GROWTH & DEVELOPMENT ASSESSMENTYUDIANITA KESUMA

*

TUJUAN UMUMSetelah materi ini mahasiswa mampu melakukan penilaian Tumbuh kembang anak

TUJUAN KHUSUSSetelah sesi ini mahasiswa mampu:Menyebutkan indikator penilaian TK Menjelaskan pengukuran BB, PB, TB, LK

dan penggunaan kurva pertumbuhan Menjelaskan penilaian Perkembangan dengan KPSP dan hasil penilaiannyaMenjelaskan penilaian TDD, TDLMenjelaskan penilaian tes IQ dan interpretasinya

GROWTH ASSESSMENTGrowth chart (body weight, body length, stature, head circumference)Body proportionsSkeletal maturationDental developmentSex Maturity

*

It is recommended to weigh children using a scale with the following features:SCALE

THE MEASURE OF LINEAR GROWTH

*

If the child is aged 2 years or older, measure standing height unless the child is unable to stand. Use a height board mounted at a right angle between a level floor and against a straight, vertical surface such as a wall or pillar.

The measure of head circumferenceHead Circumference Tape ChecklistNon-stretchable, plasticized1/4 -1/2 inch wideInsertion tape in 0.1 cm or 1/8 inch increments

Determine a childs age todayWeigh a Determine BMI (body mass index) by referring to a table or using a calculatorRecognize clinical signs of marasmus and kwashiorkorchilds weight and measure length or height record1423MEASURING A CHILDS GROWTH

*

Comparison of existing growth chartsData charactNCHSCDCWHOSourceMultiple different studiesMultiple different studiesPrimary data

Study periodPopulationAge-group

1929-19751963-19941997-2003US, white,bottle fedUS, mixed feeding, no racial/ethnic diff6 Countries pooled data. healthy children & practices, breastfedBirth-20 yrs

GROWTH CHARTThe standard growth charts 0 5 Y from WHO5-20 Y growth chart CDCPresented in 4 standard chart :

Weight for ageHeight/length for ageWeight for heightHead circumference for age Separated chart for boys and girls

*

The WHO Growth Charts

There are two separate series of charts:

2006 WHO Child Growth Standards charts for birth to 5 years Illustrate how healthy children should grow. portrayed how a sample of children did grow.

CDC Growth Reference 2007 charts for 5 to 20 years These are reconstructed CDC growth charts based on best available historical data and also supplement data from WHO growth standards. Redesigned to more closely align with optimal growth and address the issue of the increasing overweight/obesity in children and adolescence

GROWTH CHARTEach chart is composed of 7 percentile curves, representing the distribution of weight, length, stature, or head circumference value at each ageThe precentile curve indicates the percentage of children at a given age on the x-axis whose measured value falls below the corresponding value on the y-axis The 50th percentile and 0 SD (z Score) is the median, it is also termed the standard value (100%)The chart are useful because they facilitate assessment of growth over time

*

Notes:A child in this range is very tall. Tanness is rarely a problem, unless it is so excessive that it may indicate endocrine such as a growth-hormone-producing tumor. Refer a child in this range for assessment if you suspect an endocrine disorder (e.g. If perents of normal height have a child who is excessively tall fot his or her age)A Child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-length/heoght or BMI-for Age.A plotted point above 1 shows possible risk. A trent toward the 2 z-score line show definite riskIt is possibke for a stunded or severely stunded child to become overweight

INTERPRETING GROWTH INDICATORS

*

Daffa, 5 bln 14 hari, BB 8 kg, PB 70 cmBB/U : 0 +2 SD Normal

Daffa, 5 bln 14 hari, BB 8 kg, PB 70 cmPB/U : 0 +2 SD Normal

Daffa, 5 bln 14 hari, BB 8 kg, PB 70 cmBB/PB : 0 -1 SD Gizi BaikBerat Badan Ideal pd garis di median 0 ( yaitu: 8,5 kg)

Yohana, 11 bln, BB 6.5 kg, PB 66 cmBB/U : -2SD -3 SD Underweight

Yohana, 11 bln, BB 6.5 kg, PB 66 cmPB/U : -2SD -3 SD Stunted

Yohana, 11 bln , BB 6.5 kg, PB 66 cmBB/PB : -1SD -2 SD Gizi BaikBerat Badan Ideal pd garis di median (0( yaitu: 7.4 kg)Status pertumbuhan: Kekurangan gizi kronik

Weight Charts (boys left, girls right)

*

Grade of MalnutritionWeight for Age (wasting)Height for Age (stunting)Weight for Height0, Normal1, Mild2, Moderate3, Severe9075 9060 74< 609590 9585 89< 859081 9070 80< 70

Umur 7 tahun Berat badan 15 kgTinggi badan 112 cm

BERAT BADAN IDEAL : ?

BB/U = 15/22x100% = 68,2%

Kesan: wasting moderate

Umur 7 tahun Berat badan 15 kgTinggi badan 112 cm

BERAT BADAN IDEAL : ?

TB/U = 112/122x100% = 91.8%

Kesan: mild stunting

Umur 7 tahun Berat badan 15 kgTinggi badan 112 cm

BERAT BADAN IDEAL : ?

Umur 7 tahun Berat badan 15 kgTinggi badan 112 cm

BERAT BADAN IDEAL : ?

BB/U = 15/22x100% = 68,2%

TB/U = 112/122x100% = 91.8%

BB/TB = 15/19x100% = 78.9%

Kesan: moderate malnutrition

Interpreting Growth

Consider : Is the weight and length/height proportional? Is the head circumference appropriate for age? Does the childs growth follow a consistent pattern? Is growth between the 3 rd and 85th percentiles? Are there health issues or factors from the additional information gathered impacting growth?

*

NESTLE-HERMINA 2005 =RENTANG NILAI NORMAL

ANALYSIS OF GROWTH PATTERNSGrowth is a proses rather than a static quality.

An infant at the 5th percentile may be :

- growing normaly, - failing to grow, or- recovering from growth failure, depending on the trajectory of the growth curve

Typically, infants and children stay within one or two growth channels

A normal exception commonly occurs during the 1st 2 yr of life

This canalization attest to the robust control that genes exert over body size

*

FULL TERM INFANTS :Size at birth reflects the influence of the uterine environmentSmall neonates often shift percentiles upward, large neonates often shift downward to their parents mean percentileShift up/downward ending as an infants achieves a new growth channel (+ 13 18 mo)Size at 2 yr correlates with mean parental height, influence of the genes

PREMATURE INFANTS :Overdiagnosis of growth failure can be avoided by subtracting the weeks of prematurity from the post natal age when plotting growth parametersVery low birthweight (

Weight-for-age curve below 5th percentile or >-2 SD is indicator of acute undernutritionIn chronic undernutrition may be short as well as thin, height-for-age curve drops (stunting), whereas the weight-for-height curve may appear relatively normalChronic and severe undernutrition can also depress head growth, an aminous predictor of later cognitive disability

GROWTH PARAMETER < 5TH PERCENTILE / > - 2 SDNecessary to express the value as percentages of median or standard valueGrowth failure can be graded from mild to severe

CONTOH MONITORING

HEAD CIRCUMFERENCEHead circumference is measured from glabella, supraorbital ridge in front to the farthest point of the occiput in back

In infants, chronic & severe undernutrition also depresses head growth predictor of later cognitive disability

*

*

?makrocephali

*

?mikrocephali

Tinggi badan dalam sentil pada 100 anak wanita usia 12 tahun

*

Harga mean dan SD pada kurva normal Gauss

*

BODY PROPORTIONThe head and trunk are relatively large at birthProportionality can be assessed by measuring the Lower body segment (from symphysis pubis to the floor), and the Upper body segment (the height the lower body segment)U/L ratio + 1.7 at birth, 1.3 at 3 yr, and 1.0 after 7 yrHigher U/L ratio are characteristic of short-limb dwarfism, or bone disorder such as rickets

*

*

SKELETAL MATURATIONBone age correlated well with stage of pubertal development and can be helpful in predicting adult height in early or late maturing adolescents. In familial short stature the bone age is normal (comparable to chronologic age)In constitutional delay, endocrinologic short stature and undernutrition, the bone age is low and comparable to the height age

*

The most commonly used standards are those of Gruelich and Pyle, which require radiographs of the left hand and wristSkeletal maturation is linked more closely to sexual maturity rating than to chronologic ageIt is more rapid and less variable in girls than in boys

*

Male hand at 156 monthsFemale hand at 128 monthsMale hand at 48 monthsFemale hand at 37 monthsX Ray of the Hand

*

DENTAL DEVELOPMENTPrimary teeth

Teeth Eruption(mo) Exfoliation (yr) Maxil. Mand. Maxil. Mand.Central Insisivus 6-8 5-7 7-8 6-7Lateral Insisivus 8-11 7-10 8-9 7-8Caninus 16-20 16-20 11-129-11Ist Molar 10-16 10-16 10-11 10-122nd Molar 20-30 20-30 10-12 11-13

*

PERMANENT TEETH Teeth Eruption (yr) MaxillaMandibulaCentral Insisivus 7-8 6-7Medial Insisivus 8-9 7-8Caninus 11-12 9-11Premolar I 10-11 10-12Premolar II 10-12 11-13Molar I 6-7 6-7Molar II 12-14 12-13Molar III 17-22 17-22

*

SEXUAL MATURITYSexual Maturity Rating (SMR) or Tanner stages based on somatic changesIn boys : pubic hair, penis and testisIn girls : pubic hair and breasts

The first visible sign of puberty in girls is the appearance of breast buds, between 8 -13 yrIn boys, testicular enlargement begins as early as 9 yr

*

Perkembangan bentuk dan ukuran payudara (Dikutip dari Fig.14-2, Behrman et al, Nelson textbook of Pediatrics, 2000, hal.54)

*

Perkembangan rambut pubis (Dikutip dari Fig.14-1, Behrman et al, Nelson textbook of Pediatrics, 2000, hal.53)

*

Perkembangan bentuk dan ukuran genitalia (Dikutip dari Fig.18-14, Vaughan & Litt: Child Adolescent Development: Clinical Implication, 1990, hal.250)

*

PHYSIOLOGIC & STRUCTURAL GROWTHRR & PR decrease sharply during the 2 yr, then more gradually throghout childhoodBP rises steadily beginning + 6 yr of ageDevelopment of paranasal sinuses continues throughout childhoodLymphoid tissues develop rapidly, reaching adult size by 6 yr of ageThe metabolisme of medicationsNutritional needs

DEVELOPMENTAL ASSESSMENTThere are 2 steps process :

Screening procedure, to pick out children in need of more indepth assessment,

2. Developmental diagnosis, to define the developmental problems

*

SCREENING TESTThe most widely use is Denver IIThe test generates pass-fail rating in 4 domains of development : personal social, fine motor-adaptive, language, and gross motorTest for children from birth to 6 yr old

*

*

INTERPRETATION OF THE TESTNormal :No delays and a maximum of 1 cautionConduct routine rescreening at next well-child visitSuspect :> 2 caution and/or > 1 delaysRescreen in 1-2 weeks to rule out temporary factorsUntestable :Refusal on > one itemsRescreen i 1-2 weeks

KUESIONER PRA SKRINING PERKEMBANGAN (KPSP) DARI DEPKES RIYang dinilai kemandirian, sosialisasi, gerak kasar, gerak halus, komunikasi Dilakukan pada anak usia 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60, 66, dan 72 bulanKuesioner berisi 9 10 pertanyaan untuk orang tua/pengasuhJawaban Ya / Tidak

INTERPRETASI :Bila jawaban Ya:

9 10 : Perkembangan Sesuai (S)

7 8 : Perkembangan Meragukan (M)

< 6 : Perkembangan ada Penyimpangan (P)

TINDAKANPerkembangan Sesuai (S)

Tindakan : Stimulasi diteruskan, Lakukan KPSP 3 bulan kemudian (sesuai jadual) Perkembangan Meragukan (M)

Tindakan : Stimulasi tugas yang belum bisa dilakukan, evaluasi ulang 2 minggu kemudianPerkembangan ada Penyimpangan (P)

Tindakan : Intervensi Rujuk, dengan menuliskan jumlah dan jenis keterlambatan perkembangan

SCREENING OF BEHAVIORAL PROBLEMS

CHAT for autism

CONNER scale for ADHD

ThankYou

*

*

*

*

*

*

**

*

*

*

*

*

*

*

*

*

*

**

*

*

*

*

*

*

*

*

*