Developmental and Genetic Influences on Child Health Promotion

Developmental and Genetic Influences on Child Health Promotion

Marilyn J. Hockenberry

Growth and Development

Foundations of Growth and Development

Growth and development, usually referred to as a unit, express the sum of the numerous changes that take place during the lifetime of an individual. The entire course is a dynamic process that encompasses several interrelated dimensions:

• Growth—Increase in number and size of cells as they divide and synthesize new proteins; results in increased size and weight of the whole or any of its parts

• Development—Gradual change and expansion; advancement from lower to more advanced stages of complexity; the emerging and expanding of the individual’s capacities through growth, maturation, and learning

• Maturation—Increase in competence and adaptability; aging; usually used to describe a qualitative change; a change in the complexity of a structure that makes it possible for that structure to begin functioning; to function at a higher level

• Differentiation—Processes by which early cells and structures are systematically modified and altered to achieve specific and characteristic physical and chemical properties; sometimes used to describe the trend of mass to specific; development from simple to more complex activities and functions

All of these processes are interrelated, simultaneous, and ongoing; none occurs apart from the others. The processes depend on a sequence of endocrine, genetic, constitutional, environmental, and nutritional influences (Seidel, Ball, Dains, et al., 2007). The child’s body becomes larger and more complex; the personality simultaneously expands in scope and complexity. Very simply, growth can be viewed as a quantitative change, and development as a qualitative change.

Stages of Development

Most authorities in the field of child development conveniently categorize child growth and behavior into approximate age stages or in terms that describe the features of a developmental age period. The age ranges of these stages admittedly are arbitrary and, because they do not take into account individual differences, cannot be applied to all children with any degree of precision. However, categorization affords a convenient means to describe the characteristics associated with the majority of children at periods when distinctive developmental changes appear and specific developmental tasks must be accomplished. (A developmental task is a set of skills and competencies peculiar to each developmental stage that children must accomplish or master to deal effectively with their environment.) It is also significant for nurses to know that there are characteristic health problems peculiar to each major phase of development. The sequence of descriptive age periods and subperiods that are used here and elaborated on in subsequent chapters is listed in Box 28-1.

Box 28-1   Developmental Age Periods

Patterns of Growth and Development

There are definite and predictable patterns in growth and development that are continuous, orderly, and progressive. These patterns, or trends, are universal and basic to all humans, but each person accomplishes these in a manner and time unique to that individual.

Directional Trends.

Growth and development proceed in regular, related directions or gradients and reflect the physical development and maturation of neuromuscular functions (Fig. 28-1). The first pattern is the cephalocaudal, or head-to-tail, direction. The head end of the organism develops first and is large and complex; the lower end is small and simple and takes shape at a later period. The physical evidence of this trend is most apparent during the period before birth, but it also applies to postnatal behavior development. Infants achieve structural control of their heads before they have control of their trunks and extremities, hold their backs erect before they stand, use their eyes before their hands, and gain control of their hands before they have control of their feet.

Second, the proximodistal, or near-to-far, trend applies to the midline-to-peripheral concept. A conspicuous illustration is the early embryonic development of limb buds, which is followed by rudimentary fingers and toes. In infants shoulder control precedes mastery of the hands; the whole hand is used as a unit before the fingers can be manipulated; and the central nervous system develops more rapidly than the peripheral nervous system.

These trends or patterns are bilateral and appear symmetric (i.e., each side develops in the same direction and at the same rate as the other). For some of the neurologic functions this symmetry is only external because of unilateral differentiation of function at an early stage of postnatal development. For example, by the age of approximately 5 years, children have demonstrated a decided preference for the use of one hand over the other, although previously either one had been used.

The third trend, differentiation, describes development from simple operations to more complex activities and functions. From broad, global patterns of behavior, more specific, refined patterns emerge. All areas of development (physical, mental, social, and emotional) proceed in this direction. Through the process of development and differentiation, early embryonal cells with vague, undifferentiated functions progress to an immensely complex organism composed of highly specialized and diversified cells, tissues, and organs. Generalized development precedes specific or specialized development; gross, random muscle movements take place before fine-muscle control.

Developmental Pace.

Although development has a fixed, precise order, it does not progress at the same rate or pace. There are periods of accelerated growth and periods of decelerated growth in both total body growth and the growth of subsystems. Not all areas of development occur at the same pace. When a spurt occurs in one area such as gross motor, minimal advances may take place in language, fine motor, or social skills. After the gross motor skill has been achieved, development focus shifts to another area. The rapid growth before and after birth gradually levels off throughout early childhood. Growth is relatively slow during middle childhood, markedly increases at the beginning of adolescence, and levels off in early adulthood. Each child grows at his or her own pace. Distinct differences are observed among children as they reach developmental milestones.

Sensitive Periods.

At limited times during the process of growth the organism interacts with a particular environment in a specific manner. Periods termed critical, sensitive, vulnerable, and optimal are the times in the lifetime of an organism when it is more susceptible to positive or negative influences.

The quality of interactions during these sensitive periods determines whether the effects on the organism will be beneficial or harmful. For example, physiologic maturation of the central nervous system is influenced by the adequacy and timing of contributions from the environment such as stimulation and nutrition. The first 3 months of prenatal life are sensitive periods for physical growth of fetuses.

Psychologic development also appears to have sensitive periods when an environmental event has maximal influence on the developing personality. For example, primary socialization occurs during the first year when the infant makes the initial social attachments and establishes a basic trust in the world. A warm relationship with a parent figure is fundamental to a healthy personality. The same concept might be applied to readiness for learning skills such as toilet training or reading. In these instances there appears to be an opportune time when the skill is best learned.

Biologic Growth and Physical Development

As children grow their external dimensions change. These changes are accompanied by corresponding alterations in structure and function of internal organs and tissues that reflect the gradual acquisition of physiologic competence. Each part has its own rate of growth, which may be directly related to alterations in the size of the child (e.g., the heart rate). Skeletal muscle growth approximates whole body growth; brain, lymphoid, adrenal, and reproductive tissues follow distinct and individual patterns (Fig. 28-2). When growth deficiency has a secondary cause such as severe illness or acute malnutrition, recovery from the illness or the establishment of an adequate diet produces a dramatic acceleration of the growth rate that usually continues until the child’s individual growth pattern is resumed.

External Proportions

Variations in the growth rate of different tissues and organ systems produce significant changes in body proportions during childhood. The cephalocaudal trend of development is most evident in total body growth as indicated by these changes. During fetal development the head is the fastest growing body part; at 2 months of gestation it constitutes 50% of total body length. During infancy growth of the trunk predominates; the legs are the most rapidly growing part during childhood; in adolescence the trunk again elongates. In newborn infants the lower limbs are one third the total body length but only 15% of the total body weight; in adults the lower limbs constitute half of the total body height and 30% or more of the total body weight. As growth proceeds the midpoint in head-to-toe measurements gradually descends from a level even with the umbilicus at birth to the level of the symphysis pubis at maturity.

Biologic Determinants of Growth and Development

The most prominent feature of childhood and adolescence is physical growth (Fig. 28-3). Throughout development various tissues in the body undergo changes in growth, composition, and structure. In some tissues the changes are continuous (e.g., bone growth and dentition); in others significant alterations occur at specific stages (e.g., appearance of secondary sex characteristics). When these measurements are compared with standardized norms, a child’s developmental progress can be determined with a high degree of confidence (Table 28-1). Growth in children with Down syndrome differs from that in other children. They have slower growth velocity between 6 months and 3 years and then again in adolescence. Puberty occurs earlier, and they achieve shorter stature. This population of patients is frequent users of the health care system, often with multiple providers, and benefit from the use of the Down syndrome growth chart to monitor their growth (Cronk, Crocker, Pueschel, et al., 1988; Myrelid, Gustafsson, Ollars, et al., 2002).

TABLE 28-1


Birth-6 months Weekly gain: 140-200 g (5-7 oz)
Birth weight doubles by end of first 4-7 months
Monthly gain: 2.5 cm (1 inch)
6-12 months Weight gain: 85-140 g (3-5 oz)
Birth weight triples by end of first year
Monthly gain: 1.25 cm (0.5 inch)
Birth length increases by ≈50% by end of first year
Toddlers Birth weight quadruples by age 2.5 Height at age 2 is ≈50% of eventual adult height
Gain during second year: about 12 cm (4.7 inches)
Gain during third year: about 6-8 cm (2.4-3.1 inches)
Preschoolers Annual gain: 2-3 kg (4.5-6.5 lbs) Birth length doubles by age 4 years
Annual gain: 5-7.5 cm (2-3 inches)
School-age children Annual gain: 2-3 kg (4.5-6.5 lbs) Annual gain after age 7: 5 cm (2 inches)
Birth length triples by about age 13 years
Pubertal Growth Spurt
Females 10-14 years Weight gain: 7-25 kg (15.5-55 lbs)
Mean: 17.5 kg (38.5 lbs)
Height gain: 5-25 cm (2-10 inches); ≈95% of mature height achieved by onset of menarche or skeletal age of 13 years
Mean: 20.5 cm (8 inches)
Males 11-16 years Weight gain: 7-30 kg (15.5-66 lbs)
Mean: 23.7 kg (52.2 lbs)
Height gain: 10-30 cm (4-12 inches); ≈95% of mature height achieved by skeletal age of 15 years
Mean: 27.5 cm (11 inches)


*Annual height and weight gains for each age-group represent averaged estimates from a variety of sources.

Jung FE, Czajka-Narins DM: Birth weight doubling and tripling times: an updated look at the effects of birth weight, sex, race, and type of feeding, Am J Clin Nutr 42:182–189, 1985.

Linear growth, or height, occurs almost entirely as a result of skeletal growth and is considered a stable measurement of general growth. Growth in height is not uniform throughout life but ceases when maturation of the skeleton is complete. The maximum rate of growth in length occurs before birth, but newborns continue to grow at a rapid although slower rate.

At birth, weight varies more than height and is to a greater extent a reflection of the intrauterine environment. The average newborn weighs from 3175 to 3400 g (7 to 7.5 lbs). In general the birth weight doubles by 4 to 7 months of age and triples by the end of the first year. By the age of 2 to 2.5 years the birth weight usually quadruples. After this point the “normal” rate of weight gain, just as the growth in height, assumes a steady annual increase of approximately 2 to 2.75 kg (4.4 to 6 lbs) per year until the adolescent growth spurt.

Both bone age determinants and state of dentition are used as indicators of development. Because both are discussed elsewhere, neither is elaborated here (see next section for bone age; see also Chapter 31 for dentition).

Skeletal Growth and Maturation

The most accurate measure of general development is skeletal or bone age, the radiologic determination of osseous maturation. Skeletal age appears to correlate more closely with other measures of physiologic maturity (e.g., onset of menarche) than with chronologic age or height. Bone age is determined by comparing the mineralization of ossification centers and advancing bony form to age-related standards.

Bone formation begins during the second month of fetal life when calcium salts are deposited in the intercellular substance (matrix) to form calcified cartilage first and then true bone. Bone formation exhibits some differences. In small bones the bone continues to form in the center, and cartilage continues to be laid down on the surfaces. In long bones the ossification begins in the diaphysis (the long central portion of the bone) and continues in the epiphysis (the end portions of the bone). Between the diaphysis and the epiphysis, an epiphyseal cartilage plate (or growth plate) unites with the diaphysis by columns of spongy tissue, the metaphysis. Active growth in length takes place in the epiphyseal growth plate. Interference with this growth site by trauma or infection can result in deformity.

The first centers of ossification appear in 2-month-old embryos, and at birth the number is approximately 400, about half the number at maturity. New centers appear at regular intervals during the growth period and provide the basis for assessment of bone age. Postnatally the earliest centers to appear (at 5 to 6 months of age) are those of the capitate and hamate bones in the wrist. Therefore radiographs of the hand and wrist provide the most useful areas for screening to determine skeletal age, especially before age 6 years. These centers appear earlier in girls than in boys.

Nurses must understand that the growing bones of children possess many unique characteristics. Bone fractures occurring at the growth plate may be difficult to discover and may significantly affect subsequent growth and development (Urbanski and Hanlon, 1996). Factors that may influence skeletal muscle injury rates and types in children and adolescents include (Caine, DiFiori, and Maffulli, 2006; Kaczander, 1997):

Neurologic Maturation

In contrast to other body tissues, which grow rapidly after birth, the nervous system grows proportionately more rapidly before birth. Two periods of rapid brain cell growth occur during fetal life: a dramatic increase in the number of neurons between 15 and 20 weeks of gestation and another increase at 30 weeks, which extends to 1 year of age. The rapid growth of infancy continues during early childhood and slows to a more gradual rate during later childhood and adolescence.

Postnatal growth consists of increasing the amount of cytoplasm around the nuclei of existing cells, increasing the number and intricacy of communications with other cells, and advancing their peripheral axons to keep pace with expanding body dimensions. This allows for increasingly complex movement and behavior. Neurophysiologic changes also provide the foundation for language, learning, and behavior development. Neurologic or electroencephalographic development is sometimes used as an indicator of maturational age in the early weeks of life.

Physiologic Changes

Physiologic changes that take place in all organs and systems are discussed as they relate to dysfunction. Other changes such as pulse and respiratory rates and blood pressure are an integral part of physical assessment (see Chapter 29). In addition, there are changes in basic functions, including metabolism, temperature, and patterns of sleep and rest.


The rate of metabolism when the body is at rest (basal metabolic rate or BMR) demonstrates a distinctive change throughout childhood. Highest in newborn infants, the BMR closely relates to the proportion of surface area to body mass, which changes as the body increases in size. In both sexes the proportion decreases progressively to maturity. The BMR is slightly higher in boys at all ages and further increases during pubescence over that in girls.

The rate of metabolism determines the caloric requirements of the child. The basal energy requirement of infants is about 108 kcal/kg of body weight and decreases to 40 to 45 kcal/kg at maturity. Water requirements throughout life remain at approximately 1.5 mL/calorie of energy expended. Children’s energy needs vary considerably at different ages and with changing circumstances. The energy requirement to build tissue steadily decreases with age following the general growth curve; however, energy needs vary with the individual child and may be considerably higher. For short periods (e.g., during strenuous exercise) and more prolonged periods (e.g., illness), the needs can be very high.


Body temperature, reflecting metabolism, decreases over the course of development (see Appendix C). Thermoregulation is one of the most important adaptation responses of infants during the transition from intrauterine to extrauterine life. In healthy neonates hypothermia can result in several negative metabolic consequences such as hypoglycemia, elevated bilirubin levels, and metabolic acidosis. Skin-to-skin care, also referred to as kangaroo care, is an effective way to prevent neonatal hypothermia in infants. Unclothed, diapered infants are placed on the parent’s bare chest after birth, promoting thermoregulation and attachment (Galligan, 2006). After the unstable regulatory ability in the neonatal period, heat production steadily declines as the infant grows into childhood. Individual differences of 0.5° to 1° F are normal, and occasionally a child normally displays an unusually high or low temperature. Beginning at approximately 12 years of age, girls display a temperature that remains relatively stable, but the temperature in boys continues to fall for a few more years. Females maintain a temperature slightly above that of males throughout life.

Even with improved temperature regulation, infants and young children are highly susceptible to temperature fluctuations. Body temperature responds to changes in environmental temperature and is increased with active exercise, crying, and emotional stress. Infections can cause a higher and more rapid temperature increase in infants and young children than in older children. In relation to body weight, an infant produces more heat per unit than adolescents. Consequently during active play or when heavily clothed, an infant or small child is likely to become overheated.

Sleep and Rest

Sleep, a protective function in all organisms, allows for repair and recovery of tissues after activity. As in most aspects of development, individual children vary widely in the amount and distribution of sleep at various ages. As they mature the total time they spend in sleep and the amount of time they spend in deep sleep changes.

Newborn infants sleep much of the time that is not occupied with feeding and other aspects of their care. As they grow older, the total time spent in sleep gradually decreases, they remain awake for longer periods, and they sleep longer at night. For example, the length of a sleep cycle increases from approximately 50 to 60 minutes in newborn infants to approximately 90 minutes in adolescents (Anders, Sadeh, and Appareddy, 2005). During the latter part of the first year, most children sleep through the night and take one or two naps during the day. By the time they are 12 to 18 months old, most children have eliminated the second nap. After age 3 years children have usually given up daytime naps except in cultures in which an afternoon nap or siesta is customary. Sleep time declines slightly from ages 4 to 10 years and increases somewhat during the pubertal growth spurt.

The quality of sleep changes as children mature. As they develop through adolescence, their need for sleep does not decline; but their opportunity for sleep may be affected by social, activity, and academic schedules. The time spent in deep, restful sleep increases from 50% in infancy to 80% in older children.


Nutrition is probably the single most important influence on growth. Dietary factors regulate growth at all stages of development, and their effects are exerted in numerous and complex ways. During the rapid prenatal growth period poor nutrition may influence development from the time of implantation of the ovum until birth. During infancy and childhood the demand for calories is relatively great, as evidenced by the rapid increase in both height and weight. At this time protein and caloric requirements are higher than at almost any period of postnatal development. As the growth rate slows with its concomitant decrease in metabolism, caloric and protein requirements are reduced correspondingly.

Growth is uneven during the periods of childhood between infancy and adolescence, when there are plateaus and small growth spurts. Children’s appetites fluctuate in response to these variations until the turbulent growth spurt of adolescence, when adequate nutrition is extremely important but may be subjected to numerous emotional influences. Adequate nutrition is closely related to good health throughout life, and an overall improvement in nourishment is evidenced by the gradual increase in size and early maturation of children in this century (see Community Focus box).


Temperament is defined as “the manner of thinking, behaving, or reacting characteristic of an individual” (Chess and Thomas, 1999) and refers to the way in which a person deals with life. From the time of birth children exhibit marked individual differences in the way they respond to their environment and the way others, particularly the parents, respond to them and their needs. A genetic basis has been suggested for some differences in temperament. Nine characteristics of temperament have been identified through interviews with parents (Box 28-2). Temperament refers to behavioral tendencies, not to discrete behavioral acts. There are no implications of good or bad. Most children can be placed into one of three common categories based on their overall pattern of temperamental attributes:

• The easy child—Easygoing children are even tempered, are regular and predictable in their habits, and have a positive approach to new stimuli. They are open and adaptable to change and display a mild-to–moderately intense mood that is typically positive. Approximately 40% of children fall into this category.

• The difficult child—Difficult children are highly active, irritable, and irregular in their habits. Negative withdrawal responses are typical, and they require a more structured environment. These children adapt slowly to new routines, people, and situations. Mood expressions are usually intense and primarily negative. They exhibit frequent periods of crying, and frustration often produces violent tantrums. This group represents about 10% of children.

• The slow-to-warm-up child—Slow-to-warm-up children typically react negatively and with mild intensity to new stimuli and, unless pressured, adapt slowly with repeated contact. They respond with only mild but passive resistance to novelty or changes in routine. They are inactive and moody but show only moderate irregularity in functions. Fifteen percent of children demonstrate this temperament pattern.

Thirty-five percent of children either have some, but not all, of the characteristics of one of the categories or are inconsistent in their behavioral responses. Many normal children demonstrate this wide range of behavioral patterns.

Significance of Temperament

Observations indicate that children who display the difficult or slow-to-warm-up patterns of behavior are more vulnerable to the development of behavior problems in early and middle childhood. Any child can develop behavior problems if there is dissonance between his or her temperament and the environment. Demands for change and adaptation that are in conflict with the child’s capacities can become excessively stressful. However, authorities emphasize that it is not the temperament patterns of children that place them at risk; rather it is the degree of fit between children and their environment, specifically their parents, that determines the degree of vulnerability. The potential for optimum development exists when environmental expectations and demands fit with the individual’s style of behavior and the parents’ ability to navigate this period (Chess and Thomas, 1999).

Early identification of temperament provides a useful tool for caregivers in anticipating probable areas of difficulty or risk associated with development. For example, “difficult” children may be prone to colic in infancy; active children require more vigilance to prevent injury; and school entry requires different approaches for children with different temperaments.

Research indicates that irritable and unadaptable infants can raise doubts in mothers about their competence (Beck, 1996). Additional research indicates that a child’s temperament can affect parent-child interactions and influence the parents’ self-esteem, marital harmony, mood, and overall satisfaction as parents (Carey, 1998). Studies on the relationship between temperament and the ability to perform a task successfully (mastery motivation) have found that infants with high mastery are more cooperative and less difficult (Morrow and Camp, 1996). Principles that can be used by nurses in direct patient care and providing anticipatory guidance are listed in Box 28-3.

Development of Personality and Mental Function

Personality and cognitive skills develop in much the same manner as biologic growth—new accomplishments build on previously mastered skills. Many aspects depend on physical growth and maturation. This is not a comprehensive account of the multiple facets of personality and behavior development. Many aspects are integrated with the child’s emotional and social development in a later discussion of various age-groups. Table 28-2 summarizes some of the developmental theories.

Theoretic Foundations of Personality Development

Psychosexual Development (Freud)

According to Freud all human behavior is energized by psychodynamic forces, and this psychic energy is divided among three components of personality: the id, ego, and superego (Freud, 1933). The id, the unconscious mind, is the inborn component that is driven by instincts. It obeys the pleasure principle of immediate gratification of needs, regardless of whether the object or action can actually do so. The ego, the conscious mind, serves the reality principle. It functions as the conscious or controlling self that is able to find realistic means for gratifying the instincts while blocking the irrational thinking of the id. The superego, the conscience, functions as the moral arbitrator and represents the ideal. It is the mechanism that prevents individuals from expressing undesirable instincts that might threaten the social order.

Freud considered the sexual instincts to be significant in the development of the personality (Freud, 1964). However, he used the term psychosexual to describe any sensual pleasure. During childhood certain regions of the body assume a prominent psychologic significance as the source of new pleasures and conflicts gradually shifts from one part of the body to another at particular stages of development:

• Oral stage (birth to 1 year)—During infancy the major source of pleasure seeking is centered on oral activities such as sucking, biting, chewing, and vocalizing. Children may prefer one of these over the others, and the preferred method of oral gratification can provide some indication of the personality they develop.

• Anal stage (1 to 3 years)—Interest during the second year of life centers in the anal region as sphincter muscles develop and children are able to withhold or expel fecal material at will. At this stage the climate surrounding toilet training can have lasting effects on children’s personalities.

• Phallic stage (3 to 6 years)—During the phallic stage the genitalia become an interesting and sensitive area of the body. Children recognize differences between the sexes and become curious about the dissimilarities. This is the period around which the controversial issues of the Oedipus and Electra complexes, penis envy, and castration anxiety are centered.

• Latency period (6 to 12 years)—During the latency period children elaborate on previously acquired traits and skills. Physical and psychic energy is channeled into acquisition of knowledge and vigorous play.

• Genital stage (age 12 years and older)—The last significant stage begins at puberty with maturation of the reproductive system and production of sex hormones. The genital organs become the major source of sexual tensions and pleasures, but energies are also invested in forming friendships and preparing for marriage.

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Sep 16, 2016 | Posted by in NURSING | Comments Off on Developmental and Genetic Influences on Child Health Promotion

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