GROWTH The processes of growth and develop- mert make a child different from an adult; thus a child is definitely not a miniature adult. A simple and concise ‘definition of growth is that it is a process by which a living being or any of its parts increases in size and mass, either by multiplication or by enlargement of component cells. Growth. is quantitative and is measured in such terms as centimeters or inches and kilo- grams or pounds. Development refers to qualitative changes whereby maturation,. function and skills are increased or en; hanced. Development is usually synonymous with maturation or differentiation; it is the broader term and includes growth. These two terms are difficult to differentiate and may or may not be interchangeable, yet they go hand-in-hand and are actually inseparable. It is felt that omission of either word, growth or development, is just for brevity rather than a separation of the two terms. The clinical evaluation of a child must necessarily start with an appraisal of his growth and development Among these are the physical and psychological aspects. Psy- chological development may include behavior, intellectual or mental development, moral and spiritual, social, creative and aes- thetic and personality development. Whereas growth is more easily understood and meas- ured, development is more difficult to as- sess. This difficulty should not in any way decrease its importance and should always be included in the overall appraisal of the child’s development. AND DEVELOPMENT THE DIFFERENT PERIODS OF LIFE The anatomic, physiologic, psychologic, and pathologic characteristics of a child are unique at various age levels. This must be. kept in mind since diagnostic and manage- ment will be influenced by the stage of: growth and development of the child.- The different periods of growth are enu- merated in Table 3.1. FACTORS AFFECTING GROWTH AND DEVELOPMENT Numerous and diverse factors influence growth and development. It is imperative that persons responsible for the care of chil- dren are knowledgeable about these factors in order to be able to minimize those that are detrimental and enhance optimum growth and development by trying to pro- mote ideal conditions. Genetic Factors. These are discussed fully in a separate chapter. Obviously, the traits of the parents are transmitted to the children. Tall parents generally give rise to tall offspring. The physique of children is usuaily similar to those of their parents. The intelligence quotient of a child is closely re- lated to that of his parents, Race. Caucasians are taller and heavier than Asians. Infants of blacks usually de- velop motor skills faster than Caucasians. Prenatal Factors. These are very im- portant and must be checked. carefully by 4748 PEDIATRICS AND CHILD HEALTH ‘Table 3.1 PERIODS OF GROWTH Growth Period ‘Approximate Age 1. Prenatal 0-280 days: Ovum 0-14 days Embryo 14 days to 9 weeks Fetus 9 weeks to birth Early fetal life 2nd trimester Late fetal life 3rd trimester Premature infant “28” to 37 weeks = Birth Average of 280 days a 37-42 wks. 7 1, Postnatal : Infancy Birth-2 years : Neonate i First 4.weeks after birth (newborn or early infant) Infancy (middle or nursling) First year Infancy (transition, toddler or run-about) 1-2 years Childhood Early childhood (preschool child) 2.6 years Later childhood (schoo! child) 6-10 years (girls) 6-12 years (boys) ‘Adolescence 10-18 years (girls) 12-20 years (boys) Prepubescent (late school child or early adolescent) 10-12 years (girls) : 12-14 years (boys) f i Pubescent 12:14 (girls) j (adolescent proper) 14-16 (boys) a Puberty (average) 13 years (girls) : 15 years (boys) Postptibescent 14-18 (girls) (ate adolescent or youth) 16-20 (boys) the obstetrician or health personnel taking care of the mother during pregnancy. Some of these will also be discussed elsewhere. ‘The mother’s health must be kept at opti- mum levels. Ilinesses such as toxemias, hy- pertension, anemia, and congestive heart failure result in hypoxia, and less oxygena- tion for the unborn infant, Maternal malnu. trition results in low birth weight infants and a high incidence of perinatal morbidity, Infectious diseases, such as viral, proto- zoan and spirochetal infections affect growth and development during certain stages of pregnancy. The best documented of the vi ral infections is rubella; of the protozoan ix fections, toxoplasmosis; and of th spirochetal infections, syphilis, Vird! infections cause havoc and damage duis the first trimester while protozoan ant spirochetal infections are to be feared dur ing the last half of pregnancy. Abnormal uterine conditions such # myomas may affect positioning of the fet and its nutrition. Amniotic bands may a putate extremities. These amputations hi'® to be differentiated from congenital maltmations (phocomelia, hemimelia) due to drugs such as thalidomide. Fingers and toes are found in the latter condition while the. former will show only stumps. Uterine tumors may affect nutrition of the fetus in utero and result in growth retardation. Actinic rays particularly during early. pregnancy can cause congenital malforma- tions. This has been well documented in the infants of pregnant mothers who survived the Hiroshima debacle. Deformities became more serious the earlier the pregnancy, and the nearer the pregnant mother was to the epicenter of the bombing. Exposures to di- agnostic and therapeutic X-rays during the first trimester of pregnancy have resulted in a higher incidence of congenital malfor- mations, Babies of parents with exposure to radar, space radiation and intensive expo- sure to medical X-rays might also run a higher risk of congenital malformations. Immunologic factors manifested in Rh and ABO incompatibilities obviously affect growth and development towards the end of pregnancy if not managed properly. These will be discussed under the chapter on The Newborn. The immediate perinatal period and con- ditions existent during this time may affect the infant seriously. Anesthesia and anal- gesia, the method of delivery of the infant and the immediate care after delivery may allcontribute to anoxia and trauma. 3. GROWTH AND DEVELOPMENT 49 Drugs are notorious for’causing malfor- mations in the fetus. A listing is found in Table-3.2. Extreme care must be observed in prescribing drugs to the expectant mother. Not only have these been implicated in the causation of congenital defects but ma- ternal medications are known to cause ad- verse effects on the fetus and newborn. in- fant (see Chapter on Pediatric Therapeutics). Alcohol, smoking and the effects of nicotine on the unborn fetus resulting in stunting have been well documented. Maternal nutrition is of the utmost im- portance. Studies have definitely shown that the effects on growth and development par- ticularly of the brain are serious and may be permanent. Removal of specific nutrients from the maternal diet have produced. spe- cific malformations in animals. Endocrine problems, particularly diabe- tes which results in unusually large babies, give a high incidence of perinatal mortality and morbidity and congenital anomalies. Other factors are duration of pregnancy, mul- tiple pregnancies, the age of the mother and the parity or order of birth of the infant. Pre- mature and postmature babies are generally smaller in size. Multiple pregnancies also re- sult in smaller babies. The age of the mother has been associated with Down syndrome; a higher incidence is found in the older group. As a general rule the average birth weight increases with the parity ofthe mother. Table 3.2 MATERNAL MEDICATIONS THAT MAY ADVERSELY AFFECT THE FETUS Drug Effect on Fetus Dependability of Evidence Accutane (isotretinoin) Facial-ear anomalies, heart disease Suggestive Adrenal corticosteroids Cleft palate Doubtful Alcohol Congenital anomalies, IUGR* Conclusive Aminopterin Abortion Conclusive Azathioprine Abortion Suggestive Busulfan Stunted growth, corneal opacities, cleft palate, Doubtful hypoplasia of ovaries, thyroid, and parathyroids Caffeine Spontaneous abortion, stillbirth, anomalies or Doubtful premature birth Chloroquine Deafness, bilateral vestibular paresis, abnormal Suggestive retinal pigmentation Chlorambucil Absent kidney and ureter Suggestive Chlorpropamide Multiple defects Doubtful Cigarette smoking Low birthweight for gestational age Suggestive50 PEDIATRICS AND CHILD HEALTH Table 3.2 MATERNAL MEDICATIONS THAT MAY ADVERSELY AFFECT THE FETUS (Continued) Drug Effect on Fetus Dependabiig, of Evideno.” Corticosteroi Cleft palate Suggestin Cyclophosphamide Hand and feet defects, bilateral inguinal hernia Conclusy Dicumarol Fetal bleeding and death, hypoplastic nasal Conclusiy structures Lithium Cyanotic heart diseases, club feet Sugeest Lysergic acid Chromosomal damage, skeletal defects ‘Suggestin, Meclizine Spina bifida, meningocoele, talipes Doub Mepivacaine Bradycardia, death Conclusg 6 Mercaptopurine Abortion Suggestn Methimazole Goiter Conclsin ‘Methyltestosterone Masculinization of female fetus Conelui 17-Alpha-ethinyl-19-nortestosterone Masculinization of female fetus Conclusive Penicillamine Cutis laxa syndrome Suggestive Phenmetrazine Diaphragmatic defects, herniation of abdominal » Doubiful organs, deformities of lower limbs Phenytoin Congenital anomalies, IUGR, tumor Conclusie Podophyllum (in slimming tablets Multiple developmental defects; septal defect in Suggeatie ‘and stool softener) the heart, extra thumb and radius, malformed ear, skin tag (ear and cheeks) Potassium iodide Goiter Suggest Progesterone ‘Masculinization of female fetus Suggestive Propranolol Hypoglycemia, bradycardia, respiratory depression Suggestie Propylthiouracil Goiter Conclusive Quinac Agenesis of kidney, hydronephrosis, Suggestive Radioactive iodine (") Destruction of fetal thyroid Condlusive 11-Alpha-ethinyl testosterone Masculinization of female fetus Conclusive Stilbestrol(diethyletilbestrol [DES}) Vaginal adenocarcinoma in adolescence Conclusive Streptomycin Deafness Suggestive Tetracycline Retarded skeletal growth Suggestive Pigmentation of teeth, hypoplasia of enamel Conclusive Cataract, limb malformations Doubiful ‘Thalidomide Extremities: amelia, phocomelia, hemimelia Conclusive Skeleton: rudimentary scapula and maldeveloped sacrum External lesions: absence or dysplasia of ears, eyes; ‘hemangioma Digestive tract: atresia of esophagus, duodenum, us; aplasia of gall bladder and appendix ‘Miscellaneous; cardiac anomalies, hydrocephalus, ; renal agenesis, genitourinary abnormalities ‘Trimethadione and paramethadione Abortion, multiple malformations, mental ; retardation Coneluste Tolbutamide Syndactyly Conclusiv? Malformed ears, atretic auditory canals; internal hydrocephalus; partial absence of diaphragm Dextrocardia, ventricular septal defects Valproate Spina bifida Suggest” Vitamin D Supravalvular aortic stenosis, hypercalcemia Doubifil *IUGR = intrauterine growth retardation Adapted from several sources.Postnatal Factors. After the child’s birth, among the factors that affect his growth and development are: 1. genetic fac- growth potential, size at birth espe- ally in relation to duration of gestation (in- trauterine growth retardation); 3. nutrition; 4, mental deficiency; 5. endocrine disorders; 6, constitutional delay; 7. family value ori- entation; and 8. social deprivation. In our part of the world, the single most important factor is poverty, particularly if extreme. Poverty is closely interlinked with ignorance and low intelligence. This becomes avicious cycle in that the more ignorant the family, the more incapable they are of im- 3, GROWTH AND DEVELOPMENT 51 proving their socioeconomic status. This would lead to more poverty, undernutrition, lack of opportunities for good schooling and other forms of stimulation. Thus the under- privileged family will be unable as a gen- eral rule to extricate itself out of this unfor- tunate situation. Extremely low socioeco- nomic status leads to lack of pre- and post: natal care, absence of immunizations, higher occurrence of crippling (organic or emotional) diseases, lack of accident prevention, poor unsanitary environmental conditions, and understimulation, all of which are circum- stances adversely affecting growth and development. The intrauterine development of the hu- nan organism may be divided into three phases: the first two weeks comprise the ‘wular phase”, from the time of fertilization util the zygote is well implanted in the edometrium; the “embryonic stage”, from the second week to the end of the second nonth, at which time major differentiation, of organs and tissues occur; and the “fetal phase”, from the beginning of the third month to the time of birth when the fetus becomes an “infant”. Intrauterine Nutrition. During the ‘arly days after implantation, nutrition is - tcquired from the “pabulum”. This is derived ftom the digestive action of the trophoblasts and the secretions of the uterine glands which are usually heavily laden with glyco- gen. In the third week of pregnancy, angiogenetic tissues appear which later give nse to the omphalomesenteric vessels that ttansmit food elements through the placen- ‘al membrane to the fetal circulation. In the litter part of pregnancy, the permeability of tte placenta increases. There are at least six mechanisms of transplacental transfer: Losmosis which is usually employed in the first week of gestation and utilized in the transfer of electrolytes, governed by the law of simple diffusion and dependent on the concentration gradient between the mater- nal and fetal side of the membrane; 2. facili- tated diffusion which utilizes the formation of complexes for the’ transfer of substances through the carrier system; 3. active enzymatic transfer utilizing expenditure of energy with molecules transferred against electro-chemical gradient; 4. destruction by which compounds are altered sufficiently to destroy their physiological activity; 5. pinocytosis where whole molecules are en- gulfed by macrophages; 6, membrane leak- age which allows intact cells like red cells to transfer from-fetus to mother and vice-versa. Adaptive Mechanisms. The fetus nor- mally does not suffer from oxygen want, be- cause’1, there is a several-fold increase in the cardiac output; 2. there is a favorable oxygen dissociation in the fetus; 3. increased oxygen capacit . high red blood cell count; and 5. capacity to reset to anaerobic me- tabolism, The uterus undergoes preparation and growth during pregnancy which has directy; , 62 PEDIATRICS AND CHILD HEALTH bearing upon implantation, placentation, fe- tal nourishment and retention of the fetus in utero. Uterine accommodation occurs in three successive stages: 1. the phase of preparation consisting of progestational proliferation of uterine tissues; 2. the period of uterine enlargement, consisting of hypertrophy of uterine tissues, particular- ly of the myometrium; 3. the period of uterine stretching which is characterized by the marked decrease in the rate of uterine growth at a time when rapid enlarge- ment of the products of conception is taking place. Embryonic Period. The embryonic disk defines into three germ layers each differ- entiating into specific organs or tissues. The mesodermal derivatives give rise to the skel- etal system, muscle cells, dermis and subcu- taneous tissues, urinary system, mesothelial portions of the serous membranes of the peritoneal, pleural and pericardial cavities, cardiovascular system, lymphatic system in- cluding the spleen, gonads and the corre- sponding ducts, and the cortical portion of the suprarenals. The entodermal derivatives are the epithelial lining of the respiratory tract, tympanic membrane and eustachian tube, part of the bladder and urethra, pa- renchyma of the thyroids, tonsils and parathyroids, thymus, liver and pancreas, and the gastrointestinal tract. The ectodermal derivatives are the central nerv- ous system, the peripheral nervous system, the epithelium of the sensory organs, th, epidermis including the hair, nails and sy}, cutaneous glands, the hypophysis, enam¢ of the teeth, and the epithelial lining of othe, organs. ORGAN DEVELOPMENT Organ development proceeds’ according to a code system contained in the genetic blue print of the growing individual. Differ. entiation does not depend on variations in genes actually present in the differentiating cells; the genes of an individual can be al. tered only by mutation or chromosomal re. arrangement, both of which are random events. Instead, differentiation depends upon variation in the activity of the genes. At any point in time, only a portion of the genes present in the chromosomes are active; at different times any one gene may be active or inactive. After fertilization of the female gamete by the male gamete, cleavage leads to the formation of the morula, the blastocyst, and then the embryo which eventually becomes implanted in the endometrial stroma. By the second week, the’embryoblast contains both the entodermal ’and’ ectodermal germ lay. ers; by the third week, the mesodermal germ layer and the notochord. The embryonic pe- riod occurs from the fourth to ninth week. Organ growth is best summarized in the figure shown in Fig. 3.1. a Fig. 3.1. Organ growth curves, drawn to a common scale by computing their values at successive ages in terms of their total (average) postnatal increments. (From Harris, J.A., et al.: The Measurement of Man. Minneapolis, University of Minnesota Press, 1930).‘MUSCLES Development takes place at the prmuscular mesodermic tissue. The larg- est part of increment of the body takes place from the 4th month of gestation to early maturity. During mid-pregnancy, the mu: cular system is 1/6 of the total body size; at birth it is 1/5 to 1/4; at early adolescence it is U9 and by early adulthood, it is 2/5. Growth in muscle mass follows chronologi- cally the maximal growth in height. Strength doubles between 12 and 16 years. Muscles which are cross-striated are de- rved from the myotome or from mesoderm cf pharyngeal arches while smooth muscles ue derived from splanchnic mesoderm. Sieletal muscles of the trunk and limb come from the mesoderm of somites and limb buds. CUTANEOUS STRUCTURES ‘The epidermis of thé’ skin is from extgdermal origin while the dermis is meso- dermal in origin. By the third fetal month, the hair matrix, sebaceous and apocrine glands can be identified. By the 5th fetal month, the eccrine sweat glands appear. It is during the first three months of fetal life that invasion of dentritic cells of neural crest crn occur which later form the melanin deposits in the skin, During the 3rd to the 4th fetal month, the dermis differentiates into connective tissue containing collagen- us and elastie fibers. The newborn is covered with vernix caseosa. Cleaning exposes the fine downy Inir that covers the body (lanugo) which is nore abundant in prematures than in full term babies. Scalp hair may be lost and per- nanent hair, usually coarser, replaces it by 2 years, Puberty and adolescence mark the appearance of pubic and axillary hair, the former being coarse and curly. Accompany. ing these is the appearance of pimples (acne) which vary in number and have a predilec. tion for the face around the nose. Sweat gands have no function for temperature regulation until one month of age. With the onset of puberty, the axillary and labial glands undergo cyclic changes and the skin in the axillae, areolae and genitalia become 8. GROWTH AND DEVELOPMENT 53, hyperpigmented. The prepuce is adherent to the glans for sometime after birth and the labia minor may have adhesions due to absence of estrogen. ‘The subcutaneous fat appears during the last three months of gestation. This increases during the first year of life, then it begins to diminish until adolescence, when it again increases in amount. More subcutaneous fat is found in girls than in boys. NERVOUS SYSTEM 4-6nks The brain begins to develop at 4 to 6 weeks gestation; however, differentiation continues on to the postnatal period, at which time, gyrations and convolutions in- crease with the development of white mat- ter, Myelinization is completed by 6 to 12 months, and in some nerves up to 2 years. ‘The brain grows rapidly during infancy and childhood. There is 2 gradual slowing at midchildhood to 10 years, and a small ter- minal increment at adolescence. Relative size of the brain to total body weight is as fol- lows: 2nd fetal month, 50%; at birth, 10%; 5 years, 5%; and adult, 2%, The cerebrospinal fluid amounts to 200 mL by 10 years. It is normally:clear and colorleas, but may be xanthochromic during the first month after birth, depending upon various factors. Pandy’s reaction is positive in 50% of newborns and in alll prematures up to several months, but not later than 6 months, Protein ranges from 49-80 mg/dL in + the newborn and 60-180 mg/dL in the pre- mature; after several months it normally ranges from 20-40 mg/aL. Cerebrospinal fluid cells range from 20-30 mm® in the neonate to 10/mm* later, and are all lymphocytes. The pineal body normally caleifies at 10 years. This is used as a point of reference in ‘roentgenography of the central nervous sys- tem. SENSORY DEVELOPMENT ‘Tactile sense starts in early prenatal life at the face, then spreads to the limbs and finally'to the trunk in cephalocaudal succes- sion, Pain sensation is not developed in a newborn. This state of hyposthesia laste for54 PEDIATRICS AND CHILD HEALTH a week. Characteristic response to pain is generalized movement and crying. This is Jess at 1-2 months; at 7-9 months, the baby can localize the site of pain, and withdraw from it, At 12-16 months, the baby shoves the painful stimulus away and brings the hand to the irritated area. Visual sensation is not well developed at birth, Although the baby resrds at one month, clear visign is achieved only at_16 ‘weeks of age, when the macula and fovea complete their differentiation and myelinization of the visual fibers is com. pleted. The macula does not attain complete development until 6 years of age. Visual acu- ity of 20/20 is achieved at 7 years, There is characteristic hyperopia in small infants. The auditory system is functional from birtn as soon as the external canal is cleaned. ‘This sense becomes acute soon after birth and at 6 months there is localization of sound and recognition of familiar voices. Anatomi- cally, the middle ear is similar to that of the adult but the tympanic membrane is more horizontal in the young. ‘The newborn can taste but is unable to distinguish flavors, At 3 months, acute taste discrimination is achieved and changes in the formula may be refused. ‘There are no definite data regarding ol- factory sensation although it has been ob- served at birth and is known to become more acute at a later age. CIRCULATORY SYSTEM Growth of the heart is quite slow during the first four months of gestation. As early as 12 weeks of gestation, the electrocardio- gram of the fetus may be taken through the maternal abdominal wall and all the compo- nents found in the ECG tracing are present inthe baby at birth. This may be used as an index of fetal viability. At birth, the ductus venosus and the foramen ovale become functionally closed. When the newborn starts breathing, the pressure in the left atrium rises because of the increase in pulmonary blood flow. The ductus arteriosus closes after 8 to 12 weeks. The normal fetal heart rate is usually between 140-160 per minute, There is a Table 8.8 AVERAGE CARDIAC Rare FILIPINO INFANTS AND DREN AGE AND SEX.* 4 MALES FEMAL Mean Mean'i'gy Age Group ce spr 3 ——_ a _2 O-1month 47) «305145 2-6 months 139 7-12 months 133 3141 324 1384 ayy 13-24 months 128° 341129343 2-4 years 109 326 © 11095 5-9 years 93 23.7 9-92 lO-l4years 86 204 86m 30M yoara 1166. 41 20.4 By *From P.D. Santos Ocampo, A. Librea aj M. Borja. slight variation in heart rate between thy sexes, being somewhat higher amo females. It ranges from 100-110 at 1-7 year, and below 100 from then on. Table 3.3 givs the average cardiac rate in Filipino childre, Blood pressure in a child may chang from day to day and both systolic axi diastolic pressures increase with age. Th values are lower in the premature than in the term infant. Table 3.4 shows blood pre: sure values obtained in a survey done by Mojica et al. in 1975, Prenatally, the pulmonary circulations inactive. The left atrium is dependent ugon blood entering it via the foramen ovale Hence, the left ventricle develops normally because it is constantly filled with blood fron the left atrium, The ductus arteriosus is te channel responsible for promoting the nor mal functioning of the right ventricle. A the last trimester is reached, pulmonary ct culation becomes increasingly activated and pressure in the left atrium gradually ix creases. At birth, with the onset of breathing ané ligature of the umbilical cord there is a rapil drop in the resistance of the pulmonary bet The left atrial pressure exceeds that of thé right atrium. This results in the function! closure of the foramen ovale. Complete mo" phological closure requires 8 months or mor due to the fusion of connective tissue of th* valvula with the septum secundum, Prior to birth, blood entering the ascen¢‘Table 8.4 MEAN BLOOD PRESSURES OF FILIPINO INFANTS AND CHIL- DREN.* Mean Sys- tolic+2SD O-1mos. 72.00 0.6 211 mos, 81.664 0.6 iy. 87.30+0.8 56.40+0.6 2yrs 8820412 63.1506 3yrs 8747418 56.504 1.2 Ayre 8737212 66.4514 Syne 9390412 69.80 0.8 6yre 93.8441.2 60.05 1.0 ‘Tyee 96.5610 61.55+1.0 8yre 9850412 60.06 + 1.0 oye 97.0012 67.304 0.4. lOyrs 98.9522. 6150408 lyre 98.80426 7.40428 12yrs —10L.6541.8- 67.55418 13yrs 106.953.065.704 1.0 Myre -108.00+1.2 71.5006 104.0518 © 86.85416 HP. Lopez and M.R.O. ing aorta is diverted principally to the head while blood entering the aorta via the ductus is directed caudad into the descending aorta. Close to term, the ductus undergoes spas- odie contractions signalling its impending dosure at birth. Blood entering the pulmo- nary trunk is re-routed to the lungs, Ana- tomical closure takes place 1-3 months later. ‘The normal fetal HR is 140-160 beats per minute. After age 7, the HR is below 100 beats/minute. LYMPHATIC SYSTEM There is a great deal of lymphoid tissue induding lymph nodes in the neonate. This increases regularly during childhood with the peak at 6-7 years, undergoing a relative reduction after puberty and during adult life. ‘The hypertrophy of the tonsils and adenoids during childhood coincides with the time when there is greatest susceptibility to acute infections of the respiratory and alimentaty tract. The gpleen is relatively the largest lymphoid organ in proportion to the body at birth, This undergoes an increase in weight 3. GROWTH AND DEVELOPMENT 55 to twelve times at adult life, and does not atrophy unlike the nodes. BLOOD In the beginning all blood cells are nucleated. At about the 10th fetal week, 90% of cells are nonnucleated. Blood forming or- gans are successively the connective tissue ‘or mesenchyme, then. the liver, spleen and mesonephros, and lastly, the bone marrow. At birth, only the lymphocytes are found out- side the marrow. The fetal hemoglobin has close affinity for oxygen. On the 13th week of fetal life, the first adult hemoglobin appears. Cord blood fetal hemoglobin at term is 80% and at 5 months of age, only 5% fetal hemoglobin remains. At birth, the hemoglobin is lower in babies whose cords have been clamped early and higher among those whose cords have been clamped late. ‘The normal values for the blood constitu- ents vary from laboratory to laboratory. Es- timates are usually made from capillary blood and micromethods. In normal infants, at birth, the neutrophil is the predominant cell. After one week of life, the lymphocytes predominate until 4 years of age when the neutrophils equal the lymphocytes. By 8 years, the leukocyte count concentration is similar to adults, IMMUNITY ‘The baby is born with passively trans- ferred immune globulins from the mother. In additional to these, other natural defenses are physical barriers, like the skin, mucous membranes and their secretions, and opsonins or complements. It used to be thought that a newborn cannot produce an- tibodies of its own; however, lately it has been shown that neonates do produce anti- bodies, but in small amounts which are not enough for efficient protection. The antibod- ies passively transferred from the mother depend upon her experience with certain in- fections prior to the baby’s birth. These an- tibodies protect the baby up to 6 or 9 months of age. Antitoxin (diphtheria and tetanus) and antiviral immunoglobulins (measles,56 PEDIATRICS AND CHILD'HEALTH mumps and poliomyelitis) are transferred better than antibacterial antibodies (antistaphylolysin, antistreptolysin O; and almonella “H” antibodies). Antiviral immunoglobulins diminish while antibacte- rial antibodies rise by 2 months of age. The colostrum of human milk has a high titer of enteric antitoxins, hence Escherichia coli fails to thrive in the intestinal lumen. Con- trary to common belief, immunity of breast- fed babies is similar to that of bottle-fed in. fants, Premature babies however have a con- siderably lower immunity than a term new- born. Age influences the body’s immunologi- cal mechanism, e.g. a newborn is Schick negative in spite of passive transfer from the mother, allergy manifests as eczema in a baby and as asthma in bigger children. In school age children, rheumatic fever and glomerulonephritis have a higher incidence. DIGESTIVE SYSTEM From the 5th fetal week on there is elon- gation of the gut into the belly stalk (future umbilicus), At the end of this stalk is the yolk sac, which is used as a point of refer- ence, That part of the gut caudal to it be- ‘comes the large intestine and distal ileum, and the part cephalad to the yolk sac gives rise to the duodenum, jejunum and proxi- mal ileum, At the 10th fetal week, the cecum is located in the left upper quadrant and from here it goes over the duodenum to the right upper quadrant. It then undergoes de- scent to the right lower quadrant, its usual position. This descent is completed after birth. This rotation includes the mesentery and the distal ileum, Umbilical hernia and omphalocoele are a result of abdominal wall deficiency and protrusion of the gut into the umbilical cord, Meckel’s diverticulum occurs as a result of the persistance of the yolk stalk, Malrotation is a result of reversed twisting of the small gut which ends up ly- ing ventral instead of dorsal to the trans. verse colon. In the second fetal month, there is pro- fuse growth of the epithelial lining of the ‘gut resulting in lumen occlusion. Failure to recanalize causes atresia; stenosis results from partial recanalization. If two lumina are formed, duplication results. The capacity of the stomach varies w age. At birth it may contain 30-90 mr; one month, 90-150 mL; at one year, 2104 mL; at two years, 500 mL, and in later ci hood 750-900 mL. From then on the capa depends on the feeding habits of the in; vidual. The small intestine at birth measuy 300-350 cm. At one year it undergoes 1 times increase in length, and at puberty; is around 700 cm. ‘The large intestine has its own devel mental characteristics. The ascending co, is short in a newborn and increases wi, age. The sigmoid, filled with meconium located high in the abdominal cavity,(Th, rectum is relatively longer in the newbon than in the child and adult. a The activity of certain digestive enzymg also varies with age. Renin and trypsin ey of normal level at birth; amylase and lipay are low in a newborn. Lipase stays ley throughout childhood. The bacterial flora of the gut is esta lished during the first few hours after birth Breastfed infants have Lactobacilly bifidus and the artificially-fed, L. avidp Philus. ‘The stool also has its own developmest pattern. It appears as meconium in the ft day of life. It is positive for occult blood du. ing the first 72 hours. In the breastfed beb, it is homogeneous, pasty, yellow and souria odor; in the bottle-fed baby it is firmer, lis homogeneous, pale yellow, more sticky ani foul-smelling. Before these characteris: stools are produced, the baby passes c transitional stools (liquid to mushy, gree ish and sometimes with blood streaks) wii lasts for 3 days following meconium sos. RESPIRATORY SYSTEM The respiratory system arises as # outpouching from the pharyngeal pouch? part of the entodermal tube. This gradual! migrates to the thoracic area; such mig tion is completed by the third fetal mot!» From its appearance, the right primary bn chus is slightly larger than the left and! forms a more obtuse angle; hence the pre jlection for lodgement of foreign bodies. The larynx is U8 the adult size at birth but its size relative to the rest of the body is the same as in the adult. From 3 years on, longer and wider in boys. The trachea is 4 em long in a newborn, 1/2 of the adult’s, At birth, the bifurcation is located at the third or fourth thoracic vertebra; at 4 years it is at the level of T5 and finally at 12 years it is located between T5 and TE. The fetus and newborn are resistant to anoria because of low cerebral metabolism, Jow and variable energy metabolism and an anaerobic source of energy. It has been found that a newborn can stand anoxia for 14 min- utes. There may be a sparsity of elastic tis- sue leading to a high tendency to develop atelectasis. Respiratory difficulties are ag- vated by the weakness of the respiratory muscles and the soft chest wall. The stimuli contributing to the onset of respiration are many; the most tenable one is that anoxia lowers blood pH, which in turn stimulates the medulla. ‘The average respiratory rate in Filipino infants and children at different ages is tabu lated in Table 3.5. Table 3.5 AVERAGE RESPIRATORY RATE OF FILIPINO INFANTS AND CHILDREN BY AGE AND SEX* MALES FEMALES Mean +2 Mean +2 RR SD RR_ SD O1month (059 182 66 220 months 52 «225 «2G TQmonths “AS 246 48228 1324 months 488 «14936225 24 years 30 «121-29 120 59 years 2 BL 25. OR Widyears 223.58 *From P.D. Santos Ocampo, A. Librea and Borja, URINARY SYSTEM AND FLUID BALANCE ‘The internal homeostasis of the body is regulated mainly by the kidneys through the coordination of the following mechanisms: 1. excretion of nitrogenous waste mainly és 3, GROWTH AND DEVELOPMENT 57 urea; 2, stabilization of osmotic pressiure and chemical composition through the “renal threshold”; and 3. regulation of extracellular fluid volume with participation of the poste- rior pituitary; and 4. maintenance of acid- base balance. There is considerable difference in the distribution of fluid from birth to maturity. ‘The extracellular fluid in a newborn is twice that of an adult in proportion to body weight, which decreases in early infancy and ado- lescence, two periods of rapid growth. The rate of exchange (intake-output) daily is 20% of total body fluid or 50% of the extracellular volume. It is for this reason that an infant is very susceptible to dehydration during il. ness. The daily excretion of the body through the gastrointestinal tract is 1,000 mL but 50% is reabsorbed and the rest is passed out with the stools. There is some fluid lost through surface evaporation and the lungs. ‘The electrolyte concentration (Na’, CI, PO4", HCO,) is higher in infants parti- cularly in the neonate, than in adults. This is accentuated in prematures. Blood pH is slightly lower (mild acidosis) among newborns with a low HCO,” Therefore, with this condition, and lower plasma proteins, fluid is driven to the tissue spaces, passed on to the kidneys and lost in the urine. ‘The kidneys, like the rest of the urinary tract, originate from the mesoderm. In the early part of fetal life, growth is slow. Then, just before term, growth becomes rapid. At 6 months of age, it is twice the birth size; by one year, 3 times; at five years, 5 times; and at puberty, 10 times. The last renal tubules are completed from the eighth month of ges- tation to the first month of postnatal life. No new glomeruli are formed after birth and those already present may be still imma: ture and covered with a thick layer of epi thelium, In the fetus, glomerular function pre- cedes tubular function and when urine is produced, it is in large amounts with low osmolarity. In the neonate, the urinary sys. tem, although relatively immature, functions sufficiently for the maintenance of fluid and electrolyte balance. The baby normally-may not void 12 to 24 hours after birth. Mature function is achieved by 5 to 6 years of age.58 PEDIATRICS AND CHILD HEALTH SKELETAL SYSTEM Calcification of bones begins at 8-9 weeks of age and establishes the end of embryonic Table 8.6 WORKING TABLE FOR COMPA- RISON OF CHRONOLOGIC AND BONE AGES.* Age Measures of Osseous Development Birth Distal epiphysis of femur Astragalus, cuboid, calcaneus Wrist - capitate, hamate, distal epiphysis of radius Ankle ~ addition of cuneiform 111, epiphysis of tibia 1Yr 2Yre Capitellum of humerus Wrist ~no change Ankle ~ addition of cuneiform IIL, distal epiphysis of tibia ‘Wrist — addition of triangularis Ankle ~ addition of cuneiform I Wrist ~ addition of lunate Ankle — addition of cuneiform II, navicular Hip - epiphysis of greater trochanter. Wrist — addition of major multangulum, navicular Knee ~ patella Wrist - addition of minor multangulum, epiphysis of ulna Shoulder ~ union of head and tuberosity of humerus ‘Ankle ~ epiphysis of calcaneus Union of ischium and pubis 3 Yrs 3Yre 5 Yrs 6Yrs 8 Yrs |. 10 Yrs 12 Yr8 Wrist —pisiform External condyle of humerus Union of trochlea and capitellum of humerus 14 Yrs Union of proximal epiphysis of radius Union of olecranon and ulna Union of epiphysis of metacarpals and metatarsals Appearance of crest ilium Union of distal epiphysis of radius and ulna Union of distal epiphysis of tibia and, fibula * From G.H, Lowrey: Growth and Develop- ment of Children. 5th ed. Chicago, Yearbook Publishers, 1986. 16 Yrs 18 Yrs Be period and the beginning of the fetal per At birth, ossification has taken place j long bones. They are radiologically visible ‘The primary ossification centers a in fetal life and, are located in the bones. The secondary ossification centers pear after birth except in the distal epip} of the femur which occurred during the two fetal months. Therefore, its absengaiy an evidence of prematurity. The amount y calcification in the newborn depends on ma, ternal levels of calcium, phosphorus, ity min D, and proteins. Later skeletal ment depends great deal on the sta the parathyroids, thyroid, and kidneys, the supply of the above elements. > Skeletal age may be determined by:mak, ing use of the following guidelines (Tebly be 3.6.and 3.7): ay 0-5 years »— presence of ossificatim centers. ‘ih o sl cw Table 3.7 AVERAGE AGE (¥RS.) OF UN ION OF THE MORE IMPOR TANT EPIPHYSIS.* ‘a Boys Girls 6 6 Head and greater tuberosityd humerous a 7 1 Ischium and pubis ty 2 12 ‘Trochlea and capitellum merus 4 13, Olecranon and ulna acy 13-14 Epiphysis of calcaneus 16-17 14-16 Proximal radius 15-17 13-16 Trochanter and head of 16-18 15-17 Epiphysis of metacarp: metatarsals 17 16 Coracoid 18-20 17-19 Distal epiphysis of radius — 18-20 17-19 Distal epiphysis of ulna” 18:20 17-19 Distal epiphysis of tibia fibula 1820 17-19 Acromion 4 18-20 17-19 Head and greater tuber the humerus 18.20 17-19 Distal epiphysis of femur 18-20 17-19 Proximal epiphysis of tibial fibula d * From G.H. Lowrey: Growth and ment of Children. 6th ed. Chicago, Ye Publishers, 1986.S1dyears - calcification of the cartilaginous areas 14:25 years - epiphyseal fusion At birth, the anteroposterior and lateral diameters of the chest are equal, the should. ersare elevated and the neck is hardly seen. From $ to 10 years, the chest becomes ‘wader and flatter and the ribs slope down. ‘The manubrium sterni also goes down and the neck appears longer. The vertebral spine presents two concavities at birth, thoracic and sacral, At 3 months the cervical convex- ity appears; the lumbar curvature shows when the child starts to walk and develops fully by 3 years. GENITAL ORGANS The seminiferous tubules are solid at birth and develop lumens during childhood. With puberty the testes undergo rapid'en- Table3.8 TIME OF APPEARANCE’ OF SEXUAL CHARACTERISTICS* 3, GROWTH AND DEVELOPMENT 59 largement and the spermatogonia start the process of maturation (spermatogenesis). ‘At the 4th to the 7th fetal month the testes are located in the abdomen at the level of the internal inguinal ring, From here, they begin to be enveloped by the peritoneum as the tunica vaginalis and enter the inguinal canal. By the 8th month they are within the scrotum, At birth, 90% of term infants have descended testes; in prematures, 70%. Fifty percent of undescended testes undergo de- scent by one month of age. The female's germ cells begin develop- ment at 3 months in utero, These are sus: pended in the first meiotic division until the time of ovulation. At birth, the ovarian cor- tex is filled with primordial follicles. These mature with menarche, taking turns per ovulatory cycle. ‘The time of appearance of sexual charac- teristics in Filipino boys and girls are given in Tables 3.8 and 3.9. Please see Chapter on Adolescence for more data. @ilipino Boys) Table 3.9 TIME OF APPEARANCE OF ‘Average Age SEXUAL CHARACTERISTICS* Feature Changes (ears) (Filipino Girls) Budy configura- Broader shoulders Average Age tion than hips 10.12 Feature Changes (ears) air Initial appearance Body configura- Broader shoulders ofpubichair —-10-12 tion and broad pelvis. 8-10 Initial appearance Fat deposition 911 of axillary hair 12-14 i a 2 Initial appearance taal ‘ prensa ona 8.10 of facial and Pubic hair becomes body hair 13:16 etket ead Penis Initial enlargement 9-13 coarser 11.13 Rapid increase in Initial appearance size 11-13 of axillary hair Scotum and Start of testicular Breasts Initial budding oan testicles enlargement 9-11 Pigmentation of Sagging of sac, areolae 10-12 wrinkling and Enlargement of corrugation 143 breasts 1244 Breast Hypertrophy, 12-14 Menarche Appearance 11-13 ec Disappearance a Acne Appearance 1214 om! - " feeppla Prominence Vaginal canal Appearance of thin Voice Deepening 1244 whitish secre- ene Appearance 13:15 tions 10:12 “From P.D, Santos Ocampo and T.K. Briones, *From P.D. Santos Ocampo and T.K. Briones,60 PEDIATRICS AND CHILD HEALTH DENTITION There is no hard and fast rule for the development of the teeth; however the following are general observations. Hard tis. sue formation begins as early as 4 months of age for the permanent set. Tables 3.10 and 3.11 show the succession of eruption of each pair of teeth. A general rule for the first year of life is as follows: No. of teeth = age in months minus 6 ‘Table 8.10 AGE OF ERUPTION OF DE- CIDUOUS TEETH.* ‘Average Ages (in months) Maxillary Mandibular Central incisors 6-9 58 Lateral incisors 9-11 T10 Cuspids 11-22 121 First molars way 1248 Second molars 22-30 22.30 ‘Teeth eruption and shedding are slightly earlier in girls than in boys; however, the difference is not significant. Teething when delayed beyond 12 mo should necessitate investigation of the roids, parathyroids and other derivatiy the ectoderm. However, teething on occa may be delayed at 20 months for no reason. An x-ray of the maxillae and bles should show “dentum in alveclae” Table 3.11 AGE OF ERUPTION OF ONDARY OR PERMAN) TEETH* Aver Maxi age Ages (in yea: lary Mandibul Central incisors 6'/,-7", 61,7 Lateral incisors 6"/, 8% 6y,7, Cuspids ag 10-2 Second premolars 11-12 story First molars oT, 51,6, Second molars 12-13 1,12), Third molars 18-22 1721 “From P.D. Santos Ocampo, M. Borja D.L. Celestino (Unpublished data). NORMAL PATTERNS OF GROWTH Although the term “normal” may be con- troversial, normal patterns of growth for a certain population have to be established be- fore a particular child’s growth status can be assessed. The term “average” might be preferable instead of normal, The child has to be compared with his peers and with himself. Growth and development has been found to proceed in a set pattern and any marked deviation from this might be con. sidered “abnormal”. There are available ta- bles containing data on growth and develop. ment and in the last two decades, grids and charts which allow a comparison particular child not only with children own age but also with, his own patter development. THE HUMAN GROWTH CUR' ‘The human growth curve is divided three basic components Fig. 3.2. 1. First phase: the rapid and rapi celerating growth of the first years of life which is represent a combination of factors affect tal growth, coupled with the e pression of growth hormone from six months of age.Fig. 3.2 Factors thought to influence the thr 3. GROWTH AND DEVELOPMENT 61 » rhe si Ioadtsonpornes re 227 and 3.19) Subscapular SFT is measured stim ‘body compositio S _ below the angle of the scapula, He measured al i Posterior surface ‘fold of sin and subcutaneous tissue afte toes of the let arm by calipers is picked up betwees the wen peo forefin Placed ae ree etree, Petween the ger ofthe eft hand and pickets away Fe ne eeceerthesgte atm from the underlying muscle Themen pangsnatorally at the side ofthe chest.(Pigs, be picked up firmly and held basen 3. GROWTH AND DEVELOPMENT 77 Fig. 3.17 Taking the midpoint between acromial process and the olecranon, i He Fig. 3.19 Taking the triceps skinfold with a "18 Taking the mid-arm circumference. caliper78 PEDIATRICS AND CHILD HEALTH fingers all the time that the measurement is being taken. The calipers are applied to the fold a little below the fingers so that the pressure on the fold at the point measured is exerted by the caliper faces and not by the fingers. When the caliper has been ap- plied, the jaws are permitted to exert the full pressure on the skin by the examiner removing the fingers of his right hand from the frigger-lever of the caliper. The head circumference should be taken ~/ routinely up to 3 years of age, with the tape applied firmly over the glabella and the supraorbital ridges anteriorly and that part of the occiput which gives the maximal cir- cumference posteriorly. Care should be taken thgt the tape has not stretched with aging. The chest circumference is measured at midrespiration at the level of the xiphojd cartilage or substernal notch. The measure- ment is made with the child recumbent in infancy and in the standing position there- after. Chest circumference tables and charts are available in the FNRI-PPS Handbook. HEIGHT AND WEIGHT At birth, a Filipino baby usually meas- ures 50.cm and weighs 3000 g or 6", Ibs. As in all races, the male is usually longer and heavier than the female except for the pe- riod from about 8-12 years.of age when the girls surpass the boys in height and weight, until about 14 years when the boys again take up the lead. Males enter the growth spurt of adolescence two years later than females and also cease growing later as in- dicated in Table 3.1. In early adolescence, teenagers are gen- erally tall and slender but become more mus- cular and rounded due to the development of muscular tissue and the deposition of sub- cutaneous fat, ightfis a simple, reproducible growth parameter which can serve as an index of acute nutritional depletion. Reference stand- ards are available, both local and interna- tional. See Chapter on Nutrition for clapsifc ion of malnutrition. ‘Length br /height jis a reliable criterion of growth as this is(no? affected by excess fat or fluid. It reflects growth failure and chronic undernutrition especially in cay, childhood. Care must be taken to uti proper techniques and equipment in onjg to avoid errors. THE GROWTH VELOCITY In the past, a disproportionate emph,, sis has been placed on weight neglecti height and rate of growth. Although weigy is valuable in the newborn and the inf, where the rate of weight gain is rapid, ; becomes less useful as an indicator whey oa grows older. Height measureme, is a(more sensitive index of health parti: larly when two measurements are availabl at intervals, of about six months thus ena bling the ‘calculation of growth velocity, Growth velocity has been. found to be ,| screening test of high specificity and sens. tivity: Growth velocities must oscillate aroun the 50th height velocity centile. The accept. able growth velocity is the 50th centile. If growth occurs at less, this will lead to alos of height compared to the mean; if at greater than the 50th centile, excessive stature ca be expected. Measuring Growth Velocity. The mex urement of growth rate is a concept poorly understood. To estimate the rate at whichs child is growing, the height must be measured on more than one occasion over period of time and the increment in height divided by the lapse of time in between. The formula would be as follows: H, (em) ~H, (em) GV(em) = TOD where GV is growth velocity H, is initial height in centimeters H, is height at next measuremett in centimeters T is period between the two mei urements in years WEIGHT-FOR-HEIGHT MEASUREMENT Weight-for-height more accurately * seases body build and is particularly use!!!> ed a child who is acutely mal- . ed. To calculate weight-for-height first measure the child’s height. The age for which the measured height would be on the 50th percentile is located on the growth curve. This age is then found on the weight curve and the 50th percentile weight for that age is taken as the denominator of that index with the child’s actual weight as the nu- merator. To classify undernutrition accord- ing to Waterlow, which has been adopted by the World Health Organization, the follow- ing formulas for computation and percent- age of reference standards are utilized. Waterlow Classification for Wasting Computation: actual weight cage tia ideal weight for actual length/height Classification: normal > 90% mild 80-90% of reference moderate 70-80% standard severe < 70% Waterlow Classification for Stunting Computation: actual length/height ideal length/height for age x 100= % Classification normal mild moderate > 95% 90-95% 80-90% < 80% of reference ‘standard severe MNEMONICS Certain mnemonics have been utilized to facilitate rapid computation of the weights ‘and heights of infants and children in the ‘absence of handy tables and oo The fol- lowing are given: % From 1-6 years: , |, 3. GROWTH AND DEVELOPMENT 79 For infants below 6 months of age: Weight in grams = Age in months x 600 + Birth weight From 6 to 12 months: Weight in grams = Age in months x 500 + Birth weight* ¥ For children 2 years and up: Weight in kilograms = Age in years x2+8 Weight in pounds = Age in years x 5 +17 From 6 to 12 years: Weight in pounds = Age in years x 7 +5 From 3 to 12 months: Caucasian: Weight in pounds = Age in months +11 Filipino: Weight in pounds = Age in months +10 The following usual changes in weight at different ages may also be kept in mind: \- At 4-5 months . 2x birth weight At 1 year 3x birth weight | At2 years. birth weight At 3 years. 5 x birth weight At 5 years. 6 x birth weight | At Vyears.. At 10 years ‘7x birth weight . 10.xbirth weight | The average birth length is ¢ 60 m or.20 inches. The velocity of growth diminishes as the infant grows older. Total average gains jnength during the first year reach about (25 cm)distributed as follows: ‘rom birth to 3 months 9em From 3 to 6 months .. 8cm From 6 to 9 months . 5cm From 9 to 12 months... scm Simple formulas for computing height are as follows: Height in centimeters = Age in years x 5 + 80 “Average birth weight for Filipino infants is approximately_3000 grams. If value is not known for a particular child, this may be used.tlhe eee tinier emanated Height in inches Caucasian sources give the following for- mula: Height in inches = Age in years x 24, + ge in years x 2+ 32 30 Other mnemonics for height are: At lyear ‘30 inches or 1", x birth length At 2 years oun" mature height (boys) At 3 years........ 3 feet tall At years........ 40 inches or 2 x birth length At 13 years... x birth length who CIRCUMFERENCE ‘The head circumference has to be fol- lowed up with regularity during the first three years of life, It reflects the status of brain growth and might be the first indica- tion of disturbances of the skull and its con tents. The head circumference is usually bigger than the chest circumference at birth; , as the infant grows, the chest circumference catches up at about midyear; at the end of the first year, the chest circumference, par- ticularly in plump babies is bigger than the head circumference. Head circumference studies of Filipino infants are shown together with weight for length in Figs. 8.9 and 3.10. Tt is to be stressed that these studies were done on full-term healthy babies. A premature baby might have a relatively large head because of its small body while a plump baby may seem microcephalic. Genetics may also play an important role. Parents with large heads usually have offspring with big- ger head circumferences. ‘The following average increases in head circumference may be kept in mind. These will be presented in inches since it is easier to remember them this way: For the first year of life First 4 months —, in/mo ... 2 inches Next 8 months —'V; in/mo ... 2inghes Second year .. Lint ‘Third to fifth year inyr .. 15 in Sixth to twentieth — 1.5 in = Since bigger babies may normally hy, bigger heads, and smaller babies, smajy heads, correction factors to determine hey circumference are hereby given in Table 3, Table 8.12 CORRECTION FACTORS Fo; THE DETERMINATION 9) HEAD CIRCUMFERENCEs Boys Girls Inch Cm __Inch Birth va 06 8 6 weeks v4 06 14g 6 months vB 03 8 10months 100.3 Day “Amount to be added or subtracted for pound above or below the average weight. From Ziai, M.: Pediatrics, 2nd ed. Bons, Little, Brown and Company, 1975. De MEASUREMENTS ‘The chest circumference was menti in passing under head circumference. centiles from birth up to 84 months ap in Figs. 3.20 and 3.21. Transverse anteroposterior diameters of the chest have to be measured in certain disease ties. The ratio of the tranaverse to anteroposterior diameter, otherwise kn as the thoracic index, is 1.0 at birth. As child grows older, the transverse diame increases at a faster pace. The index th fore, changes, becoming 1.25 at 1 year 1.85 at 6 years. In emphysematous can! tions, a round chest with a thoraci ina close to 1 may be retained OTHER IMPORTANT ANTHROPOMETRIC MEASUREMENTS Changes in body proportions occur ds" ing growth. The head is approximately 0" fourth of the total height in the new but in the adult may be only one-eighth the total height (Fig. 3.22). Retention of fantile body proportions is found in © hypothyroid dwarf. The sitting heigh! crown-rump (crown-symphysis pubis) me urement and its relationship to the3. GROWTH AND DEVELOPMENT 81 Centimeters - in Months Fig. 3.20 Chest Circumference, Boys, 0:84 Months.82 PEDIATRICS AND CHILD HEALTH Centimeters PIs ee Pas Pio PS asp Age in Months Fig. 3.21 Chest-Circum‘arence, Girls, 0-84 Months.(Yb) @ BS an fant LL GM RATA Fl AIA AAA Cma(letal) Sma Nowbom yr 3) GROWTH AND DEVELOPMENT 83 el oy, tye 25yr Fig. 3.22 Stages of growth-relative proportions of head, trunk and extremities for diferent ages. (From Fobbins, WS etal: Growth. New Haven, Conn, Yale University Press, 1928), height and the symphysis pubis-heel (cole) measurements may be necessary in the study of certain growth abnormalities par- ticularly height problems (Figs. 3.23 to 3.28). Crown-symphysis to symphysis-sole meas- urements have a ratio of 1.7 af birth and become 1 af/10 years. The arm’span and its relationship to the total height may also be useful in the diagnosis of certain endocrine problems, When arm span exceeds total height, solgunucaid pepsi s present. ‘The midarm circumference is used to measure the degree of nutrition. This has ‘wen found to be of practical importance in areas where weighing scales are not avail- thle. (Figs. 3.29 and 3,30), Skinfold measure- ments such as those of the subscapular and triceps (Figs. 3.31 to 3.38) have also been used to measure the degree of under- or overnutrition of an individual. ‘ SEXUAL MATURITY RATING = Pubertal changes have to be assessed in children. The most popular method for seual maturity rating is that of Tanner. Fig. 3.39 See Chapter on Adolescence. POSTURE Variations in the vertebral curves and shifting of the center of gravity produce postural changes in the child. Other factors such as muscle coordination and strength, the general health, both physical and men- tal, and fatigue affect posture. PHYSIQUE Differences in physique among individu- als also exist. In the past, somatotyping was done and individuals were given numbers to designate somatotype (Sheldon). Now- adays, adjectives such as athletic, asthenic or plump suffice BEHAVIOR Numerous studies have shown that de- velopment proceeds in an orderly and pre- dictable pattern, Behavior is an expression of complex interactions. It is necessary that a thorough knowledge of normal behavior be acquired in order to detect abnormalities in development. AREAS OF BEHAVIOR ‘There are four fields of behavior: motor, adaptive, language and personal-social. Motor behavior is divided into gross mo- tor, which involves posturing of the head, trunk and extremities and includes movement of all or much of the body; and"84 PEDIATRICS AND CHILD HEALTH‘3.GROWTH AND DEVELOPMENT 85, - Centimeters Age in Months Fig. 2.24 Crown-Rump Length, Git 0:36 Months86 PEDIATRICS AND CHILD HEALTH ~ Centimeters Fig. 3.25. Sitting Height, Boys 24-84 Months.9. (GROWTH AND DEVELOPMENT 87 Centimeters rotontiinie) Fig. 3.26 Sitting Height; Boys 7-19 Years.a os. 88 PEDIATRICS AND CHILD HEALTH Centimeters Age in Months Fig. 3.27 Sitting Height, Gils 24-84 Months.3. GROWTH AND DEVELOPMENT 89 P10 Haare me aa Age'in Years: Fig. 3.28 Sitting Height, Girls 7-19 Years, »- PEDIATRICS AND CHILD HEALTH ? Centimeters 219190 Rag) 20 le 4 are ts t rt " t +380, ic Fh a Pos alee —— PH Ps Age.in Months. Fig. 9:29: Arm Circumfererice, Boys 0-84 Months.Peasant mre Centimeters +38D P95 — P90 Ae) P75 = P50 aa P25 P10 PS -38D Age in Months i Fig. 3.30 Arm Circumference, Girls 0-84 Months.92 PEDIATRICS AND CHILD HEALTH exoisesitaed +380 2 F300: 8 Age in Months 08 0 Fig. 3.31 Triceps Skinfold, Boys 0-84 Months.3. GROWTH AND DEVELOPMENT 93 Millimeters +38D 1 8 4 18 Pos: P90 PIS. P50 P25, P10 PS 3D Age in Years Fig. 9.32 Triceps Skinfold, Boys 7-19 Years.PEDIATRICS AND CHILD HEALTH etotasri lil, Age in Months Fig. 3.33 Triceps Skiniold, Girls 0-84 Months,3. GROWTH AND DEVELOPMENT Age in Years Fig. 3.34 Triceps Skintold, Gitls 7-19 Years96 PEDIATRICS AND CHILD HEALTH | Age in Months Fig. 3.35 Subscapular Skinfold, Boys 0-84 Months.. 3, GROWTH AND DEVELOPMENT 97 ” Age in Years : 7 Fig. 3.36 Subscapular Skinfold, Boys 7-19 Years.Pe 3. GROWTH AND DEVELOPMENT 99 Millimeters +3SD ; POS PI5 P50 P25 P10 P5 -3SD. Age in Years Fig. 3.38 Subscapular Skinfold, Girls 7-19 Years.motor, which is well illustrated by the |coordinated movements of small mus- such as that of the fingers. Motor wvior is of unusual interest because of neurologic implications. There are certain principles of develop- ment involved as shown by studies dealing with motor progress. The speed of voluntary movement develops at a fairly uniform rate during childhood. Rapid improvements in the of voluntary movement occurs dur- ing the preschool and slementary school pe- sods whereas steadiness in motor behavior ‘ntinues to improve throughout the child- “hood years. Since relative strength can be alfected by environmental conditions, there isvariable development in this aspect. There appears to be little correlation between in- tellectual ability and certain types of motor performance except in the earlier years. Complex motor skills are developed during theadolescent years. Factors which may influence the degree to which motor ability is perfected or de- layed in its utilization are: environmental influences and opportunities to practice a skill (this is exemplified by swimming which ismore readily learned by a child who lives wear a body of water such as a river); the aail’s physical size; his health condition (diseases like rheumatic fever may cripple a 4hild); the nutritional state of the child; his ental status such as the extent to which ‘tar has been produced by earlier unsuccess- ful attempts to perform; and adult attitudes like considering participation in the game dthasketball, masculine, Ithas been mentioned that development filows in an orderly pattern and that vari ability is rather small particularly in infancy. This is exemplified by the development of am and hand ability as observed in the pro- tess of feeding, a very basic and primitive ‘kill necessary for survival. By about the urth month, Filipino infants are able to told Tie breast or the bottle; by the seventh onth, he picks up pieces of food and other ‘thjects and puts them into his mouth; by the end of the first year, he can use a spoon, although with much spillage; by 2 years; he can manipulate a fork; and at five years he can use a knife. 3, GROWTH AND DEVELOPMENT 101 Writing movements similary follow a specific pattern, At months, he can hold a crayon in his ban ct he can imitate a vertical stroke; at 27, years, a circle; and at 4 years, a cross. ATA }Ea9S, he can draw simple representations of objects in his environment such as a house or a man, and at 6 years, he can write with regu- larity. The child's style of writing is quite set at 12 and penmanship remains such up to adulthood with minor changes. ‘The cephalocaudal pattern of develop: ment has always been observed. Fig. 3.40 shows the developmental diagram for the first year of life: Adaptive Behavior. This area has been considered the. post imidcant among thesp four areas and has been found to be most_” closely related to intelligence, It includes Such aspects as the abil utilize and manipulate objects, the use of motor and sensory coordination in the solution of prac- tical problems and the resourcefulness in utilizing past experience in adjusting to new situations. Language Development. Language has been defined as the art of communication or the ability to understand another person and to be able to make oneself understood. There are several progressive stages of language development: 1. reflex sounds and feeble ges- tures, such as crying which a perceptive mother can distinguish at the end of the third week as either due to hunger, pain, being wet or cold, and cooing which means pleasure or happiness: 2. babbling which can persist from the third to the eighth month, and consists of meaningless repetitions of certain sounds like mama and dada; 3. ges- tures which can start as early as the fourth month in order to express needs; and 7. word ‘Weage. Usually a child can comprehend more of what is said to him compared to what he can say. The first words are usually nouns like “papa” and “mama’, One word sentences are usually utilized by the end of the first year: during this time he may have three word which he uses with meaning At ight tenants, he usually has 10-12 simple words and the number increases rapidly to 300-400 words at. 2 years ofa A three years of age, the vocabulary may reach up"Me PEMEATAIGS ANU VAIL FEAL TT orm 12 3 4 eT Fig. 3.40 Development diagram for the first year of life. The infant's figure represents a diagonal STANDS ALONE WALKS with SUPPORT WR 10 CRUISES PULLS UP 8 CREEPS 7 3ITs BRIEFLY TRANSTERS onsects Ros OvER woLDs HEAD TURNS HEAD. 2 SMILES 1 REGARDS 8 9 wo Hh 2 AGE IN MONTHS ‘on which is plotted the progress of behavior (right of the diagram) against chronological age. Tt cephalocaudal pattern of behavior is diagrammatically illustrated by position of the figure. (After Ald developmental graph for the first year of life.) to a thousand words and the child should be able to combine words into sentences. At 12 ears of age, children may have as much as ‘thirty thousand or more words in his recog- nition vocabulary and ten thousand in his usage vocabulary. Personal Social Behavior. This area is very much affected by environment and cul- ture but it may also demonstrate the state of neuromuscular coordination. It includes habits affecting feeding, sleeping, bowel and bladder control and the ability to get along with other people. Social maturation and in- teractions have been measured by means of several methods, among them, the Vineland Social Maturity Scale as developed by Edgar A. Doll and the sociometric technique devised by J.L. Moreno. For 5 to 19 years old, Levine, Carey ‘and Crocker have an excellent tabulation which offers a wealth of information (Table 3.13). EVALUATION METHODS The Denver Developmental Scret* ing Test (DDST) has gained much popu! ity and is being used as simple devic'# assess the developmental status of chil during the first six years of age. The mi? rials and a copy of the form are shown'" Figs. 3.41 A-C. A Metro Manila Devtl? mental Screening Test is available Using the Gessel Developmental 1 Fig, 3.42 a developmental quotient (DQ)™ be arrived at by means of the follov" formula: a maturity DQ = chronologic age * 100 However, one should not take t face value alone and a clinical evaluati®" all aspects of the child’s assessment s! be taken in its entire totality. CautionCategory Gross Motor Skills Fine Motor Skills Sequential Concepts Receptive Language Skills Expressive Language Skills Table 3.13 DEVELOPMENTAL ATTAINMENT OF 5 TO 19 YEARS OLD 5-6 Year Old Hops on one foot; can walk on heels or toes Pencil grasp becomes sure; capital letter formations automatic; colors neatly with crayons Remembers four digits or objects sequence; knows past and future tenses; knows alphabet, days of week in order; counts to >20 Understands “where,” “when,” “why” questions Sentences average six words in length, uses noun plurals and possessives, narrative has cause-effect sequence 7-9 Year Old Secure balance during stressed gaits; begins to learn complex motor tasks, sports Prints capital and lower case letters neatly; improved awkwardly Remembers five digits or objects in sequence; uses before and after correctly; counts backward 20-1; knows days of week backward; tells time to the minute on analogue clock Understands passive verb forms (“the car was hit by the train”) Uses temporal prepositions (“before,” “after”), uses past and future tenses; narrative has proper sequence, development and resolution 10-12 Year Old Involvement with sports increases; good eye-hand coordination; more strength Cursive writing becomes automatic; works well with tools and implements; can do complex crafts, mechanical, or art projects. Remembers six digits or objects in sequence; knows months of year; alphabetize automatically to use telephone book,dictionary, card catalogue Understands multiple meaning of words; knows meaning of figurative language (simple, metaphor, parody, analogy) Changes style of language to fit several contexts (formal versus informal) and listeners (peers versus principal or parent) 13 + Year Old Much increased strength, endurance, coordination Writes or types with ease, can work with small part and tools, build difficult; refinement of crafts, artwork Remembers six to seven digits or objects in sequence; performs multistep tasks or problems; writes organized essay with appropriate introduction, development, and conclusion Understands linguistic explanations of abstract, concepts, appreciates “deep structure” humor (Call me a cab.” “Okay, you're a cab.”) Complex sentence structure uses idiomatic language, can speak and write about abstract concepts AN3WdO13A50 GNY HLMOWD ‘€ e€04A ‘Table 3.13 DEVELOPMENTAL ATTAINMENT OF 5 TO 19 YEARS OLD (Continued) 7-9 Year Old 10-12 Year Old 13+ Year Old Category 5-6 Year Old Visuospatial Matches identical shapes or and figures; copies: discri- Perceptual minates left versus ‘Skills right consistently Problem Compares lengths, sizes; Solving simple, concrete problem Reasoning solving; turns to adults for Moral answers Development Social Skills Cooperative group play; simple games; limited verbal interaction No reversals of b and d persist; sight word vocabulary increases Compares volumes; begins to reason, attempts simple conceptual problems; limited capacity for empathy; right and wrong defined in terms of punishment; interest in rrules of complex games Plays in same-sex pairs of groups; uses social mnventions (“pleas ank you,” idenfies im- or herself on telephone) automatically Attempts three-dimensional shapes in artwork; copies ‘complex figure: begins to understand maps, geography; good sight word vocabulary Abstract reasoning skills developing; begins to attempt varied problem solving strategies; can solve two-step abstract problems; can empathize (imagine what others feel); understands rules of complex games and can anticipate action (chess, sports) Group activities focus on areas of competence or common social interest; usually plays in pairs of groups of same sex Source: Levine MS, Carey WB, Crocker AC: Developmental-Behavioral Pediatrics WB Saunders 1992. Understands architectural plans, complex spatial relationships; artwork matures; uses and creates citcuits, concepts, relationships Flexible, abstract reasoning skills fully developed understands and discusses concepts (liberty, justice, freedom) and ideals (utopias); right and wrong defined in terms of impact on individuals and society Interactions involve intense exploration of feeling with friends; social activities more adultlike (sports, shopping, going to events), peer approval important, early interest in sexual relationships emerges HLW3H GTIHO ONY SOIHLVIG3d POL3. GROWTH AND DEVELOPMENT Fig. 3.41-A Simple materials used for the Denver Developmental Screening Test. be exercised before a child is adjudged as retarded. The Goodenough-Harris Draw-A-Per- son Test may be utilized in the clinic set- ting using the following norms (Table 3.14). Procedure: The child is supplied with a pencil (preferably No. 2 with eraser) and a sheet of blank paper and instructed to “Draw a person; draw the best person you can.” Encouragement may be supplied if needed, ie, “Draw a whole person”, however, under no condition should the examiner suggest specific supplementation or changes. Scoring and Norms: The child receives one point for each detail present (see the following guide). 1. Head present 2. Legs present 3. Arms present TRUNK 4. Present 5. Length greater than breadth 6. Shoulders ARMS AND LEGS 7. Attached to trunk 8. At correct point NECK 9. Present 105 Tenan War106 PEDIATRICS AND CHILD HEALTH Fig. 3.41-B Scoring form for Denver il (Denver Developmental Scr Examiner: Name: Denver Il bat Bitrate: MONTHS: one ‘YEARS. eo shea 5| & eo? sas 4 create r 7 = Ci : so ee SE = fe 5 so eee é 3 et i fe y —_ somvowe 5 = ~emn TEST BENAMOR F oe ‘mnieaita: ‘(Check boxes for 151, 2nd, oF 3d test) je secs — Tina 424} | cy smoot ‘es 5 ee a te > fl orn compiance(Seonest) yp 3 | fe eae ee ‘Tray Cotes, F a. sh onples : ¥ 7 ae Comics Ff q a Inwgostinsuroundngs.. a a, |e 5 =. ah | Mee i 2 os. Somwnat Diseresied jE 5 CELE Strout Donte 5 som Fearness H a None 42S} ig i om wig 7 5) emer Envene is 5 ar ‘Attention Span 123 is a ‘aapropaate ig 8 Stes Dace 5 ne vey Bares 5 nr ae A TR eee ener a008" SE BE DO BRA ears, ing Test, 2nd ed). (Fo" Frankenburg WK, Dodds JB: Denver, Denver Developmental Materials, Inc. Copyright 1990 by W: Frankenburg and J.B. Dodds.)3. GROWTH AND DEVELOPMENT 107 1. Tiyle got child fo smile by smiling, talking or waving. Do not touch hive. 2 Chid mus stare at hand several seconds. 4. Parent may help guide toothbrush and put toothpaste on brush |. Ohid does not have to be able to te shoes or buttow2ip inthe back, '§ Nove yam slowly in an arc rom one side tothe other, about 8° above child's face § Pass if chid grasps ratle wien itis touched to the backs or tps of fingers 1. Passichid ies io see where yarn went. Yarn should be dropped quickly Irom sight rom tester’s hand without arm movement, {LChid must ansler cube trom hand to hand without help of body, mouth, of table. 4. Pass chid picks up raisin with any pat of thumb and finger {0 Lie can vary only 30 degrees or less trom testers line 11, Make a ist with thumb pointing upward and wiggle ony the thumb, Passi child imitates and does not move any lingers other ‘han the thumb, 12 Pass ay enclosed 13. Which line is longer? 14, Pass any lines 15, Have child copy frst ‘em. Fall continuous (Not bigger.) Turn paper ‘tossing near Mailed, demonstrate round motions. ‘upside down and repeat midpoint {pass 3 of or 5 of 6) \When giving items 12, 14, nd 15, do not name the forms. Do not demonstrate 12 and 14. 16. When scoring, each pair (2 arms, 2 legs, et.) counts as one part 11 Pace one cube in cup and shake genlly near chid's ear, bt out of sight. Repeat for other ear. 18 Pom to picture and have child name i. (No credit is given for sounds only.) less than 4 pictures are named correctly, have child point to picture as each is named by tester ae fat 4 12 Using dol, tol child: Show me the nose, eyes, ears, mouth, hands, feet, tummy, har. Pass 6 of 8 £2 Using pictures, ask chid: Which one fes?... says meow?... aks?... barks? gallops? Pass 2 of 5,4 ofS 21. Ask cd: What do you do when you are cold?...ired?... hungry? "Pass 2 of 3, 3 of 3. 2 Askchld: What do you do with a cup? What isa chair used for? What is a pencl used for? ‘elon words must be included in answers. £2. Pass child corect places and says bow many blocks are on paper. 1,5). 1. Tallchld: Put block on table; under table; infront of me, behind me, Pass 4 ol 4 {Oo not help child by pointing, moving head or eyes.) 'S.Askchid: What i a ball... lake?... dask?... house?... banana)... cutan?...fonce?...celing? Passi defined in terms 1u8e, shape, what itis made of, of general category (such as banana is fru, no ust yellow). Pass 5 ol 8,7 ol 8 1, Ask cid horse i big, a mouse is _? If fire 1s hot, ce is _? I! the sun shines during the day, the moon shines tng the? Pass 2 of 3 2. Chid may Use wall or rail only, not person. May not craw 2. Chid must throw ball overhand 3 feel to within arm's each of tester. £8. Chid must pertorm slanding broad jump over width ol test sheet (81/2 inches) 8. Te chido walk lorward, <2a3a303-> heel within 1 inch of oe. Tester may demonstrate Chid must walk 4 consecutive steps. 51. Inte second year, hal! of normal children are non-compliant Fig. 3.41-C Instructions for the Denver Developmental Screening Test. Numbers are coded to scoring form (Fig, 1-16). “Abnormal” is defined as two or more delays (failure of an itam passed by 90% at that {age) in two or more categories, or two or more delays in one category with one other category having one delay and an age line that does not intersect one item that is passed. A “suspect” or “questionable” score is {ven if one category has two or more delays or if one or more categories have one delay and in the same Category the age line does not pass through one item is passed. (From Frankenburg WK: Denver 1 Developmental Screening Test, 2nd ed. Denver, Denver Developmental Materials, Inc.) eet108 PEDIATRICS AND CHILD HEALTH FIA 8&6 me fs ——s a ree _ |olm) | yo EY LA] |psleb, |3#40, Outline of neck continued with head, trunk, or both FACE 11. Eyes 12, Nose 13. Mouth 14. 12 and 13 in two dimensions 15. Nostrils HAIR 16. Present 17. On more than circumference, non-trans- parent CLOTHING 18. Present 19. Two articles, non-transparent 20. Entire drawing non-transparent, (sleeves and trousers) 21, Four articles 22, Costume complete FINGERS 23, Present 24. Correct number 25, Two dimensions; length, breadth 28, Thumb opposition JOINTS 28, Elbow, shoulder, or both 29, Knee, hip, or both PROPORTION 30. Head: 1/10 to 1/2 of trunk area 31. Arms: Approximately same length as trunk 42, Legs: 1-2 times trunk length width less than trunk length 433, Feet: 1/10 to 1/3 leg length 34, Arms and legs in two dimensions 45, Heel MOTOR COORDINATION %, Lines firm and well connected 31, Firmly drawn with correct joining 38, Head outline %9, Trunk outline 40. Outline of arms and legs 41. Features 3. GROWTH AND DEVELOPMENT 109 EARS 42, Present 43. Correct position and proportion EYE DETAIL 44, Brow or lashes 45. Pupil 46. Proportion 41. Glance directed front in profile drawing CHIN 48. Present with forehead 49. Projection PROFILE 50. Not more than one error 51. Correct Table 3.14 GOODENOUGH AGE NORMS Age 3 2 4 6 5 10 6 14 7 18 8 22 9 26 10 30 ul 34 12 38 13 42 Figs. 3.43 depicts a Screening Beha- vior Inventory derived from developmental norms observed by Santos Ocampo and coworkers in Filipino infants and children belonging to the middle socio-economic classes. Data were first listed in the second edition of this textbook. Hopefully, this instrument may facilitate the rapid screening of the developmental status of a child from birth up to 6 years of age by physicians, other health workers and parents as an initial step to suspect a possible problem in a child.110 PEDIATRICS AND CHILD HEALTH Child Informant Informant Instructions: Evaluation: Card No. Date of Examination Day ‘Month Year SCREENING BEHAVIOR INVENTORY ‘Surname First Name Date of Birth Day Month ‘Year Relationship to child Put ¥ if child can accomplish milestone in column before list under each aread behavior; X if not accomplished. Encircle ¥ or X if actually observed by examiner Area of Behavior Age Gross Motor | eee Adaptive Fine Motor Language Personal-Social Position Printed Name of Supervisor Fig. 3.43 Screoning Behavior Inventory3, GROWTH AND DEVELOPMENT 111 ‘SCREENING BEHAVIOR INVENTORY fee Gross Motor’ [Adaptive Fine Motor Language Personal Social Tonle neck reflex (crying + Nertora iz] Stantes (Moro Rete) Raines hand slightly rom | Eye follows objeato | Throaty, guraling [Smiles midline month | prooe lesa than 48°) midline ound Hands fisted Heed control 45" Bye follows object part [Laughs Responsive, Diminishes tevatha| 12 prove activity when talked to ands no longer sted Head control 90° Fa Hands together [Regards hand Sues prone Rolls over “Grasps object placed In| Moves head towards [Playewithratleinhand ‘mechs hand ound (Chest wp, arm support {Good head control ‘Renchos for objects ‘Tora to sound Nohead lag Chews Tndicates Tikes, dintines Site with suppor Rakes a small ceca ta? when ening [Peeda self with crackers Tndex finger approsch ‘mths Beara some weight on logs Recognizes familier faces ‘Sita without support ‘Transfers object fom [Dade, Mame Plays peck acboo , hand ta hand sooth Bounces [Closeopen hand ‘Stands holding on Holds bole Taitates sounds [Shy with strangers oath Waven bye bye a ‘Thumb finger grasp [Understand gestures [Docs nursery games | [Patsccake! al Walls holding on ‘Bangs objecta together [Two words with Holpsdress,holdingars oath or oot out Stands alone Throw toys [Obeyn commands cr Attempts to uae «spoon Lannthy a [One wordother than | Cooperates in dressing Dade’ Mama” | Thee words other than ‘teontha | Walls wel alone Drinks from eu Pats pictures Walks backward Tmitates a vertical [Ten words imitates housework stroke Jaweeping, washing [ Seat scin chile chair Tndicaten needs [Turns page Dor Sata onda | lume <= Uses open112 PEDIATRICS AND CHILD HEALTH fee | Grom Motor ‘Adaptive Fine Motor] Language Personal Socal ons well [Combines two or thie | Removes garnet words in sentences years [Points to one body part | Toilet trinedby ay Up. down stain lone Tunes [Pliows directions (wo lor thre) 24, yea] Names one picture Throws bale [ties plorale [ides tie [Tells ttle sores Sears 7 aboot experiences ‘Sands momentarily on one fet ‘Stands on on fot fer ve ives fall name, rox [Dresses withroperisi secmnds yeas ‘psa one ot par [Counts to three or [Separates fom mae step dow, two fet per more Imare easily ep Dowastairsone ck por | Tniten ce [Comprehensive [Buttons up ep prepositions Rod words mch as Sen. eld red, hungry opr on oe ot Recognizes color [fells “all ae® “i, years] Cnsbo all well ‘Drawaman with [Rocagnizsthree or [Dresses without i thre paris more color lopervsion Heel ote walk (Copies auare Count toto fan une «knife Set Tips, both fet Wirtesalphabet [Prints first name [fella ores Deckard ecliotos | Draws complete [Adds and subtracts [Dresses wifconpih yam [YH perma with othing ene ‘Can write fil well_|Disingulshes between eft and ight Fig. 3.44 Screening Behavior Inventory INTELLECTUAL DEVELOPMENT. contentional intelligence which may mst Intelligence is an expression which is dif ficult to define in specific terms, It is con cept which may be interpreted in various ‘ways, Some mental operations which con stitute intelligence are: recognition, atten tion span, retention and recall, inductive and deductive reasoning, abstraction and gener: alization; and organization. Two types of in. telligence which are recognized are formal intelligence or academic learning and fest as common sense or astuteness. Us ally, contentional intelligence is difficult measure, It is formal intelligence th usually measured by intelligence tests gn what is known as the intelligence tient. The intelligence quotiént or 1@ is °* tained by means of the following formult ____ mental atl ___ 100 chronologic age‘Table 3.15 DEVELOPMENTAL STAGES BY VARIOUS DIMENSIONS é $SSSSSSSSSESSSSSSSSSESSSS assist evra Scent tenance DEVELOPMENTAL Sean AGESTAGE OF DEVELOPMENT AND APPROXIMATE CHRONOLOGICAL RANGES 1. CENTRAL ‘A.INFANCY (0-1 YR) B, TODDLER (-3 YRS). PRESCHOOL (36D. LATENCY (7-11 YRS), ADOLESCENCE (11 NERVOUS SYSTEM YRS) 21 YRS) From simple reflexes From a few steps to Sensory motor pro» Brain and spinal corel Emergence & expres. to more complex sen- walking and running. cesses almost fully de- now quite mature. Be- sion of bidlogical sex- sory motor develop- Parallel play & begin- veloped. Language de- ginning emergence of ual processes. The boy (Descriptions reflect ment culminating in ning manipulation of velopment at its height biological sextal pro oF girl is now at the status of maturing being able to stand words for communica & is being wtlized cesses, height of physical Drain and spinal cord.) alone, take a few tion purposes. Begin- more for transactional growth and maturity, steps, say simple ring symbolic media- purposes in liew of Capable of reproducing words, attend to ob- tion (e.g. naming of motoric expression. the species Jjects and things, etc. _ things ML AFFECTIVE A. ORAL(O1 YR) —-BLANAL(L3YR) GC. OEDIPAL (3:7 YRS)_D. LATENCY (741 YRS)_E, GENITAL (121, (PSYCHOSEXUAL YRS) DIMENSION impulses, drives & _Impulses and drives tmnpulses and.drives—tmpulses and drives Recradescence of the (FREUD) fother internal forces are expended in de- are expended in de- are asstumed to simmer impulses ée drives are expended in en- fining the emerging fining relationships down and are chan- with more intensity. suring survival. Thus “self” g how it re- between “self rneled towards school, Old battles are re. issues revolve around lates to others. loved one”, & socialization, ete, in fought & this time food, love, care, con- Issues are: control, body clse™ Issues are: preparation for the with more immediacy tact, dependency, nur- power, limits, bound- boy'ness, girlness, mas “storm of adolescence.” ¢= need for resolution, surance, ete aries, territories, ete. _culinity, feminity, “True genitality” is competition naw a paychologiesl and biological possibility AN3NdOTAAIO ONY HLMOHO € ete 4‘Table 3.15 DEVELOPMENTAL STAGES BY VARIOUS DIMENSIONS (Continued) DEVELOPMENTAL ; 7 ae oe AGESTAGE OF DEVELOPMENT AND APPROXIMATE CHRONOLOGICAL RANGES I, PSYCHOLOGICAL A. TRUST VS. MIS. B. “AUTONOMY VS._G.“INITIATIVE VS, _D. “INDUSTRY VS.___E. “IDENTITY Vs. DIMENSION ‘TRUST (01 ¥R) SHAME AND. GUILT" (37 YRS) INFERIORITY" (711 ROLE CONFUSION” (Erikson) DOUBT" (13 YRS) YRS) (11-28 YRS) Task ofthe child & Task of the child and, Task ofthe child and Task of the child and Task isto provide a the environment isto the environment is fo the environment is to the environment is venue whereby what create a “trusting” as acknowledge child's acknowledge that not ereate relationships the child is to “BE” oF well at “trustworthy” beginning indepen: only is the child that will provide op- “BECOME” gets ce- relationship. A favor: dence and awareness aware of himself as a portunities where the solved one way or able ratio yielding of what he can do & separate entity, but child can mobilize ac- another. favorable ‘more trust eaves the what “equipment” he can explore now the quired skills learn ratio yielding more child with a sense hai. A favorable ratio possibility of what he new ones. A favorable identity leads to sense of OPTIMISM. ‘yielding more auto: can do and become. ratio yielding more OF DEVOTION & ‘omy gives the child A favorable ratio INDUSTRY gives the FIDELITY. G the environment a yielding more child a sense of 8 sense of SELE- INITIATIVE leads to a METHOD 6 COMPE- CONTROL WILL sense of DIRECTION TENCE, POWER, & PURPOSE. Iv. Coonmnive ‘A. SENSORIMOTOR B.PREOPERATIONAL —_C. OPERATIONAL: D. OPERATIONAL: (ager) ‘CONCRETE TORMAL (infancy 02 yrs) Simple (27 YRS) External world (7-11 YRS) Thinking opera- (11 YRS — ADULT) perceptual & motor adapt- beings to be internally tions are fully established. Relativistic multi-levelled ation to stimuli, No “inter- represented utilizing pro. Inside(Outside different. thinking. The young adult nal” cognitive or concep- cesses or schemes that ations are stable. can now make “ifshen’ tual representation of out- evolved from sensory Thinking, however, is. propositions & hence be- ‘side events as yet. The motor period. “Inside/ mostly concrete & mono- comes a “scientist” or a child does without know- Outside distinction” is be- thi. Thus “b ck” “phi Conversely, ing. ginning to be laid down and “white is White”. The Dut is stil weak 6» tenuous child 79 Jee & disappears with stress, centric, hhe-can sce these operations in others, making it pos sible to operationalize. HLWSH CHO ONY SOILVIG3d pL(ehiberg) | PREMORAL™ Sose abe etme inte grati cation of needs is pare: ‘mount with ro recogni tion of others needsor sn gouconvt “Adapted: Danilo. Ponce M.D. Stage of nde ‘What i aes oar Some delay of gratis tion. thers are recog nized only s¢ they serve rican for eed gatit Morality © slated by avoidance of punishment questioning seference 10 power & physical eon equences of actions deter rine their goodness or badness ig ight” ‘MedicaVinieal Services Director, SARTECY Profesor, University of Ha Medical School, Department of Paychiary > (7 vs) Soratch my vac TT Seatch yours ‘What right is what i right for the il. Other's ‘needs come to pay in so far anit faciiates oF locks pu Sait of ind ial wants needs. At sage 3 hile is incapable of rele play- Ing. Talion aw pr ciples "an ye fara, ge applies tere sy te dctated| by that wie approved oF frowned ‘pon by others. The child can now place him: felt in other people's shoes and play oles He docs ot decide for himself, hoswever what is right wrong. He snp. fo lows rules ven by thers. this see, roleplaying ‘sone sis py to learn ‘what pleases and offends ‘thers, This isthe “solieg SL ay! mss the higher form of Stage 5, based upon respect for authority Morality ddtated by aati Soa honor. Oren {ation it do one’s duty, obey fixed Files and wal order though there ‘much blind obedience to authority as Instage 5 “The “other” is neverthe: loo till he simaay MORALITY" Universh (2:48 YRS) moral ethical Moralty i¢ orientation ‘awed on con-_ Standards of fractal justi and eements, eit are bth personal atonomsats cor cis and sll: There is clear determined awareness of ti primarily relativism of directed values and toward Imperma: , —_rexpect and rence of dignity of Fegulations, human be The ing and Constitution concern of and the making “situation these univer fies” are il Chri examples. Buddha, “ats decide Gandhi and wha beg other socio fe religious personalities fre examples GLb LNSNdOTRARG ONY HLMOHD “€446 PEDIATRICS AND CHILD HEALTH Intelligence tests are inaccurate before the age of 5 years but may have a good pre- dictive value afterwards. The value of the test increases as the child goes through school, especially during elementary and high school. Although the best method of evaluating a child's intelligence is by observing his behavior in day to day situations that may challenge his ability to perform successfully the following are some tests that may be utilized. For individual testing: Bayley Scale, of Infant Development; Cattell Test for Meas: urement of Intelligence of Infants and Young Children for ages 2 through 30 months; Min. nesota Preschool Test for ages 18 months through 6 years; WISC (Wechsler Intelli- gence Scale for Children); WPPSI (Wechsler Preschool and Primary Scale for Intelli- gence); the Binet-Simon Test (Terman- Merrill version of the Standford-Binet Scale) and the Leiter International Performance Scale. The following are used for group test: ing: Goodenough Draw-A-Man Test for 3-13 years; Primary Mental Abilities Tests (Thurstones); California Test of Mental Ma turity; and the Kulhman-Anderson Intelli gence Test. For purposes of comparison, the follow. ing categorization by intelligence quotient is hereby given: Classification IQ 140 and above lear genius or genius ‘Very superior 130-139 Superior 120-129, Above average 110-119 Normal or average 90-109 - Below average 80-89 Dull or borderline 70.79 Moron 50-69 ~ Imbecile 30-49 Idiot below 30 The concept of giftedness is undergoing ‘an evolution. In the past, the most commonly used definition was having a score of 130 or higher on an IQ test. However, in 1983, H Gardner proposed moving away from a single “intelligence paradigm” and identified seven domains of intelligence, each with its own specific memory, mechanisms of learning, and relevant history of development. ‘These domains are: * linguistic + musical * logical ~ mathematical + spatial * bodily — kinesthetic + intrapersonal * interpersonal Possibly an 8% domain is: * affinity with nature Recently Goleman has popularize concept of emotional intelligence (BQ) Factors affecting intelligence are nun ous and include: 1. Genetics. It has be found that the IQ of the child is usual closely related to the parents’ IQ. In them jority of instances, it usually falls in & bracket of 15 points below the lower pu ent’s IQ and 15 points above the higher: ent’s IQ. 2. Health, physical developme: defects, and fatigue. 3. Sex. Boys usul excel in the physical sciences and mathems ies while girls are superior in the hunas ties. 4. Social and economic deprivation cluding absence of early maternal cares: an unstimulating environment. 5. Emotion factors such as “block” or presence a neurotic conflict; emotional maturity su as ability to tolerate frustration, and pe sence of motivation or interest PERSONALITY DEVELOPMENI Personality is a term that is quite dil cult to define. It may be the sum total ofal areas of development; motor, language, == tal, emotional, social and moral as see the person’s activities in relation to eves and the environment. It is used as a te which describes his over-all behavior f tern at any period of growth Although to a certain extent heredita” factors affect personality, as shown fori stance by differences at birth, environmt plays a very important role. Factors ale ing personality development may be in ent in the individual and may include i physical condition, and his mental and n° tor abilities. Necessarily, a child's perso ity will be affected by an illness partiula if chronic, crippling handicaps, or ment!3. GROWTH AND DEVELOPMENT 117 tion, Environmental factors such as The school, its curriculum and discipline that are present in the home are very _ plays a very important role in molding the important; the amount of psychological —_child’s personality and should be adjusted mothering (parenting) given the child, the to his developmental status. Other factors presence or absence of love, tolerance, __ that may affect personality development are mutual respect in the home situation, and cultural differences, position in the family an adequate economic state are vital factors. and even the name given the child, Table 3.16 CHILD DEVELOPMENT STAGES. LANDMARKS: PIAGET FREUD ERIKSON KOHLBERG COGNITIVE PSYCHO- PSYCHO- MORAL SEXUAL SOCIAL BIRTH ebbleslaughs 2MOS Premoral Stage / Heed control : of Gratification Iyefollowing/rolls 4 MOS Vocalizes socially sranger-fear appears 6 Mos Trust vs. Sits alone Oral Mistrust_ sands alone 9-10 MoS | Sensor-motor Thinking End Justifies the First word 10-12 MOS : Means walks with help fecognizes objects 1YR by name oo Walks without help 18 MOS Autonomy vs. ‘Anal Shame Might is Right Speaks in phrases 2YRS Hladderbowel control 4 Speaks in sentences 3 RS | Goperative play 4 YRS: ‘ [eerie Pre-operational Phallic Initiative'vs. | Naive instru- Gounts 10 objects 5 YRS | Thought Infantile Guilt mental Hedonism Abs “Why" Genital 6 YRS 7 YRS 7 42 DEE 8 YRS Conformity gyrs| Concrete oa industry vs Operations iority 10 YRS Law and Order 11 YRS 42 YRS First Stage of Formal Opera- Adolescence Identity vs. ‘True Morality tions Ego 18 YRS Confusion True 21 YRS | Morality i118 PEDIATRICS AND CHILD HEALTH CHILD DEVELOPMENT PRINCIPLES AND NORMS Table 3.15 summarizes the various de velopmental dimensions, the approximate age/stage of development and approximate chronological ranges according to maturity of the central nervous system, the psycho: analytic (Freud), the psychosocial (Erickson), the cognitive (Piaget), and the moraVethical (Kohlberg). In the discussion of the different stages, age equivalents are given. It should be kept in mind, however, that these are arbitrary and stages may overlap each other. ‘An even more simplistic presentation is shown in Table 3.16. |THE PSYCHOANALYTIC CONCEPTS OF PERSONALITY DEVELOPMENT ‘The Oral Stage. The erotic zone oF the source of security and aatisfacton, during this atoge io the nouthy This stage is dk vided into two: the gute phaee which usu. ally corresponds to henge from birth to 3 months andin characterised by marked pas” ity onthe part of the infants and the sym ie phane which is usually from 3018 months and which continues to be charac; {erized by dependency, Aggression ay ap pear duriog this stage td ie manifested mainly by ting The oral child lo parasitic In adjustment tnd is markedly depend. fc his needs on his environment. JectionJan « defense mechanism may revenue oe tural challenge i weaning Weaning as used here meane taking the Ghild off the nipple, from both breast or btile and transferring him tothe cup or glass for his mill supply. Weaning when not correctly done has been blamed for certain behavioral. problems which may pereist up to adulthood. An indi Vidual ho continues to be mecthcegtoved far beyond the age when the mouth should have ceased to be a source of satisfaction, is Calfed an oral person ‘The Anal Stage, During this phase, the mouth shares ila pleesure-iving role with _ the [armas] The ages encompassed are from (Besta pnonthe There a «diminishing de Se im tne parente in contrast to the previous phase. A number of unplessan, characteristics like obstinacy, selfishnes, bossiness and sadism make up the pict of the “terrible twos”. The two-year old chil is usually pictured as a scowling angry cis The child in the anal phase may throw ter per tantrums. He is quite ambivalent rj may love and hate alternately within criod of a few minutes. {Identificati Hlregression are prominent defense m: chanisms during this stage. The cultus| challenge is toilet training. When tale training is done improperly, permeney personality scars may result, The anal type of personality is sometimes seen in the obstinate and parsimonious adult. Usually 2 child is toilet ‘only when he shows signs of being ready which is at 18 to2 months for day control, and for night contr ‘Detween 2, to 8 yea —-| ‘The Phallic Stage. The erotic zone nov shifts from the anal to the genital area (ge nis or clitoris). The phallic stage usually ie fine at 9-4 years and ends at 5-7 years Dir ing this stage, the child still exhibits ax bivalence (especially towards the parents plus curiosity and exhibitionism. He ext rues to believe readily in magie and becomes preoccupied with the genitals and sex di ferences. The boy fears that he might oe his penis while the girl feels that she his Jost hers. Both interpret these anxieties o: the basis of punishment. For the boy, itiss future one, and is known as castration ans: ety. For the girl, it is punishment whct occurred in the past, and results in feces of inferiority and jealousy termed as pes srttne Qedinus complex which is tov! during these years is characterized by « attraction to the parent of the opposite & accompanied by jealousy and rivalrous i" tility toward the parent of the same = Resolution should take place as the cil enters the next phase of development. T# Oedipus complex is a potentially pathoges* state and incomplete resolution may re! in problems later in life Formal sex education should be stat during this stage, if it has not been dt earlier. Masturbation is common, one 7 son being that the boy wants to reasHHA eat his penis in sill intact. A puntivatitude aud any surgical interven tion should be &voidéd during this stage as thoe may enkamce oth castration fear and pris cnny Defense mechanima during this Hep saad apession] heals Shalenge during thie stages 4 repression of any phallic pleasure or sezualized or eroticized play. je Latency Stage. The erogenous sea remains in the phallic area. This en- compasses the ages from 5-7 years to 8-12 years. During this phase which corresponds tothe school-age child, there is an increas- ing eccumulation of knowledge and develop: ment of physical ability. The latency child already has good reality adaptation and has conscious fear of death. ‘There is a relative decrease in sex interest. There is an identi fcation with the parent of the same sex and nore differentiation along masculine and feminine lines. Progressive development of the ego occurs as a result of growth, educa- tion, and experience. Resolution of the Oedi- yl complex should occur during , ually with the help of repression and identification. The latency child now starts -vfoming ideals and superego formation be: fins, Also observed are obsessiveness and ‘ompulsiveness, the beginning of collections, and club or gang formation. The defe mechanisms noted during this stage {ionalization, ane{ sublimafion| The chil. ‘exposed to more complex social pressures during this stage usually involving work re- quirements at home and at school. The quest for status is obvious at this stage level. ‘Adolescence. The primary erotic zone still ig focused on the sexual parts. The ‘equivalent age levels are from 10 to 12 yeara to 16 to 18 years. There is a rapid develop. nent of the sex orgaps ang a maturation of sexual reproductive “capacities. Genital and heterosexual interests and activities are com- mon with a marked resurgence of drives and instineta resulting in a threat to the ego. There is @ rebellion against the superego (mostly the parents). The question of “who tm comes up often. There are inconsist- encien in behavior, vacillation in moods, an intense interest in peer groups, fads involv. ing clothing, hair and music, a distrust of 3, GROWTH AND DEVELOPMENT 119 adults, the need for secrecy and fears of “go- ing crazy” or losing control. The defense met id during this stage is|intel- fect aiseton Society expects greater Fe sponsibility, control of sexual and aggres- sive impulses and expects the adolescent to remain under parental control, ERIKSON’S PSYCHOSOCIAL THEORY Erikson’s theories on development are similar to Freud in that they also involve ‘stages. In fact, most of these stages parallel the Freudian stages. Erikson however places ‘more emphasis on the social interactions and less on the sexual matters’ Thus he speaks of psychosocial stages of development. He calls them so because he believes that the psychological development of individuals de- pend on the social relations established at various points in life. Erikson’s Eight Stages of Development ‘According to Erikson’s view, each stage revolves around a different theme or con- flict. Stage 1-This corresponds to Freud’s oral stage and the basic theme is trust vs, mistrust. The focus is on in- {aut.- parent interaction. With con- sistency and reliability in handling of the child, he develops trust. Stage 2~The major issue is autonomy ~ the ability to do as one pleases, not to be pushed around by others. Thi is the famous “NO” stage in which the child must show that he is an individual in his own right but at the same time he worries if he is capable of being s0, Stage 3~This takes place during the pre- school period. Initiative or the child's ability to work towards a goal or make plans is the major issue, One-of his ambitions as in Freud's phallic stage is to win his mother away from his father but feels that he is wrong to wish to possess his mother and thus experiences guilt.