that age is needed. If the child’s size is the same as most other children Weight should be measured and plotted on a of the same age, then the child is probably growth chart at every clinic visit. growing normally. The most commonly used growth charts are centile charts.3-10 What is the value of measuring heightand head circumference? An assessment of growth can be made byThese are also important measurements comparing a child’s size to that of other childrenof growth. Height is the best method of of the same age.measuring linear growth (stature) as heightreflects growth over a longer period thandoes weight. Measuring height is thereforeimportant in older children.
  4. 4. 52 GROWTH AND DEVELOPMENTCENTILE CHARTS of the row would be the 50th centile. It is called a centile chart as it reflects the relative size of 100 normal children, and ‘centum’ is the Latin word for a hundred. International centile charts are used in3-12 What is a centile chart? all countries.A centile chart is a size for age chart that isused to decide whether the size of a child falls 3-14 What is the normal size for children ofwithin the normal (average) range or whether a given age?the child is larger or smaller than normal. The The size of most children (94%) falls betweensize of a healthy child will increase normally the 3rd and the 97th centiles. These childrenwith age. Without knowing a child’s age, one are regarded as having a normal (average orcannot decide whether the size is normal or appropriate) size for their age and are growingnot. Therefore, accurate ages are needed when well. Centile charts, therefore, indicate theusing a centile chart. range of normal growth.A centile chart is based on the sizemeasurements of thousands of healthychildren recorded at different ages. A centile The range of size between the 97th and 3rdchart is made up of lines called centiles. centiles is regarded as normal. NOTE The size range for older children is different The growth of healthy children usually follows to that in newborn infants when the 10th and the centile lines. 90th centiles are used to define appropriate size for gestational age. NOTE With increasing age, the centiles move further and further apart, as some normal 3-15 What size measurements are usually children grow faster and others slower than the plotted on a centile chart? average. As a result, the normal range becomes wider. Boys are slightly larger than girls. However, Weight, height (or length), head circumference the same charts are often used for both boys and and weight-for-height can all be plotted on a girls when routinely plotting size-for-age. centile chart. Weight is the measurement most commonly plotted on a centile chart.3-13 What are the important centiles on acentile chart? International centile charts are shown at the end of this unit.Most centile charts have 7 centile lines onthem, i.e. the 3rd, 10th, 25th, 50th, 75th,90th and 97th centiles. Ninety seven percent 3-16 When is a child larger than normal?of healthy children will fall below the 97th When the infant’s size measurement fallscentile. Similarly 50% of healthy children will above the 97th centile. Children are heavierfall below the 50th centile and 3% below the than normal if their weight is above the 97th3rd centile. Therefore, each centile indicates centile. Similarly, they are taller (longer) thanwhat percentage of healthy children should normal if their height (length) falls abovehave a size that falls below that line. This the 97th centile. They have bigger heads thanmethod enables one to compare the size of any normal if their head circumference falls abovechild with the expected size of children of the the 97th centile.same age. NOTE If 100 healthy children of the same age 3-17 When is a child smaller than normal? were lined up from the tallest to the shortest, the height of the tallest child would be the 100th When the infant’s size measurement centile, that of the second tallest the 99th centile, falls below the 3rd centile. Children are and so on. The height of the child at the centre underweight if their weight is below the 3rd
  5. 5. GROWTH AND DEVELOPMENT 53centile. Similarly,children are shorter than 3-18 How should you plot a child’s weightnormal if their height (length) falls below on a centile chart?the 3rd centile. They have smaller heads than 1. Make a mark along the bottom of the chartnormal if their head circumference falls below opposite the age of the child. Now draw anthe 3rd centile. imaginary vertical line up from the mark. NOTE 3% of normal children fall above the 97th 2. Similarly, make a mark opposite the child’s centile and 3% below the 3rd centile. Therefore, weight along the left or right hand side the size of 6% of children falls outside the normal of the chart. Now draw an imaginary (i.e. average) range, i.e. above the 97th or below horizontal line from that mark. the 3rd centiles. Note that ‘normal’ refers to the average range of size for age. Therefore, some 3. Make a dot at the point on the chart where perfectly healthy children might fall outside the the two imaginary lines meet. This is called 3rd and 97th centiles. plotting the weight. It will give the child’s weight for its age.Recently Z-scores (standard deviations fromthe mean) have also been used to assess a The same method is used to plot the infant’schild’s size. A Z-score of –2 is equivalent to the height (or length) and head circumference on3rd centile. centile charts. At the first visit it is helpful to fill in the calendar months along the bottom of the 11,5 5 11,5 11 11 10,5 5 10,5 5 10kg 10kg g 9,5 5 9,5 5 9 9 8,5 5 8,5 5 8 8 7,5 5 7,5 5 7 7 6,5 5 6,5 5 6 6 5,5 5 5,5 5 5kg g 5kg 4,5 5 4,5 5 4 4 3,5 5 3,5 1 5 year 3 3 12 13 14 15 16 17 182,5kg k 2,5kg g age in month nm 2 Birth 1 2 3 4 5 6 7 8 9 10 11 w weight age in months nm 1,5 5 1 write 1 to 2Figure 3.1: Plotting a child’s weight on a centile chart
  6. 6. 54 GROWTH AND DEVELOPMENTcentile chart, starting with the month in which index (weight in kg divided by height in metres)the child was born. This is done so that further is used to determine fatness or thinness.growth is easily plotted.3-19 Can length and height both be plotted GROWTH CURVESon the same chart?Yes. As a child gets older height can be plotted 3-21 What is a growth curve?on the chart used before to plot length. Forpractical purposes, the measurement of length A growth curve (or growth line) illustrates theis the same as height. way a child is growing over a period of time. A growth curve can be determined when a3-20 What is the value of knowing a child’s child’s size measurements have been made onweight-for-height? two or more visits and have been plotted as dots on a centile chart. If these dots are nowThe weight-for-height gives an idea of how joined together with a line, you will have afat or thin a child is. Thin children have a low growth curve. Therefore, the best way to assessweight for their height while fat children have growth is to look at the growth curve overa high weight-for-height. Often the body mass the past few months and compare the growth curve to the centiles.10kg 10kg g 9,5 5 9,5 5 9 9 8,5 5 8,5 5 8 8 7,5 5 7,5 5 7 7 6,5 5 6,5 5 6 6 5,5 5 5,5 5 5kg g 5kg 4,5 5 4,5 5 4 4 3,5 5 3,5 1 5 year 3 3 12 13 14 15 16 17 182,5kg k 2,5kg g age in months nm 2 Birth 1 2 3 4 5 6 7 8 9 10 11 w weight age in months nm 1,5 5 1 0,5 5 write birth month 1 to 2 Y 0 write birth month and year Birth to 1 Year Growth Monito Chart revised: AuguFigure 3.2: A normal growth curve plotted on a centile chart
  7. 7. GROWTH AND DEVELOPMENT 55 A growth curve is a line linking size measurements 3-25 Is weight or height the better measure of growth? recorded over time. In younger children, weight is the most sensitive index of growth and poor weight gain3-22 What is the value of a growth curve? is usually the first sign of malnutrition. In olderA growth curve shows not only whether the children, height is the better index of growth.child’s size is normal or not, but also whetherthe child is growing normally, faster or slowerthan expected. Therefore, a growth curve is a far Height is the best index of growth in older children.better method of assessing growth than usingsize measurements taken on one occasion only 3-26 Is it important if a child is heavier thanas it reflects the child’s growth rate. normal? Some children who are heavier than normal A growth curve indicates the child’s growth rate. are perfectly healthy. They are simply bigger for their age than most children. Other children are heavier than normal because they3-23 What is the normal growth rate? are obese (too fat).If the child’s growth rate is normal, the growthcurve will closely follow along (be parallel to) 3-27 Is it important if a child is lighter thanthe centile lines and not cross more than one normal?centile. This is a very important observation. SomeA normal growth curve is plotted in Figure 3.2. children who weigh less than normal are healthy and simply smaller for their age than A normal growth curve follows the centile lines. most children. However, in a poor community, most children who weigh less than normal are malnourished (undernourished) or have an NOTE Special growth rate charts can be used to determine accurately whether a child’s growth illness. rate is normal or not. These charts are useful during the growth spurt of puberty. 3-28 What should you do if a child is heavier or lighter than normal?3-24 How fast should most children grow? Determine the child’s growth pattern.Most children double their weight from birth to6 months and treble (increase by three times)their birth weight by one year. The increase in GROWTH PATTERNSweight and height is fastest in the first year oflife and then slows down until puberty whengrowth is again fast for a short while. Growth in 3-29 What is a growth pattern?head size is almost complete by 2 years. The position of the child’s weight, height, head NOTE Only when a child reaches 4 years is circumference on the centile lines, and the the birth length doubled. Thereafter the growth curves for all these measurements, normal increase in height during childhood is determines the child’s growth pattern. approximately 4 cm per year. Therefore, more than one measurement of size (e.g. weight and height) is needed to establish the growth pattern. Most normal healthy children have a weight, height and head circumference within the
  8. 8. 56 GROWTH AND DEVELOPMENTnormal range and the growth curves for all in the normal range. Their growth curve forthese measurements are normal. Therefore, weight often shows a weight gain faster thanall measurements of size fall between the 97th normal. They are too fat.and 3rd centiles and the growth curves have A weight above the 97th centile with a heightfollowed and not crossed more than one centile. below the 50th centile suggests a hormonalThis is the most common growth pattern. problem, which needs to be investigated.3-30 What other growth patterns are NOTE Some children grow faster than normal and their size measurements cross centiles.common? This growth pattern is seen normally at puberty• Large-for-age and in some children after an illness or period• Overweight-for-age of malnutrition (catch up growth). Rapid gain• Wasted in weight only is also seen with obesity, some endocrine disorders and generalized oedema.• Growth faltering• Stunted 3-33 What is a wasted child?These growth patterns indicate that the childmay have a medical, nutritional or social Wasting is a danger sign and suggestsproblem. It is, therefore, very important that malnutrition or illness. These children usuallyall children who do not have a normal growth look very thin and have a weight that fallspattern are identified as soon as possible in below the 3rd centile while their height andorder that they can be carefully examined. head circumference often fall within theSome of these children will be healthy even if normal range. These children also have a bodytheir growth pattern differs from the average. mass index below the 3rd centile, i.e. they are underweight for their height. Special weight for height charts are available. Their growth It is important to identify children who have a curve may show weight faltering. growth pattern that differs from the average NOTE Mid-arm circumference and triceps skin-fold growth pattern. thickness can also be measured and plotted on centiles to identify thin children and fat children.3-31 How can you recognise a large-for-age Special arm tapes are used to detect wasted children. Abdominal circumference is anotherchild? measure that can be used to detect fatness inThese children appear healthy but are children.symmetrically large. Their weight, height andhead circumference are all equally above the 3-34 What is growth faltering?97th centile. Their growth curves run parallel Infants with growth faltering (failure toabove the 97th centile. Most of these children thrive or slow growth) have not beenhave tall parents and are genetically large. gaining weight normally. Their weightSome may have been large at birth with a may be static (remaining the same) or mayhigh birth weight. They are normal on general even be dropping. Their height and headexamination and can be managed as normal circumference may also not be increasingchildren. They often have an earlier puberty normally. This is a very important growththan most children. pattern to recognise as most of these children have a medical, nutritional or social problem,3-32 Which children weigh too much? which needs to be urgently diagnosed andThese children can often be recognised by managed. Faltering weight gain must besimple inspection. Their weight falls above the detected as soon as possible so that the cause97th centile (overweight-for-age) while their can be corrected. Growth faltering may be theheight and head circumference usually fall first sign of HIV infection.
  9. 9. GROWTH AND DEVELOPMENT 5710kg 10kg g9,5 5 9,5 5 9 98,5 5 8,5 5 8 87,5 5 7,5 5 7 76,5 5 6,5 5 6 65,5 5 5,5 55kg g 5kg4,5 5 4,5 5 4 43,5 5 3,5 1 5 year 3 3 12 13 14 15 16 17 18,5kg k 2,5kg g age in months nm 2 Birth 1 2 3 4 5 6 7 8 9 10 11 w weight age in months nm1,5 5 10,5 5 write birth month 1 to 2 Y 0 write birth month and year Birth to 1 Year Growth Monito Chart revised: AugusFigure 3.3: A growth-faltering curve plotted on a centile chart NOTE Children who are symmetrically small Slow growth or growth faltering are important (stunted) often have a normal growth rate. They signs that the child may be ill or not getting are simply growing parallel to, but below, the 3rd enough food. centile. The most common cause of stunting is chronic3-35 How can you recognise stunting? malnutrition during the first years of life. However, some healthy short children areStunted children are shorter than normal for genetically small, and look like their parents.their age. As they are often symmetrically Being born very pre-term or growth-restrictedsmall and do not look thin, their stunting is can also result in stunting. Some importantoften missed. Usually their growth curves have medical disorders, such as Foetal Alcoholfollowed the centiles although their weight, Syndrome, can cause stunting.height and head circumference all fall belowthe 3rd centile. Stunting usually occurs before3 years of life. The most common cause of stunting is chronic malnutrition. It is very important to identify all children with a height below the 3rd centile.
  10. 10. 58 GROWTH AND DEVELOPMENT3-36 What is the long term effect of OVERWEIGHT AND OBESITYstunting?Short children usually become short adults ascatch-up growth is difficult to achieve. Severe 3-40 How do you decide whether a child isstunting due to malnutrition before 2 years of overweight?age is associated with schooling difficulties later. It is better not to use weight alone to decide whether a child is overweight as some children3-37 What is the common growth pattern are heavy because they are simply big whilein poor communities? others are heavy because they are fat. Usually the body mass index for age (i.e. weight in kg/A very common pattern of growth in poor height in m2) is used to decide whether a childcommunities throughout the world is normal is overweight due to excess fat. Special chartsweight gain for the first 6 months while the are used to define the normal body mass indexinfant is being breastfed. Then, between for age. A body mass index for age between6 months and a year, there is faltering of the 5th and 85th centiles is usually regarded asboth weight and length as the child receives normal.inadequate food. By a year the child is stunted,with a weight and length below the 3rd centile. NOTE Even body mass index cannot alwaysAfter a year, the weight may slowly increase differentiate between obesity and a high leanto slightly above the 3rd centile but height mass.remains below the 3rd centile. This patternof low weight and height often continues into 3-41 When is a child overweight?adulthood and reflects chronic malnutrition. Children are usually considered overweight if their body mass index is between the 85th3-38 When does the puberty growth spurt and 97th centile. These children also look fat.occur? A child is not considered overweight if thePuberty is a time of rapid growth. It occurs weight for age is above the 97th centile but theearlier in girls than in boys. Puberty also body mass index is normal. These children areoccurs earlier in well-nourished children than simply big for their malnourished (undernourished) children. NOTE The definition of overweight remainsThe puberty growth spurt usually lasts 2 years, very controversial and a number of differentstarting at about 11 years in girls and 13 years definitions are used. Overweight (which refers toin boys. the BMI) must not be confused with overweight- for-age.3-39 What is the effect of emotion ongrowth? 3-42 What is obesity?Love and emotional security are needed for There is still no internationally acceptednormal growth. Stressed and emotionally method of defining obesity in childhood.deprived children grow slower that normal However, the clinical diagnosis can usuallyand may become stunted. be made on simple inspection of the child as these children appear very fat. A body mass NOTE Growth hormone is not secreted normally in index for age above the 97th centile is regarded emotionally deprived children. This has been well- as obesity in older children and adolescents. documented in some children in orphanages. The diagnosis of obesity can usually be made by simple inspection.
  11. 11. GROWTH AND DEVELOPMENT 59 NOTE A high skin-fold thickness can also be used counseling are often needed. Good eating to define obesity. Waist circumference may also habits for the family should prevent obesity. be useful. Short, fat children need investigation for endocrine abnormalities.Obesity is a common childhood problem in THE ROAD-TO-HEALTHaffluent countries and over the past 20 yearshas reached epidemic proportions in some CARDcommunities, especially with girls. Obesechildren have excessive fat stores due to a 3-44 What is the Road-to-Health Card?high energy intake and inadequate exercise.The cause is almost always due to the child’s The patient-held Road-to-Health Card is thelifestyle. Fast foods, soft (fizzy) drinks and child’s formal medical record. It gives thehours of watching TV each day are associated child’s medical history, immunisation record,with obesity, as is rapid weight gain in infancy. developmental milestones and growth record.Genetic factors are not as important as diet. Growth is plotted on a weight-for-age chartHowever, many obese children have obese (growth chart) which is part of the Road-to-parents. Obese children have difficulty with Health Card.sports and often have emotional problems A blank Road-to-Health Card growth chart isdue to a poor body image and lack of self given at the end of this unit.confidence. They are miserable and unhappywith their weight and shape. Obese children,and especially obese adolescents, are at The Road-to-Health Card is an essential part ofincreased risk of growing up to be obese good primary care.adults with a high risk of chronic illnesses inadulthood (hypertension, type II diabetes and 3-45 What is the importance of the growthheart disease). chart? The weight-for-age chart is an essential part of Childhood obesity is a major problem in wealthy the Road-to-Health Card. The area between countries. the 3rd and 97th centiles is shaded in. It is important that the infant’s weight remains3-43 How do you manage childhood within this shaded area and increases parallelobesity? to the centiles. If the infant’s weight keeps within this normal weight-for-age range, it isThis is very difficult and often not successful. following the ‘road to health’ along which theManagement consists of a low-calorie diet, child should steadily walk. Normal growthincreased exercise and family therapy. The suggests good nutrition.whole family needs to be educated abouthealthy eating and lifestyle behaviour. The Monitoring weight gain or loss on the Road-goal is to lose weight and then maintain a to-Health Card is one of the most importantnormal weight. A motivated child and parents methods of identifying children at risk ofare essential if the management is to be malnutrition. This is a major part of primarysuccessful. The help of a dietician is valuable health care. It is important that each motherin drawing up a balanced diet that is practical, understands and takes an interest in her child’saffordable and not too high in energy. Bad Road-to-Health Card.eating habits of the whole community shouldbe addressed. Soft drinks and refined foods The growth chart is an extremely importantshould be avoided and time watching TV method of screening children for Emotional support and psychological
  12. 12. 60 GROWTH AND DEVELOPMENT3-46 When should the Road-to-Health Card tract infection and chronic heart disease must bebe used? excluded.It is important that the Road-to-Health Cardbe presented by the mother every time thechild attends a clinic or hospital or visits a NEURODEVELOPMENTprivate doctor. Each child must be weighedat every visit and the weight must be plotted 3-48 What is neurodevelopment?accurately on the card. The pattern of weightgain must always be examined and the growth Neurodevelopment is the progressive, orderlycurve explained to the mother or caregiver. change of behaviour and activities whichThe type of feeding should be recorded on are seen as a children becomes older. Theirthe card. If necessary, counseling or advice physical ability and understanding of theon feeding must be given. There is important world around them increases and maturesinformation about the child on the card and with age. A healthy neurological system andthis must be updated at each clinic visit. a safe, stimulating environment is needed for normal neurodevelopment, as is normal3-47 What is growth promotion? hearing and vision.Once the child’s growth has been assessed, 3-49 How is neurodevelopment monitored?advice and counseling should be given tothe mother to promote normal growth and Developmental milestones are used to monitornutrition. It is of little value to assess growth neurodevelopment in childhood. These arewithout taking active steps to promote good easily observable developmental achievementsgrowth. such as smiling, sitting and walking. Milestones are assessed by both history3-48 When and where should children with and examination. The neurodevelopmentalgrowth problems be referred? monitoring of milestones must be part of the routine growth and developmental screeningIf failure to gain weight adequately does of all children.not respond to management at a primarycare clinic, the child must be referred forfurther assessment and management. This Milestones are used to assess neurodevelopmentis particularly important in children with a in childhood.weight that falls or crosses centiles. NOTEThe formal assessment ofUsually these children are referred to a special neurodevelopment is often divided into:nutritional clinic where the following stepsshould be followed: • Gross motor development (locomotion) • Fine motor development (manipulation of1. Exclude any chronic illness such as objects) tuberculosis or HIV infection. • Language and communication (using sounds2. A dietician or nutritional counselor should and words) educate the mother or caregiver. • Personal and social development (relating to3. A social worker should interview the family and society) mother or caregiver and assist where help is needed. 3-50 What are normal milestones?4. If the child is still not improving, refer to a Neurodevelopmental milestones are largely paediatrician. predictable as children get older although NOTE Important medical problems such as mal- there is a range between different normal absorption, hypothyroidism, diabetes, urinary children. Delayed milestones are warning signs
  13. 13. GROWTH AND DEVELOPMENT 61that neurodevelopment may be abnormal. 3-52 What are the physical changes duringChildren with delayed milestones should puberty?be referred for formal neurodevelopmental These can be formally graded into 5 stagesassessment. (from pre-puberty to full sexual development).The following milestones should be achieved: Genital development (appearance of penis, testes and scrotum) and pubic hair are scored1. Smile at mother: 8 weeks in boys while breast development and pubic2. Good head control: 6 months hair are scored in girls. Menstruation in girls3. Sit unsupported: 9 months starts towards the end of puberty when the4. Crawl well: 12 months growth spurt is almost complete.5. Make babbling noises (‘baby sounds’): 12 months NOTE These are the stages described by Tanner.6. Stand without help: 15 months7. Walk without help: 18 months8. Understand simple commands: 24 months CASE STUDY 19. Use one or two words: 36 monthsNormally developing children should reach A 12-week-old infant is seen at a routinethese milestones before (often long before) visit for immunisation. The infant’s weightthese cut-off ages. is measured and found to fall below the 3rd centile. The birth weight was normal (3000 g) NOTE A number of formal screening tools are at term. The child appears well. The mother used to monitor neurodevelopment. The Denver Developmental Screening Test is commonly used has stopped breastfeeding. in children from birth to 6 years of age. Language and cognitive development is often screened at 1. What does this child’s weight at 6 weeks school, e.g. ‘IQ’ testing. suggest? This child is not thriving, either due to inadequate feeds or illness. The problemSEXUAL DEVELOPMENT is probably that the mother has stopped breastfeeding. She needs nutritional advice and the infant must be closely followed up.3-51 What is puberty?Puberty is the time when the physical 2. What is the value of using a weight-for-signs of sexual maturity (secondary sexual age chart to assess a child’s weight?characteristics) appear due to the secretionof sex hormones in older children. Puberty is Plotting weight for age on a Road-to-Healthearlier in girls (8 to 13 years) than boys (10 to Card is an excellent way of deciding whether15 years). The timing of puberty has become an infant’s weight falls within the averageprogressively earlier over the past 100 years. A range. It is only of limited value knowing themarked growth spurt occurs during puberty. weight if it is not compared to the weight ofThere are also many emotional and social other healthy children of the same age.changes. 3. What does the 3rd centile mean?Puberty may occur too early (precociouspuberty) or too late (delayed puberty). Both It means that only 3% of healthy children of thatmay be due to endocrine disorders. Therefore, age will weigh less. The 3rd centile is usuallythese children must be referred for a specialist used as the bottom of the normal range.opinion. Precocious puberty is more commonin girls.
  14. 14. 62 GROWTH AND DEVELOPMENT4. What is a growth curve? 3. How often should a child’s weight be routinely measured to monitor growth?A growth curve is obtained by joiningmeasurements plotted on a centile chart Monthly, until the child is 1-year-old, and then(growth chart) over a period of time. Knowing every 6 months until they are 5. Weight shouldthis child’s weight at birth and at 6 weeks also be monitored at every visit to the clinic,allows you to draw a growth curve. His growth hospital or general practitioner.curve will be falling rather than followingparallel to the centile lines. This indicates that 4. How valuable is height for monitoringthe child is not thriving. growth? Height is a good measure of growth over a5. What other measurement could be long period of time. Therefore, height shouldrecorded? be measured every year from 1 year. LengthIt would be useful to measure and plot the (usually measured while the child is under 1circumference of the child’s head on a centile year) and head circumference are not routinelychart to see if the head size is still in the measured unless there is a good indication.normal range. Weight is the best measure of growth over a short period such as the time between visits to6. When does a child weigh more than the clinic.normal? 5. How can you detect wasting?When the weight falls above the 97th centile. A wasted child is very thin. Weight usually falls well below the height on the centiles. TheCASE STUDY 2 body mass index will also be low. Wasting is an important sign of malnutrition due toA 4-year-old child gained weight normally until starvation or illness. These children usuallya few months ago when she had measles. Since have lost a lot of weight recently. This needsthen her weight has dropped from the 50th to urgent investigation.the 10th centile. The mother is concerned thatshe has almost droped off the road to health(i.e. no longer following the centile line). CASE STUDY 31. Is the mother correct to be worried? A 5-year-old child is examined at a preschool. Both her weight and height fall equally belowYes. This pattern of weight loss (growth the 3rd centile. She does not appear to be thinfaltering) suggests that there is a medical and looks generally well. She has attended theproblem. The child may have a complication of local clinic regularly and her size has been wellmeasles such as diarrhoea or tuberculosis. documented as following the centiles on her Road-to-Health Card since birth. At birth she2. What is the value of monitoring growth? weighed 2000 g at term.This child is a very good example of howvaluable routine growth monitoring is to 1. What is the growth pattern of his child?identify problems. The cause of her weight loss This child is stunted. Plotting her weight andcan now be investigated and corrected before height for age shows that she is symmetricallyher weight drops below the normal range. small as both weight and height are equally low on the centiles.
  15. 15. GROWTH AND DEVELOPMENT 632. What is the common cause of this growth 2. Which children are overweight?pattern? The term ‘overweight’ is used to mean that theUsually chronic malnutrition (undernutrition) child is too fat. As this child is very heavy foris the cause of slow growth in poor her age with a normal height, she probably iscommunities. However the size of this child overweight.has followed the centiles from birth. She wasunderweight for her gestational age at birth. 3. How can you confirm that this child isThis is the probable cause of her stunting. overweight?Always examine the child well as she may havea medical cause of slow growth, such as Foetal Her weight and height should be used toAlcohol Syndrome. calculate the body mass index for age (weight/ height2).3. How should she be managed? The definition of overweight is a body mass index between the 85th and 95th centile, whileHer mother should be given dietary advice obese children have a body mass index aboveand reassured. It would be important to follow the 97th centile.this child’s growth. 4. Is being overweight an inherited4. What are the effects of emotion on problem?growth? Overweight children often have overweightEmotional stress and insecurity prevent parents. While genetic factors are important,normal growth. Therefore stunting can also be most overweight children eat too much andthe result of emotional as well as nutritional have too little exercise.deprivation. 5. What are the complications of being5. Can poor growth affect the timing of overweight or obese?puberty? Overweight and obese children often haveYes. Puberty occurs earlier in well nourished difficulty with sports and may have emotionalchildren than children who are growing slowly problems due to a poor body image. Obesebecause of malnutrition. children often grow up to be obese adults with an increased risk of hypertension, diabetes and heart disease.CASE STUDY 4 6. How should overweight children beA mother is worried that her daughter is managed?overweight. Her weight falls above the 97thcentile while her height is on the 75th centile. It is difficult to get an overweight child to loseThe mother also looks overweight. weight. The whole family has to be educated and involved in a weight loss programme. A1. Can you use weight for age to tell if a dietician may be helpful in drawing up a well-child is too fat? balanced diet that is practical, affordable and not too high in energy. Time spent watchingAny child with a weight above the 97th centile TV must be limited and exercise encouraged.weighs more than normal. However, if herheight is similarly over the 97th centile, she isprobably just a big child for her age. Therefore,a high weight for age alone does necessarilymean the child is too fat.
  16. 16. 19 kg Childs Date for next visit name: 18,5 nr. day month year 18 18 centile 4 97th 1 17,5 BCG IMMUNISATIONS 17,5 DTP 17,5 2 17 17 17 0 1 2 3 4 3 16,5 Polio 16,5 Polio 16,5 4 16 16 16 1 2 3 1 2 5 15,5 Hib, DTP & Hep B Measles 15,5 Measles 15,5 6 15 15kg 15kg birth 6wks 10wks 14wks 9mths 18mths 7 ile 14,5 14,5 14,5 50th cent 8 14 14 14 Discuss: 9 64 GROWTHDEVELOPMENT 13,5 13,5 13,5 Breastfeeding 10 13 Child spacing 13 13 Food intake 11 12,5 Oral rehydration solution 12,5 12,5 GROWTH AND AND DEVELOPMENT 12 12 12 12 13 11,5 11,5 11,5 ile 14 11 11 11 3rd cent 15 10,5 10,5 10,5 16 10kg 10kg 10kg 17 9,5 9,5 9,5 18 9 9 9 19 8,5 8,5 8,5 th centile 60% of 50 20 8 8 8 21 7,5 7,5 7,5 22 7 7 I can talk 7 23 6,5 6,5 6,5 24 6 6 6 Write on the chartFigure 3.4: The Growth Monitoring Chart on the the Road-to-Health Card 5,5 5,5 5,5 - Any illness e.g. 5kg 5kg 5kg ~ diarrhoea, ~ ARI, etc. 4,5 4,5 4,5 - Admission to hospital, 2 - Solids introduced, years - Breastfeeding stopped, 4 4 - Birth of next child, etc. 24 25 26 27 28 29 30 31 32 33 34 35 3,5 3,5 1 age in months year like this: 3 3 12 13 14 15 16 17 18 19 20 21 22 23 2,5kg 2,5kg age in months given 2 Diarrhoea Birth 1 2 3 4 5 6 7 8 9 10 11 Extra meals weight ARI age in months write 1,5 2 to 3 Years birth month 1 Watch the direction of the curve showing the childs growth 0,5 write 1 to 2 Years birth month GOOD VERY DANGEROUS Worm medicine 0 Means the child is Child may be ill, growing well. DANGER SIGN needs extra care. write birth month Growth Monitoring Chart Not gaining weight. Birth to 1 Year Find out why. (2-7 September) and year Admitted to hospital Chart revised: August 2003 jjb
  17. 17. GROWTH AND DEVELOPMENT 65 kg lb lb 40 40 18 97th 38 38 17 90th 36 36 16 34 75th 34 15 32 32 50th 14 30 30 25th 13 28 28 10th 12 26 3rd 26 11 24 24 10 22 22 9 20 20 18 18 8 16 16 7 14 14 6 12 12 5 10 10 4 8 8 3 6 6 2 4 4 kg lb lb Birth 3 6 9 12 15 18 21 24 27 30 33 36 Age (months) Published May 30, 2000. SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000).Figure 3.5: Weight-for-age percentiles: Boys, birth to 36 months