CHAPTER I

INTRODUCTION
1.1 Trigger
A 7-month-old girl was brought to puskesmas because she was still
unable to roll to her sides or to lift her head.
Her responses to light and sound were impaired. She was born at full
term with birth weight 3150 grams. Her weight now is 5100 grams, head
circumference is 39 cm, and body length is 55 cm. Her mother only gives her
breast milk and formula.
Recently , her mother noticed that her baby had white or opaque pupil in
her left eye. The babys brother was suffered from fever and rose-pink
maculopapular rash when their mother was at 8 weeks of gestational age.
1.2 Clarification-Definition
1. Opaque pupil
Condition that the light cant through the pupil
2. Rash
A temporary eruption on the skin
3. Fever
An elevation of body temperature over than 37,5
4. Maculopapular
There are macula and papular on the skin. Macula is anatomic
nomenculator for a skin, spot, a thickening because of colour or
some other characteristic. Popular is a small circumscribed,
superficial, solid elevation of the skin less than 1 cm.
1.3 Keywords
1. 7 month old girl
2. She cant roll over and lift he head
3. Impaired to response to light and sound
4. Gestational Age
5. NBW
6. Her weight now is 5100 grams, head circumference is 39 cm, and body
length is 55 cm.
7. 5 month old weight is 3400 grams
8. Breast milk and formula feeding
9. Fussy in the evening
10. Heavy breathing
11. Murmur on physical examination
1.4 Core Problem
What happen during the pregnancy and after birth that make the infants
growth and development has problem?

1.5 Problem Analysis

Pregnancy

Unremarkable
Born at full term
Appropriate for gestational age

Growth and Development

Embryogenesis

Organogenesis

Birth

Organ Maturation

2450 g

1.6 Hypothesis
The problem during the pregnancy and formula feeding affected the
During 5 month

infants nutrient after birth, so it is affect the growth and development.

1.7 Learning Issues
1. Growth and development
a. Definition
Murmur on physical examination
Unable to roll and lift her head
Factors
that
affect growth
Her mother give her b.
breast
milk
: formula
40 : and
60 development in infants
c. Delay development
2. Embryogenesis & Organogenesis
a. Definition
b. Stages/Phase
3. Nutrition.
4. Formula milk composition.
5. Congenital heart disease.
a. Why the infant had heavy breathing when she drinks milk?
b. What caused the murmur?
6. What is the parameter for physical examination in growth and
development?
7. What appropriate gestational age?
8. Low birth weight.
9. What treatment can be given to the infants delay development?

10. What is the relation between delay growth and motoric development?

CHAPTER 2
DISCUSSION
2.1 Growth and Development
a. Definition
Growth and development actually is two different cases, but it is
related each other. The definition of growth and development itself is

Growth is about changes in quantity, like size or the number of cell,

organ, organ system, or individual.

Development is increase of structure and body function that become
more complex, as a result of maturation. It is about differentiation
process of cell, matrix, tissue, organ, and organ system that is
developing such that it can fulfill its functions. It is including
emotional, cognitive, and behavior development as the result of
interaction with others.
So, we can conclude that growth has an impact on the physical aspect,

while development related to the maturation of organ function. 1 However,

these two happen at the same time synchronously in each person.
b. Factors that affect growth and development in infants.2
There are two main factors that affect growth and development in
infant.
1) Genetics
Parental size has a direct influence on a childs
growth potential and their predicted adult height; more
so for height than weight. A child with short stature may
be of concern because of possible illness or poor
nutrition, but for a short child with short parents they
are possibly genetically small. Extreme shortness may
be due to a combination of genetic and non-genetic
factors. Complex calculations can be performed to
predict the childs height potential based on their
parents heights.
2) Environment
Environment is the factor that determined whether
inherent potential achieved or not. Environment factors
divided into two, they are prenatal factor and postnatal
factor.
a) Prenatal factor
Prenatal environment factor affect the growth
and

development

of

the

fetus,

start

from

conception until birth.

4

Maternal nutrition
Bad maternal

nutrition

more

often

produce baby with LBW (Low Birth Weight). It

also can cause disorders in infants brain

development, anemia, and many others.

Mechanic
Trauma and deficiency on amnion fluid

can cause congenital disorder in the infant.

Toxin
Organogenesis is period that is very
sensitive on teratogen, for example is drugs,
like thalidomide, phenitoin, methadion, and
others that can cause congenital disorder.
Mother that is smoker or alcoholic often
deliver infant with LBW, disability, or mental

retardation.
Infection
Intrauterine infection that is often cause
congenital disability is TORCH (Toxoplasmosis,
Rubella, Cytomegalovirus, Herpes Simplex).
Other infection that also can cause disease on
infant

are

malaria,

varisela,

HIV,

Coxsackie,

Echovirus,

campak,

listeriosis,

polio,

leptospira, mikoplasma, influenza virus, and

hepatitis virus.
Stress
Stress experienced by pregnant mother
can affect the growth and development of the
infant,

like

congenital

disability,

mental

disorder, and others.

b) Postnatal factor
Ethnicity
It was traditionally believed that different
ethnic

groups

show

different

patterns

of

growth; on average African-Caribbean groups

are taller and heavier, and Asian and Chinese

groups are shorter and lighter when compared

with Caucasians.
Birthweight
Small birth size may be associated with
increased

risk

of

cardiovascular

diseases,

suggesting that foetal under-nutrition may

increase susceptibility to diseases occurring
later in life. Evidence from animal studies
suggests that the foetus may adapt to an
adverse intrauterine environment by slowing
down growth and metabolism, whereas large
birth

size

may

predict

increased

risk

of

obesity, diabetes and some cancers.

Birthweight is one of the most accessible
and

reliable

indicators

and

universally

measured. In general, lower birth weight is

associated with higher risk or morbidity. At a
population level, groups with lower mean
birthweight often have higher infant mortality
(eg infants of mothers who smoke, or of
mothers

from

lower

socioeconomic

background). Asthma, lower developmental

outcomes and hypertension have all been
reported to be more common among small

birth weight infants.

Prematurity
A child born before 37 completed week
gestation is considered preterm. Weight is
plotted on an appropriate intrauterine growth
chart. In Victoria, these charts are based on
data from Kitchen and used until the expected

birth date plus 2 weeks. Growth of premature

infants is monitored by a pediatrician.

Hormones
Anomalies in circulating hormones such
as growth hormone, insulin like growth factor,
testosterone,

oestrogen,

thyroid

hormone,

cortisol, insulin affect birth weight and growth.

Nutritional
The direct impact of inadequate nutrition
including energy, protein and micronutrients
caused by illness, neglect, or food insecurity.
Breastfed infant have been long-recognised to
have different growth in the first year of life
compared to non-breastfed babies. Significant
difference

between

the

growth

rates

of

formula and breast fed infants was first

reported in the DARLING (US) study showing
that BF infants grow more quickly initially, for
the first 3 -6 months, and then more slowly
over the next 6 9 months. At the end of 12
months, breastfed infants were generally 0.5
0 6 kg lighter than formula fed infants. Data
from seven longitudinal studies of infant
growth were pooled and this confirmed that
infants breast fed for at least 12 months grew
more rapidly in the first 2 months and less
rapidly from 3 12 months. This provided the
rationale for formation of a working group to
develop new standards.
c. Delay development.
Developmental delay is a term that generally refers to children who do
not show the expected developmental properties according to their age. 3 The
main causes of developmental disabilities remain unknown. Delay in
development can be caused by a high risk pregnancy.3 A pregnancy is
7

considered high-risk if the mother, fetus, or infant is more exposed to death,

disability or sickness. The most important factors for these risks are
maternal malnutrition, pregnancy at the young maternal age, short interval
between two pregnancies, the fifth or more pregnancies, preeclampsia,
placental abruption, immaturity and intrauterine growth restriction, mothers
underlying diseases, addiction, and being deprived of primary care during
pregnancy.
Infants who are in danger of developmental delay have a history of
one or more risk factors in the period before, during, or after birth. In these
high-risk infants, gross motor developmental delay is 30% more than in a
normal population. Most infant deaths and developmental disorders are
related to immaturity, low birth weight, maternal complications during
pregnancy, and congenital malformations (chromosomal and metabolic).
Low levels of parental education, age of the mother, high gravidity,
low birth weight, and preterm labor are significantly associated with delayed
motor and social development. Due to the numerous problems involved with
having a child afflicted by developmental delay, early diagnosis and timely
referral are very important and can benefit children with developmental
disabilities and their families. Thus, monitoring child development and
screening to detect such problems at each child visit is very important. The
developmental evaluation should include five motor development areas
(gross and fine motor skills), cognitive and emotional development,
communication (perception and speech) development, problem-solving
development, and socio-personal development.
We can determine that infant has delay development by look at the
normal body weight, length, and head circumference growth. There are rules
of thumb for growth.4

This is a table of development stage.4

From that table, we know that she still unable to roll to her side
because she had delay development in gross motor. Actually she should
have been able to do that when 4 months. And this is a red flag to

her parents.
2.2 Embryogenesis & Organogenesis
a. Definition
According to Dorland's Illustrated Medical Dictionary, embryogenesis
is (1) The production of embryos; (2) The development of the new
individual happens sexually namely from the zygote.5 In general,
embryogenesis is the process of cell division and differentiation of cells
from human embryos that occurs during the earliest stages of human
development.6 Precisely, embryogenesis occurs when the sperm meets and

10

merges with the ovum which is called fertilization until the end of the 8th
week of human development.
b. Stages/Phase of Embryogenesis.7
1) Fertilization
Fertilization is the process by which male and female gametes
fuse, occurs in the ampullary region of the uterine tube. This is the
widest part of the tube and is close to the ovary. Spermatozoa may
remain viable in the female reproductive tract for several days.
The phases of fertilization include
a) Phase 1, penetration of the corona radiate of the 200 to 300
million spermatozoa normally deposited in the female genital
tract, only 300 to 500 reach the site of fertilization. Only one of
these fertilizes the egg. It is thought that the others aid the
fertilizing sperm in penetrating the barriers protecting the female
gamete. Capacitated sperm pass freely through corona cells.
b) Phase 2, penetration of the pellucida zone. The zone is a
glycoprotein shell surrounding the egg that facilitates and
maintains sperm binding and induces the acrosome reaction. Both
binding and the acrosome reaction are mediated by the ligand
ZP3, a zona protein. Release of acrosomal enzymes (acrosin)
allows sperm to penetrate the zona, thereby coming in contact
with the plasma membrane of the oocyte. Other spermatozoa have
been found embedded in the zona pellucida, but only one seems
to be able to penetrate the oocyte.
c) Phase 3, fusion of the oocyte and sperm cell membranes. The
initial adhesion of sperm to the oocyte is mediated in part by the
interaction of integrins on the oocyte and their ligands,
disintegrins, on sperm. After adhesion, the plasma membranes of
the sperm and egg fuse. Because the plasma membrane covering
the acrosomal head cap disappears during the acrosome reaction,
actual fusion is accomplished between the oocyte membrane and
the membrane that covers the posterior region of the sperm head.
In the human, both the head and the tail of the spermatozoon enter
the cytoplasm of the oocyte, but the plasma membran is left
behind on the oocyte surface. As soon as a spermatozoon has
11

entered the oocyte, the egg responds in three way : cortical and
zona reaction, resumption of the second meiotic division,
metabolic activation of the egg.

2)
Cleavage
Once the zygote has reached the two-cell stage, it undergoes a
series of mitotic divisions, increasing the numbers of cells. These cells,
which become smaller with each cleavage division, are known as
blastomeres. Until the eight-cell stage, they form a loosely arranged
clump. After the third cleavage, however, blastomers maximize their
contact with each other, forming a compact ball of cells held together
by tight junctions. This process, compaction, segregates inner cells,
which communicate extensively by gap junctions, from outer cells.
Approximately 3 days after fertilization, cells of the compacted embryo
divide again to form a 16-cell morula (mulberry). Inner cells of the
morula constitute the inner cell mass, and surrounding cells compose
the outer cell mass. The inner cell mass gives rise to tissues of the
embryo proper, and the outer cell mass forms the trophoblast, which
later contributes to the placenta.

12

3) Blastocyst Formation
About the time the morula enters the uterine cavity, fl uid begins
to penetrate through the zona pellucida into the intercellular spaces of
the inner cell mass. Gradually, the intercellular spaces become confl
uent, and fi nally, a single cavity, the blastocele, forms. At this time, the
embryo is a blastocyst. Cells of the inner cell mass, now called the
embryoblast, are at one pole, and those of the outer cell mass, or
trophoblast, flatten and form the epithelial wall of the blastocyst. The
zona pellucida has disappeared, allowing implantation to begin.

13

4) Gastrulation
The most characteristic event occurring during the third week of
gestation is gastrulation, the process that establishes all three germ
layers (ectoderm, mesoderm, and endoderm) in the embryo.
Gastrulation begins with formation of the primitive streak on the
surface of the epiblast. Initially, the streak is vaguely defined, but in a
15- to 16-day embryo, it is clearly visible as a narrow groove with
slightly bulging regions on either side. The cephalic end of the streak,
the primitive node, consists of a slightly elevated area surrounding the
small primitive pit. Cells of the epiblast migrate toward the primitive
streak. Upon arrival in the region of the streak, they become fl askshaped, detach from the epiblast, and slip beneath it. This inward
movement is known as invagination. Cell migration and specifi cation
are controlled by fi broblast growth factor 8 (FGF8), which is

14

synthesized by streak cells themselves. This growth factor controls cell

movement by downregulating E-cadherin, a protein that normally binds
epiblast cells together. FGF8 then controls cell specifi cation into the
mesoderm by regulating Brachyury (T) expression. Once the cells have
invaginated, some displace the hypoblast, creating the embryonic
endoderm, and others come to lie between the epiblast and newly
created endoderm to form mesoderm. Cells remaining in the epiblast
then form ectoderm. Thus, the epiblast, through the process of
gastrulation, is the source of all of the germ layers, and cells in these
layers will give rise to all of the tissues and organs in the embryo.
5) Neurulation
Neurulation is the process whereby the neural plate forms the
neural tube. By the end of the third week, the lateral edges of the neural
plate become elevated to form neural folds, and the depressed mid
region forms the neural groove. Gradually, the neural folds approach
each other in the midline, where they fuse. Fusion begins in the cervical
region (fifth somite) and proceeds cranially and caudally. As a result,
the neural tube is formed.

15

2.3 Nutrition

16

For an infant, breastfeeding is the natural first food. All energy and
nutrients for the infants needs in the first months of life are provided in
breastfeed. During the second half of the first year and up to one-third during
the second year of life, breastfeed provides up to half even more of a childs
nutritional needs. Breastfeeding is recommended by WHO and UNICEF.
Breast milk is important to promote the sensory and cognitive developments,
protect the infant againts chronic and infectious diseases.8
Exclusive breastfeeding for first 6 months is important, start within the
first hour of life, the infant receives breast milk without any food and drinks
even water. Exclusive breastfeeding reduces the infant mortality that caused
by childhood illnesses such as diarrhoea or pneumonia, and helps for a
quicker recovery during illness.8

WHO in 2003 issued recommendations on infant right feeding

practices, there are:9
1) Breastfeed as soon as possible after birth ( < 1 hour ) and exclusively
for 6 months.
2) Give MPASI (Makanan Pendamping ASI) at 6 months age while
continuing breastfeeding for up to 24 months. The good MPASI is

17

eligible timely, nutritionally complete, sufficient and balanced, safe and

granted it the right way.
Exclusive and sustained breastfeeding and the use of human milk when
breast feeding is not possible, is the normal way to nurture all children
including premature and sick newborns from birth to two years of agen and
beyond. Expert recommend that babies be given only breast milk for 6
months. Healthy solid foods are started at 6 months with breast milk staying
in the diet for two years and longer. Breast milk is good for mothers and their
babies. Breast milk has nutrients that cannot be replaced by formula or other
foods.10
Optimal breastfeeding under 2 years of age has the greatest impact on
child survival with the potential to prevent 13 % of all deaths in children
under 5 years. Systematic reviews have shown that exclusive breastfeeding
for 6 months compared to exclusive breastfeeding for 3 to 4 months, can
decrease diarrheal morbidity and prolong lactational amenorrhea while
incurring no growth deficit among infants either in low or high in- come
countries. In addition to the short-term effects of breastfeeding on reduction
of morbidity and mortality and improvement in cognitive and brain
development, recent evidence further highlights the long-term effects on
intelligence, educational attain- ment and income.11
Benefits for baby.10
Babies who are breastfed have fewer and less severe:

Chest infections
Ear infections
Stomach and bowel upsets
Allergies
Urinary tract infections
Serious infection in the blood and bowels (sepsis & necrotizing

enterocolitis)
Meningitis

Babies who are breastfed are less likely to have:

Diabetes
Crib death (SIDS)
Obesity
Certain childhood cancers

18

Ongoing bowel problems (Crohns & celiac disease)

Higher blood pressure

Benefits for mother.10

Mothers who breastfeed their babies have:

Less bleeding right after birth

An earlier return to pre-pregnancy weight
Less chance of breast, ovarian, & endometrial cancer
Less chance of diabetes
Less chance of hip fractures and weak bones (osteoporosis) later in life
More opportunity to bond and enjoy their baby
Other benefits:

Reduced health care costs

Healthier baby easier to take care of
Healthier baby less missed work time
Cheaper breast milk is free, formula is expensive
Environmentally friendly less waste
2.4 Formula Milk Composition
The nutrient content of infant formula for sale in the United States is
regulated

by

the Food

and

Drug

Administration (FDA)

based

on

recommendations by the American Academy of Pediatrics Committee on

Nutrition. The following must be included in all formulas produced in the
U.S.12

Protein
Fat
Linoleic acid
Vitamins: A, C, D, E, K, thiamin (B1), riboflavin (B2), B6, B12
Niacin
Folic acid
Pantothenic acid
Calcium
Minerals: magnesium, iron, zinc, manganese, copper
Phosphorus
Iodine
Sodium chloride
Potassium chloride
Carbohydrate
Nucleotides

19

There are the comparison of composition between breastmilk and

formula milk.12

2.5 Congenital Heart Disease.13

Congenital heart disease is a general term used to describe
abnormalities of the heart or great vessels that are present from birth. Most
such disorders arise from faulty embryogenesis during gestational weeks 3
through 8, when major cardiovascular structures form and begin to function.
The most severe anomalies are incompatible with intrauterine survival.
Congenital heart defects compatible with embryologic maturation and birth
generally affect individual chambers or discrete regions of the heart, with the
remainder of the heart developing relatively normally.
Some forms of congenital heart disease produce clinically important
manifestations soon after birth, which is frequently brought on by the change
from fetal to postnatal circulatory patterns (with reliance on the lungs for
oxygenation birth, rather than the placenta as in intrauterine life).

20

Approximately half of congenital cardiovascular malformations are diagnosed

in the first year of life, but some mild forms may not become evident until
adulthood (e.g., ASD).
The diverse malformations seen in congenital heart disease are caused
by errors that occur during cardiac development; thus, a brief review how the
heart normally forms is in order before discussing the specific defects ( Fig.
12-3 ). The fine details of this complex process are beyond our scope here.
Suffice it to say that the earliest cardiac precursors originate in lateral
mesoderm and move to the mid-line in two migratory waves to create a
crescent of cells consisting of the first and second heart fields by about day 15
of development. Each heart field is marked by the expression of different sets
of genes; for example, the first heart field expresses the transcription factors
TBX5 and Hand1, whereas the second heart field expresses the transcription
factor Hand2 and fibroblast growth factor-10. Both fields contain multipotent
progenitor cells that can produce all of the major cell types of the heart;
endocardium, myocardium, and smooth muscle cells. As an aside, there is
considerable interest in the therapeutic potential of such early cardiac
progenitors, which could conceivably be used to regenerate portions of the
adult heart that are damaged or otherwise dysfunctional.
Even at this very early stage of development, each heart field is
destined to give rise to particular portions of the heart. Cells derived from the
first heart field mainly give rise to the left ventricle, whereas cells derived
from the second heart field give rise to the outflow tract, right ventricle, and
most of the atria. By day 20, the initial cell crescent develops into a beating
tube, which loops to the right and begins to form the heart chambers by day
28. Around this time, two other critical events occur: (1) cells derived from
the neural crest migrate into the outflow tract, where they participate in
the septation of the outflow tract and the formation of the aortic arches;
and (2) the extracellular matrix (ECM) underlying the future
atrioventricular canal and outflow tract enlarges to produce swellings
known as endocardial cushions. This process depends on the delamination

21

of a subset of endocardial cells, which invade the ECM and subsequently

proliferate and differentiate into the mesenchymal cells that are responsible
for valve development. By day 50, further septation of the ventricles, atria,
and atrioventricular valves produces the fourchambered heart.
Proper orchestration of these remarkable transformations depends on a
network of transcription factors that are regulated by a number of signaling
pathways, particularly the Wnt, VEGF, bone morphogenetic factor, TGF-,
fibroblast growth factor, and Notch pathways. It should also be remembered
that the heart is a mechanical organ that is exposed to flowing blood from its
earliest stages of development. It is likely that hemodynamic forces play an
important role in cardiac development, just as they influence adaptations in
the adult heart such as hypertrophy and dilation. In addition, specific microRNAs play critical roles in cardiac development by coordinating patterns and
levels of transcription factor expression.
Many of the genetic defects that affect heart development are autosomal
dominant mutations that cause partial loss of function in one or another
required factor, which is often transcription factors (discussed below). Thus,
even relatively minor changes in the activity of one of the many factors
necessary for normal development can lead to defects in the final product, the
fully developed heart. It can be imagined (but is unproved) that transient
environmental stresses during the first trimester of pregnancy that alter the
activity of these same genes might give rise to defects resembling those
produced by inherited mutations.

22

a. Why the infant had heavy breathing when she drinks milk?
Heavy breathing actually is caused by congenital heart disease.
Congenital heart disease is a defect results when the heart or blood
vessels near the heart don't develop normally before birth. Severe heart
disease generally becomes evident during the first few months after
birth. Some babies are blue or have very low blood pressure shortly
after birth. Other defects cause breathing difficulties, feeding problems,
or poor weight gain. Minor defects are most often diagnosed on a
routine medical check up. Minor defects rarely cause symptoms. While
most heart murmurs in children are normal, some may be due to
defects. So, heavy breathing is the symptom of congenital heart
disease.14
b. What caused the murmur?
A heart murmur is an extra or unusual sound which may be heard.
It may be caused by an underlying heart problem, but often there is no
cause at all. Murmurs can be heard when the heart contracts (a systolic
murmur) or when the heart relaxes (a diastolic murmur). People who
have a healthy heart can sometimes have murmurs. People with anemia
can have murmurs and they are often heard in pregnant women due to
the unusually large flow of blood through the heart. Sometimes heart
murmurs are heard because of a defect in a heart valve, or because of a
congenital abnormality in the heart, such as a hole in the heart.
(Congenital means that you were born with the condition.) Some heart
valve defects may be minor, but there can be more serious problems
that may need treatment for example if the heart valve is narrowed,
prolapsed (weak or floppy) or leaking.
In less than one per cent of children, a cardiac murmur may mean
heart disease, either congenital or acquired. Although there can be
numerous causes of organic murmurs, the most common are:
a valve within the heart that does not open or close properly;
an abnormal communication between two chambers in the heart.
When a heart murmur is the result of a valve that leaks or does not
open properly, there is abnormal blood flow within the heart. The

23

blood flow is turbulent and pediatric cardiologists can hear this

turbulence with a stethoscope.
When the heart murmur is the result of an abnormal
communication between two chambers in the heart, an abnormality in
the wall (septum) that separates the chambers of the heart can be the
cause.15
When there is a hole in the wall or an abnormal connection
between the chambers, the blood from the right and left sides of the
heart mix. This abnormal flow creates a murmur which can be detected
during a physical examination.15
2.6 Physical Parameter in growth and development
The first consideration in examining a child in growth and development
is ensuring accurate measurements. Height (or length), weight, and head
circumference should be measured correctly and plotted on an appropriate
growth chart over time. The child should be undressed for a thorough
examination.16
1) Height/Length
Length is measured in children too young to stand; height is
measured once the child can stand. In general, length in normal-term
infants increases about 30% by 5 month and > 50% by 12 month;
infants grow 25 cm during the 1st year; and height at 5 year is about
double birth length. In most boys, half the adult height is attained by
about age 2; in most girls, height at 19 month is about half the adult
height.
Rate of change in height (height velocity) is a more sensitive
measure of growth than time-specific height measures. In general,
healthy term infants and children grow about 2.5 cm/month between
birth and 6 month, 1.3 cm/month from 7 to 12 month, and about 7.6
cm/year between 12 month and 10 year. Before 12 month, height
velocity varies and is due in part to perinatal factors (eg, prematurity).
After 12 month, height is mostly genetically determined, and height
velocity stays nearly constant until puberty; a childs height relative to
peers tends to remain the same. Some small-for-gestational-age infants
tend to be shorter throughout life than infants whose size is appropriate

24

for their gestational age. Boys and girls show little difference in height
and growth rate during infancy and childhood.
Extremities grow faster than the trunk, leading to a gradual
change in relative proportions; the crown-to-pubis/pubis-to-heel ratio is
1.7 at birth, 1.5 at 12 month, 1.2 at 5 year, and 1.0 after 7 year.
2) Weight
Weight follows a similar pattern. Normal-term neonates generally
lose 5 to 8% of birth weight in the days after delivery but regain their
birth weight within 2 wk. They then gain 14 to 28 g/day until 3 month,
then 4000 g between 3 and 12 month, doubling their birth weight by 5
month, tripling it by 12 month, and almost quadrupling it by 2 year.
Between age 2 year and puberty, weight increases 2 kg/year. The recent
epidemic of childhood obesity has involved markedly greater weight
gain, even among very young children. In general, boys are heavier and
taller than girls when growth is complete because boys have a longer
pre-pubertal growth period, increased peak velocity during the pubertal
growth spurt, and a longer adolescent growth spurt.
3) Head circumference
Head circumference reflects brain size and is routinely measured
up to 2 year. At birth, the brain is 25% of adult size, and head
circumference averages 35 cm. Head circumference increases an
average 1 cm/month during the 1st year; growth is more rapid in the 1st
8 month, and by 12 month, the brain has completed half its postnatal
growth and is 75% of adult size. Head circumference increases 3.5 cm
over the next 2 year; the brain is 80% of adult size by age 3 year and
90% by age 7 yr.
2.7 Gestational Age
Pregnancy (gestation) is the time from conception until the moment of
birth, calculated from the first day of the last menstrual period (mesntrual age
of pregnancy). Pregnancy at term (term/term is the gestational age of 37-42
weeks (259-294 days) complete. Pregnancy preterm (preterm) is gestation less
than 37 weeks (259 days). And pregnancy through time (post term) is
gestation more than 42 weeks (294 days).17
Mother's age is closely related to birth weight. Pregnancy under the age
of 20 years is a high-risk pregnancies, 2-4 times higher compared to

25

pregnancies in women who are old enough. At a young age, the development
of reproductive organs and physiological functions have not been optimal.
Besides the emotional and mental state is not mature enough, so that during
pregnancy the mother has not been able to respond perfectly pregnancy and
complications occur frequently. Besides getting younger maternal age, the
child born will become lighter. Although pregnancy is very risky but under the
age of pregnancy over the age of 35 years are also not recommended, very
dangerous. Given the start of this age often emerging diseases such as
hypertension, benign gynecological or degenerative diseases of the joints of
the spine and pelvis. Another difficulty of pregnancy over the age of 35 years
is that when the mother turns diseases feared as above babies born with
abnormalities. In the process of childbirth itself, pregnancy at this age will
face difficulties due to poor uterine contractions and bone abnormalities often
arise mid pelvis. Given that the age factor plays an important role on the
health and welfare of pregnant women and infants, then you should plan
pregnancy at the age between 20-30 years.
2.8 Low Birth Weight
Low birth weight (LBW) is defined by the World Health Organization
(WHO) as weight at birth less than 2500 g (5.5 lb). Low birth weight
continues to be a significant public health problem globally and is associated
with a range of both short- and long-term consequences. It is estimated that
15% to 20% of all births worldwide are LBW, representing more than 20
million births a year.18 Preterm birth is the most common direct cause of
neonatal mortality. Every year, 1.1 million babies die from complications of
preterm birth. Low birth weight is not only a major predictor of prenatal
mortality and morbidity, but recent studies have found that low birth weight
also increases the risk for non communicable diseases such as diabetes and
cardiovascular disease later in life.18
The great majority of low birth weight births occur in low- and middleincome countries and especially in the most vulnerable populations Regional
estimates of LBW include 28% in south Asia, 13% in sub-Saharan Africa and
9% in Latin America.18 The incidence of LBW is estimated to be 16%
worldwide, 19% in the least developed and developing countries, and 7% in

26

the developed countries.19 The incidence of LBW is 31% in South Asia

followed by East and North Africa (15%), Sub-Saharan Africa (14%), and
East Asia and Pacific (7%). Asia accounts for 75% of worldwide LBW
followed by Africa (20%) and Latin America (5%).
There are multiple causes of low birth weight, including early induction
of labour or caesarean birth (for medical or non-medical reasons), multiple
pregnancies, infections and chronic conditions such as diabetes and high blood
pressure. It has been reported that preterm small for gestational age birth is
associated with medical conditions related to chronic hypertension and preeclampsia/eclampsia. The presentation of pre-eclampsia highlights the
complex interactions that exist between nutrition, preterm birth and small for
gestational age. The mothers nutritional status alters her risk of preeclampsia.18
Reducing the incidence of low birth weight requires a comprehensive
global strategy, which must include multiple elements: improving maternal
nutritional status; treating pregnancy associated conditions such as preeclampsia; and providing adequate maternal care, perinatal clinical services
and social support. Reductions in neonatal morbidity and mortality will only
be achieved if pregnancy care is fully integrated with appropriate neonatal and
post-neonatal medical and nutritional care for preterm and small for
gestational age infants.18
2.9 Treatment for Infant with Delay Development
Assessment is aimed at defining a childs strengths and weaknesses.
Parents should always feel free to discuss the assessment procedure with the
staff involved. Parents are usually the best observers of their children. Their
contribution to the assessment is important. They need not feel apprehensive
about asking for a second opinion.20
The initial stage of the developmental assessment is often with a
paediatrician (childrens medical specialist). During the assessment, the doctor
takes a medical history, observes the child, does a physical examination and
may order some relevant investigations, for example, blood and urine tests.
The doctor may carry out or recommend testing of vision and hearing. The
next stage aims to gather information about the childs skills across all areas of
development, and to understand how the child learns and relates to the family

27

and those around him or her. This will involve the child and family being seen
by one or more of the following: occupational therapist, speech pathologist,
physiotherapist, psychologist, teacher and social worker.20
Children are observed playing and interacting with others. Depending on
age and development, they may be given a series of tasks such as completing
puzzles, naming pictures or climbing steps. The assessment is very helpful in
beginning to understand the childs development. However, it is also important
to remember that an assessment provides only one example of the childs
ability over a relatively short period of time. As children progress their needs
change. Those working with them will monitor progress and assessments will
be repeated when necessary.20
2.10 The relation between delayed growth and development and cognitive
development.
Developmental delay is a descriptive term used when a young childs
development is delayed in one or more areas compared to other children.
These different areas of development may include gross motor development
(how children move), fine motor development (how children manipulate
objects and use their hands), speech and language development (how
children communicate, understand and use language), cognitive/intellectual
development (how children understand, think and learn), social and
emotional development (how children relate with others and develop
increasing independence).20
Children with an intellectual disability show a delay in their
understanding of the world and take longer to think and learn new skills,
e.g. talking, self help skills such as dressing and eating independently. The
age of acquiring a specific skill depends on the rate of learning. Children
with a mild intellectual disability may not cause concern until their third or
fourth year with a delay in their talking. Yet others may only come to notice
in their kindergarten years when their play, self help and learning skills are
less well developed than children of similar age. For some children with a
very mild intellectual disability the problem may not become apparent until
their early school years.20
Children with an intellectual disability may also have problems in
other areas such as vision and hearing. These problems may affect their

28

learning. Some children may have epilepsy or may develop it during

childhood. Drug therapy may be necessary, and if so, the doctor aims to
control the seizures by choosing medication that best suits the child. A child
with an intellectual disability can still learn but needs more time and
practice than other children. Like all children they need to feel good about
themselves.20

CHAPTER 3
CLOSING
Conclusion
There is embryogenesis abnormality happened in 3-8 weeks during
pregnancy that caused Congenital Heart Disease after birth and lack of proper
nutrition given to the infant that make the baby has problem in growth and gross
motor delayed development.

29

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31