PART 2: THE GROWING YEARS — FROM INFANCY TO ADOLESCENCE
NORMAL GROWTH AND DEVELOPMENT
Growth And Development Is Predictable
Growth and development is not haphazard-it has a
timetable. Although there may be some variations, the pattern is predictable. One can know in general what to expect
at what age from normal children, i.e. children who follow
the norms and standards. These standards are established by observing a large number of normal children. A graphical
representation of these norms (called growth curves or growth charts) shows how children growing at different
paces would grow (Fig. 1). A child’s growth when assessed subsequently should be on the same line as before. If it
goes towards the lower side, the child is faltering.
Faltering may be temporary, due to some illness, but if it persists for 2
or 3 months, the child should be seen by a paediatrician.
Some Basic Facts To Remember Paediatrician and expert on growth and development Dr.
Arun Phatak, whom I had invited to collaborate with me on this chapter, appeals to mothers to keep these points in
mind:
Fig. 1
Growth Chart
Big is not necessarily beautiful. Fat babies,
especially those who were small at birth, can have their own problems. An
active child, who does not fall ill too often and
continues to grow and develop at her own pace, is normal.
Small parents tend to have small children.
Children born small are likely to remain smaller
than those born big. About 85% of children who are born at the expected time, but are of small size will show
catchup growth by 2 years of age. Others may have a growth spurt during adolescence.
Multivitamins and tonics do not give strength or
increase height and weight. At the most, they may ensure that the child does not have any deficiency of vitamins or
minerals. Some of the tonics contain alcohol, which is harmful for your child.
Do not give your child drugs containing
cyproheptadine to stimulate her appetite and to increase her weight. They
are harmful as are drugs containing anabolic steroids that are also wrongly given for this purpose.
The latter are especially dangerous for female children because they can cause permanent enlargement of the
clitoris and give rise to secondary male sex characteristics.
Treatment with growth hormone for short stature may help some children. It should be given only if an expert
endocrinologist recommends it.
Weight
Weight is the most commonly used parameter of growth. Weighing scales are of different types and the weight
may vary from one scale to another. Preferably, the child
should be weighed on the same scale on subsequent occasions. The beam scales and the electronic scales are more reliable
than the spring scales.
At the time of birth, a normal child achieves about 5%
of her final adult body weight. The normal birth weight of children in our country varies from a little less than 3
kgs to 4kgs.
During the first few days, children normally lose water from their bodies, and so they lose about 10% of their
body weight. They regain their birth weight when they are
about 10 days old. Babies who have been breastfed on demand from birth lose less weight than babies who are given a feed
only at fixed times. Also, babies who are breastfed on demand
regain their birth weight sooner.
A healthy baby should gain between half to 1 kg per
month, or a minimum of 125 gm each week. Your child’s growth curve should follow the reference curve on the chart.
The child’s curve may be above or below the reference
curve, but it must be about the same shape. Some babies may gain weight faster than the reference curve in the early
months of life. This is normal for babies who are exclusively
breastfed and the fast weight gain usually slows down after about
4 to 5 months. A baby not exclusively breastfed, who continues
to gain more than 1 kg of weight per month, may be becoming overweight and needs close attention from your doctor.
After 4 months, your baby will gain about 400 gm in
weight every month. If she was born as a normal full-term
infant, the child will double her birth weight by 5 months and
triple it at 1 year. Thus, if she weighed 3 kgs at birth, she should
be around 6 kgs at 5 months, and 9 kgs at 1 year. If she
was born premature with a very low weight at birth, she will be
much more than double her birth weight at 5 months.
Similarly, if she had a much higher weight at birth, she will be less
than double at 5 months.
Initially, during the first few months, the weight gain
is rapid. Then it slows down. From the second year onwards,
till the adolescent period, the child gains just 2 to 21/2 kgs every year, i.e. 200 gms a month (the weight of a glass of
water). Many mothers get worried about this deceleration in
weight gain, but it is a natural phenomenon. It is for the same reason that, after the age of 1 year, the paediatrician may
like to see the child for routine check-ups at 3-month intervals and
not every month.
From 2 to 7. years of age, your child’s weight in
kilograms can be calculated according to the following formula:
(age [years] + 4) x 2
Thus, at 5 years, she should weigh about 18 kgs.
From 8 to 10 years in girls and 8 to 12 years in boys,
the weight can be calculated as per the following formula:
(age [years] + 5) x 2
Thus, a child at 9 years should weigh around 28 kgs.
Still, your 9-year-old may weigh less than 28 kgs and
yet be normal. If her overall state of health is satisfactory,
the decision on whether she is abnormally underweight or not should not be taken in a hurry. Also remember that some
children grow faster during a particular season of the
year as compared to another. During the period of slow growth, the child’s appetite may also become less.
It is better to see the growth charts and how the child
is progressing. For instance, in Fig. 2, the child A has
more weight than child B throughout the first year of life,
but if we see their progress since birth, the growth of child B is better
than that of A. Indeed, child A has started faltering
after the age of 7 months and needs to be seen by her paediatrician.
Length And Height
A smaller child’s length is taken on a flat table.
Height is measured when she is able to stand erect.
A full-term, normal infant has a length of about 50 cms.
At 3 months and 9 months, it increases to 60 and 70 cms, respectively. At 1 year and 4 years, it is about 75 and
100 cms, respectively. Then the height increases by about 5 cms
each 65 year, until the age of 10 and 12 years in girls and
boys, respectively. After this, the spurt of adolescent growth
begins with a corresponding rapid increase in height and
weight.
Several formulae are available for predicting the adult height of a child. You can work out the expected height
of your child in a rather simple way. In the case of boys,
double the height at 2 years; and for girls at 1½ years. So if
your daughter is 75 cms at 1½ years, you can expect her to
reach an adult height of about 150 cms, i.e. 5 feet.
The length/height of a child is more controlled by her genetic programming than by environmental factors.
Tonics, injections and other drugs do not make a child taller.
Fig. 2
Head Circumference
Your doctor will keep a watch on your child’s head circumference, especially in the first year of her life.
The head measures about 34 cms at birth. The soft spot at the
back of the head cannot be felt after about 2 months of age. The
soft spot in front (anterior fontanelle) may appear to widen
after birth. It usually closes between 6 months and 2 to 3
years of age. The head circumference is approximately 44 cms at 6 months and 47 cms by 1 year. So you will
notice a
rapid increase of about 10 cms in the first 6 months and only
3 cms in the next 6 months. The circumference of the head is slightly bigger than that of the chest at birth, but
both of them become equal by the age of 1 year.
Teeth
Twenty milk teeth (temporary or deciduous teeth) appear between the age of 6 months and 2½ years. The first
tooth appears at about 6 months, though the gums start getting ready for teeth to come out at the age of 3 to 4 months.
You will notice that the child is drooling more, is
irritable and enjoys biting your finger. These temporary teeth fall between
6 and 12 years of age and then permanent teeth keep erupting. At 12 years, the child should have a total of
28 teeth. The 4 wisdom teeth come up any time after the age of 18.
An important point worth remembering about teething is that there is a marked variation in the eruption of
teeth. Though many children around 1 year have about 6 teeth,
quite a few others may be toothless on their first birthday, though they are otherwise completely normal. Delayed eruption
does not necessarily indicate calcium or vitamin deficiency. Similarly, some normal babies may be born with a tooth.
Pubertal Growth
The onset of puberty in a girl is heralded by ‘breast
budding’, when the breast becomes slightly elevated as a small mound.
On an average, this happens at around 10 years, but it
can happen any time from 8 to 13 years of age. Any extremes need to be brought to the notice of the doctor. One year
later, the child shows a rapid increase in height and weight. Menstruation starts a year after this period of rapid
growth or 2 years after the breast budding. With breast budding, the child develops few, straight pubic hair (stage 2 of
puberty). In stage 1, there is no pubertal growth. In stage 3, the
breasts enlarge and pubic hair becomes darker and begins to
curl. Menstruation starts in stage 4. In stage 5, the breast
is fully developed, the pubic hair becomes coarse and curly and spreads to the inner surface of the thighs. At
this
stage, the increase in height is rather slow. It is likely to stop
increasing any more.
In boys, puberty begins a year later than in the girls.
The first sign is the enlargement of the testes. At the next stage, the scrotum appears thin and red (stage 2 of puberty).
This happens around the age of 11 years, but may also be seen
any time from 9 to 14 years of age. In stage 3, the penis
enlarges, the pubic hair appears and the child may have nocturnal emissions. Two years after stage 2, boys have a sudden
spurt in height (stage 4). The pubic hair becomes more curly
and coarse. In stage 5, the pubic hair spreads to the inner
thighs. As in girls, the increase in height is now slow and is
likely to stop soon. The boys may also develop a tender swelling
of the breasts at around stage 4 of the growth. It may last a
few months and then disappear. The adolescent may find that
his voice cracks when he speaks. This is normal.
The size of the two breasts may differ somewhat in
girls. This is also normal.
DEVELOPMENT OF MOTOR AND MENTAL SKILLS
Far more important than the physical stature are the
skills that the child acquires — the various activities that
she learns to perform. Some normal children acquire the skills fast
and some learn them slowly. For instance, although about 50%
of children learn to walk alone by 12 months, 3% walk by
the ninth month, while almost all (i.e. 97%) are walking by 15 months. If a child is not able to walk alone even by
15 months, she should be assessed by a paediatrician for possible developmental delay.
Milestones
Often, a few of the child’s activities are selected as
a rough guide to her developmental status. These are called milestones. Like the milestones on the highway, they
tell us whether the child’s journey on the road of life is progressing
well.
The milestones tell what the average child is expected
to do at that age, but that also means that 50% of children will be learning that activity later.
Normal Variations
However, in case your child appears slow when compared
to other children or in comparison with her older sibling,
do not jump immediately to the conclusion that she is mentally backward. No two children are alike. Also, a girl is
likely to walk and develop speech earlier than boys.
Some children learn certain skills later, but are
advanced in other milestones of development. Sometimes, a child stops learning any new skill for a while and then suddenly
picks up quite a few skills within a short period of time. Keep in mind that sometimes, a child who is lagging
behind might be slow in picking up almost all new skills and
this slow pace of development persists all through. On the other
hand, some children are slow all around, but start developing
at a faster pace with the passage of time.
However, if you have any doubt about your child’s development, do not delay in consulting your
paediatrician.
MONTHWISE DEVELOPMENT IN THE FIRST YEAR
The different milestones in the first important year of
your child’s life are discussed under 3 headings.
Motor
development, which deals mainly with movements and manipulation of different parts of the body.
Perception
and social responses related to the child’s sensory system, ability to comprehend and social
behaviour.
Speech.
NEWBORN BABY
Motor Development
While lying on her back without a pillow, the baby
mostly keeps her head to one side. When put on her stomach, she raises her head momentarily and makes an effort to turn
it to one side.
With a gentle push to her sole, she may appear to crawl.
In general, she keeps her hands fisted. If you put your finger in her palm, she grasps it firmly (the grasp
reflex). When made to stand on a firm surface, she takes a few steps as if she were walking (the walking reflex). The
walking reflex may not be well elicited if the child is not
fully awake. The grasp reflex and the walking reflex disappear in about 2 months.
Perception And Social Response
The newborn wrinkles her forehead and blinks when subjected to strong light and sound. She may also
suddenly move her arms outwards and start crying. A crying baby usually stops crying the moment you cuddle her in your
arms. Suckling at the breast offers mutual satisfaction to the
mother as well as the baby. It gives the newborn comfort and a
feeling of security, besides fulfilling her nutritional needs.
Speech
The lusty cry of a baby due to hunger or any discomfort may herald the development of speech in due course
of time.
ONE MONTH
Motor Development While on her back, the child kicks her legs in joy. When
put on her stomach, she lifts her head and turns it to one side to spare her nose. When held up against your shoulder, she
lifts her head momentarily away from your shoulder. Her hands are fisted. She can now bring her hand within the range
of her eyes.
Perception And Social Response
If a brightly-coloured rattle or a ring is moved 20 cms
in front of the child’s face, she fixes her gaze on it. If you
move it from midpoint to one side, she follows it with her eyes. She
may not respond the first time you show her the rattle; repeat the action a few times if required. If the baby is lying on
her back, she may follow you, within the range of her eyesight.
Her eyes may move from one side to the other and sometimes
it may appear that she has a squint. This is often
transitory and disappears by the age of 5 or 6 months. At this age, she
gives more attention to black and white pictures.
In a quiet place, shake a rattle about 8 cms away from
the baby’s ear. She will respond to the sound by wrinkling
her forehead, stopping any activity that she is doing,
suddenly blinking, or by crying. On completing 1 month, the child’s hearing is fully matured. She even seems able to
differentiate between some sounds.
If you are pregnant and are reading these lines, read a story aloud each night during the last 1 or 2 months
of pregnancy. Then, after your baby is born, read her the same story when she is awake and about a month old.
You will be pleasantly surprised; she may become quiet and more attentive as if she is listening to a sound
that she can recognise.
Suckling at the breast and feeling secure in her mother’s arms, the baby looks lovingly at her mother’s face and
often manages to have eye contact with her.
Speech
The child may make some throaty sounds like ‘ah’ and
‘coo’.
The child turns the head to one side to spare the nose
TWO MONTHS
Motor Development
When put on her stomach (prone), the child lifts her
head at an angle of about 45º and can hold it there for about 10 seconds. When held up against the shoulder, she can
now keep her head up for a little longer. The fist is now
kept open more often.
Perception And Social Response
The child listens to sounds more attentively. She shows
a more mature response by pausing when she hears the rattle and does not blink or show any signs of fear.
The first smile of the child in response to your smile
is noticed at around 6 weeks of age. This social smile
should not be confused with the spontaneous smiles of babies during
the first weeks of life.
Speech
The child may make a few throaty sounds such as ‘goo’,
‘ab’ and ‘coo’.
THREE MONTHS
Motor Development
The fist is now kept open all the time. If the child is
given a rattle in her hand, she holds it firmly and may start playing with it. When lifted up from her supine (lying on her
back) position, her head also follows suit for some time. When
put on her stomach, she raises her head and can keep it at
an angle of 90° for about a minute.
Perception And Social Response
If the child is shown a pencil while on her back, her
eyes follow it from one corner of her eye to the other.
Now comes the smile of recognition. At 6 weeks, she
gives a momentary smile when talked to, making it delightful
to talk to her. The smile is now more definite and she
recognises the mother or the mother figure. Not yet conscious of strangers,
she may oblige even others with a smile.
Dad’s darling
Speech
If she is happy after her feed, she may make sounds like
‘ah’, ‘goo’ and ‘ma’.
FOUR MONTHS
Motor Development The child tends to bring anything given to her to the
mouth. While on her back, she now looks at her hands. It helps her to get an idea of her body. That is why it is important not
to keep the child wrapped all the time. For the same reason,
mittens should be avoided, especially when the child is awake.
Perception And Social Response
Now, not only does she smile, but she also laughs
delightfully. Her hearing can also be tested better now. Stand behind
her so that she cannot see you. Sound a rattle or a bell at
a distance of 20 to 24 cms from her ear. She will turn her
head towards the direction of the sound. The room should be otherwise quiet for this test.
Speech
Now, you can ‘hear’ her laughing. This is her way of communicating.
FIVE MONTHS
Motor Development
Offer your thumbs to the child as she lies on her back.
Let her grasp them. Give her a little support to make her sit. You will notice that she will herself come to a sitting position.
Put her on her stomach. If awake and satisfied, she may
roll over onto her back on her own.
Perception And Social Response
The baby can now inspect a new object for a prolonged
period. She may start differentiating strangers from those close
to her. She may not laugh when strangers approach her or
she may even start crying. She can now make out from the tone of your voice if you
are annoyed with her.
Speech
Nothing significant happens at this stage as far as
speech development is concerned.
SIX MONTHS
Motor Development
She can now roll over on her own from her back on to her stomach, when placed on a firm surface.
When placed on her stomach, she tries to reach for a toy put in front of her, though she may or may not succeed
at this stage.
She can now transfer a rattle placed in one hand to the other. When made to stand, her legs may be able to bear
her full weight.
Rolls over from back to stomach at almost 6 months
Perception And Social Response
Her hearing is now more sensitive. If a piece of paper
is crumpled near her ear, out of her sight, she will turn
her head towards the sound.
She smiles when she sees her own reflection in a mirror.
She is now likely to become very conscious of strangers.
Speech
She may now try to join a few syllables and say ‘da-da’
or may use them separately as ‘ma’, ‘goo’ or ‘da’.
SEVEN MONTHS
Motor Development
When made to sit, she can stay for some time without falling over.
While on her back, she may play with her feet; she may even put her toe into her mouth.
While on her stomach, she may make attempts to move forward to catch a toy.
She now takes all objects to her mouth and can feed
herself a biscuit.
If not the thumb, the toe shall do!
Perception And Social Response
If an object falls on the ground, she follows it with her eyes and keeps looking in that direction till she
locates it. She can now play simple games like ‘peek-a-boo’ and enjoy them.
Speech
The same as at 6 months.
EIGHT MONTHS
Motor Development
When made to sit, the child can now stay for a prolonged period without falling over.
When on her stomach, your child can now change her position in her attempt to reach an object placed at an
angle and not directly opposite her.
Perception And Social Response
While the child is playing with a toy, cover it with a
piece of cloth. She will try to remove the cloth to get the toy again.
Now she may even behave as if she is afraid of
strangers, and become more cranky in general.
Speech
There’s nothing new except that she may now try to
vocalise in soft whispers rather than loud sounds.
NINE MONTHS
Motor Development
The child may start creeping and crawling at this age. Children who are kept on their stomach from an early age
while awake, may creep and crawl earlier than others who
are kept mostly on their back or in the lap.
Your child can now raise herself from the lying position
and sit up on her own.
When encouraged to walk and held by her hands, she attempts to take a few steps forward.
From a sitting position, she can pull herself up by holding onto some piece of furniture and stand up on
her own.
Perception And Social Response
Now your child may show interest in softer sounds made
by a watch or a musical instrument.
She now enjoys dropping objects again and again on the ground and wants you to pick them up and give them back
to her.
She now likes to play ‘hide-and-seek’.
Speech
She may now properly join two syllables and say ‘dada’, ‘mama’, or ‘baba’.
TEN MONTHS
Motor Development
The child can now walk more confidently when held by her hands.
She can also sit from a standing position by taking your support or the support of a piece of furniture.
She now rocks on her hands and knees and may crawl all around the house.
When a small object like a bead or a button or a pellet
is placed before her, she now picks it up with her thumb
and index finger. In earlier months, she would have tried to
get at it with her palm or without the fine coordination movement that she now exhibits.
Perception And Social Response
She now claps, copies ‘ta-ta’ or ‘bye-bye,’
likes to look at pictures in a book and starts understanding the meaning
of ‘No’.
Speech
She repeats ‘da-da’ or ‘ma-ma’ after you. When
you ask her about familiar persons or objects by saying, ‘Where is papa?’
or ‘Where is the fan?’ she may now look in the
direction of that particular person or object.
ELEVEN MONTHS
Motor Development
Make your child stand on a firm surface, while
supporting her body. Leave her alone. She may be able to stand on her own
for a few moments. Some children develop this skill
after their first birthday.
She can now also turn the leaves of a book with thick pages. Holding on to furniture, she can now walk
sideways. When given a crayon and paper, she tries to scribble on the paper, especially if she is shown how to
do so by someone else.
Perception And Social Response
If you laugh at some action of hers, she will repeat
that act again for you; she is obviously pleased with your appreciation.
She now covers her own face with any cloth in the ‘peek-a- boo’ game. She purposely drops things down and expects
you to pick them up.
The child now wants to eat by herself. Encourage her to do this even if she tends to make a mess. She can
also drink from an ordinary glass or a cup. Many children learn this skill even earlier.
Speech
The child may use some jargon at this age, but she is
less likely to use words with meaning on her own. She may imitate you or may say ‘mum’ when she sees water being
brought in a glass.
TWELVE MONTHS
Motor Development
The child may now be able to stand without support,
though she might have done this even before her first birthday. Quite a few children only stand without support between 11 to
13 months. Some children may even be able to take a few
steps at this age, but most will do it later.
Perception And Social Response
Your child’s hand and eye coordination is now much improved. She can now finger feed herself. If you take a
bottle and drop a few objects into it, she can copy this action
well. She responds to ‘No’ and may also shake her head for ‘No’.
She now enjoys playing simple games like ‘catching
cook’ with you. While being dressed, she may straighten her
arm or leg to help you. She now feels shy in the presence of strangers and may cry when you leave home.
Speech
The child can now imitate words like ‘dada’ or ‘mama’
spoken by you. She may be able to say 1 or 2 words with
meaning. She may then say ‘mama’ while looking at you.
It must be noted at this point that some normal children may not say a single word with meaning even at the age
of 2 years. In such a case, we ask 2 questions:
Can the child hear normally?
Does she understand and answer simple questions in different ways? For example, when
asked where the fan is, does she point her finger towards it?
If the answer to both these questions is in the
affirmative, I assure the mother that her child will start speaking
in a couple of months. In a lighter vein, I often add: ‘Thank
God there is peace at the moment. Later, she will speak so much that you will get fed up.’
YEAR-WISE DEVELOPMENT FROM 2 TO 5 YEARS
TWO YEARS
A child of 2 years walks freely on the ground. She can
also go up and down the stairs by herself. While going down, she
may stop on each step with both feet before taking another
step.
She can stand up on her own from a supine position. She can now climb onto and come down from furniture without
help. She is on the move all day long.
With her building blocks, she can now build a tower of 6 cubes (At 15 months, the child can build a tower of 2
cubes, putting one cube on top of another. At 18 months
and 21 months, she can build towers of 3 and 5 cubes, respectively). When shown how to, she can imitate a
vertical stroke with a crayon or a pencil. She can now turn
single pages of a book.
She may now imagine different situations and start
playing make-believe games. She can imitate others and wants to be in the company of other children.
The child can now make simple sentences of 2 to 4 words and may keep chattering all the time.
Help your 2-year-old to pass urine before she goes to sleep, and she may remain dry throughout the night. The
child gives you the first signal of bladder control at
around 15 months of age when she starts telling you that she
has wet her pants. After about 18 months, she is mostly dry during the day, but may wet her clothes
occasionally. (See section on Toilet
Trainingin the
chapter on PSYCHOLOGICAL CONCERNS.)
THREE YEARS
The child can now walk up and down the stairs on her
own. She goes upstairs one foot per step, and downstairs two
feet per step. She can now build a tower of 9 cubes, can
pedal a tricycle and hold a pencil in her hand instead of in her
fist. With a pencil, she now copies a circle and imitates a
cross.
She knows her age, name and sex and asks questions like ‘Why’? ‘Where’? ‘How’? all day along. She
may be able to count upto 10 and sing a few songs and nursery rhymes.
She imagines new games with objects and with people and her friends.
FOUR YEARS
She can now stand on one foot for 5 seconds or more,
walk upstairs and downstairs on her own with one foot per step, draw a circle, copy a square and a cross, and tell a
story.
FIVE YEARS
She can stand on one foot for 10 seconds or longer. She
can dress and undress herself, copy a diamond and use a spoon properly. She goes to the toilet and manages to clean
and wash herself. She loves to hear new stories, songs, jokes and simple riddles and then ask others to solve them.
Part 2 The Growing Years - From Infancy to Adolescence
