GROWTH AND DEVELOPMENT GROWTH - PowerPoint Presentation

1. GROWTH AND DEVELOPMENT

2. GROWTH ; refers to increase in the physical size of the bodyDEVELOPMENT ; refers to increase in skills and functionsBoth are considered togetherNormal growth and development take place only if there is optimal nutrition Free from recurrent episodes of infections

3. ‘’CONCEPT OF NORMALCY’’A normal child may be defined as one whose characteristics fall within the range of measurements accepted as normal for the majority of children in the same ( or reference ) age group Conventionally these limits – ‘’the limits of normal variation’’- are assumed to include two standard deviations above and below the mean (i.e. between 3rd and 97th centiles)

4. Assessment of growthLongitudinal ; measuring the same child at regular intervalsCross sectional; comparing a child’ s growth with that of his peersCross sectional comparisons involve large number of children of the same age

5. Methods of assessmentParameters of growth are WeightHeight(or length)Head and chest circumferencesMid upper arm circumferenceThese characteristic are measured and compared with reference standards

6. Indices : Anthropometric indices are combinations of the measurements. They are important since mere measurements provide little useful information. For example, mere body weight has little utility unless it is related to age or height.In children three common indices used are WFH (weight for height) HFA (height for age) WFA (weight for age).

7. These indices could be expressed in the form of Z-scores, percentiles,and % of median which can then be used to compare a child to a reference population. To be useful, these measurements must be taken accurately using reliable equipment and correct measuring techniques.

8. (a) Z score : The deviation of the value for an individual from the median value of the reference population, divided by the standard deviation for the reference population.

9. (b) Percentile :The rank position of an individual on a given reference distribution, stated in terms of what percentage of the group the individual equal or exceeds. Percentiles are easy to use and thus preferred in clinical settings. The percentile is interpreted by the percent of individuals above and below specified percentile value.For example 35th percentile is described by 35% of the individuals lying below the value and 65% above.

10. Disadvantage Towards the extremes of the reference distribution there is little change in the percentile values for significant changes in height or weight.

11. (c) Percent of MedianThe ratio of a measured value in the individual, for example weight, to the median value of the reference data for the same age or height, expressed as percentage.

12. Advantages of using Z score over percentage of median1. Z-score cut-off point always at -2 Z-score2. Different cut-off points for % of median for different ages of children3. Z-score and percentage of median can yield differentresults - can cause misclassification4. Clearer interpretation of Z-score5. Misleading interpretation of % of median

13. DEVELOPMENT

14. DEVELOPMENTDevelopment is defined as the progressive acquisition of various skills (abilities) – CNS maturation.Development is an ordered process.Development occurs in a cephalocaudal and a proximodistal progression.There are critical periods for growth and development.Rates in development vary.Development continues throughout the individual's life span.

15. Growth Pattern

16. Gross Motor SkillsThe acquisition of gross motor skill precedes the development of fine motor skills.Both processes occur in a cephalocaudal fashionHead control (2-3m) preceding arm and hand controlFollowed by leg and foot control.

17. Head Control NewbornAge 6 months

18. Sitting UpAge 2 monthsAge 8 months

19. Fine Motor Development6-month-old12-month-old

20. Speech Milestones1-2 months: coos2-6 months: laughs and squeals8-9 months babbles: mama/dada as sounds10-12 months: “mama/dada specific 18-20 months: 20 to 30 words – 50% understood by strangers22-24 months: two word sentences, >50 words, 75% understood by strangers30-36 months: almost all speech understood by strangers

21. PERSONAL SOCIAL DEVELOPMENTSocial smile – 2mRecognizes mother – 3mStranger anxiety – 6mSmiles at mirror – 6mKnows gender – 3y

22. GROWTH MONITORING

23. COMPONENTS OF GROWTH MONITORING1.Accurately determine age.2.Accurately measure weight, length/height and head circumference.3.Plot measurements on appropriate growth chart. 4.Correctly interpret and assess the pattern of growth.5.Gather additional information to contribute to the assessment. 6.Discuss growth pattern with parent/caregiver and agree on subsequent action if required.

24. ANTHROPOMETRY FOR ASSESSING GROWTH WEIGHT :Most reliable criterion of assessment of health and nutritional status of children.Weight for age is most sensitive to changes in diet or infectious diseases.If only one measurement can be done, this is the most crucial.

25. RECORDING WEIGHTChildren should be weighed at each visit.To enhance accuracy of measurements:Use same scale at each visit.Scale should be zeroed daily and calibrated weekly.Infant scales should be used for children < 10kg.

26. WEIGHING SCALES:Beam type weighing scale (Detecto scale): -accuracy of + 20gElectronic weighing scales: -accuracy of + 5g

27. Salter spring machine: - suitable for field conditions. - convenient to carry.Bathroom type of weighing scale: - not very reliable.

28. Weighing Infants Remove all clothingYou can weigh infant wearing a dry diaperWeigh infants supineRecord weight to the nearest 0.1 kg

29. Weighing Older Children Remove all clothingWeigh older infants sitting with dry diaperRecord weight to the nearest 0.1 kg

30. WEIGHT INCREMENTSAGEINCREMENTS0 – 3 m200g / w4 – 6 m150 g /w7 – 9 m100 g / w10 – 12 m 50 – 75 g /w1 – 2 y2.5 kg / y3 – 5 y2.0 kg /y

31. Weight gainA baby should gain -500 grams /month in first three months- minimumHealthy babies double their birth wt by 5 months treble by end of first yearWeight increases : 7 kg 1st year 2.5 kg 2nd year 2 kg / year till puberty

32. HEIGHT/LENGTH:Indicator of nutritional status over a long period of time.Upto 2 y of age recumbent length instead of height is measured.Instrument used for measuring baby’s length - Infantometer.For older children a stadiometer or a non stretchable fibre glass tape is used.

33. Infantometer

34. Measuring InfantsMeasure length of children 0-2 years supine.Use 2 people. Straighten knees and keep ankles in neutral.Record measurement to the nearest 0.5cm.

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37. At birth length of baby is 50 cmDuring first year –increases by 25 cmDuring 2nd year –increases by 12 cmNutritional stunting; low height for age reflects past or chronic malnutritionNutritional wasting ;weight for heightAcute malnutrition

38. HEAD & CHEST CIRCUMFERENCEAt birth 34 cm(2 cm more than chest circumferemce)By 6-9 months two become equal after which the chest circumference overtakes the head circumferenceIn severly malnourished children this overtaking may be delayed by 3-4 years due to poor development of thoracic cage

39. GROWTH CHARTSGrowth chart or “Road -to- health” chart is a visible display of a child’s physical growth.Why Use Growth Curves?Easy and systematic way to follow CHANGES IN GROWTH OVER TIME for an individual child.Weight should be plotted at regular intervalsMonthly from birth to 1 yearEvery 2 m during second yearEvery 3 m thereafter till 5 y of age.

40. Reference valuesFor national and international comparisons and for monitoring reference or standard values of growth are essential1-Harvard and Boston standardsBased on observations made on children in BOSTON from 1930 to 19562-WHO reference valuesBased on extensive cross sectional data assembled by the UNITED STATES NATIONAL CENTRE FOR HEALTH STATISTICS(NCHS)3-INDIAN standards

41. Reference Vs Standard values :If the values are derived from a population racially different from the population under study such values should be considered as reference values only and not as standard valuesIt would be absurd to apply Harvard standards of growth to Eskimos who are racially different

42. WHO child growth standards ,2006In 1993, comprehensive review by WHO that concluded that NCHS growth references which had been recommended for international use are not adequateA Multicentre Growth Reference Study (MGRS)Was undertaken between 1997 and 2003 in BRAZIL, GHANA, INDIA, NORWAY,OMAN AND USA

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44. What are the pre-printed curves?Growth data collected from large numbers of children in a particular population.Normative growth rates (curves) created normative data on weight, height and head circumference by age and sex.

45. WHO Growth Charts

46. Growth charts used in IndiaWeight-for-age chart.Has 4 reference curves.Topmost curve corresponds to 80% of the median of the WHO reference standards.Lower curves correspond to 70%,60% and 50% of median.Weight lying above 80% curve = normalBetween 80% and 70% = Grade I(mild) malnutritionBetween 70% and 60% = Grade II (mod.) malnutritionBelow 60% = Grade III (severe) malnutritionBelow 50% = Grade IV;needs hospitalization

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48. IN FEBRUARY 2009, India has adopted the new WHO child growth standards The growth chart shows normal zone for weight for age undernutrition(-2SD) severly underweight zone(-3SD)

49. How to Use and Interpret a Growth CurveMeasure and weigh child using same methodology at each visit.Plot measurement on the vertical axis against age on the horizontal axis.Connect the dots and compare growth point with previous points.Assess growth percentile and look at the rate (speed of growth) over time.Direction of growth is more important.Curve running parallel to reference curves is satisfactory.Flattening or falling of growth curve suggests Growth Failure, earliest sign of PEM.

50. USES OF GROWTH CHARTS Growth monitoringDiagnostic tool: For identifying high risk children for e.g. malnutrition can be detected long before sign and symptoms become apparentPlanning and policy makingEducational tool: because of its visual character , mother can be educatedTool for action: for health workerEvaluation: to evaluate effectiveness of corrective measuresTool for teaching: importance of adequate feeding

51. Additional information to be recorded on growth chartIdentification and registration.Birth date and weight.Chronological ageHistory of sibling health.Immunization procedure.Introduction of supplementary foods.Episodes of sickness.Child spacing.Reasons for special care.

52. Defining Failure to Thrive(FTT)/Growth Failure (GF)There are several definitions Serial weight measurements that downwardly cross 2 major percentile lines on the growth chart over time.For a child already < 3% weight for age, failing to follow along its own upward curve.

53. Growth curve of child 1Birth-2.5 kg1 m- 3.4 kg2 m- 3.4 kg No weight gain

54. Growth curve of child 2Birth:4.2kg 1 m: 4.6 kg2 m: 5.0 kg3 m: 5.2 kg4 m: 5.6 kgDespite weight gain, curve not parallel to reference curve. Falling trend.Weight Gain But Growth Failure

55. Cases

56. Case 1: AishaAisha is a 3 month old infant who is being exclusively breast fed.Her mother is concerned she is not getting enough breast milk and wants to supplement with infant formula and porridgeShe was 2.5kg at birth, 3.4 kg at 6 weeks and currently weighs 4.4kg

57. Case 1: AishaPlot Aisha’s growth chart.What do you want to know?What will you tell the mother?

58. WeightBirth-2.5kg6 w-3.4kg3m-4.5=kgAisha’s growth chart.

59. Case 1: AishaYou explain to the mother that her daughter is getting enough from the breast milk.She was small at birth and is growing along her curve.Encourage her to continue exclusive breastfeeding till 6 months of age.Schedule follow-up in 1 month

60. Case 2: RaniRani is a 4 month-old enrolled at your clinic since birth.

61. Case 2: RaniMother reports that the baby is doing well except for loose stools often on since 15d.Mother has introduced top feeds with bottle along with breastfeeding since 1m as she thinks her milk is not enough for the baby.Rani’s weight has been as follows: 3.2kg at birth, 4.2kg (1 mo), 5.2kg (2 mo), 5.4 kg (3 mo), and 5 kg (4 mo).The rest of her examination is normal

62. Case 2: Rani Plot Rani’s growth chart.How would you describe her growth?What would you recommend to her mother?

63. Emily’s Growth CurveRani’s growth chart

64. Case 2: RaniRani has failure-to-thrive. Her curve has fallen suddenly suggesting acute malnutrition.Conduct a complete nutritional assessment.Advise and reassure mother to continue exclusive breastfeeding till 6m. Explain to mother the ill effects of bottle feeding (you can show her the child’s graph)Manage diarrhoea with ORS or antibiotic, as needed.Ask about other illnesses.

65. THANK YOU

66. MUACInterpretation of mid upper arm circumference using Shakir’s Tape.