chapter 006

. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Chapter 6Growth and Measurement

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

Growth and Measurement Weight and body composition offer much information about an individual’s health status and often provide a clue to the presence of disease when they are out of balance

Focus is on the evaluation of individual’s anthropometric parameters and the examination for growth, gestational age, and pubertal development

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Physical Examination Preview From the history, assess the patient’s size, including the following: Recent growth, weight gain, or weight loss

Chronic illnesses affecting weight gain or loss

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Physical Examination Preview (Cont.) Obtain the following anthropometric measurements, and compare them to those in standardized tables: Standing height Weight Frame size Calculate the body mass index.

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Anatomy and Physiology

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Anatomy and Physiology Growth is the increase in size of an organ or person.

Growth depends on sequence of endocrine, genetic, constitutional, environmental, and nutritional influences.

Through the biologic process of development and maturation, individual organ systems acquire function.

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Endocrine Influences Growth process requires interaction and balance of many hormones

Hormones affecting growth: Growth hormone

Anterior pituitary Secreted in pulses with 70% secreted during sleep

Promotes growth and increase in organ size

Regulates carbohydrate, protein, and lipid metabolism

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Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 8

Figure 6-01. Hormones affecting growth during childhood and the ages at which they are most influential. (Redrawn from Hughes, 1984.)

Growth Hormones


Endocrine Influences (Cont.) Hormones affecting growth (Cont.):

Thyroid hormone Stimulates growth hormone secretion Stimulates production of IGF-1 (insulin-like growth factor 1) and interleukins (6 and 8) that have an important role in bone formation and resorption

Affects the growth and maturation of other body tissues

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Insulin-like growth factor 1 Growth hormone–dependent peptide primarily produced by the liver

Synthesis regulated by insulin Mediates the direct effects of growth hormone on the peripheral tissues

Negative feedback effect on growth hormone secretion

Stimulates target cells that control connective tissue growth and ossification to stimulate muscle and skeletal growth

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Ghrelin Peptide synthesized in the peripheral tissues and gastric mucosa

Helps control growth hormone release Influences food intake and obesity development

Leptin Key role in regulating body fat mass Its concentration thought to be a trigger for puberty

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Testosterone and estrogen Secreted by the gonads during puberty Rising levels cause release of gonadotropins (luteinizing hormone and follicle-stimulating hormone), which further increase testosterone and estrogen release

Genitalia grow to adult proportions Promotes bone maturation and epiphyseal fusion

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Androgens Secreted by the adrenals Promote masculinization of the secondary sex characteristics and skeletal maturation

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Endocrine Influences (Cont.) Growth at puberty is dependent on the interaction of growth hormone, IGF-1, and the sex steroids (androgens).

The sex steroids stimulate an increased secretion of growth hormone, which in turn mediates the dramatic increase in IGF-1, resulting in the adolescent growth spurt.

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Growth Differences by Organ System Brain: peak fetus, early infancy Skeleton: peak fetus, infancy, adolescence

Muscle: peak fetus, adolescence Adipose: peak infancy, adolescence Lymphoid: peak age 10 to 12 years Neural: peak age 4 to 14 years Genital: peak adolescence

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Figure 6-02. Growth rates for the body as a whole and three types of tissues. Lymphoid type: thymus, lymph nodes, and intestinal lymph masses. Neural type: brain, dura, spinal cord, optic apparatus, and head dimensions. General type: body as a whole; external dimensions; and respiratory, digestive, renal, circulatory, and musculoskeletal systems. Genital type: includes the reproductive organ system. (From Wong, 1999; modified from Harris et al, 1930.)

Differences in Growth by Organ System (Cont.)


Infants and Children Fetus

Head growth predominates Infant

Trunk growth predominates Weight gain at rapid but decelerating rate

Child Legs are fastest growing Weight gained at steady rate

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Figure 6-03. Changes in body proportions from 8 weeks of gestation through adulthood.


Adolescence Trunk and legs elongate. 50% of ideal weight is gained.

Of adults who become obese 30% are obese during childhood 70% are obese during adolescence

Skeletal mass and organ systems double in size.

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Pregnant Woman Progressive weight gain is expected. Fetus is 6 to 8 lb of weight gained. Rest of gain is from increase in maternal tissue and fluids. Fluid volume: 2 to 3 lb Blood volume: 3 to 4 lb Breast enlargement: 1 to 2 lb Uterine enlargement: 2 lb Amniotic fluid: 2 lb Maternal fat and protein stores: 4 to 6 lb

Weight gain is slow in first trimester and rapid in second trimester and slows in third trimester.

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Older Adult Stature declines in older adult, beginning at 50 years of age. Thinning intervertebral discs Development of kyphosis with osteoporotic vertebral compression

An increase in overweight and obese older adults has been documented over the past 15 to 20 years.

A decrease in weight for height and body mass index has been found in longitudinal studies among individuals over age 60.

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Older Adult (Cont.) A loss of 5% body weight over several years often occurs. Accompanied by an increase in body fat as skeletal muscle declines

Most likely due to decreased exercise and reduced anabolic steroid secretion

An age-associated reduction in the size and weight of various organs has been identified. Liver Lungs Kidneys

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Review of Related History

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History of Present Illness Weight loss and weight gain

Undesired weight loss, anorexia, vomiting or diarrhea, difficulty swallowing, excessive thirst, frequent urination, change in lifestyle, activity and stress levels

Medications: chemotherapy, diuretics, insulin, fluoxetine, diet pills, laxatives, steroids, oral contraceptives

Changes in body proportions Coarsening facial features, enlarging

hands/feet, moon facies Change in fat distribution Medication: steroids

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Past Medical History Chronic illness

Gastrointestinal Renal Pulmonary Cardiac Cancer HIV or other infections Allergies

Previous weight loss or gain efforts Weight at 21 Maximum body weight

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Family History Obesity Constitutionally short or tall stature Precocious or delayed puberty

Genetic or metabolic disorder Cystic fibrosis Dwarfism

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Personal and Social History Usual weight and height Activity and exercise pattern Use of alcohol Use of recreational drugs

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Infants Estimated gestational age, birth weight, length, head circumference

Following an established percentile growth curve

Development: achieving milestones at appropriate ages

Congenital anomaly or chronic illness

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Children and Adolescents Sexual maturation of girls: early (before 7 years) or delayed (beyond 13 years); signs of breast development and pubic hair, age at menarche

Sexual maturation of boys: early (before 9 years) or delayed (beyond 14 years); signs of genital development and pubic hair

Short or tall stature Medications: steroids, growth hormones

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Pregnant Women Pregnancy weight, dietary intake Age at menarche Date of last menstrual period, weight gain pattern, following established weight gain curve for gestational course

Eating disorders History of pica (eating laundry starch, ice, clay, raw rice)

Nausea and vomiting

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Older Adults Chronic debilitating illness

Problems with meal preparation Difficulty feeding self, chewing, swallowing, poorly fitting dentures

Ability to follow prescribed diet Difficulty with digestion

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Examination and Findings

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Equipment Standing platform scale with height attachment

Skinfold thickness calipers Measuring tape Infant scale Recumbent measuring device (for infants)

Stature-measuring device (for children)

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Weight and Standing Height Weight Height Frame size

Determined to assess the appropriateness of a person’s weight for age, height, and gender when using weight tables

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Body Mass Index The most common method used to assess nutritional status and total body fat

For adult men and women, the following are classifications of weight for height by BMI values (kg/m2): Undernutrition―under 18.5 Appropriate weight for height―18.5 to 24.9

Overweight―25 to 29.9 Obese―30 to 39.9 Extreme obesity―40 and higher

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Calculating the BMI The formula to calculate the BMI using pounds (be sure to convert ounces to a decimal) and inches: [weight in pounds ÷ (height in inches)2 ] × 703

The formula to calculate the BMI using kilograms and centimeters: weight in kg ÷ [height in meters]2

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Infants Recumbent length Weight Head circumference Chest circumference Gestational age Size for gestational age

Classification Weight Percentiles Appropriate for gestational age (AGA) 10th to 90th

Small for gestational age (SGA) Less than 10th Large for gestational age (LGA) Greater than 90th

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Infants (Cont.) Size for gestational age (Cont.)

Classification Weight Percentiles Appropriate for gestational age (AGA) 10th to 90th

Small for gestational age (SGA) Less than 10th

Large for gestational age (LGA) Greater than 90th

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Children Stature and weight

BMI is now standardized for use in children and adolescents, and it is calculated the same way as for adults Underweight ‒ BMI for age under the 5th percentile

At risk of overweight ‒ BMI for age greater than the 85th percentile

Overweight ‒ BMI for age greater than the 95th percentile

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Children (Cont.) Upper/lower segment ratio

A higher upper-to-lower body segment ratio than expected may be associated with dwarfism or bone disorders

Arm span Arm span that exceeds height is associated with Marfan syndrome

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Figure 6-08. Measuring the stature of a child.


Sexual Maturation Assessment of children and adolescents involves evaluation of secondary sexual characteristics development

The height growth spurt and timing of other physiologic events are associated with the stage of secondary sexual characteristic development.

Sexual maturation Girls: breast, pubic hair, menarche Boys: genital development, pubic hair, ejaculation

The duration and tempo of each stage vary between individuals.

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Sexual Maturation – Male and Female Most girls start puberty between 9 and 12 years of age with breast enlargement. A girl’s breast often develop at different rates and appear asymmetric. During this stage pubic hair is lightly pigmented, sparse, and straight along the labia majora.

On the other hand, most boy start puberty between 10 and 13 years of age with testicular enlargement. Pubic hair development , enlargement of the penis, and the growth spurt follow.

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Figure 6-09. Five stages of breast development in females. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)

Sexual Maturation - Females


Figure 6-10. Six stages of pubic hair development in females. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)


Sexual Maturation - Males

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Figure 6-11. Five stages of penis and testes/scrotum development in males. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)


Figure 6-12. Six stages of pubic hair development in males. (From Frisch, 1972. Reproduced with permission from Pediatrics, volume 49, by the AAP.)


Pregnant Women Weight gain

Weight gain during pregnancy should be calculated from the woman’s prepregnancy weight.

To provide guidance in weight gain during pregnancy, first determine the prepregnancy body mass index (BMI).

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Pregnant Women (Cont.) Weight gain

Monitor the woman’s weight throughout pregnancy using the BMI weight gain curve guidelines on the prenatal weight gain chart.

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Older Adults Measurement procedures for the older adult are the same as those used for the general population.

Compare the individual’s weight for height, and triceps skinfold thickness by gender and age.

Approximately 60% of adults over age 65 years are overweight with a BMI greater than 25, and 20% are obese with a BMI greater than 29.

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Abnormalities

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Abnormalities Acromegaly

A rare disease of excessive growth and distorted proportions caused by hypersecretion of growth hormone and insulin-like growth factor after closure of the epiphyses

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Abnormalities (Cont.) Cushing Syndrome

A disorder associated with a prolonged and excessively high exposure to glucocorticoids

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Abnormalities (Cont.) Turner syndrome

A genetic disorder in which there is partial or complete absence of a second X chromosome

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Figure 6-15. Turner syndrome. (From Patton and Thibodeau, 2010.)


Abnormalities (Cont.) Hydrocephalus

An excess volume of cerebrospinal fluid (CSF) in the brain leading to an enlarged head circumference

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Figure 6-16. Infantile hydrocephalus. Paralysis of the upward gaze is seen in an infant with hydrocephalus resulting from aqueductal stenosis. It appears more apparent on the right. This phenomenon is often termed the sunsetting sign. (From Zitelli and Davis, 1997. Courtesy Dr. Albert Biglan, Children's Hospital of Pittsburgh.)


Abnormalities (Cont.) Failure to thrive

Growth in an infant or child below the 3rd to 5th percentiles on a growth chart, or

Slower than normal rate of growth in a short period of time (e.g., from the 50th percentile to below the 10th percentile on the growth chart)

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Figure 6-17. Psychosocial failure to thrive as the result of neglect. This 4-month-old infant was brought to the emergency department because of congestion. She was found to be below weight expectations and suffering from severe developmental delay. Note the marked loss of subcutaneous tissue manifested by the wrinkled skinfolds over the buttocks, shoulders, and upper arms. (From Zitelli and Davis, 1997.)


Abnormalities (Cont.) Growth hormone deficiency

Failure of the anterior pituitary to secrete adequate growth hormone to support growth in stature

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Figure 6-18. The normal 3-year-old boy is in the 50th percentile for height. The short 3-year-old girl exhibits the characteristic “Kewpie doll” appearance, suggesting a diagnosis of growth hormone deficiency. (From Zitelli and Davis, 1997.)


Abnormalities (Cont.) Precocious puberty

The onset of secondary sexual characteristics before 7 years of age in girls and 9 years of age in boys with progressive sexual maturity

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Figure 6-19. Precocious puberty with pubic hair development in a young girl. (From Zitelli and Davis, 2007.)


Question 1Which of the following regulated the synthesis of IGF-I growth hormone?

A. InsulinB. LeptinC. GHRHD. Gonadotropins

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Question 2The majority of adult obesity begins:

A. In adolescenceB. In childhoodC. After the skeletal growth is completedD. Once sexual maturation is complete

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Question 3Developmental changes of puberty are caused mainly by the interaction of the pituitary gland, gonads, and:

A. HypothalamusB. Islet cellsC. ThalamusD. Wernicke area

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Question 4Most girls start puberty at what age?

A. 7 to 9 years oldB. 9 to 12 years oldC. 12 to 15 years oldD. 16 to 19 years old

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Question 5Which of the following is a genetic disorder in which there is a partial or complete absence of a second X-chromosome?

A. AcromegalyB. Growth hormone deficiency C. Precocious pubertyD. Turner syndrome

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