GROWTH AND DEVELOPMENT Joel D. Lazaro * Lourdes S. Tanchanco "comperencars eed (6 Digerontite the terms growth and development | + Recognize the importance of growth and | development | entity factors afecting growth and development | + Interpret growth measurements "+ Demonstrate the patterns of growth at diferent ages + Discuss the various developmental milestones and phases of development “plain the volue of developmental screening and | setae i etren aed cn s strode rowth is defined as an increase in the’ -physical size and mass of an individual or a single organ. It begins at conception and continues at a rate that depends on a variety of Development, on the other hand, refers to the process of acquiring skills in an orderly and predictat It involves refinement and er hector Milling in the achievement of increasingly complex abilities in ‘various domains. It culminates in the acquisition of rege alae aioe ‘environmental resources in order to sustain: life. Although growth is often used synonymously with development, these 2 terms refer to different processes, Development is viewed as the more encompassing concept and includes growth IMPORTANCE OF GROWTH AND DEVELOPMENT Growth and development are significant determinants of the health and well-being of children. When children achieve their optimal growth and development, their physiologic processes are considered normal and their physical and psychological needs are being met. A deviation in growth may be an early sign of undertying problems. Impairments in growth are associated with delays in cognitive development and decreased intellectual capacity. Deficits in growth have been associated with increasingchild mortality. Growthis,therefore, an important indicator of an individual's health, adequacy of dit, impact of illness, and general well- being. Likewise, the growth status of infants and children may also be indicators of the health and socioeconomic development of the communities to which they belong. Normal human development offers a window to the status of CNS development. deviations from which become red flags of neurodevelopmental disorders. An evaluation of human development provides the clinician with the opportunity to create early detection programs. Studies in this field have far-reaching implications in child rearing, education, health care, and social pelicy. Optimizing, development enables communities and societies to flourish. In the Philippines, laws exist that promulgate carly childhood care and development. Republic Act 6972 or the Barangay-level Total Development and Protection of Children Act seeks to establish at least one day-care center in every barangay in the country which promotes growth and nutrition monitoring, ‘intellectual and mental stimulation, and supervised group play, among other tasks. Republic Act 8980, otherwise known as the Early Childhood Care and Development Act, seeks to provide a comprehensive range of health, nutrition, early education, and social services that cater to the holistic needs of childrenNB * Part? © Pediatric Norms 0-6 years old, and an integrated approach in the planning, management, and monitoring of early childhood care and primary education inthe country. a FACTORS AFFECTING GROWTH AND DEVELOPMENT + Growth and development are influenced by the interplay of factors which are dependent on a Sequence and interaction of genetic, hormonal environmental, and nutritional determinants These factors can be subdivided into hereditary and environmental ones (1e., nature and nurture) Heredity factors are traits that children are bom with and inciude growth patterns, parental characteristics, gender, race, and genetic disorders. These are fundamentally influenced by or entertwined with environmental processes. 1 Growth Patterns Normal human growth is characterized by periods of rapid growth (growth spurts) and periods of ‘seeming quiescence, 2 Genetics Parental characteristics such as height, head size, and general physique may be transmitted from parents to their offspring, Temperament and intelligence are other traits that are transmitted to succeeding generations. Temperament is a person's way of approaching or reacting to @ situation. Itis primarily inborn and is consistent as the child grows older, although it may be influenced by parental handing and life experiences. Certain genetic disorders may adversely affect growth. Chromosomal abnormalities, ike Down syndrome, and metabolic and congenital endocrine disorders may also adversely affect growth potential J Gender Boys are usually heavier and taller than girls during the Ist year of life until the time when growth spurts occur in girls. This is because prepubertal ‘growth spurts occur earlier in girls. Once the boys ‘experience the prepubertal growth spurt, they again become heavier and taller than girls. Race/Ethnicity eis well established that Caueaslan children heavier and taller than their Asian counterpar Since many Filipino children are used to haviy nannies and helpers in the household, thei acquisition of self-help skills is relatively achieved a ‘later age in contrast to their Caucasian counterparts, 1 Hormonal Factors ‘The interaction and balance of many hormones are important for growth and development to occur. Growth at puberty is dependent on the interaction of the growth hormone, insulin-like growth factor 1, and sex steroids. Thyroid hormones affect the growth of the skeleton and other body tissues 4 Environment Environmental factors are modifiable, and the timing and chronicity of these factors are also important determinants of growth. Environmental factors may be categorized into prenatal and postnatal. The prenatal period isthe time when growth most rapidly occurs. As such, environmental factors occurring at this time have a significant role in influencing growth and brain development. Such factors include nutrition, infections, and neurotoxins. Adequate nutrition is known to affect growth and brain development, Studies have shown that micronutrient (eg, zinc) supplementation improves linear growth among children who were initially deficientin these nutrients. While studies on iron do not demonstrate significant contribution to linear growth, iron has ‘been implicated in improving mental and motor development in children. Intrauterine infections (eg, TORCH infections) have long been associated With intrauterine growth retardation, Exposure to developmental neurotoxins such as alcohol during the prenatal period has also been proven to cause brain dysfunction, physical deformities, and growth retardation When these factors occur postnatally, they Saually affect growth and development. Children who were previously protein-energy deficient experience retarded growth, Somatic growth of obese children, on the other hand, is accelerated. ‘The presence of chronic illnesses or parasiticChapter « {infestations has also been implicated tn a ate of linear growth, Socloveonomle lactors such os poverty also influence growth, Children trom pout families are smaller than thelr age-matched poots Infamnities with higher tneome, ly, cllldren from affluent families who receive ideal care anil nutrition are able to attain their growth potential Cultural factors that alfect feeding habits and child. rearing may also affect growth. PATTERNS OF GROWTH Basic laws govern developm nt. Normal CNS is essential for normal development and goes through defined stages and phases. Although the sequence of development is the same for all ehildnn, the rate differs from one child to another. It follows cephalocaudal and proximo-distal directions, and proceeds from gross, undifferentiated skills to, precise individual responses. It Is also viewed as a transactional process between the child and the environment, with one havi the other. ‘A child 1s born with an average weight of 3,000 g and an average length of 50 cm. The head circumference of term newborns ranges trom 32-37 em. Individual growth rates vary greatly. However, children grow most rapidly during the Ist year of life. The birth weight doubles at profound effect on dwth and Development of lufants and Children © 19) S months and triples at L year This perio) ot rapid growth slows down during the 4nd yoars of life, An infant's Length increases by 50% of by around 25 cm during the Ist year of Ie, 10-15 em during the 2nd year ef Wife, and: round 7-10 em during the ard year of lite, Hy 2 years ole, the child's head is about (wo-thirds: of its ult slze, proportions andl body also change eild grows (Figure #1) ‘The change tn the proportion af the body is related to sketetal prowith The head becames relutively st as compared to the rest of the body as the child grows older. owth of the trunk predominates during, Infancy. The fat content of the body inc rapidly until 9 months of aye. Leg proportion Incr rest of the ody as the child system has a particular rate of terized by spe growth chy ie periods of rapid growth, While rates of growth and final growth nutcomes vary between individuals the pattern and sequence of growth are the same unless external environmental or pathophysiologic processes Interfere. The general growth curve is observed for musculoskeletal, respiratory, digestive, and excretory systems while the CNS, lymphoid, and reproductive systems have their unique patterns (Fig FIGURE 8-4. Changes in the proportion and body shape from fetal to aduttife Mote ram Rotbins W Brod S Hogin AG, Growth, New Haven: Yale Univesity Press (1928)120 © Part2 © Pediatric Norms 200% 180} fi 3 140 az0f- 100% “BRAIN WEAD 0} oo} a GENERAL SIZE ATTAINED IN PERCENT OF TOTAL POSTNATAL GROWTH 2 ° 8 10 42 4 36 18 20 AGE. YEARS. FIGURE 8-2. General growth curve and growth pattems of specitic organ systems ‘Source: Tanner JM. Growth at Adolesceree. Orford: Blackwell Pubishing Co. 1962) Skeletal growth continues until the fusion of the epiphysis of the long bones has occurred. This happens at around 14 years in femalesand 17 years in males, Skeletal growth proceeds slowly until around 30 years old, with the apposition ofthe upper and lower surfaces of the vertebral bodies. Growth proceeds only around 3-5 mm at this time, Lymphatic tissues are small but well-developed at birth. They grow rapidly to reach adult dimensions until around 6 years old. The size of lymphoid organ ‘and tissues peaks at around 10-12 years, after which they decrease in Genital tissues (Le., reproductive organs) ‘grow slowly before puberty. They double in size during adolescence when they mature and become functional Brain and neural tissue growth completes physical development early. The brain continues to grow dramatically after birth. From an ave woight of 400 g at birth (40 weeks), It re 4,000 gat the end of the Ist year. In the ce the Ast myelin cells are seen at the posterior fro and parietal lobes at 40 weeks. Myelination of t) anterior frontal and temporal lobes continue durin: the Ist year of life. By the end of the 2nd year, myelination of the cerebrum is complete. Thus, the most rapid and critical period of brain growth is between conception and the Ist 2 years of life, the period when early intervention, when needed, is, most essential. Brain growth continues until about 10-12 years, with an increase in the size of the head due to the development of air sinuses and the thickening of the scalp and skull. Deciduous teeth begin to calcify at 3 months age of gestation. Each tooth erupts when it has sufficient calcification to withstand chewing. They erupt between 6 months and 24 months of age. In some normal infants, eruption of the Ist teeth may beas late as 12-13 months. Eruption of permanent teeth begins at around 6 years old and is completed at around 18 years old GROWTH MEASUREMENTS The growth of children should be measured Periodically as single measurements of anthropometrics offer little value. Sequential ‘measurements over a specific period of time (also called growth monitoring) are a better gauge of a child's growth. Growth measurements need to be compared with previous measurements as well as normal values forage and gender: Growth charts are Important tools in assessing somatic growth which includes height or length, weight for length, body ‘mass index (BMI), and head circumference. Special Srowth charts areavailable for children who are born Premature and for those with underlying conditions (e4, Down syndrome), J Weight Infants should be we they are naked or children should be platform scale, ‘ighed on an infant scale while only wearing a diaper. Older ‘made to stand on the middle of aChapters © Growthand Devel 2 Length ‘The recumbent length is the measurement of choice for infants from birth to 24 months because of the normal lordosis in this age. With the iulant placed supine on a measuring device, the parent or an assistant hotds the infant's head against a headboard. The lege are held straight ty atasping the knees, with the feet flat against the footboard, Height For children 2 years of age and older, the ‘measurenteat of standing height ts preferred over length They are maut to stan erect with their back agains the measuring device. The occiput, the upper pat ofthe back, buttocks. and thehelsshould touch the backboard of the device. The external auditory meatus and the lower border af the orbit of the tyes should be ona plane parallel tothe floor. A flat horizontal board should be brought down firmly on thehead. —! Head Circumference The head circumference should be measured routinely during the 1st 2 years of life. It reflects the rate of growth ofthe brain and the cranium. The measuring tape is wrapped around the infant's head using the occipital protuberance and the glabella fof supraorbital prominence as landmarks. This indicates the point of largest circumference. — Chest Circumference ‘The chest circumference is not routinely taken, but Ic can be useful for purposes of comparison with the head circumference if one suspects a problem ‘with elther the head or chest size. At birth, the head circumference is equal to the chest circumference or may be larger by about 2 cm until about 5 months. Between 5 months and 2 years, the head circumference should approximate the chest circumference. After 2 years, the chest circumference is larger than the head circumference as the organs in the chest grow more rapidly than the brain at this time. The chest circumference is obtained by wrapping the measuring tape around the chest at the level ofthe nipple line, taken during the phase between inspiration and expiration pment of Infants ane 21 1 Body Mass Index ‘The BMI {san indirect measure of hody tat 0 lewlated using the weight and height For chiiss and adolescents, the Interpretation of BM! is bots ages and sex-specific. The following formula ts used to.compute for UME: weight ii iabt (ka) 1 Mid-upper Arm Circumference ‘The mid-uppor arm circumference (MUAC) provides fn alternative to the measurement of “thinness” when the weight-for-length/height cannot be obtained. This is generally used for children 1-5 years old, but has been utilized in infants 6-11 months. ‘With the clothing of the hid removed to expose thearm, locate the tpsofthe shoulder ani the elbow, and place a measuring tape over these two sites. ‘The midpoint fs marked and the tape Is used to measure the circumference of the upper arm atthe midpoint, taking care not to exert tension on the tape, The reading is made to the nearest 0.1 em. ‘The UNICEF has released in 2009 a new set of colored MUAC tapes to facilitate its use in the community. The colors correspond to the following, readings: red (< 11.5 cm), yellow (11.5-12.5 em), and green (> 12.5 cm). This new tape corresponds to the revised cut-off for severe acute malnutrition of 115 em, 1 Triceps Skinfold Thickness ‘This measurement provides another index of the nutritional status of an individeal and can be correlated with body fat content. The site of measurement is determined by having the individual bend the right arm at a right angle. Using a measuring tape, the site halfway between the tip of the olecranon and the seromial process on the posterior aspect of the arm is identified, With the arm ina relaxed position the triceps skinfold is ited by about 1 cm using the thumb and index Anger and a caliper is used to grasp the raised skinfold An average of 2 readings to the nearest millimeter with the gaugeat eye level recommended a122 = Part? © Pediatrie Norms GROWTH STANDARDS MNEMONICS in the absence of actual measurements that can. be derived irom growth charts, mnemonics have been devised to approximate the desired growth measurements forage. Table 8-1 shows some typical examples. GROWTH CHARTS ‘The growth of an individual can be compared with that of his/her peers using norms from established growth charts, The World Health Organization aunched the new Child Growth Standards (WHO- CGS) for infants and children up to the age of 5 years in 2006. These charts were designed for use internationally regardless of the race, genetics, and socioeconomic status, Obtained from data conducted in alongitudinal design with subjects from a diverse set of countries (ie, Brazil, Ghana, India, Norway, Oman, and the US), the study demonstrated that children from different regions of the world, when placed In the optimal environment and supported by appropriate nutrition (exclusive or predominant breastfeeding for at least 4 months with continued breastfeeding for at least 12 months, and appropriate complementary feeding by 6 months), have the potential to grow and develop better in comparison With their peers. As full longitudinal data are not yetavailable for children beyond 5 years old, reconstruction using th Statistics from WHO ter for He the 1977 US. National Ce Growth Charts, supplemented bY a fs 6 S to smoothen the transition to age 5 years, led Standards (WHO-GRS) in 2007. BMI charts were developed for WHO-GRS instead of weight for heigh “The DOH, through Administrative Order 2010 0015, adopted the WHO-CGS as the standard for use in nutritional assessment of children 0-5 years, growth monitoring and promotion, and Operation Timbang (OPT) activities. This allows for comparison of Filipino children against a single international standard ‘A complete set of the WHO-CGS and WHO-GRS is included in the appendix. DEVELOPMENTAL MILESTONES AND PHASES OF DEVELOPMENT In contrast to growth, developmental skills are qualitative and, therefore, more challenging to evaluate and measure. The pioneering work of Gesell and Amatruda provides a system of analyzing development progress. The system made use of the 4 fundamental streams of development, namely ross motor, fine motor, language, and personal- social. In each domain, functional skills that should be acquired ata certain age are identified and are known as developmental milestones. Gross motor milestones focus on posture and large movements. The pattern follows a 8-4. Useful mnemonice for common growth standards pommeneee | SASS eae Useful mnemonics [0-6 months Agein months » 600 + bith weighting) 6-12 months (gen months after — ane 3.600 + (egein months efter 6 months ¥500) + bith weight Gn @ -6 years ‘Age in years a2 + 8 in kg) 7-42 years % lage inyears 7) ~ 5] im kg) (0-3 months Birth weight + 9em 4-6 months Birth weight + 9m Bem ight + ome tenetn [7a months Bith weight + 9em> 8m + 5am [20-22 monthe Bicth weight + 9em+ Bem +5em+3om Lengiiyheghe | 2-42years Agein years x6 +77 (nom) (allages, * a acre “(paternal + matemat height) + 43] ga amy tparerial height an ages. gt 4 lbaterral + maternal height) 13} Gn em) e Aap tom vaio sree ,eS Chapter 8 © Growth and Development of Infants and Chi cephalocaudal route and is dependent on the integrity of the nervous system, musculoskeletal system, and the opportunity to execute certain skills, Fine motor milestones are concerned with eye-hand coordination, object manipulation, and problem-solving skills. The pattern follows a proximo-distal route, Language milestones ‘emphasize verbal expression (expressive language) and language comprehension (receptive language). ‘There are important prerequisites to language development such as intact auditory function, integrity of the oromotor structures, cognitive ability, and a stimulating environment. Language is the best predictor of later intelligence. Personal- social milestones involve self-help and adaptive skills and reflect the individual's mastery over the environmont.Itis related to environmental exposure and practice and, therefore, the most culturally sensitive of all the developmental streams. ‘The anatomic, physiologic, and psychologic characteristics of a child are unique at various age levels, Even the diagnosis and management of disorders are influenced by the stage of development. Table 8-2 enumerates the different development periods. Prenatal period Ovalar 0-44 days Embryonic 14 days 0 9 weeks Fetal © weeksto birth Postnatal per Neonatal 0-28 days Infancy (0-42 months Toddler 13a Preschool 3-6 years ‘School-age 6-12years ‘Adolescence 13-18 yeors O Prenatal Period The prenatal period begins with the ovum's fertilization by the sperm. Intrauterine development in humans is divided into 3 phases. The 1st2 weeks is the ovular stage, beginning from the 0 becomes fertilized until the zygote is we in the endometrium. Itis followed by the eb stage. starting from the 2nd week to the end of te nd month, Major tissue and organ differentiation ‘occurs at this stage, making it the most critical period of prenatal development. The embryonic disk is Aivided into 3 germ layers, each later differentiating Into specific tissues and organs. The endodermal layer gives rise to the gastrointestinal tract, liver, pancreas, and genitourinary tract; the mesodermal layer to the musculoskeletal, cardiovascular, urinary, and lymphatic systems; the ectodermal layer to the central and peripheral nervous system and the epidermis, including hair.nails.and teeth. In the fetal stage, the fetus increases in size and weight from the 3rd month of gestation until birth. The milestones of prenatal developmentare depicted in Table 8-3. Implications to practice Daring prenatal development, there are periods of susceptibility to teratogens The Ist 2 weeks of life are usually not susceptible to these forces: however, a high rate of lethality may oceur. The embryonic period, the stage of organogenesis, is the period ‘of highest susceptibility to teratogens. Each organ system has its own peak of vulnerability, After the 9th week or the period of functional maturity, sensitivity to teratogens decreases. 1) Neonatal Period In the neonatal period, the most crucial developmental event isthe attainment of physiologic stability in the sleep-wake cycle and respiratory and feeding-elimination patterns. The challenge lies in differentiating whether instability is due to physiologic variability or disease. Sensory functions are operational even before birth; at birth, majority are already mature. Infants are born with intact senses. Touch is the Ast among the different senses to develop, and itis the most developed at birth. At the beginning of the 3rd trimester all parts of the fetus are sensitive to touch. “The fetus is able to feel pain; thus, there is ameed to relieve pain even in the earliest days off. The sense of smell and sense of taste also develop prenatally.124 © Pare? © Pedutrie Norms Femugation ana implartabon occurs ryan pera De NS. embryo appears. rier ergeim and 210367 "Fest missed merstua peed 3 | Somites beg to form. |Vascuar system appears in the mid | Mesoderm appears triaminar embryo) Je of tho 3rd week when diffusion of nutrients alone Te unabve to tustamn the nutribonal requrements of the embryo. Neural feds fuse. Lung due appears as an outgrowth a | Fading of embryo nto hunan tke shape | Am and leg buds appear; crown-rump length: 0.4-0.55 6m fom the veriricular wall ofthe foregut. Primnive lens 5 | Prive mouth Digtal rays on hans A Prmve nose, phitran, ana primey {Crown mg engin 28-2.3em ate form 7 Teyenes vege § TOvares anctestes cistinguisnabie Fetal period beens. 8 ‘Crown-rump lengin: Sem Wewnt 9 g Face recognzably human 2 | ectomal genitalia dutinguishable ras begun » Length: 19m Wegnt:9 8 Usual lewer limit of wabilty a the primitive alveol have formed and surfactant production Turd weester Begins. Lengtr: 25em | “ot pematue birth Eyes oven, 28 Fetus moves head down. Weeght: 1,000 g | ew: 460 we besos boty soe resin fo on and cael) | newal apparatus functioning sufficiently to give the fetus some chance of survival in case C= erm Infants show an innate preference for sweet tastes. ‘The acceptance of sweet, and refusal of bitter tastes seem to be ingrained in the constitutional make- up of infants while the response to odors is more experiential. Rejection of bitter tastes is likely a survival mechanism as many noxious substances re bitter in taste. Infants are able to hear at birth, Recognition of language and voxes whilein the womb aids in maternal bonding, Auditory discrimination develops rapidly after birth. Babies are able to detect new sounds from the ones they have heard before. At birth infants are born with a complete, albeit immature, visual system, AC birth, the point ‘of clearest vision of the infant is around 20-30 cm ‘way, about the distance ofthe face of the caregiver ‘when the child is being carried, Visual stimuli are ‘rtical for the development of vision. Because of the Importance of vision and hearing in the optimum evelopment of children early screening for hearing and vision problems is recommended.Chapter8 © Growth and Development of Infantsand Chilite» © 125 Motor function in the neonatal period is governed by reflex. This will eventually be integrated, into voluntary movement patterns, allowing for the development of symmetrical and purposeful ‘moverment patterns, Newborns can turn their head from side to side when lying on their abdomen, thereby preventing suffocation. When a newborn is pulled up from a supine position, the head lags as head control is absent, The development of fine ‘motor contro! is subtle, At birth, the hands are fisted. The grasp is more reflexive than purposeful, as objects are dropped immediately. Primitive forms of language are seen in the neonatal period. Crying is a potent means of communication along with cooing and gurgling sounds by the 6th week. Receptive language skill is manifested by startle reflex in response to auditory stimuli, Personal-social skill is observed when a newborn fixates and watches the faces of familiar caregivers. The milestones of neonatal development are summarized in Table 8-4. 4. Developmental milestones In the Prone: Arme/iegs Nexed; pelvis nigh Ventral suspension: Head held below ogy | Supine: Arme/egs semi fexed Pollo sit: Complete heat og, Hold upright: Legs extended (Grasp reflex Drop objectimmodiataly Hane remain fisted ‘Sweeping movements towards object Expressive: Crying/ whimpering Receotive: Started by loud sound Gross metor Fire motor Language Gaze at faces, colored objects, and Personat social | "200 nee Implications to practice Since homeostasis and the regularization of physiologic functionsare the thrusts ofthe neonatal period, ts essential that caregivers provide safe, predictable, and timely responsesto the needs ofthe neonate, Newborn universal screening for metabolie disorders and hearing is strongly recoraimenc anticipatory care. Infancy Infancy is the most rapidly progressive stage of child development, During this period, the baby starts his/her journey in becoming an independent and naturally curious child. Gross motor skills in the 1st year af ile develop along 2 aves of posture and motion, From the newborn period when there iscomplete headlag by 2 months, the baby can hold his/her head up inthe sare plane asthe rest of the body, and by 3 months can maintain the head up well beyond the horizontal plane. At 4-5 months, the infant can keep his/her chest and abdomen up by maintaining the weight on extended elbows, Subsequenty.theinfant rolls over at 5-6 months sts 2t7-8 months, erawls at €-9 months, pulls to stand at9-10 months, and walks independently at around 12 months motor skills during infancy focus on the development of mature pincer grasp and voluntary release. The initial fisted hand posture during the rnewbom period and the unfisting by 3 montis pave the way tothe reaching and holding of objects at 4 ‘months. AtS-6 months, the hands join together inthe ‘midline allowing for transfers, bringing of objects wo the mouth, and bimanual manipulation at7 months. {At around 8 months, the index finger approach is observed, followed by the evolution of the pincer grasp or thumb-finger grasp at 9-10 months. By 10-12 months, the voluntary release of objects held {snoted, allowing forthe throwing of objects. Language development involves both expressive and receptive language skills. Expressive language evolves irom the most basic crying as an effective way to communicate seen during the newborn period, to gurgling and cooing sounds at 6 weeks to3 months. Repetitive consonant-vowel combination or babbling soon evolves at 5-6 montis. By 9-10 months, *mama/papa’ develops from babbling which at this time ay sill benon-specificin ceference to mother cor father: Aitional single words aside from mama/ papa may be uttered by 12 months and thereafter Receptive language begins with thenon-speciicand reflexive startle response ofthe newborn to sounds126 © Part2 © PediatricNorms alerting response to human voice by 3 months, and the more specific localization by turning the head to the source of sound by 5-6 months, By 6-7 months, Infants recognize and respond to their names, and by 9 months understand the concept of “no {At year old, infants follow a L-step command aided by gestures, ‘The developmental milestones ofthe infant are shown in Table 85. Implications to practice ‘The caregiver should provide a safe environment ‘and adequate opportunities for infants to practice Independent ambulation. Risks for physical inj ‘must also be avoided. | 3mos | Head hold Smos [Rollover | owner [toa Se ee lone soar |i Tapes cao [eg fits saa [Sa oes Bess? [one [Mego Sear eae cosas Sone ‘9mes | Understand “no” : sane | mgenconmnd 5 Todsler Period Toddlerhood cover of age and is conside’ developmental phases. 's the period from 1-3 years red 1 of the challenging Developmental challenges re expanded because of the from infancy ere and shaped by increasingly growing social sphere an ereasingiy Sophisticated language skills. This per Het by tension between the child's growing sense o autonomy and internal/external limitations, in the toddler period, balance and coordination improve rapidly. Such improvement makes the toddler active and agile. From a I-year-old child who walls: with a wide-based gait and with the arms up, the change is seen in a few weeks to a narrow-based ‘walk with arms held lower. By 15 months, toddlers can run, pivot, and walk backwards. By 18 months, they can walk up the stairs with rails and can throw a ball. Motor skills become more sophisticated; at 2 years, todaler can jump with both feet at once, kick a ball forward, and walk downstairs. Toddlers are also capable of increasingly refined fine motor skills as seen in the way they manipulate objects while playing. Graphomotor skills start to develop with the toddler spontanecusly scribbling by 15 months, lining and drawing circles with a series of perseveration lines between 2 to 2.5 years. Language becomes elaborate and is the most significant development inthe toddler years. From single word utterances at 1 year old, the toddler's vacabulary soon increases; by 2 years, toddlers may have acquired 300 words. ‘They are able to speakin 2-worded phrases, mostly noun-vorb combinations. By 3 years old, vocabulary ‘booms to about 900 words Sentences on the average are composed of 3-4 words, uttered in a telegraphi manner. The abiliy to understand Fe rena geese gi toddler i able tofolow commands atten ‘commands without gesture at 15 months and follow 2-step commands at 18-24 ‘months. At the age of 3 years, the child understand: monet ofhunger and exhaustion and is able to ing feeding and dressing, Bythe iol R the childs ready to be coiettrained and by Sth supers Te ae a8 pon dots levelopmental mileston the vider period are depicted in able 86Chapter8 * Growth and Development of Infantsand Chiltrer - 127 15 mes_| Run, pivot, wak backwards 18 mos_[Walk upstairs wth als [Grose motor [24 mes [Jump with both fect “ump Torwera 30 mes Pedal treyele 15mos_| Spontaneous scribing 418 mos_| imitate streke on paper Fnemetor [24mos | iitete vertical ines os | Drow cle with series of oom porseverating lines Two-worded phrases Language | 24mos. | adleto folow 2step ‘commands Implications to practice Because of the drive for autonomy in toddlers, caregivers must be prepared to set limits and provide a safe environment where toddlers can do some exploration. The risk of accidental ingestion of harmful substances and the battle of wills in terms of discipline are significant challenges. U Preschool Period ‘The preschool years which span the age of 3-5 years depicta period of transformation from a dependent, sometimes clingy toddler into a socially competent and cognitively prepared child who is ready to start school. The preschooler traverses a {great deal of developmental landscape. Motor skills progress steadily and become more sophisticated, ‘A 3-year-old can ride tricycle, hop at 4 years, and skip at S years. Growing competence Is also seen in fine motor skills as reflected in improving eye-hand coordination. By this time, a preschooler is able to hold a crayon or pencil using a tripod grasp and to draw acircle and a person with at east 2 body parts at 3 years, a cross at 3.5-4 years, a square at 4-45 years, and a triangle at 5 years. Language skills, both expressive and receptive, grow in complexity. Linguistic development is an ve and important determinant of future cognit academic competence. By 3 years, preschoolers understand the semantics of language in which Sys | Ride tricycle Groce pais ays [Hop Sys [Skip Draw circle or a person Sys | with 2 body parts Fine BS-4yrs | Drawe cose motor us 4-45 ys | Drawa square Sys |Drawa triangle 3-4 worded telegraphic ays ‘sentences Understand prepesitions Language Complete sentences, 445 | understone conceptof size é Understand concept of time Y° | Follow 3step commands 3s | Dress under supervision Dress independent Pecsinat | Ay | “Sra ‘social Do simpee erranas 548 | Helpin nousenoic chores words have meaning. They are able to state their ‘name, age, and sex when asked. By 4 years, they can talkin complete sentences and understand concepts of size. At § years, they understand the concept of time and follow 3-step commands. The preschoolers are more independent in activities of daly living, og, dressing and feeding, Social competence is played, ‘out as thelr social group expands beyond the home, especially in the context of group and interactive play. ‘The developmental milestones of preschool children are shown in Table 8-7. Implications to practice The preschool period is a time for the caregiver to allow a certain degree of independence to assess the child's learning readiness in school. This is the stage when the child enters the school systems where gradual transition of care commences from the family to the teachers as the child prepares for formal schoolingYB > Parez © Pediatrie Norms U1 School-age Period ‘The ages 6-12 years In th wvolopment of a child correspond to the years when formal education begins, This isthe period when significant advances {in social skills and cognitive abilities take place, School-age children begin the process of moving out from the family circle to expand their mteraction witha langer soctal and academic world, By the age of 6 years, most children have smooth and strang gross motor skills, Chmblng, running, swimming, and skipping, rope are some uf the many motor skills that children at this age can master, There are wide variations inthe manner by ‘wiih children master different motor skills due to diferencesin stamina, Interest and physical courage Fine motor skills in the school-age period also become mature and sophisticated as they are utilized for activities of independent living at home and graphomotor activities in school. By the age of 6 years, handedness pattern is established and ‘most are able to handle a pencil well enough to copy the alphabet, Sie-year-old children can still have directional challenges and find mirror images confusing, This is why they may still reverse some letters like “bt and “a" This problem is resclved by the age of 7 years. By theage of years, children ae able toexpress their thoughts and feelings, They are also able to follow 3 commands in a row. These are important skills needed for successful social interaction and academic performance in school ‘The developmental milestones of school-age children are categorized in Table 8-8. cross mat [7s | “eae ove [rere seme ters ee metor eee eat Ta fn ior es Verelie ercons Language 6.5 | follow 3-seriol command Pesos ggg | res ww conpieay | social 5 | Tie shoe laces Implications to practice ; Sehoobage ehiidren further hone their skills and acquire Iteracy needed for higher education, The Caregiver inust consciously alle theste ebildren te Stain mastery and Independence in doing acadernic Work as well as to take opportunities to develop frendships and relationships outside the farnily Health professionals should he alert to detect learning difficulties, behavior problems, school maladjustment, and bullying problems. DEVELOPMENTAL SCREENING AND SURVEILLANCE Since child development ts an important and dynamic process, efurtsare exerted to ensure thatit Is optimized, alung with timely interventions, should be made. Developmental surveillance and screening should be essential parts in well-child visits. Developmental surveillance is the process of ‘monitoring.a child's developmental progress at each well-child visit This process is in compliance with the guidelines of the Philippine Pediatric Society for well-child care and the Magna Carta for Disability (Republic Act 7277) which espouses the early detection of developmental delays. It involves taking, a complete medical history. reviewing developmental milestones, and making, skilled observations of the child, as well as accurate record-keeping of observations and interventions. The process gives the healthcare provider the opportunity to monitor developmental trajectories of children and discuss developmental concerns with parents. In the course of developmental surveillance, developmental screening tests can be employed. Screening identifies children who have orare at risk of developmental delays while accurately classifying others who are on a par with the standards. ‘These screening tests should be easy and quick to administer, acceptable to the children and their Parents, reliable and valid as well as highly sensitive and specific. However, these tests are not meant to ‘measure cognitive ability nor diagnose disorders. Table 8-9 shows the common uced attaopeenad screening tests. In interpreting developmental sereenin shephyskian shouldewluncthe reals neighChapter 8 * Growth and Development of fnfants and (0 of the other evidence obtained in the medical history, physteal examination, 120 and at times, laboratory tests. lopmental sere wrefore, Suet Min cuncwct cad EERE, | once | Reset t sail Surdanivedsiscratona vas aan [himeaas rene | o-ve [Sacer eee ‘various ooaem ae o-Byrs | Questionnaire for parents | Amercin Aeateny of Peace Commies on Prac 0 “bul Wedean Secon of Ophamelogy 1996 rd 2002 Barest Beacham Chen ese. Aon ReV Pe ecco Counc far he Weare of Chiron Republic At 980. sty “hilghood care and developments Republic of the pines De ons MBsterM. The Wet Heath Organization eal ata ancl pent and mina mchooley Safsoncatons tn Eider 200832 518-526 Del undo Eran fA Santos Damp P, Hvar ios Wentoakopeaavis sod chi sean Quzo CY: Free 200 panne Repu ef be PlipiotAdminirae ner 2010-0018 tesa PH Alin Inns’ dteconfthe sound ptens in eras nient pec Cope Pek 1951-28. 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