Growth and Development

Normal Growth

Average weights, heights and head circumference and plotting growth

• The average weight of a newborn baby is 3500g; the average height/length is 51cm and the average head circumference is 35cm.
  • NOTE: There is NORMAL weight loss in the first few days of life (up to 10% of birth weight).  This returns to birth weight at 7-10 days of age.
  • Birth weight usually doubles in the first 4 months (daily weight gain of 20-30g) and has tripled by a year (15-20g/day); and quadrupled by 2
• All children should be weighed and measured regularly and measurements plotted on the appropriate WHO growth chart
  • NOTE: If the baby was pre-term- it is important to plot the gestational age (this can either be done as suggested on the charts i.e. actual age is a dot and an arrow to gestational age, OR just plotting the gestational age.  This should be done for up to a year after birth.
  • ALSO: the expected height should be plotted in the appropriate box (on the right)
    
    • This is calculated by:
      • in males- mean parental height +7cm
      • in females- mean parental height -7cm

Disorders of Growth

• Most commonly, failure to thrive or constitutional short stature

Normal Development

• Reflexes of the newborn
  • Moro reflex – (startle reflex- 0-2 months)
    • Pull the baby up and drop suddenly (activated by sudden head movements)
    • The legs and head extend while the arms jerk up and out with the palms up and thumbs flexed.  The arms then come together and the hands clench and usually the baby cries
    • Persistent bilateral Moro reflexes suggests damage to the CNS, whilst unilateral persistence suggests injury e.g. fractured clavicle or injury to the brachial plexus e.g. Erb’s palsy
  • Walking/Stepping reflex
  • Rooting reflex
  • Sucking reflex
  • Palmar grasp reflex
  • Plantar reflexes
    • The plantar reflexes are normally upward in babies <1 year
    • If it persist in children >2 years, this may be a sign of UMN dysfunction
  • Others include the tonic neck reflex, gallant reflex, swimming reflex and galant reflex
• Developmental Milestones
  • 4 broad categories which are assessed as part of development
    • Gross Motor
      • 6 weeks – Head control in vertical
      • 3 months- No head lag on pulling to sit; lying on abdomen with good head control; held sitting with lumbar curve
      • 6 months- Sits with support; lying on abdomen with arms extended; lying on back- lifts and grasps feet; pulls self to sitting; back straight with support; rolls front to back
      • 9 months- Sits without support; Leans forward from sitting to reach out; can perhaps stand holding on the furniture/parent; may crawl
      • 12 months- First steps/ walks with support/ cruising
      • 13 months- Walks unsupported
      • 18 months- Runs; can climb onto chair; squats to pick up toy
      • 2 years- up and down stairs; sits on and steers a trike
      • 3 years- stairs with alternating feet; jumps off bottom step; can stand on one foot momentarily; rides tricycle
      • 4 years- hops on preferred foot; climbs ladders; walks and runs on tiptoes
    • Fine Motor
      • 6 weeks- can follow torch with eyes
      • 3 months- Hand regard; hands held in midline
      • 6 months- Grasps toys; transfers hand to hand; (loss of plantar grasp reflex); mouths
      • 9 months- Using index finger pointing; pick up small objects
      • 12 months- casting toys; bangs toys together
      • 18 months- builds a tower of 3 bricks; enjoys picture books
      • 2 years- tower of 6/7 bricks; scribbles; matches toys
      • 3 years- tower of 9 cubes; copies circle; matches colour
      • 4 years- threads beads; copies cross; draws a man with head, legs, and trunk
      • NB Some babies will ‘bottom shuffle’ rather than crawl.  These babies are more likely to walk later, although most will walk by 18 months.  Normal variant; often familial
    • Language and Hearing
      • 6 weeks- stills to voice
      • 3 months- starting to vocalise
      • 6 months- Babbles, screams when annoyed
      • 9 months- Localises sound consistently; babbling for self-amusement; imitates sounds
      • 12 months- First words
      • 18 months- 5-20 words; points to body parts
      • 2 years- 50+ words; talks to self; understands simple instructions
      • 3 years- Knows own name; asks questions; nursery rhymes
      • 4 years- Recounts stories of experience; counts to 20
    • Social
      • 6 weeks- social smile
      • 3 months- reacts pleasurably to familiar situations
      • 6 months- still friendly with strangers
      • 9 months- plays peek-a-boo; distinguishes strangers
      • 12 months- drinks from cup; less mouthing
      • 18 months- Feeds with spoon; mimics adults
      • 2 years- Feeding less messy; puts on hat/shoes; developing symbolic play
      • 3 years- Washes hands; vivid pretend play; understands sharing
      • 4 years- Dresses and undresses (except laces); washes and dries hands; understands turn-taking

Assessing growth and development (NB see also failure to thrive/short stature)

• Note that children with developmental delay can present for many reasons.  Some may be identified incidentally, presenting for another problem (which could be directly related to development e.g. malnutrition, or it might be completely unrelated); some may present at follow up for problems during pregnancy or during infancy e.g. infections, preterm birth, complicated labour etc; some may present for a known genetic condition
  • If developmental delay is not the presenting concern of the parents (but is considered by the doctor)- there are ways of asking about this without worrying the parents
    • “Do you have any concerns about the way your child is behaving/learning/developing; about the way he/she is using their arms/legs; about how your child talks or understands what you say; about how they are learning to do things for themselves?”
    • “Does your child enjoy playing with toys?  Describe what they do whilst playing.  Does your child get along with other?”
    • “Has your child ever stopped doing something he/she could previously do?”
  • Also note that it is not uncommon for parents to be concerned about development which is actually normal. It is important to reassure the parents of what is normal and offer advice as to when concern is appropriate
  • Follow-up consultations are extremely useful as they will help to track development (i.e. is this delayed or a developmental disorder which may never develop ‘normally’)
• Also note that early identification of developmental delay can be very helpful for the patient and family in managing this

Consultation

• WIPE (Wash hands, introduce self, check patient details, explain your role)
• Presenting complaint
  • Evaluate details surrounding the concern about development e.g. how/when was it noticed?; has it become more/less obvious?
  • Ask about whether they have noticed any other problems in development
  • Important red flag complaints (these should be asked about if not already discussed) include
    • Loss of developmental skills (previously gained)
    • Concerns about vision (consider urgent referral to paediatric ophthalmology)
    • Concerns about hearing (NB whilst the majority of cases will not be serious- it is important to fully evaluate this)
    • Persistently low muscle tone/floppiness or persistent toe walking
    • No speech by 18 months (particularly if the child does not communicate by other means- requires urgent hearing test)
    • Asymmetrical movements
  • Some milestones that warrant real concern
    • Sit unsupported by 12 months; walk by 18 months (boys) or 2 years (girls) (requires urgent creatinine kinase check); run by 2.5 years
    • Hold object in hand by 5 months; reach for object by 6 months; points at object at 2 years
  • Some milestones that are commonly delayed
    • Late talking and/or walking is not uncommon
      • Some children may never crawl (ask about crawling vs bottom shuffling)
• Past medical/developmental history
  • Start from the pregnancy up to date
    • Was the pregnancy planned?  Were all antenatal checks ok?  Was the baby pre-/post-term?
    • Were there any problems with the labour?
    • Were there any problems post-natally?
    • Up to now, have there been any developmental problems?  Any other significant medical events/conditions?  Is the child taking any medication?
      • Are vaccinations up to date?
• Family history
  • Often very useful in this situation- including details of any siblings and their development, as well as parents and other relations
• Social history

Examination

• Always measure height and weight and plot on a chart (see above)
• Examining a child for developmental problems can vary depending on the age.
• Begin always with a general inspection i.e. look at the child at rest/play
  • Are they moving normally?  Are they interacting normally?
  • Are there any features suggestive of a genetic abnormality?
• Go on to examine specific features of each developmental category depending on their age e.g.
  • If the patient is older, ask if they can jump or stand on one leg etc; if they can draw a picture; if they can tell you what some objects are… etc
  • If the child is an infant, assess whether they can sit up unaided, or control head stability; or hold an object (and what they do with the object)… etc
• If there is a problem with vision or hearing, examine these systems appropriately (may also require referral in any case)
• It may also be appropriate to examine the chest and abdomen if a systemic cause is suspected

Discussion

• The presence of red flag/concerning features should warrant referral to a specialist (speach and language, physio, medical specialty etc) or at least warrant a follow up appointment in 3 months
  • the later delays are identified and managed the harder it can be to resolve them
• If there is a genuine delay, it is good to investigate reversible causes
  • Investigate with FBC, bone profile, TFTs, CK and vit D (depending on presentation)
  • Undernutrition; iron deficiency anaemia; hypothyroidism; social circumstances can all influence development and may be reversible
• For many, reassurance will all that will be required- but it is important to educate parents about when to be concerned and always offer the option to return if they ever have any other concerns