Normal Growth, Principles of

growth & Teeth Eruption

Ganesh K Rai
 Outline of presentation
• Definition of growth and development
• Factors affecting growth
– Fetal growth
– Post-natal growth
• Principles/Laws of growth and development
• Rate of growth
• Period of growth
• Growth charts
• Dental development
• Growth denotes a net increase in size or mass of
tissues.
– Largely attributed to multiplication of cells and
increase in intracellular substance.
– Hypertrophy or expansion of cell size contributes to a
lesser extent
• Development specifies maturation of functions.
– Maturation and myelination of nervous system
– Acquisition of a variety of skills for optimal
functioning.
• Growth and development usually proceed
concurrently.
 Factors Affecting Growth
Fetal Growth
• Factors affecting fetal growth:
– Fetal
– Placental
– Maternal
• Genetic factors contribute 40% of variation in the
birth weight
• Environmental factors contribute 60 %
• Genetic potential:
– Tall parents have tall children
– Size of the head is more closely related to that of
parents than:
 size and shape of hands and feet.

– structure of the chest and fatty tissue has better

genetic association than other somatic characteristics
• Sex
– Boys are generally taller and heavier than girls at the
time of birth.
• Fetal hormones:
– Thyroxine and insulin regulate tissue accretion and
differentiation
– Glucocorticoids influence the prepartum maturation of
organs such as:
 liver
 lungs and
 gastrointestinal tract
– Growth hormone is not known to influence fetal
growth
• Fetal growth factors:
– A large number of growth factors are synthesized
locally in fetal tissues
– They act principally by autocrine and paracrine
mechanisms.
– Their prime effect is on cell division
– They also influence other aspects of tissue growth
– These factors can be both growth promoting or
inhibitory
1. Growth promoting factors:
– insulin like growth factor (IGF)-1 and-11
– epidermal growth factor (EGF)
– transforming growth factor (TGF-a)
– platelet derived growth factor (PDGF)
– fibroblast growth factor (FGF)
– nerve growth factor
2. Growth Inhibitory factors:
– Mullerian inhibitory substance
– Inhibin/ activin family of proteins
 Placental factors
• Fetal weight directly correlates with placental weight at
term.
• Fetal growth is dependent on the structural and functional
integrity of the placenta.
• Weight of placenta increases to cater to increased needs
of the baby with advancing gestation
• Villous surface area increases and diffusion distance
decreases
• Placenta remodeling facilitates nutrient transport across
the placenta
 Maternal factors
• Mother’s nutrient intake and body composition
at the time of conception and during pregnancy
• Negatively influencing (retarding) factors on fetal
size and health.
– Teenage or advanced age
– Recent pregnancy
– High parity
– Anemia
– Tobacco smoking or chewing
– Drug or alcohol abuse
– Pregnancy induced hypertension
– Pre-eclampsia
– Multiple pregnancies
– Preexisting chronic systemic diseases:
 chronic renal failure, congestive heart failure
 acquired infections (TORCH)
 Postnatal Period
• Growth of the child during postnatal life is
determined by:
– Genetic potential
– Internal and external influences
• Genetic factors
– Chromosomal disorders and mutations in specific
genes can affect growth.
 Turner syndrome and Down syndrome
 Mutation of single genes: Prader-Willi syndrome,
Noonan syndrome.
– Most disorders lead to short stature
– Some genetic defects can also result in tall
stature:
 e.g. Klinefelter syndrome and Sotos syndrome
• Intrauterine growth restriction (IUGR):
– IUGR result in low birth weight (LBW)
– LBW constitutes an important risk factor for postnatal
malnutrition and poor growth

• Animal milk increases morbidity due to infections:

– leading to underweight and stunting

• Faulty complementary feeding practices

• Hormonal influence:
– Growth hormone and thyroxine influence both
somatic and skeletal growth.
– Androgens and estrogens have influence on the
growth spurt and final adult height

• Sex
– Pubertal growth spurt occurs earlier in girls.
– Their mean height and weight are usually less than
those in boys of corresponding ages at the time of
full maturity
• Trauma
– A fracture at the end of a bone may damage the
growing epiphysis and hamper skeletal growth

• Nutrition
– Protein-energy malnutrition, anemia and vitamin
deficiency states retard growth
– Calcium, iron, zinc, iodine and vitamins A and D
deficiencies are closely related to disorders of growth
and development
• Infections:
– Persistent or recurrent diarrhea and respiratory tract
infections are common causes of growth impairment.
– Systemic infections and parasitic infestations may also
retard the velocity of growth.

• Chemical agents:
– Androgenic hormones: dual effect:
 Initially accelerates the skeletal growth
 However, they cause the epiphyses of bones to close
prematurely, leading to early cessation of bone growth
 Social Factors

• Socioeconomic level
• Poverty
• Natural resources
• Improved nutrition of children
• Climate:
– Velocity of growth is higher in spring and low in
summer months
– Infections and infestations are common in hot and
humid climate.
– Weather affects agricultural productivity, ready
availability of food
• Emotional factors:
– Children from broken homes and orphanages do
not grow and develop at an optimal rate.
– Growth hormone release is influenced by:
 Anxiety
 Insecurity
 Lack of emotional support and love
• Cultural factors:
– Methods of child rearing and infant feeding in the
community are determined by cultural habits and
conventions.
– Religious taboos against consumption of particular
types of food

• Parental education:
– Mothers with more education are more likely to
adopt appropriate health promoting behaviors
 Laws (Principles) of Growth

1. Growth and Development is a continuous process from

conception to maturity
2. Normal development requires an anatomically and
functionally normal central nervous system and pathways
3. Development occurs in a orderly and predictable sequence
4. Rate of development varies from child to child
5. Response to stimuli change from generalized mass activity
involving whole body, as seen in newborn, to discrete
voluntary actions that are under cortical control
6. Certain primitive reflexes have to be lost before voluntary
functions are required
1. Growth and Development is a continuous process
from conception to maturity:
• Newborn is not able to turn around, sit, reach for
objects, laugh or interact.
• In due course of time, child acquires all these functions

2. Normal development requires an anatomically

and functionally normal central nervous system and
pathways:
• A child with abnormal CNS (e.g. anencephaly) or
damaged neurons (e.g. hypoxic insult) is unlikely to have
normal development
3. Development occurs in a orderly and predictable
sequence:
• From cephalic to caudal (head to toe) and proximal to
distal
• Head control develops before sitting and standing
• A child can do much with hands before walking

4. Rate of development varies from child to child:

• A child learns to sit before standing
• But, age of attainment of sitting and standing varies
among children
5. Responses to stimuli change from generalized
mass activity involving whole body, as seen in
newborn, to discrete voluntary actions that are
under cortical control:
• Child moves from non-specific and symmetrical
responses (vocalizations, kicking with both hands and
legs) to asymmetrical and precise responses over time
(grasping with one hand, use of specific word)

6. Certain primitive reflexes have to be lost before

voluntary functions are required:
• Grasp reflex has to be lost before an Infant can reach for
a object and grasp voluntarily
 Different tissues grow at different
rates
• Brain growth:
– Brain enlarges rapidly during latter months of fetal life
and early months of postnatal life.
– At birth, head size is about 65-70% of expected head
size in adults.
– It reaches 90% of adult head size by age of 2 yr.
– Fetal phase and first two years are crucial periods for
brain development.
– Later periods are important for acquiring
neuromotor functions and cognitive ability
• Growth of gonads.
– Gonadal growth is dormant during childhood
– They become conspicuous during pubescence

• Lymphoid growth.
– Growth of lymphoid tissue is most notable during
mid-childhood.
– During this period, lymphoid tissue is overgrown and
its mass may appear to be larger than that of adult.
– A sign of accelerated lymphoid growth:
 Frequent finding of large tonsils
 Palpable lymph nodes in normal children between 4
and 8 yr.
 Periods of growth
Prenatal period
• Ovum: 0 to 14 days of gestation
• Embryo: 14 days to 9 wks of gestation
• Fetus: 9 wks to birth
• Perinatal period: 22 wks to 7 days after birth
Postnatal period
• Newborn: First 4 wks after birth
• Infancy: First year
• Toddler: 1-3 yr
• Preschool child: 3-6 y
• School age child: 6 -12 y
 Adolescence
• Early: 10-13 yr
• Middle: 14-16 yr
• Late: 17-20 yr
 Growth Charts (curves)
• Are used to measure growth:
– WHO, CDC, National center for health statistics
(NCHS) growth charts
– Weight for age
– Length/Height for age
– Weight for length/height
– Head circumference
Z Scores is calculated as below:
• Observed value − median reference/ SD of
reference population
• Z scores are labeled as 1, 2, 3, –1, –2, and -3
• Value of –2 Z score corresponds to 3rd
percentile.
• These indicate how far points are above or below
the mean (Z score 0).
• A range of ±2 Z scores includes 95.4% of all
observations
• Conventionally accepted limits of normality
• Distance growth curve is a measure of size over time:
– It records height, weight, and/or head circumference as a
function of age
– It gets higher with age
• Velocity growth curve measures the rate of growth at
a given time for a particular body feature:
– such as height or weight
– Height velocity curve is highest in infancy, up to 2 years of
age, with more consistent annual growth afterwards and
increases again at puberty
• Any faltering in growth process may indicate disease.
Distance & Velocity growth curve
• In a child’s life, rate of growth is steady, accelerates
or decelerates
• Fetus grows fast in the first half of gestation:
– Thereafter, rate of growth is slowed down until baby is
born.
• In early postnatal period, velocity of growth is high:
– especially in the first few months.
• There is slower but steady rate of growth during
mid-childhood.
• A second phase of accelerated growth occurs at
puberty.
• Growth decelerates, thereafter, for some time and
then ceases altogether.
Distance Growth Curve of Height for Boys

Velocity height curve

Growth faltering
 Anthropometric measures of normal full
term newborns:
• Birth weight: 2.5–4.0 kg
• Length: 50 cm (around)
• Head circumference: 34–35 cm

Source: IAP
 Weight gain: Average daily weight gain
• First 3 months: 30 g
• 3–6 months: 20 g (birth weight doubles by 5–6
months of age)
• 6–9 months: 15 g
• 9–12 months: 12 g (birth weight triples by first
birthday)
• 1–3 years: 8 g (around 3 kg/year). birth weight
quadruples by 2 years of age.
• 4–6 years: 6 g (around 2 kg/year); this rate of gain
continues till the onset of puberty
 Length/height gain (height velocity)
• Birth to 3 months: 3.5 cm/month
• 3–6 months: 2.0 cm/month
• 6–9 months: 1.5 cm/month
• 9–12 months: 1.2 cm/month
• 1–3 years: 1.0 cm/month
• 4–6 years: 5 cm/year (at 4 years =
100 cm; double of birth length)
 Gains in length
• During first year of life: 25 cm
• During second year of life: 12.5 cm
• During third year of life: 7.5–10 cm
• 7 cm/year at 3–4 years
• 6 cm/year at 5–6 years
• 5 cm/year till puberty
• In immediate pre-pubertal period:
– Growth velocity slows down before the pubertal
spurt begins (adrenarche)
 Abnormal growth:
• Less than 7 cm/year for less than 4 years of age
• Less than 6 cm/year for 4–6 years
• Less than 4.5 cm/year for 6 years–onset of puberty
 Changes in head circumference
• At birth: 35 cm
• Birth to 3 months: 2 cm/month
• 3–6 months: 1 cm/month
• 6–9 months: 0.5 cm/month
• 9–12 months 0.25 cm/month
• On first birthday: 46–47 cm, 35% increase from
birth size
• At 2 years age: 48 cm
• At 5 years: 50–51 cm
• 12 years: 52 cm
 Dental Development

• Eruption of teeth follows a definite sequence.

• Eruption of temporary or deciduous teeth begins
at about 6 months
– with upper or lower central incisors, followed by
lateral incisor.
• By 1 year of age 4–8 teeth are present.
• Permanent teeth begin to erupt at 6 years.
 Timing of dentition
Time of eruption (months) Time of fall (years)
Primary dentition
Upper Lower Upper Lower

Central incisors 8-12 6-10 6-7 6-7

Lateral incisors 9-13 10-16 7-8 7-8

First molar 13-19 14-18 9-11 9-11

Canine 16-22 17-23 10-12 9-12

Second molar 25-33 23-31 10-12 10-12

 Time of eruption (years)
Permanent Teeth
Upper Lower Upper Lower

First molar 6-7 6-7 First 10-11 10-12

premolar
Central incisors 7-8 6-7 Second 10-12 10-12
premolar
Lateral incisors 8-9 7-8 Second 12-13 11-13
molar
Canine 11-12 10-12 Third 17-21 17-21
molar
Thank You