DEFINITIONS

Growth

Growth is defined as the quantitative, progressive process of

physical maturation. It includes multiplication of cells and a
net increasee in intracellular substance leading to increase in
size, length, height, and weight of the various tissues,
organs and body.
• Development

Development is the qualitative process of progressive

increase in physiological, psychological, emotional and social
maturation of an individual which results from the maturation
and myelination of the nervous system. It is orderly and
difficult to measure.
 PRINCIPLES OF GROWTH AND
DEVELOPMENT
 Growth and Development are Continuous Processes
from Conception Until Death
 Growth and Development is Orderly and Sequential

 Development Proceeds from General to Specific

Responses
 Development is Directional

 Development Proceeds from Gross to Refined Skill

 Growth and Development is Unique for Each Child

 Growth and Development are Interrelated

 Development Becomes Increasingly Differentiated,
Integrated and Complex
 Development Depends on Maturation and Learning

 Development Proceeds from Simple to More

Complex
 Different Aspects of Growth Develop at Different
Rates
 Development is Predictable and is a Continuous
Process
 Growth is Both Quantitative and Qualitative

 New Skills Predominate and a Great Deal of

Skill and Behavior is Learned by Practice
 Children are Competent to Survive with the
FACTORS AFFECTING GROWTH AND
DEVELOPMENT
Heredity and Genetic Factors
1. Characteristics of Parents
2. Race and Nationality
3. Gender
Environmental factors
 Prenatal Environment
 Postnatal Environment

1. Socioeconomic Factors
2. Emotional Factors
3. Nutrition
4. Exposure to Infections and Infestations
5. Exposure to Trauma and Chronic Disease
6. Exercise and Environmental Stimulation
GROWTH AND DEVELOPMENT FROM BIRTH TO
ADOLESCENCE/ASPECTS OF DEVELOPMENT
Overview of the various aspects of development across
different stages:

Motor Development

Motor development involves both gross motor and fine

motor development. It is dependent on the
neuromuscular maturation and skeletal maturation of the
child. Thus nutritional status and environmental stimuli
following birth has a significant influence on the motor
development of the child.

Language Development

Language development is the gradual development of

true speech to express own self. It depends on the
maturation of hearing, level of understanding, imitation
and an environment of encouragement.
Personal and Social
Development
Personal and social development is the process through
which a child adjust to their social situations as per
society’s expectations. It involves social smile,
recognizing primary caregivers, engaging in play with
other children and gradually developing interpersonal
relationships.

Sensory Development

Sensory development includes development of

reaction to specific stimuli through neuromuscular
myelination. A newborn is born with the senses of smell,
touch and hearing, their visual capacity is developed
over time at around 6–7 years age.
Intellectual Development

Intellectual development involves application of

intellect in everyday life. Along with neuromuscular
maturation it is also dependent on maturation on
innate abilities, learning from environmental stimuli,
reinforcement and insight.

Emotional Development

Emotional development is an important part of a child’s

development. The love, affection and care received from
the mother in the early life is the seed for the
development of the tree of emotion.
 Sexual Development
Sexual development after birth is influenced by the
development of physical, mental, emotional and
sociocultural aspects.

Moral Development

Moral development is the mental process which helps in

formation of value system. It includes abiding social
rules and justice based on internalized value systems.

Spiritual Development

Spiritual development is the multidimensional process of

learning about life. It involves the expression and
understanding of faith, religious belief, rituals,
interpretation of religious symbol and acceptance of
others’ beliefs.
GROWTH AND DEVELOPMENTAL THEORIES (FREUD, ERICKSON,
JEAN PIAGET, KOHLBERG)

Researchers have advanced several theories about the various stages

and aspects of growth and development of children. The theories
of child’s growth and development are as following.

Freud’s Stages of Psychosexual Development

Sigmund Freud (1856–1939) is probably the most well-known

theorist when it comes to the development of personality.
Freud’s Stages of psychosexual development are as following:

[Link] Stage (Birth to 18 Months)

During the oral stage, the child is focused on oral pleasures (sucking).
Too much or too little gratification can result in an Oral Fixation or Oral
Personality, evidenced by a preoccupation with oral activities. This type
of personality may have a stronger tendency to smoke, drink alcohol,
have over eating, or bite his or her nails.
 [Link] Stage (18 Months to 3
Years)
The child’s focus of pleasure in this stage is on
eliminating and retaining feces. Through society’s
pressure, mainly via parents, the child has to learn to
control anal stimulation in the form of “toilet
training”. After effects of an anal fixation during this
stage can result in an obsession with cleanliness,
perfection, and control in later life (anal retentive).
On the opposite end of the spectrum, they may also
become messy and disorganized (anal expulsive).
[Link] Stage (3 to 6 Years)

During this stage the pleasure zone switches to

the genitals. Freud believed that during this stage
boys develop unconscious sexual desires for their
mother. Because of this, he becomes rivals with his
father and consider him as him as competitor for
the mother’s affection. During this time, boys also
develop a fear that their father will punish them
for these feelings. This group of feelings is known
as Oedipus Complex (after the Greek Mythology
figure who accidentally killed his father and
married his mother).
[Link] Stage (6–12 Years)

During this stage, sexual urges remain

repressed. Sexual drive is expressed in a socially
acceptable way such as engagement in school work,
sports etc. mostly with same sex peers.

[Link] Stage (Puberty and Later)

The final stage of psychosexual development begins

with the onset of puberty when sexual urges are
once again awakened. Through the lessons learned
during the previous stages, adolescents direct
their sexual urges onto opposite sex peers, with the
primary focus of pleasure is the genitals.
Erik Erikson’s Stages of Psychosocial Development
(Theory of Psychosocial Development)

Stage 1: Trust vs. Mistrust (Birth to 1 Year)

This is the most fundamental stage in life.

During this period the infant is completely
dependent on their primary caregiver for fulfillment
of needs such as food, care, love and safety. The
development of trust is based on the quality of the
child’s caregiver’s attention in meeting the needs of
the child.

.
Stage 2: Autonomy vs. Shame and Doubt (1–3 Years)

The second stage of Erikson’s theory of psychosocial

development takes place during early childhood and
is focused on children developing a greater sense of
personal control. Like Freud, Erikson believed that
toilet training was a vital part of this process. However,
Erikson’s reasoning was quite different than that of
Freud’s. Erikson believed that learning to control one’s
bodily functions leads to a feeling of control and a
sense of independence
Stage 3: Initiative vs. Guilt (3–6 Years)
During the preschool years, children begin to assert
their power and control over the world through
directing play and other social interactions. Children
who are successful at this stage feel capable and able to
lead others.

Stage 4: Industry vs. Inferiority (6–12 years)

This stage covers the early school years. Through social
interactions, children begin to develop a sense of pride
in their accomplishments and abilities. Children who
are encouraged and commended by parents and
teachers develop a feeling of competence and
confidence in their skills.

Stage 5: Identity vs. Confusion (12–18 years)

During adolescence, children explore their
independence and develop a sense of self. Those who
receive proper encouragement and reinforcement
through personal exploration develop a strong sense of
self identity and a feeling of independence and
control over situations happening with them.
Stage 6: Intimacy vs. Isolation (18–30
Years)
This stage covers the period of early
adulthood when people are exploring personal
relationships. The theorist believed that it’s vital
for people to develop close, committed
relationships with other people. Those who are
successful at this step will form steady,
committed and secure relationships.

Stage 7: Generativity vs. Stagnation (30–65 Years)

During adulthood, human continue to build their

lives, focusing on career and family. Those who
are successful during this phase feel that they are
contributing to the world by being active in their
home and community. Those who fail to attain this
Stage 8: Integrity vs. Despair (65 Years and
Above)
This phase occurs during old age and is focused on
reflecting back on life. Those who are unsuccessful
during this stage will feel that their life has been wasted
and will live in regrets. The individual will be left with
feelings of bitterness and despair. Those who feel
proud of their accomplishments will feel a sense of
integrity.
Jean Piaget’s Theory of Cognitive
Development(Theory of mental or Intellectual
development
Stage I: The Sensory-motor Stage (Birth to 2 Years)
During this stage, information is received by the
child through all the senses. The child utilizes
innate behaviors to enhance this learning
process, such as sucking, looking, grasping,
crying and listening. By this time children
master two major phenomena:
• Causality
• Object permanence
Reflexes (0–1 Month)
• The child uses only innate reflexes. For example,
if the child receives the breast of or a dummy
nipple into the mouth, they start sucking on it
reflexively. If an object is placed in their palm,
the hand will automatically grab it. These reflexes
have the sole function of keeping the child
alive.
 Primary Circular Actions (1–4 Months)
The child now has a fixation with its own body; they tend to
perform actions repeatedly on themselves (like sucking their
own hand, looking at their fingers). The reflexes are refined to
form more complex versions in an attempt to mature their
gross and fine motor skills.
Secondary Circular Reactions (4–8 Months)
At around four months, the child begins to take an
interest in their environment. They notice that they can
actually influence events in their world.
Co-ordination of Secondary Circular Reactions (8–12
Months)
During this period the child begins to engage in goal-directed
behavior; they begin to develop cause-effect relationships.
So learn to pull a cart to gets things closer rather than
crawling towards it.
Tertiary Circular Reactions (12–18 Months)

By this time they, children develop motor abilities of

walking, grabbing, grasping and releasing. Thus they can
tract any moving object. They can imitate the gestures
and sounds of things they observe.

Symbolic/Mental Representation (18–24 Months)

At this stage, the child develops symbolic thought and

the ability to mentally represent objects in their head.
Normally, the child would need to resort to trial-and-error
to achieve a desired effect.
Stage II: The Pre-operational Stage (2–6
Years)
During this stage, magical and wishful thinking emerges.
They lack logical thinking and have a poor concept of
cause. They perceive sickness as the effect of their
mischievous act. and struggle to perceive situations
from another point of view. Major characteristics of this
stage is symbolism (a child can use one object to
represent another e.g. sticking their arms out and running
to symbolise an aeroplane flying), egocentrism
(perception of the world in relation to oneself only),
and conservation.

Stage III: The Concrete Operational Stage (6–12 Years)

This stage sees another shift in children’s cognitive

thinking. It is aptly named “concrete” because children
struggle to apply concepts to anything which cannot
physically be manipulated or seen. Although, the child
continues to improve their conservation skills,
Stage IV: The Formal Operational Stage (12 Years
and Older)
During this age, children acquire the ability think,
systematically, scientifically. Logical conclusions can
be inferred from verbal information (abstract
reasoning), and “concrete”, physical objects are no
longer necessary. In the later adolescence and early
adulthood they can apply such abstract reasoning in the
emotional and personal areas also. But their decision
making do have an influence of magical thinking or the
ideology within which they grew up.
Kohlberg’s Theory of Moral Development

The various stages of Kohlberg’s moral development are as

following.
Level 1: Preconventional Morality
Stage 1: Obedience and Punishment
The earliest stage of moral development is especially
common in young children, but adults are also capable of
expressing this type of reasoning. At this stage, children see
rules as fixed and absolute. Obeying the rules is important
to the child to avoid punishment.
Stage 2: Individualism and Exchange
At this stage of moral development, children account for
individual points of view and judge actions based on how
they serve individual needs. Reciprocity (exchanging
things with other people) is possible, but only if it serves
child’s interests.
 Level 2: Conventional Morality

Stage 3: Developing Good Interpersonal Relationships

This stage is often referred to as the “good boy-fine girl”
orientation. During this stage, children focus on living up to
social expectations and rules of being “nice”. These choices
influence their relationships.

Stage 4: Maintaining Social Order (Law and Order

Orientation)
At this stage of moral development, people begin to
consider society as a whole when making judgments.
People at this stage focuses on maintaining law and
social order by following the rules, doing one’s duty and
respecting authority. E.g. saving human life is important in
a disaster than saving property.
Level 3: Postconventional Morality

Stage 5: Social Contract and Individual Rights

At this stage, people begin to consider values,
opinions and beliefs of other people. Personal values
are used to achieve social consciousness. Social
rules, laws are developed believing that people
with abide by them.

Stage 6: Universal Principles

Kohlberg’s final level of moral reasoning is based
upon universal ethical principles and abstract
reasoning. At this stage, people follow their
internalized principles of justice, even if they
conflict with laws and rules (e.g., supporting
education of women even being a part of strict
patriarchal society.)
James Fowler’s Stagesof Faith Development (Spiritual
Development)

Stage 0: “Primal or Undifferentiated” Faith (Birth to 2

Years)
This stage is characterized by an early learning of the
safety of their environment. If consistent care and comforts
is received from primary caregivers, one will develop a
sense of trust and safety about the universe and the
divine. Conversely, negative experiences (abuse, neglect)
will cause one to develop mistrust and fear in respect
to universe and divine.
Stage 1: “Intuitive-Projective” Faith (3–7 Years)
Children at this stage can express their thoughts through
languages. They don’t develop a formalized religious belief.
Concepts of faith and religion is learned mainly through
experiences, stories, images, and the people that one comes
in contact with.
Stage 2: “Mythic-Literal” Faith (7–12 Years)

In this stage children starts believing in justice and fairness in

religious matters. They also believe in reciprocity of the
universe (e.g., doing good will result in good result, doing bad
will cause harm to self or a dear one). They perceive their
deities or Gods with anthropomorphic images (e.g., Gods have
along beard, goddess wears lots of jeweleries etc.) and
understands the moral values of stories. A few people remain
in this stage throughout their life.

Stage 3: “Synthetic-Conventional” Faith (12 Years to

Adulthood)

This stage is characterized by identification of the

adolescent/adult with a religious institution, authority, belief
system and the development of a personal identity.
 Stage 4: “Individuative-Reflective” Faith (Mid- Twenties to
Late Thirties)

This is a stage of angst and struggle. The individual takes

personal responsibility for his or her beliefs and feelings. As one
is able to reflect on one’s own beliefs, they become more open
minded.

Stage 5: “Conjunctive” Faith (Mid-Life Crisis)

This stage acknowledges paradox and transcendence relating

reality behind the symbols of inherited systems. The individual
resolves conflicts from previous stages by a complex
understanding of a multidimensional, interdependent “truth”
that cannot be explained by any particular statement.

Stage 6: “Universalizing” Faith, or "Enlightenment” (Later

Adulthood)

This stage is rarely achieved by individuals. These individuals

would treat any person with compassion as he or she views
people as from a universal community, with universal principles
 Theory of Language
Development
Six Stages of Language Development
According to Frederick T. Wood’s, language acquisition takes
place in six consecutive stages:
[Link] Stage
During the first year of life the child is in a pre-
speech stage. Developmental of speech include the
development of gestures, making adequate eye contact,
sound repetition between infant and caregiver, cooing,
babbling and crying. Examples of such pre-speech sounds
are, dada-dada, mama-mama and waaaah.

[Link] or One-Word Sentence

The child usually reaches this phase between the age of
10 and 13 months. Although the child tends to utter a
single word at a time in a particular context, along with non-
verbal cues.
[Link]-Word Sentence

By 18 months the child reaches this stage. His/her

“sentences” now usually comprise a noun or a verb plus a
modifier. This enables the child to formulate a sentence
which may be either declarative, negative, imperative or
interrogative.
[Link]-Word Sentences
The child reaches this stage between the age of two to two
and a half. The child can now form sentences with a subject
and a predicate.
[Link] Complex Grammatical Structures
Children reach this stage roughly between two and half to
three years of age. They use more intricate and complex
grammatical structures, elements are added
(conjunction), embedded and permuted within sentences
and prepositions are used.
Adult-Like Language Structures

The five to six-year-old child reaches this

developmental level. Complex structural
distinctions can now be made, such as by using
the concepts “ask/tell” and “promise” and
changing the word order in the sentence
accordingly.
 FETAL DEVELOPMENT
Embryology is the study of embryo development. This includes the developmental
process of a single-cell embryo to a baby.
• First Trimester
1–2 Weeks from Conception (3–4 Weeks after the Last Menstrual Period)
Ovulation occurs. If the ovum is fertilized, it starts to divide rapidly and forms a ball
of cells. It is implanted in the uterus. Amniotic sac begins to form. At this point in
its growth, the ball of cells is called an “embryo”.
3–4 Weeks from Conception (5–6 Weeks After the Last Menstrual Period)
The embryo grows to a length of 6 mm. It changes from a flat disc to a curved, C-
shaped form. Organs begin forming. Mother misses her scheduled menstrual period.
Notocord is developed. The heart starts as a tube, which begins to beat as it grows.
Simple structures form on the sides of the head. Bump like limb buds (which later
transforms into arms and legs), start to form.
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5–6 Weeks from Conception (7–8 Weeks after the Last Menstrual Period)
The embryo is about 14 mm (½ inch) long. About half of the embryo’s length is the
head, due to the rapid growth of the brain. The heart starts to form the normal four
chambers. A heartbeat can be seen on ultrasound. Kidneys begin to form.
7–8 Weeks After Conception (9–10 Weeks After the Last Menstrual Period)
The embryo is about 31 mm (1¼ inches) long. The embryo changes shape as the
face forms and small tail bud begins to go away. Basic parts of the brain and the
heart are now formed.
9–10 Weeks After Conception (11–12 Weeks After the Last Menstrual Period)
The crown-rump length is 61 mm and weight is approximately 14 grams. The
embryo now is called a “fetus” as all the main body parts are formed. The ears move
up to their normal position.

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11–12 Weeks After Conception (13–14 Weeks After the Last Menstrual
Period)

The crown-rump length is 86 mm and fetus weighs 45 grams

approximately. The fetus begins to swallow amniotic fluid which is
replaced with fetal urine. The placenta is fully formed. On ultrasound
examination neck can be clearly seen between the head and body and
the sex of the fetus can also be seen.

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Second Trimester
13–14 weeks after conception (15–16 weeks after the last menstrual
period): The crown-rump length is about 120 mm and weight is 110
grams approximately. The fetal head is still large, face is well formed.
The arms and legs are formed, and can move and bend. Sex organs are
almost fully formed.
15–16 weeks after conception (17–18 weeks after the last menstrual
period): The crown-rump length reaches 140 mm and weighs 200
grams. The fetal head seems less large as legs grow longer. Sucking
motions of mouth begins and ears stand out from the head. The skin is
almost transparent. The fetus may develop regular pattern of sleep.

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17–18 weeks after conception (19–20 weeks after the last menstrual
period): The crown-rump length is 160 mm and weighs 320 grams.
Fetal movement or “quickening” can be felt by mothers. The entire fetal
skin is covered by “vernix caseosa” and fine hairs called “lanugo”.
19–20 weeks after conception (21–22 weeks after the last menstrual
period): The crown-rump length is 190 mm. and weighs around 460
grams The skin is plethoric and wrinkled. The underneath blood vessels
are clearly visualized. Fingerprints begin to form.
21–22 weeks after conception (23–24 weeks after the last menstrual
period): The fetus weighs 630 grams, crown-rump length is 210 mm. If
delivered, chance of survival is increased.
23–24 weeks after conception (25–26 weeks after the last menstrual
period): The fetus weighs 820 grams, crown-rump length reaches 230
mm. Secretion

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Third Trimester
25–26 weeks after conception (27–28 weeks after the last menstrual
period): The fetus weighs 1000 grams and continues to gain weight,
crown-rump length reaches 250 mm. Can open eyes slightly, eyelashes
are formed.
27–28 weeks after conception (29–30 weeks after the last menstrual
period): The crown-rump length is around 11 inches and fetus weighs
1300 grams. Temperature and respiratory regulatory centers of brain
starts functioning. Bone marrow starts forming blood cells.
29–30 weeks after conception (31–32 weeks after the last menstrual
period): The fetus weighs around 1700 grams and the crown-rump
length is around 280 mm. The skin layer thickens and more fat builds up
under the skin.

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31–32 weeks after conception (33–34 weeks after the last menstrual period):
The crown-rump length is around 300 mm and weighs around 1900 –2100 grams.
33–34 weeks after conception (35–36 weeks after the last menstrual period):
The fetus weighs around 2000 grams. The lungs and the nervous system keeps
maturation. Fat stores under the skin. Scalp hairs becomes coarser and blacker.
Testes in male fetuses start to move from the abdomen into the scrotum. The labia
majora in female fetuses begin to cover the labia minora.
35–36 weeks after conception (37–38 weeks after the last menstrual period): By
this time fetal lungs matures. The fetus descends into the mother’s pelvis which
causes increased pressure on mother’s bladder and bowel.
37–38 weeks after conception (39–40 weeks after the last menstrual period) is
the full term of pregnancy. Most babies are born during this time. The average
length at birth is 50 cm. On average, an Indian full-term baby weighs between 2.6
Kg to 3.2 Kg.

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GROWTH AND DEVELOPMENT FOLLOWING BIRTH
Systematic Changes During Growth and Development
Respiratory System
Respiratory rate in neonates is about 36 to 40 breaths per minutes and gradually it
diminished to 16 to 20 breaths per minutes at 15 years. In newborn baby the
breathing is diaphragmatic and breath sound is bronchovesicular. In infancy it is
mainly thoracic and breath sound is vesicular. Sinuses gradually developed which
complete within seven years of age.
Cardiovascular System
Functional closure of temporary structures of fetal circulation occurs soon after birth
and anatomical closure occurs within 2 to 3 months. Apex beat shifted from 4th
intercostal space to 5th intercostal space. There is gradual change in pulse and blood
pressure as the age increases. Pulse rate in newborn is in between 120 and 160 beats
per minutes, at one year it is about 100 to 160 b/m, at 4 years it is 80 to 120 b/m, 8
years it is 70 to 100 b/m, at 15 years it is 70 to 90 b/m and at 18 years it is 70 to 80
b/m.
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Brain Growth
Brain growth occurs 2/3rd in the first years, 4/5th second year and fully
developed within 5 years.
Gastrointestinal System
The secretary enzymes of the digestive tract are usually adequate for the
newborn baby. Fat is handle less. Liver in neonates is usually 4 percent
of body weight and increases gradually to 10 times in puberty from 120
to 160 gms to 1500 to 2300 gms at 15 years.
Urinary System
The kidneys are large at birth. The urine amount gradually increases
from 250 mL per day in neonates to 1200 mL per day in 14 years. The
amount of creatinine is low in infants about 10–20 mg/kg/day which
gradually changed to 40 mg/kg/day in older children.

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IMPORTANT DEVELOPMENTAL MILESTONES OF FIRST THREE YEARS AT A
GLANCE
2 Months
• Smiles on social contact, identifies mother, listens to voice, and coos. Follows objects with eyes.
3–6 Months
• Holds head steady. Turns over. Sits with support.
• Reaches out; grasps large object. Enjoys mirrors.
• Laughs aloud. Makes sounds. Shows joy, interest, fear, and surprise.
6–9 Months
• Sits unsupported, crawls
• Observes, picks, transfers from hand to hand, and bangs and drops large objects.
• Notices small objects → raking movement → immature grasp → mature pincer grasp with
thumb
and index finger (9 months)
• Waves bye-bye, separation anxiety

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9–12 Months
• Stands without support.
• Plays with objects, enjoys inserting and dumping out.
• Retrieve hidden toy, Enjoys “peek-a-boo”.
• Point to body parts.
• Respond to his name and to “No”.
• Two to three words with meaning.
• Nonverbal gestures.
15 Months
• Walks alone
• Follows simple commands; names familiar object
18 Months
• Runs stiffly
• Explores
• Scribbles
• 10 words; names pictures

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24 Months
• Runs well, climbs stairs; jumps
• Tower of seven cubes; imitates horizontal stroke
• Three words sentences
• Handles spoon; helps to undress.
36 Months
• Rides tricycle; throws ball.
• Copies circle; imitates cross.
• Knows age and sex; counts three objects; speeches fluently. Listens to stories.
• Plays simple games; pretends.
• Helps in dressing; washes hands

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RED FLAGS OF DEVELOPMENTAL MILESTONES

The above-mentioned cutoff for developmental milestones should be

kept in mind by pediatric nurses. They should make parents aware of
developmental milestones in all the domains and insist them to check
them periodically.

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Red Flags of Cognitive Delay and Behavioral Problem

Difficulty in following simple instruction and learning new skills
Slow in daily activities
Poor recall
Poor expressive language
Little interest in surroundings and other children
Poor eye-contact/smiling
Limited use of words or gestures to communicate needs

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Red Flag Signs at 18 Months
Has trouble seeing or hearing
Does not say a single word
Does not point, wave or use gestures
Does not follow simple commands
Does not enjoy eye contact or cuddles
Is not walking alone
Prefers to use one hand

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Red Flags in Preschool Children
 Inability to perform self-care tasks, handwashing, simple
dressing, and daytime toileting
Lack of socialization
Unable to play with other children
Unable to follow directions during examination.
Red Flags in School Age Children
School failure.
Lack of friends.
Aggressive behavior: Fights, fire setting, and animal
Social isolation abuse.

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ASSESSMENT OF GROWTH
Assessment of physical growth can be done by anthropometric measurements. Child
health nurse must be knowledgeable and skilful about measurement of different
growth parameters. The criteria for assessment of physical growth are mainly
weight, recumbent length or height, head circumference, chest circumference and
mid upper arm circumference. Assessment of body mass index, body ratio,
fontanelle closure, skinfold thickness, dentition and bone age also used as
parameters for evaluation of physical growth.
Anthropometric Measurements
It typically includes measurement of height, body weight, head circumference, chest
circumference, mid upper arm circumference.
Recumbent Length and Height
Skeletal growth is indicated by increase in length and or height. Yearly increments
in height are higher during early years following birth which diminishes gradually.
At birth, average length of a healthy Indian newborn baby is 50 cm. It increases to
60 cm at 3 months, 70 cm by 9 months and 75 cm at one year of age.
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Weight
It is one of the best criteria for assessment of growth and a good
indicator of health and nutritional status of child. Among Indian
children, weight of the full-term neonate at birth is a proximately 2.5 Kg
to 3.8 kg. There is about 10 percent cent loss of weight during first week
of life, which regains by 10 days of age. Thereafter, weight gain is about
25–30 gm per day for first 3 months and 400 gm per month till one year
age. The birth weight is doubled by 5 months, trebled by one year, four
times by two years, five times by 3 years, six times by five years, 7
times by 7 years and 10 times by 10 years of age. Then weight increases
rapidly during puberty followed by gradual maturation to adult size to
have pace with metabolic requirement during this period.

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There are following formulas which are used for estimation of body
weight of children (in emergency situations when a child’s body weight
can’t be measured due to their illness severity e.g., severe burn injury,
etc.)
For infants <12 months: Weight (kg) = (age in months + 9)/2

For children aged 1–5 years: Weight (kg) = 2 × (age in years + 5)

For children aged 5–14 years: Weight (kg) = 4 × age in years.

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Chest Circumference
Chest circumference (Thoracic diameter) is an important parameter for growth and
nutritional status assessment. At birth it remains 2–3 cm less than the head
circumference. During this time the chest is approximately round in shape with
nearly equal transverse and antero-posterior diameters. Thereafter, he width of chest
becomes greater than depth due to rapid increase in transverse diameter.
Mid-upper Arm Circumference (MUAC)
MUAC is used as an indicator of sum of the muscle and subcutaneous fat in the
upper arm in children between the age of 6 months and 5 years. It is used as an age-
independent screening tool for severe malnutrition. It is measured to the nearest 0.1
cm, using a flexible non-stretch tape laid at the midpoint between the acromion and
olecranon processes on the shoulder blade and the ulna, of the arm .

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Body Mass Index (BMI)

• BMI is a calculation based on the height and weight of the child and is
recommended for all children older than two years of age.
The formulas for the calculation of BMI in children are as follows:
• BMI = weight in pounds/[height in inches × height in inches] × 703
• BMI = weight in kilograms/[height in meters × height in meters]
Fontanelle Closure
• At birth, anterior and posterior fontanelle are usually present. Posterior
fontanelle closes early within 6–8 weeks following birth. The
anterior fontanelle normally closes by 18 months with in
average of 12–18 months.

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Osseous Growth
Growth of bones follows a definite pattern and time schedule from intrauterine life
and continue upto 25 years of age. Bone age is an important indicator of
physiological development, children’s biological age (distinct from the
chronological age). It is a common index used in pediatric radiology, endocrinology,
pediatric forensic medicine and in legal issues.
Stem Stature Index
• It refers to the sitting height (crown-rump length) as a percentage of total height or
recumbent length. It is 70 at birth, 66 at 6 months, 64 at one year, 61 at 2 years,
58
at 3 years, 55 at 5 years, 52 at puberty and 53 to 54 at 20 years.
Span
• It is the distance between tips of middle fingers when the arms are outstretched. In
young children, it is 1 to 2 cm less than the length or height. At 10 years of age,
it is equal and after 12 years it is 1 to 2 cm more than the height.
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Skinfold Measurements
Common sites for skinfold measurements include the biceps, triceps,
iliac crest, thigh, calf, subscapular, abdomen, and chest. For the triceps
skinfold, grab the skin 2 cm above the midpoint of the right upper arm
with the thumb and index finger to create a skinfold. Then, place the
calipers at the midpoint to obtain the measurement. Similarly, at other
sites, the skinfold measurement is obtained by grabbing the skin 2 cm
away from the measuring site. Despite standard measuring techniques,
skinfold testing has high variability and has limited use in the clinical
setting.

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Dentition or Eruption of Teeth
Dentition is not a dependable parameter of growth. As there is a
variation for the time of eruption of teeth. A child has two types of
teething, i) temporary/primary teeth also called as deciduous teeth or
milk teeth, ii) permanent teeth.
First primary teeth commonly the lower central incisors may appear by
the 7 months of age. But it can be delayed even upto 15 months
(considered within the normal range). Primary teeth are smaller in size
and white in colour than permanent teeth. Primary teeth eruption
follows the “Rule of 4s” which means 4 teeth erupt every 4 months
beginning with four teeth at the age of 7 months. The teeth eruption
usually occurs symmetrically in each arch starting with eruption of
central incisors. No dentition beyond 1.5 years needs special attention.

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Growth Chart
It is already discussed earlier that assessment of growth by objective anthropometric
methods of weight, length/ height, and body mass index (BMI) is crucial in child
care to assess the nutritional status and for the early identification of growth failure.
In 2006, World Health Organization (WHO) has published their first global growth
standards in the form of Growth chart for children under the age of 5 years. It is
adopted by India along with other countries for regular monitoring of growth of
children at grassroot level.
Types of Growth Chart
Growth charts mainly belong to two types: i) growth standards and ii) growth
references. Growth standards are prescriptive and define how a population of
children should grow if they receive an optimal nutrition and healthy environment.
Growth references on the other hand are descriptive and are prepared from a
population which is thought to be growing in the best possible state of nutrition and
health in a given community.

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Advantage of using WHO Growth Chart (2006)

This is a more objective and easy way to compare children of all
countries, races, ethnicity in terms of height, weight, and obesity.
The disadvantage of using charts such as these is that they are likely to
over diagnose underweight and stunting in a large number of apparently
normal children in the developing countries such as India.

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Developmental Screening Tests
Developmental assessment is essential to detect developmental delays
among children. Most of the developmental assessment tools covers
four areas i.e. gross motor, fine motor-adaptive, language and personal-
social behaviour. The most widely used screening test for detecting
developmental delays upto 6 years is known as Denver Developmental
Screening Test-II (DDST-II), Gessell DST, Bayley DST, Woodside DST,
cognitive adaptive test, Early Language milestones scale, etc. Indian
developmental screening tests includes Baroda DST, Trivandrum DST.

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