PED: Growth and Development Part I

13 September 2019 ∙ Jocelyn S. Sanchez, MD

Table 1. Critical period for certain domains

OUTLINE Periods of Growth Critical Period
I. Objectives IV. First Year Infancy (First year of life) Motor skills
II. Pediatrics A. 0 – 2 Months ® Independent ambulation –
A. Paradigm Shift B. 2 – 6 Months walking or moving from place
B. Critical Periods for C. 6 – 12 Months to place
Certain Domains V. Second Year ® “Rule of thumb: if the child
III. Growth and Development A. 12 – 18 Months does not sit up at 18 months,
A. Interplay of Nature B. 18 – 24 Months then most likely he will not
and Nurture VI. Childhood walk.” [Dr. Sanchez]
B. Domains of A. Preschool Years (2 –
Development 5 Years) Toddler-Preschool (2-5 Language and Social skills
C. Principles of Child VII. Review Questions years old) ® First words and phrases
Development VIII. References School-age (6-11 years Cognitive skills
IX. Summary old) ® Concepts
I. OBJECTIVES
• Know and appreciate the role of growth and development in III. GROWTH AND DEVELOPMENT
pediatrics • The study of the child begins with an understanding of the
• Track a child’s developmental progress in the following normal patterns of growth and development
domains: • Being familiar with normal patterns of growth and
® Locomotor development allows identification and management of
® Language abnormal variations [Kliegman et al]
® Cognitive Table 2. Growth vs Development
® Social/Emotional Growth Development
• Know red flag signs in child development Increase in physical size or Increase in skill and
• Discuss cognitive/moral development, self-concept, and the whole body or any of its complexity of function
sexuality of the adolescent. parts (locomotor, language,
II. PEDIATRICS cognition, social/emotional)
• Branch of medicine that deals with the medical care of Quantitative – measured in Qualitative changes
newborns, infants, children, and adolescents [Dr. Sanchez] cm, in, kg, lb
• Ensure that growth and development of a child is proceeding “You have to plot them in an
on track and optimally age and gender specific
® It is the responsibility of the pediatricians to make sure chart.” [Dr. Sanchez]
that children are healthy and free of diseases by doing
check-ups, routine vaccinations and anticipatory care [Dr. Growth
Sanchez]
• Measures length/height, weight and head circumference
• One goal of pediatrics is to help each child achieve his or her
• Assessed by plotting measurements on growth charts and
individual potential through periodically monitoring and
comparing with previous measurements obtained at health
screening for the normal progression or abnormalities of
visits [Kleigman et al]
growth and development [Kliegman et al]
• There are differences and uniqueness anatomically,
A. PARADIGM SHIFT physiologically, developmentally and behaviorally during
• “Changes in society about how things work” [Dra. Sanchez] different stages of growth
• BEFORE Table 3. Periods of growth
® Parents bring their children for pediatric consult only when Stage Time Period
they are sick
PRENATAL 0-280 days (~9months)
§ Example: fever, cough, colds, diarrhea, difficulty of
breathing POSTNATAL
• PRESENT
Infancy 0 – 2 years old
® Common chief complaint is about the child’s growth and Neonate First 4 weeks after birth
developmental status
Infant First year
§ Examples: language delay, hyperactivity, difficulty in
Toddler 2 years old
walking, poor academic skills
® “Parents are becoming very aware of growth of Childhood 2 – 11 years old
development. They tend to compare.” [Dra. Sanchez] Early (Preschool) 2 – 5 years old
® Parents are becoming more concerned and aware of how Middle (School-age) 6 – 11 years old
their child is growing and behaving
Adolescence 10 – 20 years old
B. CRITICAL PERIODS FOR CERTAIN DOMAINS Early 10 – 13 years old
• Critical Period [Dr. Sanchez] Middle 14 – 16 years old
® A maturational stage in the lifespan of an individual during Late 17 – 20 years old
which the nervous system is especially sensitive to certain Development
environmental stimuli • Continuous process that begins from conception to maturity
® Studies have shown that if for some reason the individual • Changes in the developing brain (i.e., cognition, language,
does not receive the appropriate stimulus during this behavior) [Kleigman et al]
critical period, it may be difficult to develop these functions • Developmental Milestones [Kleigman et al]
later on in life.
® Assess development focused on discrete behaviors that
® Examples: the clinician can observe or accept as present by parental
§ Critical period for Language is around the toddler years report
(2-5) but actually even before 2 years old. If the child is
® Based on comparing the patient’s behavior with that of
not speaking (or you did not give enough stimulation
many normal children within specific age ranges
during that time) and it is not corrected, the chance of
® Other types of assessment: intelligence test, school
developing it fully will be compromised.
performance, and personality profiles

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Growth and Development Part I

A. INTERPLAY OF NATURE AND NURTURE • First office visit should occur within 2 weeks after discharge to
• Factors that affect growth and development are always an determine how smoothly the mother and child are making the
interplay of nature and nurture transition to home [Kleigmann et al]
® Babies that are discharged early, breastfeeding, and at risk
Table 4. Nature vs Nurture
for jaundice – seen 1 to 3 days after discharge
Nature Nurture
§ Some influences on § Environmental influences Physical Development
development originate from before and after birth • Limb movement consists of uncontrollable writhing, with
heredity ® Good nutrition purposeless opening and closing of hands
§ Inborn traits that are ® Upbringing and • Smiling occurs involuntarily
inherited from parents experience • Sleep and wakefulness are evenly distributed throughout the
24-hour day
Examples: looks, color of Examples: use of gadget,
eyes, hair and skin, height, watching tv, anything outside • Behavioral states: Quiet sleep, Active sleep, Drowsy, Alert,
intelligence hereditary influences Fussy, Crying
® “Active sleep is the REM stage sometimes they move, they
B. DOMAINS OF DEVELOPMENT startle at voices and sometimes when you touch them.
1. Locomotor This is the stage wherein there’s some habituation. During
Newborn Screening when you prick with the needle, the
• Gross motor
baby will cry but later on the crying will subside.” [Dr. Sanchez]
® Ability to control large muscle groups while maintaining
® Drowsy state – same stimulus that undergoes habituation
proper balance stance and gait
in active sleep may push the child into fussing or crying
® Examples: crawling, walking, sitting
[Kleigmann et al]
• Fine motor
® “Alert stage wherein the child’s eyes are wide open. That
® Ability to use hands to manipulate objects means they are ready to take in stimulus. So don’t engage
® Examples: grasping, writing with the child when the child is drowsy or fussy.” [Dr. Sanchez]
2. Language ® “Fussy stage is a transitional stage. If stimuli are too much
• Receptive skills then they may break down into fussiness. Movement is
® Ability to comprehend jerky and disorganized, and these movement can startle
® Examples: turning their heads toward mother’s voice, them.” [Dr. Sanchez]
responding to simple directions ® “Crying is the most effective mode of attracting caregivers.”
• Expressive skills [Dr. Sanchez]

® Ability to produce verbal and non-verbal symbols • Birth weight: 3.4 kg

® Examples: crying, babbling, pointing, talking
3. Socio-emotional
• Ability to interact, to form and maintain relationships
• Example: making friends
4. Cognitive
• Ability to learn and understand
• Ability to solve problems
C. PRINCIPLES OF CHILD DEVELOPMENT
1. Child development proceeds along a predictable pathway.
• Basic skills develop first before complex ones
• “You have to have head control first, sit up first, stand,
walk, and run.” [Dr. Sanchez]
2. The range of normal development is wide.
3. Various physical, social and environmental factors, as
well as diseases, can affect child development and health.
• If the child is always sick, neglected, or has a syndrome,
then it may affect the child’s development
4. The child’s developmental level affects how you conduct
the history and physical examination.
• Examining a neonate is different from examining an
adolescent (i.e., the way you ask questions and do
physical exam)
IV. FIRST YEAR
• Provide the platform for remarkable growth and development,
setting the trajectory of a child’s life [Kleigmann et al]
• Neural plasticity - ability of brain to be shaped by
experience, both positive and negative
® At its peak during the first year of life
® Total brain volume doubles
• Physiologic changes allows the establishment of feeding
routines and a predictable sleep-wake cycle [Kleigmann et al]
A. 0 – 2 MONTHS
• “The newborn always begins at birth and includes the first
month of life. Regardless of when the child was born. During
this time, there is marked physiologic transitions that occur in
all organ systems and the infant learn to respond to the many
forms of external stimuli.” [Dr.Sanchez]
• Any developmental status should consider the parents’ role
since infants thrive physically and psychologically only in the
context of their social relationships [Kleigmann et al]
® Grows at approx. 30 g/day during the 1st month
§ Period of fastest postnatal growth [Kleigmann et al]
® May initially decrease 10% below birth weight due to
excretion of excess extravascular fluid and limited
nutritional intake; improves as colostrum is replaced by
higher-fat breast milk, as infant learn to latch and suck
efficiently, and mother’s breastfeeding technique
improve[Kleigmann et al]
• Length: 50 cm
• Head circumference: 35 cm
• Principles of Physical Development
® Cephalocaudal – downwards; head to toe
® Proximodistal – center to outwards; arms and legs, then
hands and feet
Figure 1. Cephalocaudal and Proximodistal Principles of Physical
Development [Quizlet Inc.]
• Milestones [Kleigman et al.]:
® Gross Motor
§ 2 months: Holds head steady
§ 3 months: Pulls to sit without head lag and brings hands
together at midline
Language Development
• Crying
® “To gain attention of caregivers” [Dr. Sanchez]
® Healthy infants may cry up to 3hrs/day, then decreases to
1 hour or less by 3 months
® Crying normally peaks at 6 weeks of age
• Milestones [Kleigman et al.]:
® 1.5 months: smiles in response to face and voice

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Growth and Development Part I

Socio-emotional Development ® Can match affective expressions (smiling or surprise) of a

• Dependent on the environment to meet their needs [Kleigmann et
al]
• At 2 months old: Emergence of smile and increase eye
contact
• Consistent availability of a trusted adult to meet the infant’s
urgent needs creates the conditions for secure attachment
• Infants cry in response to the cry of another infant – early sign
of empathy
• Management of crying/fussiness:
® Teach caregivers about precry cues
® Calmly respond to signal for feeding (crying)
® If sensory overstimulation is a factor – create a non-
distracting, calm environment and swaddle the baby
® If lack of sensory stimulation is present – mother-infant
skin-to-skin contact and carrying of the infant may help
Cognitive Development
• Differentiation of patterns, colors and consonants
• Recognize facial expressions (smiles)
• Identify mother’s voice and smell
• Match abstract properties of stimuli (contour, intensity, or
temporary pattern) across sensory modalities [Kleigmann et al]
• Can discriminate rhythmic patterns in native vs non-native
language [Kleigmann et al]
• Seek stimuli actively, as though satisfying innate need to
make sense of the world
® Infants habituate to the familiar, attending less to
repeated stimuli and increasing their attention to novel
stimuli. [Kleigman et al]
• Caretaking Activities:
® Provide visual, tactile, olfactory, and auditory stimuli to
support development
B. 2 – 6 MONTHS
• Infant’s range of motor and social control, and cognitive
engagement increases dramatically
• Routines are established
• Parents are less fatigued
Physical Development
• At 3-4 months, rate of growth slows to approximately 20
g/day
• By 4 months, birth weight is doubled
• Early reflexes that limited voluntary movement recede (e.g.,
primitive reflexes) [Kleigman et al]
® Waning of grasp reflex allows infants to hold objects and to
let them go voluntarily
® Novel objects may elicit purposeful but inefficient reaching
• Increasing truncal flexion allows for intentional rolling [Kleigman et
al]
• Maturation of the visual system → greater depth of perception
[Kleigman et al]
• Infants achieve stable state regulation and regular sleep-
wake cycles
® Total sleep requirements = 14-16 hours/day
§ With about 9-10 hours concentrated at night and 2
naps/day
• Milestones [Kleigman et al.]:
® Gross Motor
§ 3 months: pulls to sit without head lag and brings hands
together at midline
§ 4 months: asymmetric tonic neck reflex is gone which
allows infants to examine objects in the midline and
grasp them with both hands
§ 6 months: sits without support
® Fine Motor:
§ 3.5 months: grasps rattle
§ 4 months: reaches for objects, palmar grasp is gone
§ 5.5 months: transfers object hand to hand
Socio-emotional/Communication Development
• Interaction through facial expressions: anger, joy, interest,
disgust, surprise
• Cooing (from 6 weeks to 3 months)
• Mutual attachment and enjoyment
trusted adult
• Caretaking activities:
® Initiating games (e.g., facial imitation, singing, hand
games) increased social development
§ This face-to-face behavior shows the infant’s ability to
share emotional states (1st step in the development of
communication) [Kleigman et al]
• Lack of reciprocal language and movements – at risk for
autism spectrum disorders
Cognitive Development
• Hatching (4 months)
® Holds his head steady
® Socially, becoming interested in a wider world
§ Distracted during feeding
§ Follow a person across the room with eyes and head
• Exploration of their body, staring intently at hands, shakes
rattle, vocalizing, blowing bubbles, touching their ears,
cheeks, and genitals → allows for an early stage in the
understanding of cause and effect (voluntary movement
results in tactile and visual sensations)
• Milestones [Kleigman et al.]:
® 3 months: discovery of hands (self-discovery)
® 4 months: can inspect hands at midline
Help Me Grow Video – 2 Months Transcription
https://youtu.be/wjTqC-WcNos
• Cognitive Development
® Needs practice hearing words, although they won't
understand the words said to them
® Talk to them about what you are doing together
® Tracking: eyes can now follow moving objects
® Get the baby to look at your face or bright objects and
move slowly in one direction and let them follow it
® Suspend toys just within reach
§ Will look at toys and at some point, bat at the toys,
which helps develop eye-hand coordination
• Social and Emotional Development
® When eyes are bright and alert, time to play and interact
® If they fuss, cry or arches back, getting overwhelmed and
needs comfort or a break
® When they cry, try to understand what your baby needs
® Soothing makes them feel safe, secure and loved
® May try to bring hands up to mouth.
§ Don't discourage
§ Special way babies try to soothe themselves, like they
did in the womb
® If you become overwhelmed or begin to feel angry with
your baby, ask for help or find a way to take a break
§ You may need to put your baby down in a safe place
and step away for a short time
§ Never hit or shake a baby!
• Large and Small Muscle Development
® Let your them experience different positions throughout the
day on their tummy, back or sitting on your lap
§ Helps your baby develop strength and muscle
coordination
§ Plenty of tummy time helps develop strong muscles
® Able to lift head slightly and turn head from side to side
§ Try placing a small blanket roll under their chest, which
helps them to lift head a little more easily
• Language and Communication Development
® Beginning to carry on conversations (e.g. cooing)
® When your baby smiles and you smile back, two-way
communication has begun
® Also communicate by crying or fussing as a way to signal
they are hungry, tired too stimulated, or want attention
• Things you can do to help your child grow and learn:
® Play, talk and sing to your baby
® Always hold your baby when eating and make mealtimes
enjoyable
® Give them lots of time to play on the floor to develops
muscle strength and control
• Signs that indicate your child may not developing as
other 2-month-old children:

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Growth and Development Part I
® Not having regular times when alert and interactive
® Never smiles
® Body seems too stiff or too floppy
® Never turns head from one side to the other
C. 6 - 12 MONTHS
• With the achievement of sitting, increased mobility, and new
skills to explore the world, infants show advances in cognitive
understanding and communications [Kleigman et al]
• Infants develop will and intentions [Kleigman et al]
Physical Development
• Growth slows
• Achievement of sitting position
® Sit unsupported by 6-7 months; by 6 months [Kleigman et al.]
® Pivot while sitting at 9-10 months
Figure 2. Achievement of a sitting position
• 6.5 months: rolls back to stomach
• Crawling and pulls to stand at 8 months
• Increased mobility and new skills to explore the world
® Thumb-finger grasp at 8-9 months
® Neat pincer grasp by 12 months
• By 12 months
® Birth weight – tripled
® Length – increased by 10%
® Head circumference – increased by 10 cm
• Walking by 1 year (for some infants [Kleigman et al])
• Motor achievements correlate with increasing myelinization
and cerebellar growth
• Gross motor skills expands the infant’s exploratory range and
creates new physical dangers and opportunities for
learning[Kleigman et al]
• Tooth eruption occurs, starting with mandibular central
incisors – reflects skeletal maturation and bone age [Kleigman et
al]
Language Development
• 6 months – monosyllabic babbling
• 7 months – inhibits to “no”, follows one-step command with
gesture [Kleigman et al.]
• 8-10 months – polysyllabic babbling; babies can
discriminate between languegs
® Infants in bilingual homes learn the characteristics and
rules that govern 2 different languages
• 9 months – awareness of reciprocity of emotions
® Joint attention or social interaction
® Show parents toys as a way of sharing their happy feelings
• 10 months – saya “mama” or “dada”, follows one-step
command without gesture, points to object [Kleigman et al.]
• 12 months
® First true word is the sound used to consistently refer to a
specific object or person
• Response to simple words: ‘no’, ‘bye’, ‘give me’
• Picture books provide an ideal context for verbal language
acquisition
Socio-emotional Development
• Stranger Anxiety
® Looking back and forth between parents and stranger
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® Clinging
® Crying
® Helpful Tips to deal with Stranger Anxiety:
§ Avoid direct eye contact
§ Talk to parents first
§ Introduce toys
§ Allow child to be examined on the parent’s lap
• Autonomy
® Infant’s emerging independence
® Poor weight gain due to infant’s emerging independence
and parent’s control of the feeding situation
® Helpful Tips to help develop Autonomy:
§ 2-spoon method of feeding (1 for the child and 1 for
the parent)
§ Finger foods
§ High chair with tray table
Cognitive Development
• 6 months – manipulation of objects
® Objects are picked up, inspected, passed from hand to
hand, banged, dropped, and then mouthed
Figure 3. Baby mouthing an object
• 9 months (8 months [Kleigman et al.]) – object permanence
(constancy)
® Understanding that object continue to exist, even when not
seen
• 12 months – egocentric symbolic play which displays the
beginning of symbolic thought
Help Me Grow Video – 6 Months Transcription
https://www.youtube.com/watch?v=wjTqC-WcNos
• Cognitive Development
® Shows that they are very interested in people by making
eye contact, smiling and cooing
® Mouthing things is the baby's way of exploring
§ Interested in grabbing, holding and tasting everything
they can get their hands on
§ Not being naughty, just being very curious
§ Be sure everything the baby puts in his mouth is safe
and made of non-toxic materials
® Love to hand objects to you and have you hand them back
® Playing peek-a-boo teaches the child that things that go
away come back
® Enjoy books with simple pictures
® Playing with you is the best way for the baby to learn
® The American Academy of Pediatrics recommends no TV
or video watching for children under the age of 2 years
• Social and Emotional Development
® Developed a special relationship with those he knows
® May become quiet or even distressed when meeting
someone he doesn't know
§ It is the beginning of stranger anxiety
§ Suck on their fingers or thumb to comfort themselves
® Allow the baby to play where they can see you
® Begin to show many emotions (joy, fear, interest, surprise)
• Language and Communication Development
® Instead of just crying, may make a loud noise and wave
hands to get attention
® May react strongly to the emotions of others
§ Laughing if the other person is laughing
§ Showing sadness if someone is crying
® Communicate by smiling, laughing, crying, yelling and
moving their bodies
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Growth and Development Part I
® Begin to use more babbling sounds, and use voice to
express joy and displeasure
® When you talk to them, they will make sounds back
® When the baby is looking at something, point at it and
explain what it is
® Have fun together by copying the baby sounds and actions
® If they wave, wave back and say "Hello!"
® Talking to baby encourages them to use listening skills and
learn what words mean
• Large and Small Muscle Development
® Once in the sitting position, can hold head steady and
body is quite straight, though still need support to sit
§ Cushions or pillows can be used to support and soften
fall when they topple over
§ Never leave a baby alone when in supported sitting
® Can lift head, chest and tummy off the floor
§ Can roll over from back to tummy and sometimes from
tummy to back
® Like to bounce when held in a standing position
® Get down on the baby's level and see what kind of dangers
might need to be taken care of or removed
§ The baby could roll over and be able to reach a cord
® Encourage fine motor or small muscle development
§ Give the them toys they can explore with fingers
§ Practice using both hands to explore at the same time
§ Work hard to reach toys by stretching and grabbing
§ Enjoy holding a small toy and shaking it
§ It'll be a few more weeks before the baby can use
thumb and fingers to pick up small objects
® Not have a definite hand preference at this time
§ Develops when the baby is about two years old
• Signs that indicate your child may not be developing as
other 6-month-old children:
® Seems to have very stiff tight muscles
® Seems very floppy like a rag doll
® Refuses to cuddle
® Shows no special reaction for those who care for them
® Does not seem to enjoy being around people
® Does not respond to sounds around them
® Has difficulty getting objects to their mouth
® Does not try to reach for toys
V. SECOND YEAR
• This is a time of rapid growth of development, particularly in
the realms of social-emotional and cognitive skills as well as
motor development [Kliegman et al]
• The toddler’s newly found ability to walk allows separation
and independence
® However, the toddler continues to need secure attachment
to the parents
A. 12-18 MONTHS
Physical Development
• Relatively short legs and long torsos, with exaggerated
lumbar lordosis and protruding abdomen
• Initial toddling: wide-based gait, knees bent, and arms flexed
at the elbow; entire torso rotates with each stride, toes may
point in or out and the feet strike the floor flat → appearance
is that of genu varus (bowleg)
® Refinement → greater steadiness and energy efficiency
• Most children begin to walk independently at about 12-15
mon of age [Kliegman et al]
• Increase in head circumference of 2 cm over the year
• Milestones [Kleigman et al]
® Gross Motor
§ 12 – 15 months: walks alone
§ 16 months: runs
® Fine Motor
§ 12 months: turns pages of book
§ 13 months: scribbles
§ 15 months: builds tower of 2 cubes
Language
• By 15 months, the average child:
® Points to major body parts
® Uses 4-6 words spontaneously and correctly
Trans 2.01 PED TG1: Lara, Galanido | TH: Castro
§ No alphabets and numbers
§ Words that can be considered are the ones that can be
used meaningfully, or for communication
• Enjoys polysyllabic jargoning
• Most communication of wants and ideas are non-verbal
® Receptive skills develop earlier than expressive skills
® They may use gestures, pointing, facial expressions
• Milestones [Kleigman et al]
® 15 months: speaks 4 – 6 words spontaneously and
correctly; average child ponts to major body parts
® 18 months: speaks 10 – 15 words
Socio-emotional Development
• “Intoxicated” and “Giddy” with their new ability to walk and
their power to control the distance between themselves and
their parents [Kleigman et al]
® Toddlers who are overly controlled and discouraged from
exploration will feel doubt, shame, anger, and insecurity
® They are normally curious – move around, pull cabinets –
they explore
§ Allow them to do these things because that is how they
learn
§ Do not discourage and let toddlers practice their
independence since these are age-appropriate skills
§ Insecure kids – too clingy to their parents, even with
their simple movements they look at their parents; they
are hesitant
• Exploring toddlers orbit around their parents, moving away
and then returning for a reassuring touch before moving away
again.
• Young children who turn to strangers when distressed are
particularly worrisome [Kleigman et al]
Cognitive Development
• Improved dexterity (reaching, grasping, releasing) and
mobility
• Manipulation of objects
• Playthings are used for their intended purpose
® Example: They play with toys purposefully
§ Use toy cars appropriately, not just spinning or taking
note of the wheels
• Imitation of parents and older siblings or other children –
important mode of learning [Kleigman et al]
• Make-believe (symbolic play) centers on the child’s own body
® Example: They use the spoon to pretend to eat, or hold a
phone and raise it to their ears
• Milestones [Kleigman et al]
® Uses stick to reach toy
® Pretend play with doll
• Most children still take two daytime naps, through the duration
steadily decreases [Kleigman et al]
B. 18-24 MONTHS
• Emergence of symbolic thought and language causes a
reorganization of behavior, with implications across many
developmental domains [Kliegman et al]
Physical Development
• Improvements in balance and agility
• Emergence of running and stair climbing
• By 24 months, children are ½ of their adult height
• 90% (85% [Kliegman]) of adult head circumference is achieved
® With just 5cm gain over the next few years
Cognitive Development
• Firm establishment of object permanence
® Has the ability to anticipate where an object will end up
® Know where to look for their toys
• Cause and effect are better understood
® Before, they just play on their toys accidentally; they bang
and smash and a sound is produced, or a light is emitted
® They can now use their toys purposefully – can switch on
and off, they can make the sound or movements of the
toys happen
• Toddlers have advanced flexibility in problem solving
® If a toy goes under the sofa, they use a stick to retrieve it
• Make-believe (symbolic transformation)
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Growth and Development Part I
® Play is no longer always centered on the child’s own body
® Instead of using spoon to pretend to eat, they’ll use it to
feed their dolls, stuffed toys, or even the people around
them
Socio-emotional Development
• Rapprochement[Kliegman]/Rapproachment [Sanchez] – (word does
not exist in the dictionary)
® Reaction to growing awareness of the possibility of
separation
§ They anticipate that their mother will be going away at a
certain time of the day – heightens separation anxiety
• Separation anxiety
® Child does not want to be separated from their parents
® Transitional object
§ Functions as a symbol of the absent parent
§ Can be used when the child experiences separation
anxiety (e.g. special blanket, stuffed toy)
Figure 3. Child with a transitional object
• Child’s use of “No” is a way of declaring independence [Kleigman
et al]
• Self-conscious awareness and internalized standards of
behavior first appear [Kleigman et al]
• Beginning of the formation of a conscience but there is a
relative weakness of internalized inhibitions [Kleigman et al]
® Example: child will tell themselves, “no, no” when tempted
to touch a forbidden object but will touch it anyway
Language
• Dramatic development in language (10-15 words at 18
months, to 50-100 words at 2 years)
• Combing words to make simple sentences
® You have to have at least 50 words in your vocabulary for
you to be able to combine words together
• 2-step commands
® e.g. get the ball and close the door (two different critical
elements)
§ NOT get the trash and throw it in the trash bin – same
element
• Labeling of objects coinciding with the symbolic thought
• Language is used as a tool to control over his surroundings
® Less crying, more use of words
• Emergence of language marks the end of the sensory-motor
period [Kleigman et al]
• Children with delayed language acquisition often have greater
behavior problems and frustrations due to problems with
communication [Kleigman et al]
• Helpful Tips to facilitate language development:
® Use clear, simple sentences
® Ask questions
® Respond to a child’s incomplete sentences
® Use of gestural communication with appropriate words
Help Me Grow Video – 2 Years Transcription
https://www.youtube.com/watch?v=y9Mm85UAWvM
• Playing with toys, creative materials, other children, and the
parents provide valuable ways for the two-year-old to learn
• Cognitive Development
® Able to point to and name many things
® Enjoy looking at pictures in books, the more realistic the
pictures, the better
® If they see themselves in a photo, likely to recognize it as
their picture
® Begin to sort and match
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§ Encourage this by pointing out things that match
® If they have heard action songs, able to perform some of
these actions along with the song
® Can follow simple two-step instructions
® Make-believe play begins
§ Imitate what they see their parents do around the
house, like sweeping or washing dishes
§ Ex: Baby shows what she is thinking with more
understanding when she can pretend (by putting her
dolly in a box in pretending the box is a bed)
• Language and Communication Development
® Vocabulary seems huge compared to a few months ago
® Knows and uses 200 to 300 words
§ Many of these are nouns (names of family members,
pets, and words like “car”, “doll” or “cat”)
§ Some may use a few pronouns (no, me, mine)
® You will be hearing sentences that may be two to three
words long like, "mum milk please."
® Minor pronunciation errors (e.g. "tat" for cat are common)
® Understands the power of "no," and will use it to
communicate to others often
® Use a variety of ways to communicate through words,
body language, facial expressions and, when overcome
with frustration or anger, tantrums
® Enjoy listening to other speak, and will repeat some other
words they hear
® Use new-found language to communicate their desires and
you will hear many words
® Understand simple instructions, and will respond the
communication directed to them
® Begin to have questions about everything in their world
around them
§ Help child develop more language by talking about what
they are doing
• Social and Emotional Development
® Very intense in their reactions and parenting can be a bit of
a challenge at this stage
§ Normal at this age to see a child have a tantrum when
he/she doesn't get her way
§ Needs help to learn to control their intense feelings
§ Stay calm when the child is having a tantrum
- Helps them learn to calm themselves
® If they show defiant behavior, need to redirect them
® Episodes of feeling anxious and upset when they are
separated from their parents
® Interested in playing with other children
§ Give regular chances to play with children their age
§ Playtime with other children helps them learn to develop
friendships, learn to cooperate and practice sharing
- Have their challenging moments because they need
help learning to share and cooperate
- Acknowledge their feelings and teach social skills at
the same time when a child is arguing over a toy
- You can say, "I know the truck is your favorite toy,
but Sam would like a turn at pushing it."
- Need adult supervision
• Large and Small Muscle Development
® Walking is their primary way to get around, and can run
® Move around obstacles instead of running into them
® Start and stop and walk backwards
® Walk up and down the stairs while holding onto the railing
or your hand
® Enjoy games and songs that involve actions and able to
perform the actions with improved imitations
® More developed ways of using their fingers and hands
§ Easily pick up small objects and manipulate them
§ Likely be putting toys together and taking them apart
§ When playing with blocks, able to build the tower have
several blocks high
§ When allowed to use crayons or markers, will scribble
around in circles
- Handedness is still not fully established, but you may
notice a preferred hand when scribbling
§ Less mouthing of toys and other objects, and more
§ likely to learn about things by looking and touching them
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• Things you can do to help your child grow and learn:
® Help them work through feelings of frustration and anger
® Keep reading or telling stories every day
® Ask them to find objects for you or name body parts and
objects
® Play matching games together
® Sing songs
® Provide toys that encourage creativity such as blocks,
cars, dolls, empty boxes, markers and paper
® Make sure your home is safe (child proofed)
• Signs that indicate a child may not developing as 2-year
old children:
® Unable to walk well, or walking on tiptoes
® Does not speak at least 50 words
® Not using two words sentences
® Does not imitate actions or words
® Does not follow simple instructions
VI. CHILDHOOD
A. PRESCHOOL YEARS (2 – 5 YEARS OLD)
• Critical milestones are represented by the emergence of
language and exposure to an expanding social sphere
• They explore emotional separation, alternating between
stubborn opposition and cheerful compliance, between bold
exploration and clinging dependence
• Brain Development [Kleigman et al]
® Increase in cortical area, decrease in cortical thickness,
and change cortical volume
® Not uniform across the brain but vary by region
® Dramatic increase in brain metabolic demand
® Form of “scaffolding” – use of greater number of brain
regions in younger children compared to older children
§ Discarded with increasing age
® Characterized by growth and expansion
§ In later years, pruning.
Physical Development
• Emergence of “picky” eating habits
• Establishment of handedness (by the 3rd year [Kleigman et al])
• Physical energy peaks
• Genu valgum (knock knees) and mild pes planus (flat foot);
torso slims as legs lengthen [Kleigman et al]
• Sleep declines to 11-13 hours / 24 hour
• Bowel and bladder control emerge
® Bedwetting is normal up to:
§ Age 4 in girls
§ Age 5 in boys
• Visual acuity
® 20/30 by age 3
® 20/20 by age 4
• Increase of 2kg (4-5 lbs) in weight and 7-8 cm (2-3 in) in
height per year [Kleigman et al]
• Birth weight quadruples by 2 ½ years
• 4-year-old approximately weighs 40 lbs and 40 inches tall
® Some variations exist due to difference in race
• All 20 primary teeth have erupted by 3 years old
• Children with early adiposity rebound (increase in BMI) –
increase risk for adult obesity
• Most walk with a mature gait and runs steadily before the end
of their 3rd year
Language
• Speech vs Language [Kleigman et al]
® Speech – production of intelligible sounds
® Language – refers to the underlying mental act
§ Includes both expressive and receptive functions
§ Receptive language (understanding) varies less in its
rate of acquisition than expressive language
§ Language acquisition depends on environmental input
- Key determinants: amount and variety of speech
directed toward children, frequency with which adults
ask questions and encourage verbalization
§ Linked to both cognitive and emotional development
§ Delays – first indication that a child has an intellectual
disability, has an autism spectrum disorder, or has been
maltreated
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§ Language development lays the foundation for later
success in school
• Most rapid language development occurs between 2 and 5
years [Kleigman et al]
® When developmental dysfluency and stuttering are most
likely to emerge
§ If stuttering is extreme, refer for evaluation
• From 50 – 100 words to > 2,000 words
• Advancement in sentence structure (from telegraphic to
sentences with major grammatical components)
• Rule of thumb: the number of words in a typical sentence
equals the child’s age.
• Use of possessives and progressives, questions, and
negatives
• By age 4: count to 4 and use past tense
• By age 5: they can use the future tense
• Literal meaning of words
• Asks lots of questions
• Communicates their natural curiosity
• Helpful tips:
® Parents should have a regular time each day for reading or
looking at books with their children; make use of dialogic
reading (repeatedly make the child focus on a picture, ask
questions, and give the child feedback)
® Television should be limited to 2 hr/day of quality
programming
Cognitive Development
• Magical thinking, fantasy, and imagination
® Includes confusing coincidence with causality, animism
(attributing motivations to inanimate objects and events),
and unrealistic beliefs about the power of wishes [Kleigman et
al]
• Perception-dominated
• Symbolic play (fantasy and imagination)
• Egocentrism – child’s inability to take another’s point of view;
does not connote selfishness [Kleigman et al]
• Tantrums
® Inability to delay gratification
® Inability to suppress or displace anger
® Unable to verbally express emotional state
® Peak prevalence between 2 – 4 years of age
® Tantrums lasting more than 15 min or regularly occurring
more than 3 times/day may reflect underlying medical,
emotional, or social problems
• By age 3, children have self-identified their sex, and actively
seeking understanding of the meaning of gender identification
[Kleigman et al]
• Helpful tips:
® Corporal punishment is highly discouraged
® Count down
® Setting limits
® Communication of rules
® Time out
® Frequent approval
Emotional and Moral Development [Kleigman et al]
• Emotional challenges – accepting limits while maintaining a
sense of self-direction, reining in aggressive and sexual
impulses, and interacting with a wide circle of adults and
peers
• At 2 year of age, behavioral limits are predominantly external
® Need to be internalized by 5 years of age
• Children start testing adults; increases when given attention
• Experience complicated feelings towards their parents
® Strong attachment and possessiveness – parent of the
opposite sex
® Jealousy and resentment – other parent
® Fear that these negative feelings might lead to
abandonment
® Resolution of this crisis → identify with their parents rather
than compete with them
• Curiosity about genital and adult sexual organs is normal, as
is masturbation
® Excessive masturbation that interferes with normal activity,
acting out sexual intercourse, extreme modesty, or mimicry
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Growth and Development Part I
of adult seductive behavior suggests possibility of sexual
abuse or inappropriate exposure
• Modesty appears gradually between 4 and 6 years of age
• Teach children about “private” body areas before school entry
• Moral thinking – constrained by cognitive level and language
abilities
• Child’s impulses are tempered by external forces
® Not yet internalized societal rules or a sense of justice and
fairness
® As child internalizes parental admonitions, words are
substituted for aggressive behaviors and then child learns
to accept personal responsibility
"$
• Actions are viewed by damage causes, not by intent
Help Me Grow Video – 5 Years Transcription
https://www.youtube.com/watch?v=7kAJvGARsn0
• Cognitive Development
® Easily identify objects by their shape and color
§ Pick out basic colors (red, yellow, blue, green, orange)
® Match and sort objects
§ Understand that one group of things are animals, while
the other group of things are all cars
® Count up to 10, perhaps beyond
® Understand and use concepts such as smaller, bigger, or
biggest, and sort objects by their size
® Understand direction such as under, over, and on-top
® Recognize some letters and numbers
• Social and Emotional Development
® Play well with other children and usually prefer to play with
other children
§ Helps children learn how to be part of a social group
§ Important because in school, children need to
understand how to get along with others, take turns,
help one another and solve problems
® More sensitive to the needs and feelings of others
§ May see another child crying and try to comfort them
® Can be very bossy
§ Know how to take turns and share, but may not want to
§ Can be sometimes be critical of other children
® Like to be the center of attention
• Large and Small Muscle Development
® Make drawings or paintings that contain details
§ May show a mouth, eyes, ears, feet and fingers
® Copy shapes and may be able to write letters without
copying
® Hand muscle development and coordination is evident
when they cut paper with scissors
® Use building toys that require them being fitted together
such as interlocking blocks
® Likely has a preference for using either right or left hand
® Go down the stairs by alternating their feet on each step
§ Run, hop and skip using alternate feet too
§ All the skills required good balance
® Enjoy playgrounds with swings, slides and climbing
structures
§ Physical exercise is very important for learning
• Language and Communication Development
® Speak clearly enough that they can be easily understood
® Able to reason, argue and use words like "because"
® Use longer sentences and tell longer stories
® Use future tense in their communication
® Able to say their name and address if this has been
practiced with them
® Sometimes, use swear words to get attention, often in
imitation of what they have heard adults say (TG Note:
Watch your words, adults!)
• Things you can do to help your 5-year-old grow and
learn:
® Helping your child get ready for kindergarten
® Play fun games that involve sorting and matching or have
your child sort laundry, match socks or sort the silverware
® Keep it fun by making everyday household tasks a game
® Provide a lot of opportunities to practice writing letters or
copying shapes
Trans 2.01 PED TG1: Lara, Galanido | TH: Castro
® Sing songs together, and you don't have to be a good
singer either
® Help your child learn to get along with other children by
giving them opportunities to play with other children
® Provide a wide variety of creative materials like Play-Doh,
paper and markers
® Read books and tell stories
§ They enjoy visiting the local library for story hour, and to
sign out books to read at home with you or other family
members or friends
• Signs that indicate that your child may not be developing
as other five-year-old children:
#
® Extremely aggressive behavior
® Unable to separate from parents without major protests
® Avoids or seems disinterested in interacting with other
children and adults
® Easily distracted and unable to concentrate on any single
activity for more than five minutes at a time
® Rarely uses pretend play
® Seems unhappy or sad much of the time
® Trouble eating or sleeping
® Seems uncomfortable holding a crayon or marker and
unable to make at least a crude drawing
VII. REVIEW
1. Which of the following is FALSE regarding a child’s
growth:
A. It is measured quantitatively including height, weight and
head circumference
B. Assessed using age-specific growth charts
C. Reflects changes in the child’s developing brain
D. Indicates the increase in physical size of the child
2. The ability of an infant to turn his/her head towards
his/her mother’s voice is an example of which domain of
development?
A. Cognitive Skill
B. Receptive Skill
C. Expressive Skill
D. Gross Motor
3. A one month old baby grows approximately at what rate?
A. 10 g/day
B. 20 g/day
C. 30 g/day
D. 40 g/day
4. BB, a 7-month old infant, came in with her mother for a
routine check-up. Which of the following findings could
indicate delayed development?
A. Responds ‘tatababata’ when you talk to her
B. Puts in her mouth everything that she can get her hands
on
C. Becomes quiet or distressed when meeting someone she
doesn’t know
D. Refuses to cuddle
5. T/F. Object permanence is a developmental milestone for
a 4-month old infant.
6. A mother of a 3-year old tells you that her child is
constantly rebelling and having temper tantrums. Your
most appropriate answer to the mother is to:
A. Physically punish the child every time the child says “no” to
change the behavior
B. Allow the behavior because this is normal at this age
period
C. Set limits on the child’s behavior
D. Ignore the child when this behavior occurs
7. You are evaluating the developmental level of a 2-year-
old. Which of the following will you expect to observe in
this child?
A. Uses a fork to eat
B. Uses a marker to scribble
C. Uses a knife for cutting food
D. Pours own milk into a cup
8. One of the red flags on the development of a 2-year-old
girl are the following except:
A. Unable to walk well
B. Does not speak at least 50 words
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Growth and Development Part I

C. Does not follow simple instructions

D. Does not use spoon and fork when eating VIII. REFERENCES
Quizlet Inc. (2019) Key Concepts and Theories of Growth and
9. You are in a family reunion and you noticed that your Development. Retrieved from https://quizlet.com/219356725/nur
grandmother restricts your 18-months-old nephew to 37900-sherpath-key-concepts-and-theories-of-growth-and
run and play with a big ball. What will you do? development-flash-cards/
A. Scold your grandmother and tell her not to be KJ Kliegman, R. M. et al. (2019). Nelson Textbook of Pediatrics. 21st edition.
B. Explain politely to her that your nephew needs to learn by Chapter 22 (The First Year) Chapter 23 (The Second Year)
Chapter 24 (The Preschool Year)
experience
C. Wait until your nephew cries if he stumbled when running
and playing
D. You do not have to do anything
10. What programs and how long should a 3-year-old child
spend in watching television?
A. Any program as long as it’s not rated SPG; 4-5 hours per
day
B. Any program as long as the parents are watching with the
child; no screen time limit
C. Quality television programs; 7-8 hours a day
D. Quality television programs; 2 hours per day
# Answer Page Section
1 C 1 III. Growth and Development
2 B 2 III. B. 2. Language
3 C 2 IV. A. 0-2 Months
4 D 3-4 Help Me Grow Video Transcription
5 F 3 IV. B. 6-12 Months
6 C 5-6 VI. Preschool Years: Cognitive Dev.
7 B 4-5 Help Me Grow Video Transcription
8 D 4-5 Help Me Grow Video Transcription
9 B 4 V.A. 12-18 Months
10 D 5 VI. Preschool Years: Language Dev

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Growth and Development Part I

IX. SUMMARY
Table 1. Growth vs Development Table 2. Periods of growth
Growth Development Stage Time Period
• Increase in physical size or the whole • Increase in skill and complexity of PRENATAL 0-280 days (~9months)
body or any of its parts function (locomotor, language, cognition,
POSTNATAL
social/emotional)
Infancy 0 – 2 years old
• Quantitative – measured in cm, in, kg, lb • Qualitative changes
Neonate First 4 weeks after birth
Table 3. Nature vs Nurture Infant First year
Nature Nurture Toddler 2 years old
• Inborn traits that are inherited from • Environmental influences before and Childhood 2 – 11 years old
parents after birth Early to Preschool 2 – 5 years old
® Good nutrition Middle to School-age 6 – 11 years old
® Upbringing and experience Adolescence 10 – 20 years old
Early 10 – 13 years old
• Examples: looks, color of eyes, hair and • Examples: use of gadget, watching tv,
skin, height anything outside hereditary influences Middle 14 – 16 years old
Late 17 – 20 years old

Table 4. Growth and Developmental Milestones Summary (Including Kleigman et al.)

Age Group Physical and Locomotor
0-2 months • BW: 3.4 kg (increase 30
g/day)
• Length: 50 cm
• HC: 35 cm
• Smiling involuntarily
• Sleep distributed
throughout the day
2-6 months • 3-4mos: 20 g/day
• 4mos: birth weight
doubled
• Loss of primitive
reflexes
• 14-16hr/day sleep
requirement
6-12 months • BW: tripled
• Length: inc. by 10%
• HC: inc. by 10cm
• Achievement of sitting
position
• Thumb-finger grasp (8-
9mos)
• Neat pincer (12 mos)
• Tooth eruption
(mandibular central
incisors)
Language Cognitive
• Crying (3hrs/day) • Differentiation of
patterns, colors and
consonants
• Identify mother’s voice
and smell
• 4mos: Hatching
• Exploration of body,
staring at hands, shakes
rattle
• Eyes follow moving
objects
• 6mos: monosyllabic • 6mos: manipulation of
babbling objects
• 7mos: inhibits to “no” • 9mos: object
• 8-10mos: polysyllabic permanence
babbling
• 9mos: reciprocity of
emotions
• 12mos: first true word
Socio-emotional
• Smile and eye contact
• Secure attachment
• Cry in response to cry of
another infant
• Facial expressions:
anger, joy, interest,
disgust, surprise
• Stranger anxiety
• Autonomy
Caretaking Activities
• Provide visual, tactile,
olfactory and auditory
stimuli
• Initiating games
• Avoid eye contact, talk
to parents first, introduce
toys to avoid stranger
anxiety
• 2-spoon method of
feeding
Red Flags
2 Months
• Not having regular times
when alert and
interactive
• Never smiles
• Body seems too stiff or
too floppy
• Never turns head from
one side to the other
6 Months
• Stiff tight muscles
• Floppy like a rag doll
• Refuses to cuddle
• No special reaction for
those who care for them
• Does not enjoy being
around people
• Does not respond to
sounds
• Difficulty getting objects
to mouth
• Does not reach for toys

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Growth and Development Part I
12-18 months • Short legs and long
torsos
• Exaggerated lumbar
lordosis
• Protruding abdomen
• Wide-based gait, knees
bent, and arms flexed at
the elbow
HC increases by 2 cm
18-24 months • Balance and agility
• Running and stair
climbing
• 24 mon: ½ their adult
height
90% of HC is achieved
PRESCHOOL • Picky eating habits
YEARS (2-5 • Birth weight 4x by 2 ½
YEARS) yr
• 4 yr: 40 lb and 40 in
• Physical energy peaks
• Sleep declines to 11-
13hr/24hr
• Visual acuity: 20/30
(age 3) and 20/20 (age
4)
• Genu valgum and mild
pes planus
• 3 yr: all 20 primary teeth
have erupted
• Handedness
• Bowel and bladder
control: girls (age 4) and
boys (age 5)
Trans 2.01 PED TG1: Lara, Galanido | TH: Castro
• Point to major body • Dexterity (reaching, • Intoxicated and giddy 12 Months
parts grasping, releasing) • Control distance • Not interested in playing
• 4-6 words • Manipulation of objects between self and • Does not react to loud
• Polysyllabic jargoning • Playthings used for parents noises or turn toward you
• Nonverbal intended purpose when you speak
communication of wants • Make-believe (symbolic • Does not make a range of
and ideas play) centers on own sounds
body • Not pointing as a way to
show what they’re
interested in
• Not moving about by
crawling or scooting
• Not trying to stand up
• Cannot walk when hand is
held
• 10-15 words to 50-100 • Established object • Separation anxiety • Use clear, simple 2 Years
words permanence Transition object: symbol sentences • Unable to walk well, or
• Combine words • Cause and effect of the absent parent • Ask questions walking on tiptoes
• 2-step commands • Flexibility in problem • Respond to a child’s • Does not speak at least
• Labeling of objects solving incomplete sentences 50 words
coinciding with symbolic Make-believe (symbolic • Use of gestural • Not using two words
transformation) sentences by age two
thought communication with
Language used to control appropriate words • Does not imitate actions
or words
over surroundings
• Does not follow simple
instructions
• 50-100 words to >2000 • Magical thinking, • Tantrums • Corporal punishment is 5 Years
words fantasy and imagination ® Inability to delay highly discouraged • Extremely aggressive
• Advancement in • Egocentrism gratification and to • Count down behavior
sentence structure § Perception-dominated suppress or displace • Setting limits • Unable to separate from
(major grammatical anger parents without major
• Communication of rules
protests
components) ® Unable to verbally • Time out
• Avoids/disinterested in
• Rule of thumb: number express emotional • Frequent approval interacting with other
of words in a typical state
children and adults
sentence equals the ® Peak prevalence • Easily distracted and
child’s age between 2-4 yr unable to concentrate on
• Possessives, § More than 15 min or any single activity for
progressives, more than 3 times/ day more than five minutes at
questions, negatives reflect medical, a time
• Literal meaning emotional or social • Rarely uses pretend play
• Lots of questions problem • Unhappy or sad much of
• Natural curiosity the time
• Trouble eating or
sleeping
• Seems uncomfortable
holding a crayon or
marker and unable to
make a crude drawing
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