GROWTH &

DEVELOPMENT IN
CHILDREN
Martira Maddeppungeng
DEPARTMENT OF CHILD HEALTH,
HASANUDDIN UNIVERSITY
DR. WAHIDIN SUDIROHUSODO HOSPITAL

Children
Have a typical characteristic always
growth & development different from the
adult.
Children is not a miniature of the adult
The law protection of child No. 23 year 2002
Section 4 from the law protection of child :
every child is entitled to be able to live,
growth, develop and participating to the
manner born

 Child :
conception 18 years (Convention of Child
Right /CRC and Indonesian Child Protection
Right)
Based on :
anatomical growth (epipyphise clossing, reproductive
system maturation etc. )
Psychosocial development (adolescent adulthood)

Child not a miniature of adult !!

Specific aspects : growth and development

CHILDREN Hope The parents

The nation
The world

GROWTH-DEVELOPMENT
IN CHILDREN
GROWTH the change of large, amount,
measures or dimension of the cell stage,
organ and individual
- body weight, body length, bone age,
circumference head, circumference of the arm
DEVELOPMENT increasing of the skill in
struture and body function which more
complex, regular pattern, can be forecasted,
the result of process maturation

Stages of growthdevelopment
I. The periods of prenatal (intra uterin) is divided 2 :
a. The periods of embryo conception age of
eight weeks
b. The periods of foetus age of nine weeks
the birth
- Early Foetus (9 weeks trimester 2)
acceleration growth, forming of physic, body
appliance have been formed & start to
function
- Advanced foetus final trimester of growth
take place fastly & existence of growth of
functions of Ig G transfer, the accumulation
of fat of esensial (Omega 3 and Omega 6)

Stages of growthdevelopment
II . The periods of postnatal (after birth)
1. The periods of neonatal (0-28 days) adaption to
environment, the change of blood circulation, start
to the function of body organ
2. The periods of baby
- The periods of early baby (1-12 months) rapid
growth, maturation process take place continue,
the increasing of nerve system function
- The periods of final baby (1-2 years) speed of
growth start decrease, progress of growth of
motor & function of escretion

3. The periods of preschool (2-6 yr) stable of

the growth, corporeal activity increase & the
increasing of skilled & process of thinking
4. The periods of school ( 6-10 yr, 8-12 yr)
rapid growth, skill and intelectual more
expand, like to play in the team
5. The periods of adolescent ( 10-18 yr, 12-20
yr) the transition of period of child to adult,
acceleration growth, marking of secondary sex

The characteristic of growth

1. Change of measure physical ;
increasing of the body organ
improvement of requirement of body
increased
2. Change of proportion head of the
newborn baby relative have the bigger
proportion than age furthermore.
Center body in umbilicus, adult as
high as pubis symphisis

The characteristic of growth

3. The vanish of old marking growth
process disappearing of the thymus
gland, fall out of the milkteeth, the
vanish of primitive reflects
4. Appear of the new marking the
maturation effect of organ function
permanet tooth, the marking of
secondary sex

Proportion of body height

200
LYMPHOID TYPE

180

PERCENTAGE

160
140
120
NEURALTYPE

100
80
GENERAL TYPE

60
40

GENITAL TYPE

20
0

12

16

20

AGE IN YEARS
Fig 5. Main types of postnatal growth of the various parts and organs of the
body. (After Scammon: The measurement of the body in childhood. In: Harris
B et al (eds): The Measurement of Man. Minneapolis, University of Minnesota
Press, 1930)

Curve growth pattern

Pattern growth of general

Pattern growth of organ limfoid
Pattern growth of brain & head
Pattern growth of organ reproduce

Pattern growth of general

Characteristic body length
Fast until age 2 yr stabile (influence of
growth hormone)
Puberty effect hormone of sex
the growth go on quickly stopping

22

Mencapai tinggi, cm per tahun

20
18
16
14
12
10
8
5
4
0

10

12

14

16

18

UMUR, TAHUN
Gambar 1. Kurva laju kenaikan tinggi badan anak laki-laki
de Montbeillard

Pattern growth of organ

limfoid
Growth quickly until 200% at age 12 yr,
downhill gradually until adult age become
100% child at the period of puberty
stronger endurance relative

Pattern growth of brain &

head
Brain & head are growth more quickly
than other organ since intrauterine

Pattern growth of organ

reproduce
A period of child growth development sex
organ very tardy
A period of puberty remarkable acceleration
Growth of organ reproduce in line with growth
of ability of sexual

Table 3. Classification of Sex Maturity Stages in Girls

(Tanner)
SMR
Stage

PUBIC HAIR

BREAST

1
2

Preadolescent
Sparse, lightly pigmented,
straight, medial border of
labia
Darker, beginning to curl,
increased amount
Coarse, curly, abundant but
amount less than in adult
Adult feminine triangle,
spread to medial surface
of thighs

Preadolescent
Breast and papilla elevated
as small mound; areolar
diameter increased
Breast and areola enlarged,
no contour separation
Areola and papilla form
secondary mound
Mature; nipple projects,
areola part of general breast
contour

3
4
5

*Adapted from Tanner JM: Growth at Adolescence, 2nd ed. Oxford, Blackwell
Scientific Publications, 1962

Table 4. Classification of Sex Maturity Stages in Boys

(Tanner)
SMR
Stage

PUBIC HAIR

PENIS

1
2

None
Scanty, long, slightly
pigmented

Preadolescent
Slight
enlargement

Darker, starts to curl,

small amount

Longer

Resembles adult type, Larger; glans

but less in quantity;
and breadth
coarse, curly
increase in
size
Adult size
Adult distribution,
spread to medial
surface of thighs

TESTES

Preadolescent
Enlarged scrotum,
pink texture
altered
Larger
Larger, scrotum
dark

Adult size

*Adapted from Tanner JM: Growth at Adolescence, 2nd ed. Oxford, Blackwell
Scientific Publications, 1962

Fig 15. Female pubic hair development. Sexual maturity rating 1 (SMR 1) : Prepubertal; no pubic hair.
SMR 2 : Straight hair is extending along the labia and, between ratings 2 and 3, begins on the
pubis. SMR 3: Pubic hair has increased in quantity, is darker, and is present in the typical female
triangle but in smaller quantity. SMR 4: Pubic hair has increased in quantity, is darker, and is more
dense, curled, and adult in distribution but less abundant. SMR 5 : Abundant, adult-type pattern;
hair may extend onto the medial aspect of the thighs. (From Daniel WA, Paulshock BZ. A
physicians guide to sexual maturity rating. Patient Care May 30,1979, with permission. Illustration
by Paul Singh-Roy)

Fig 17. Male genital and pubic hair development. Ratings for pubic hair and for genital development can
differ in a typical boy at any given time, because pubic hair and genitalia do not necessarily
develop at the same rate. Sexual maturity rating 1 (SMR 1): Prepubertal; no pubic hair. Genitalia
unchanged from early childhood. SMR 2: Light, downy hair develops laterally and later becomes
dark. Penis and testes may be slightly larger; scrotum becoms more textured. SMR 3 : Pubic hair
has extended across the pubis. Testes and scrotum are further enlarged; penis is larger, especially
in length. SMR 4 : More abundant pubic hair with curling. Genitalia resemble those of an adult;
glans has become larger and broader, scrotum is darker. SMR 5 : Adult quantity and patterm of
pubic hair, with hair present along the inner borders of the thighs. The testes and the scrotum are
adult in size. . (From Daniel WA, Paulshock BZ. A physicians guide to sexual maturity rating.

Fig 19. Sex maturity ratings of breast changes in adolescent girls. (Courtesy of
JM Tanner, M.D., Institute of Child Health, Department of Growth and
Development, University of London, London, England)

BREAST 5
PUBIC HAIR 5

PUBIC HAIR 5

GENITAL 5

MENARCHE

PUBIC HAIR 4
PHV
PUBIC HAIR 3
GENITAL 4

BREAST 4
PUBIC HAIR 4
PUBIC HAIR 3

BREAST 3

PUBIC HAIR 2

PHV

GENITAL 3

PUBIC HAIR 2
BREAST 2

GENITAL 2

Fig 20. A. Sequence of pubertal events in males. B. Sequence of pubertal

evets in females. (From Root AW. Endocrinology of puberty. J
Pediatr 1973; 83:119).
PHV = Peak Height Velocity

Child Growth

Increases of physical sizes

1.
2.
3.
4.

height
weight
head circumference
etc

Increases of cells, matrixes, connective tissues,

bones, muscles, organ systems etc.

Determinant factors of growth

internal :

genetic : father, mother, grandpa,

grandma
intrauterine process : nutrition, disease,
drug, polution, toxin ,

external : nutrition, disease, polution,

exercise, emotional support

 Addition of body length

Trimester I
Timester II
Trimester III
Trimester IV

:
:
:
:

2,8 4,4 cm / months

1,9 2,6 cm / months
1,3 1,6 cm / months
1,2 1,3 cm /months

Addition of body length

0-3 mth =
3-6 mth =
6-9 mth =
9-12mth =
1-3 yr =
4-6 yr =

3,5 cm/mth
2,0 cm/mth
1,5 cm/mth
1,2 cm/mth
1,0 cm/yr
3,0 cm/yr

Estimate of body length

a. Born
b. Age 1 yr
c. 2-12 yr

= 50 cm
= 75 cm
= age (year) x 6 + 77

Influence of genetic to
body height
Range of predictional final height at 18 years old
Boys = (Father + mother height + 13 cm ) + 8,5 cm
2
Girls = (Father + mother height 13 cm) + 8,5 cm
2

Body weight
Influenced by :
Genetic (clan)
Intake nutrition (eat, drink, snack)
Absorbtion of intestine & escretion
Physical activity
Metabolism of the body, hormone
Chronic disease (heart, urinary tract infection,
tuberculosis)
content water and body fat

 Addition of body weight

Trimester I : 700 1000 gram/month
Timester II : 500 600 gram/month
Trimester III : 350 450 gram/month
Timester IV : 250 350 gram/month

 Circumference head
Relating to growth of brain volume
Circumference head more bigger (macrocephaly)
88 % IQ normally
5 % mild mental retardation
7 % severe mental retardation (Lober &
Priestly, 1981)
Circumference head more small than normally
(microcephaly) mental retardation
History of pregnancy, birth, disease untill age 3
year close with mental retardation

Age ~ brain
20 weak ~ 100 g
Born

~ 400 g

18 month ~ 800 g
3 year

~ 1100 g

Adult

~ 1400 g

37

38

Development
Development increasing of the
ability/ function from all the body
organ systems; result from
increased of the maturatiy body
organ system function

 The characteristic of development

Development entangle the change every
growth accompanied by change of function,
example development of the reproduction
system accompanied by change of organ
sexual
Early development determining the growth
hereinafter. Cannt pass one development
phase before passing step before all

 Development have the constant pattern

area lead to caudal (cephalocaudal)
area of proximal to shares of distal
(proximodistal)
Development have the successive phase
successive and regular pattern
Development have the different speedy
Development have the correlation with growth

Child Development

Increases of all child functions

1.
2.
3.
4.
5.
6.
7.
8.
9.

Sensory : auditory, visual

Motor : gross, fine motor
cognitive (knowledge, inteligence)
communication / language
socio-emotional, behavior
self help
creativity
leadership
spiritual

Increases maturation of organ system : mainly brain and

neuromuscular system
Determinant factors of child development

internal : genetic + intrauterine processes

external : nutrition, diseases, quality of family,
baby sitter (care-givers), playmates, school

 Development monitoring
4 aspects of development
1.
2.
3.
4.

Gross motor
Fine motor and vision
speech,language and hearing
Sosial, emosional, behavioral

Child Developmental
Aspects

CHILD GROWTH &

DEVELOPMENT Determinat factors :
(genetic- heredokonstitutional)

+ EXTRINSIC ( environment)

INTRINSIC

Role of environment :
fulfill the basi
needs
for Child Growth &
Development

Mother, Substitute
Mother, Substitute
Father, siblings, caregiver,
toys, stimulation, norm,

Biopsychosocia
needs

(Kobayashi, 1985; Bronfenbrenner, 1986; Sularyo, 1989; Ismael, 1991, Needlman, 2000)

What is the role ?

I. Genetic
The parents : father, mother,
grandmother,
grandfather
Sex, ethnic, nation
II. Environment

The Basic Needs for Better Growth &

Development
1. BIOLOGICAL NEEDS : nutrition (breastfeed
exclusively
), immunisation, hygiene, health
services, clothes, housing, sanitation,
plays
facility, sport, recreation
2. PSYCHOSOCIAL NEEDS
Emotional needs : democratic parenting
love, warm, attention, care, protection, help,
support, reward, guidance, models
Stimulation / play needs : auditory, visual,
gross
& fine motor, communication /
language,
cognitive / intelligence,
emotion & social,
self-help,
creativity, leadership, spiritual

Basic Needs for Better

Growth & Development
I. BIOLOGICAL NEEDS
1. Nutrition : since intra-uterine (fetal)
Balance of : protein, carbohydrate,
fat, vitamin, mineral
Protein : cells & organ growth and
function, protection for infection
Carbohydrat : energy, cells
activities
Fat : energy, cells functions &
activities
Vitamin & Mineral : regulator

Basic Needs for Better

Growth & Development
(Biologic
Nutrional Needs)
intake problems :
apetite :

disease :systemic, oral, teeth, pharyngeal, bowel,

attention, emotional

food appearence, smell, taste, colour, shape

much snack or drink between meals
models : parent, sibling, playmates
attitude of care giver

Food Substitute / supplement

added if needed
depend on individual daily intake
depend on individual problem or diseases
depend on status growth & development

Basic Needs for Better

Growth & Development
(Biologic Needs)

2. Immunization : since newborn 18 years

protect for diseases prevent severity

Hepatitis B, BCG, DPT, Polio, Measles
HiB, MMR (Mumps, Morbilli, Rubella),
Thypoid Fever, Chicken Pox, Infulenza etc

3. Hygiene :

Personal : wash hand, nail, bath, toilet

Food : meals, vegetables, fruit, water, snack
House, School, Playground, Transport, Public
Area
Environment : smoke, dust, waste, toxins,
insect

Basic Needs for Better Growth

& Development (Biologic
Needs)
4. Play
/ physical activities
stimulates growth hormones, apetite,
metabolism of protein, carbohydrat, fat
stimulates muscles & bone growth
stimulates developmental

5. Medical services :

prevention for diseases : immunization,

education
monitoring growth & development
early detection & treatment
diseases
delay of growth & development

Basic Needs for Better

Growth & Development
II. EMOTIONAL NEEDS : since
intrauterine (6 months of
pregnancy)
DEMOCRATIC PARENTING love,
warmth, attention, care, protection,
reward, fair
guidance, models, less prohibition
no physical punishment
develop basic trust, emotional
inteligence, self-esteem,
cooperation, creativity

Basic Needs for Better

Growth & Development
(Emotional Needs)

Parenting styles
1.
2.
3.
4.

Democratic (authoritative)
Dictator (authoritarian) punishment, abuse
Permissive no rule
Uninvolved neglect

Child Temperament
1. Easy
2. Difficult
3. Slow to warm

Basic Needs for Better

Growth & Development
III. STIMULATIONS NEEDS : since intra
uterine (6 mo of pregnancy)
sensoric, motoric, cognitive, communication language, socio-emotional, self-help, creativity,
cooperation and leadership, spiritual etc
through repetitive experiences : parents
sounds, music, movement, touch, speak,
singing, act, play, brain gym, write, draw,
repetitive experiences : stimulates complecity
connection (synaps) between brain cells,
left & right brain
develop multiple inteligence

Timing for stimulations synaptogenesis.

Huttenlocher, 1987; Jernigan, et al, 1991; Pfefferbaum et all, 1994

Cerebral glucose metabolic

rate

Age (in years)

(Chugani, 1999)

Basic Needs for Better

Growth & Development
(Stimulation Needs)

Left brain

logico mathematic, rational analytic, science

grammar, reading, writing

Right brain

imagination, creativity, art

socio-emotional, musical, singing, spatial
cooperation, leadership
spiritual

Stimulators : parent, care-giver, siblings,

playgroup, school, TV, magazine, books, tools

Basic Needs for Better

Growth & Development
(Stimulation Needs 1)
Since intra-uterine until school-age

Since intra-uterine until school-age

Based on : DEMOCRATIC PARENTING
love, warmth, attention, care, protection,
reward, fair, guidance, models, less
prohibition
By mother, father, other care-giver
(baby sitter, grandma-pa, aunt)
Everytime you have time to make
contact with your baby / child
Everyday

Which one is the most

important for better
All of the basic needs important :
growth
&
development
?
Biological needs
Emotional needs
Stimulations needs

They influences and supports each

others
If insufficifient delay growth &
development occur deviant

What should be done

for better child growth
1. Meet all the BASIC NEEDS for growth &
& development
(1)?
development
since intra-uterine
:

BIOLOGICAL NEEDS: nutrition, immunization,

hygiene, sport, medical services etc.
EMOTIONAL NEEDS: democratic parenting
love, warmth, attention, care, protection,
reward, guidance, models
STIMULATIONS: NEED sensoric, motoric,
cognitive, language, socio-emotional, selfhelp, creativity, leadership, spiritual etc

What should be done for

better child growth &
development (2)?
2. The Basic Needs should be met by :

2. The Basic Needs should be met by :

mother & father
health staff : as educator, services
other care-giver (baby sitter, grandma,
aunt)
sibling
playgroup, preschool staff
educator
mass-media

What should be done for

better child growth &
3. Monitoring periodically
development
(3)? for growth
& developmental

growth : using growth curve chart

development : using screening tool
(Denver II) or milestones

4. If any suspicious of delay growth

or development consult to family
physician or paediatrician

Monitoring & early

detection
Growth monitoring:

Weight, height, head circumferrence

Nutritional status : weight - height

Development monitoring

Gross motor
Fine motor (and vision)
Speech, hearing, communication, cognition
Social, emotional, behaviour

Family education and conseling in

Growth and development

Nutrition, immunisation, play, stimulation, education
Protection from risks of :
Bio-physics hazard : infection, polution, accident, addiction
Psychosocial hazard : abuse, neglect, exploitation ,

Normal development milestone

Gross motor

Percentile
90 Denver II

Roll over
5.4 mos
Sit no support
6.8 mos
Stand holding on
8.5 mos
Stand 2 seconds 11.6 mos
Stand alone
13.7 mos
Walk well
14.9 mos
Run 19.9 mos

Communication /language

P90

Laughs

3.1 mos
Squeals

Turn to rattling sound

Turn to voice
Dada/mama non specific
Dada/mama
specific
2 words
6 words
Points 2 pictures

Denver II

4.3
mos
5.6 mos
6.6 mos
9.1 mos
13.3 mos
16.5 mos
21.4 mos
23.6
mos

Personal-social

Smile spontaneously
Feed self
Play pat-a-cake
Wave bye-bye

P 90 Denver II

2.1 mos
6.5 mos
11.4 mos
14 mos

Fine motor
Grasp rattle
Put block in cup
Scribbles
Tower of 2 cubes

33 3.9 mos
13.8 mos
16.3 mos
20.6 mos

Corellation between parental concern

and delayed development
Parental concern
General ( ..my child left behind.. )
Fine motor
Language
Behavior
Academic skill (> 4 ys old)
Gross motor
Social skill
Self help

Probability

80 %
75 %
55 %
41 %
40 %
ns
ns
ns

(Glascoe, 1996)

Schedule for routine

monitoring
0 1 years : 1 monthly
1 3 years : 3 monthly
3 5 y ears : 6 monthly
> 5 years

; 12 monthly

Monitoring
I.

History (+ observation)

II.

Physical Examination

III.

Developmental Screening

IV.

Family Education

I. TAKE HISTORY of RISK FACTORS

Factors influence quality of growth and
development :
A. INTRINSIC
B. EXTRINSIC

A. INTRINSIC risk factors

birthweight, Apgar score, asphyxia,
convulsion, hyperbilirubinemia, infection,
congenital abnormality, temperament

B. EXTRINSIC risks factors (environment)

1. MICRO environment (quality of mother,
care- giver)
2. MINI environment (quality of father, siblings
housing, toys, faciliities, rule, norm, reward)
3. MESO environment (neighbour, health &
educational services, sanitation)
4. MACRO environment (WHO, Unicef,
proffesion program and services)

 1. MICRO Environment (quality of

mother) :
age, height, health status during pregnany
and delivery (anemia, nutritional status,
therapy), smoking, drugs, alcohol,
educational status, occupacy), family
planning (number of children, spacing,)
infectious diseases, knowledge and
behavior, marietal status (single parent,
diforce, unwanted child etc)

2. MINI environment (father, siblings,

caregiver, facilities etc) :
Father : age, height, educational status, occupancy, salary,
knowledge / skill/ behavior, diseases, marietal status,
family planning
Siblings : number, spacing, ages, health status (nutrition,
immunisation, congenital abnormality, delayed
development),
Caregiver: education, knowledge/skill/behavior, norm,
value, rule, reward, punishment,
Facilities : toys, housing sanitation (water, air,
illumination).

 3. MESO environment :
neighbour (economic status, behavior),
playtmatch, play fasilities, health and
educational services, sanitation,
environmenmtal ststus, socio-culture

4. MACRO environment:
awarness of health staff, officials,
profesionals WHO, Unicef, governmnet
programme etc

OBSERVATION

: When a child enter :

face, head, body proportion, attention, communication,

interaction, movement, behavior
.

History
- Parental concern about child development

II. Physical examination

1. Height, weight, head circumferrence
2. General physical examination

Body length or height

Length and weight for age precentiles curve 0 36 month

For BODY GROWTH MONITORING
BOYS

GIRLS

Age (months)

Age (months)

Length

Length

Weight

Age (months)

Weight

Age (months)

Head circumferrence for age 0 36 mo : for brain growth monitoring

Weight for length 0 36 mo : for nutritional status monitoring
BOYS
Age (months)

GIRLS
Age (months)

Head circumferrence

Weight
Length

Head circumferrence

Stature and weight percentile for age 0 12 years

For GROWTH MONITORING

Weight and stature for age precentile curve : nutritional status

BOYS

GIRLS

Weight

Weight

Stature

Stature

Body mass index (BMI) for age 2 20 year precentile: nutritional status
Body mass index = weight / height in m2
BOYS

Body mass index

Age (years)

GIRLS

Body mass index

Agen (years)

Interpretation of
nutritional status
- 2 SD until + 2 SD = well nourished
< - 2 SD until 3 SD = mild-moderate
malnutrition
< - 3 SD = severe malnutrition

Head Circumferrence

Head Circumferrence
Curves
Boys

Girls

Head Circumferrence
557 Macrocephal (follow up 20 ys) :
88 % normal IQ,
5 % mild mental retardation,
7 % severe mental retardation
(Lober & Priestly, 1981)
Microcephal : mentally retarded

III. Developmental Screening

1. DENVER II Developmental Screening Test

2. Pediatric Symptom Checklist (PSC)
3. CHAT (Checklist for Autism in Toddlers)

4. Bayley-III

1. DENVER II
Gross motor
Fine motor, visual
Speech, language, hearing,
communication
Social, emotional, behaviour

 interpretasi(5)
Normal
- delay (-), max 1 C
Suspec
- 2 or more C and or 1 or more D

2. PEDIATRIC SYMPTOMS CHECKLIST

(Murphy & Jellineck, 1994)

For ages :

4 16 years

Contents : 35 items of child behaviour, answer by parent,

45 minutes
never
(score 0)
sometimes
(score 1)
often / always
(score 2)
Interpretation: score > 28 should be reffered
Good sensitivity & excellent specifity
(Glascoe, 1996)

3. CHAT (Checklist for

Autism in Toddlers)

American Academy of Pediatrics

Autistic Spectrum Disorder (ASD) > 18 mos of age
9 questions for parents
5 observation
Interpretation :

Severe risk of ASD

mild riskASD
others developmental disorders
normal

Sensitivity < Pervasive Develop. Dis. Screen Test

IV. Family education

Growth and development
Nutrition, immunisation, play, stimulation,
education
Protection from risks of :
Bio-physics hazard : infection, polution,
accident, addiction
Psychosocial hazard : abuse, neglect,
exploitation,

Child Right Convention

DISORDER GROWTHDEVELOP
Delay speech/language
Palsy Cerebral
Down sindrome
Short stature
autistic spectrum disorder
Mental retardation
Attention defisit disorder hyperactifity (ADDH)