Subject: Pediatrics: Post Natal Growth and Development I Lecturer: Dr.

Caparas-Yu Date of Lecture: 16 November 2011 Transcriptionists & Editor: emilyfernando & zafrilsalvador Pages: 9
OBJECTIVES: I. To differentiate growth and development II. To describe the factors that affect growth and development III. Enumerate the different periods of development IV. Illustrate patterns of growth of organ systems through growth curves V. Discuss the development of the different organ systems from its embryonic stage to its full maturity ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I. GROWTH AND DEVELOPMENT (a-d)

a. GROWTH - Process by which a living being or its part increases in size and mass either by multiplication or by enlargement of component cells - Measureable: expressed in height(cm, in) and weight(Kg, lbs) - QUANTITATIVE (easier to assess) DEVELOPMENT - A complex process of growing and acquiring skills occurring in an orderly, predictable patterns as a result of maturation and experience - Differentiation of function and skills - QUALITATIVE- difficult to measure because youre assessing skills - It is orderly, predictable, and has a pattern - *so all you have to do is to know the NORMAL value in a specific age, different organs system BASIC LAWS THAT GOVERN DEVELOPMENT - Development goes through defined stages and phases The development of each organ system undergoes different stages/phases. e.g Stool Pattern: Meconium first stool of newborns; blackish-greenish materials which last for the first 3days of life Transitional Stool- occurs on the 4th-7th day of life Adult formed stool- occurs at 1 week old and beyond A baby should undergo the different patterns of stool of development. Same goes with the development of language and motor skills, which should also undergo certain stages - Development infers change For each stage or phase, there should be a change. If it becomes stagnant and there is no development on a certain period then there is a problem on the baby (development is delayed) - Development is seen as an increase in function and ability There should be no deterioration E.g. To be able to observe babys gross motor skills to fine motor skills: th 6 month- baby can sit 10th-11th month- baby is able to stand Gross motor skills th 12 month- walk with support th th 15 -18 month- walk without support 2 yrs old- able to scribble; draw straight line 3yrs old- draw circle Fine motor skills 4 yrs old- draw combination of circle and lines there should be development from gross motor to fine motor skills - Development involves maturation Maturation of organ system and maturation of cells; responsible for the development of each organ system - Development and maturity takes time There should be a maximum time where you will allow development to be normal E.g. babies can normally walk at 15-18 months, if the mother claims her baby started walking at 11months, it is still considered normal, because normal walking time is between 15-18 months; however if the baby could not walk for 18 months and beyond, then you should be alarmed and investigate. BASIC PRINCIPLES - Continuous process, intimately related to the central nervous system If the baby is not able to walk at 2 yrs old, treatment or management is towards the assessment of the brain and spinal cord - Follows a definite sequence although rate may differ Some babies may present development at an earlier age

b.

c.

d.

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SY 2011-2012

- Follows a cephalocaudal pattern starting from the eyes -->mouth neck shoulder hands extremities e.g 1 month= baby can regard; 2month- baby can smile - Proceeds from gross undifferentiated skills to precise and refined individual responses Development of the gross motor skills gradually progressing to fine motor skills

II. FACTORS THAT AFFECT GROWTH AND DEVELOPMENT (a-n)

a. GENETICS - Occurrence of chromosomal abnormalities, congenital anomalies, inborn errors of metabolism, mental retardation or any familial disease in blood relatives increases the risk of the same condition in the infant b. NUTRITION (maternal) - Organism assimilates food and uses it for growth and maintenance - Adequate amount is needed to produce a healthy baby - Fetus is affected by mothers food intake - Any food intake of the mother will go through the placenta then passed on to the baby - If the mother suffers malnutrition, baby may also suffer malnutrition which may lead to intrauterine growth retardation, etc c. RADIATION st - 1 trimester could lead to congenital malformations when exposed - 2nd trimester exposure should be on moderations rd - 3 trimester safe d. ENDOCRINE / METABOLIC DISORDERS - Hyperthyroid mother hyperthyroid baby - Mothers with uncontrolled DM large, hypoglycemic infant in the first few hours of life e. MATERNAL ILLNESS - Hypertension f. MATERNAL INFECTION - TORCHES [TOxoplasma, Rubella, Cytomegalo virus, HerpES]- most documented maternal infection that can affect the fetus g. ABDOMINAL UTERINE CONDITIONS - MYOMA can lead to amputation of the limb of the fetus [3rd trimester] h. IMMUNOLOGIC DISORDERS - Immunocompromised - ABO and RH incompatibility, Erythroblast fetalis i. DRUGS that should be avoided during pregnancy - Thallidomide phocomelia [absence of the limbs in the 1st semester]; anti-emetic - Cyclophosphamide multiple malformations; chemotherapeutic drug - Streptomycin deafness of the fetus; anti-TB - Diphenhydantoin intrauterine growth retardation IUGR and congenital anomalies; anticonvulsant, Dilantin - Sex Hormones masculinizing or feminizing effect; contraceptice pills - Tetracycline teeth pigmentation, retarded skeletal growth; respiratory tract infection - Alcohol intrauterine growth retardation IUGR and congenital anomalies - Caffeine stillbirth, premature birth and congenital anomalies j. MEDICAL conditions of the mother that can affect the fetus - Diabetes mellitus- increased glucose level (maternal hyperglycemia) which can pass through the placenta and results in fetal hypoglycemia (development of hyperinsulinemia) Insulin- promotes growth which results to enlargement and multiplication of cells and tissues End point= infant of diabetic mother or LGA (large gestational age babies) present with hypoglycemia st during 1 week of life - Hypertension- inadequate blood supply at the placenta, which can result to intrauterine growth retardation or even spontaneous abortion - Congenital Heart Disease- inadequate blood supply at the placenta which can lead to fetal anoxia - Autoimmune Disease - Sickle Cell Anemia - TORCHES Infection - Intercurrent Surgery or Trauma - Sexually Transmitted Disease- such as syphilis, gonorrhea and Chlamydia - Maternal Hypercoagulable States - Exposure to prescription medications k. MATERNAL HISTORY - Chromosomal abnormalities - Congenital anomalies - Inborn errors of metabolism - Mental retardation - Any familial disease in blood relatives increases the risk of the same condition of the fetus

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MATERNAL CONDITIONS AFFECTING THE FETUS OR NEONATE [TABLE] DISORDER EFFECTS AUTO ANTIBODY AGAINST FOLATE Neural tube defects RECEPTORS Preterm, premature rupture of CERVICAL NEOPLASIA membranes CHOLESTASIS Preterm delivery CYANOTIC HEART DISEASE Intrauterine growth restriction DIABETES MELLITUS MILD DIABETES MELLITUS SEVERE DRUG ADDICTION ENDEMIC GOITER GRAVES DISEASE HERPES GESTATIONALIS [non-infectious] HYPERPARATHYROIDISM HYPERTENSION IDIOPATHIC THROMBOCYTOPENIC PURPURA ISOIMMUNE NEUTROPENIA or THROMBOCYTOPENIA MALIGNANT MELANOMA MYASTHENIA GRAVIS MYOTONIC DYSTROPHY OBESITY PHENYLKETONURIA POOR NUTRITION PREECLAMPSIA, ECLAMPSIA RENAL TRANSPLANT RHESUS OF OTHER BLOOD GROUPS SENSITIZATION SICKLE CELL ANEMIA SYSTEMIC LUPUS ERYTHEMATOSUS Large for gestational age, hypoglycemia Growth restriction Intrauterine growth restriction, neonatal withdrawal hypothyroidism Transient neonatal thyrotoxicosis Bullous rash Neonatal hypocalcemia Intrauterine growth restriction, intrauterine fetal demise Thrombocytopenia Neutropenia or Thrombocytopenia Placental or fetal tumor Transient neonatal myasthenia Neonatal myotonic dystrophy, congenital contractures, respiratory insufficiency Macrosomia, hypoglycemia Microcephaly, retardation Intrauterine growth restriction, adult insulin resistance, schizophrenia (?) Intrauterine growth restriction, thrombocytopenia, neutropenia, fetal demise Intrauterine growth restriction Fetal anemia, hypoalbuminemia, hydrops, neonatal jaundice Preterm birth, intrauterine growth restriction Congenital heartblock, ras, anemia, thrombocytopenia, neutropenia

l.

MECHANISM Block cellular uptake of folate Associated with loop electrosurgical excision procedure or laser cone therapy Unknown, possibly hepatitis E Low fetal oxygen delivery Fetal Hyperglycemia produces hyperinsulinemia; insulin promotes growth Vascular disease, placental insufficiency Direct drug effect plus poor diet Iodine deficiency Placental immunoglobulin passage of thyroid-stimulating antibody Unknown Maternal calcium crosses to fetus and suppresses fetal parathyroid gland Placental insufficience, fetal hypoxia Nonspecific maternal platelet antibodies cross placenta Specific antifetal neutrophil or platelet antibody crosses placenta after sensitization of mother Metastatis Immunoglobulin to acetylcholine receptor crosses placenta Genetic anticipation Unknown Elevated fetal phenylalanine levels Reduced fetal nutrients, nutritional programming Uteroplacenta insufficiency, fetal hypoxia, vasoconstriction Uteroplacental insufficiency Antibody crosses placenta directed to fetal cells with antigen Maternal sickling producing fetal hypoxia Antibody directed to fetal heart, red and white blood cells, platelets

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m. MATERNAL INFECTIONS AFFECTING THE FETUS OR NEWBORNS [TABLES] INFECTION MODE OF TRANSMISSION OUTCOME ----------------------------------------BACTERIA---------------------------------------GROUP B STREPTOCOCCUS Ascending cerivical Sepsis, Pneumonia ESCHERICHIA COLI Ascending cervical Sepsis, Pneumonia LISTERIA MONOCYTOGENES Transplacental Sepsis, Pneumonia UREAPLASMA UREALYTICUM Ascending cervical Pneumonia, Meningitis MYCOPLASMA HOMINIS Ascending cervical Pneumonia CHLAMYDIA TRACHOMATIS Vaginal passage Conjunctivitis, Pneumonia SYPHILLIS Transplacental, Vaginal passage Congenital Syphilis BORRELIA BURGDORFERI Transplacental Prematurity, Fetal demise Ophthalmia (conjunctivitis, Sepsis, NEISSERIA GONORHOEAE Vaginal passage Meningitis Prematurity, Fetal demise, Congenital MYCOBACTERIUM TUBERCULOSIS Transplacental Tuberculosis GRANULOCYTIC EHRLICHIOSIS Transplacental Sepsis ----------------------------------------VIRUS---------------------------------------RUBELLA Transplacental Congenital rubella Congenital cytomegalovirus or CYTOMEGALOVIRUS Transplacental, Breast Milk (rare) asymptomatic HUMAN IMMUNODEFFICIENCY Transplacental, Vaginal passage, Congenital acquired VIRUS Breast milk immunodeficiency syndrome Vaginal passage, Transplacental, Neonatal hepatitis, Chronic HBsAg HEPATITIS B Breast milk carrier Uncommon but neonatal hepatitis, HEPATITIS C Transplacental Chronic carrier possible Fetal, neonatal death; LYMPHOCYTIC CHORIOMENINGITIS Transplacental Hydrocephalus, Chorioretinitis HERPES SIMPLEX TYPE 2 OR 1 Tansplacental Congenital Herpes Simplex Virus Neonatal Encephalitis, Disseminated Vaginal passage, Ascending Viremia VARICELLA-ZOSTER Transplacental, early Congenital anomalies Transplacental, late Neonatal varicella PARVOVIRUS Transplacental Fetal Anemia Hydrops COXSACKIE B Fecal-Oral Myocarditis, Meningitis, Hepatitis POLIOMYELITIS Transplacental Congenital Poliomyelitis EPSTEIN-BARR Transplacental Anomalies (?) RUBEOLA Transplacental Abortion, Fetal measles Chorioretinitis, Focal Cerebral WEST NILE Transplacental Necrosis ----------------------------------------PARASITES---------------------------------------Transplacental Congenital toxoplasmosis or TOXOPLASMOSIS asymptomatic Transplacental Abortion, Prematurity, Intrauterine MALARIA Growth Restriction TRYPANOSOMIASIS Transplacental Congenital Chagas Disease HOOKWORM None Maternal Anemia, LBW ----------------------------------------FUNGI---------------------------------------CANDIDA Ascending; cervical Sepsis, Pneumonia, Rash ----------------------------------------PRION---------------------------------------Transplacental, Colostrum Hypothetical route, no long-term CREUTZFELD-JAKOB DISEASE data

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n. TABLE 96-3 AGENTS ACTING ON PREGNANT WOMEN THAT MAY ADVERSELY AFFECT THE STRUCTURE OR FUNCTION OF THE FETUS AND NEWBORN

DRUGS Alcohol Amphetamines Carbamazepine Carbon monoxide Chloroquine Cigarette smoking Cocaine/crack Cyclophosphamide Danazol 17-Ethinyl testosterone (Progestoral) Hyperthermia Methyl mercury Methyltestoserone Phenytoin Prednisone Progesterone Quinine Statins Stilbestrol (diethylstilbestrol [DES]) Streptomycin Tetracycline Thalidomide Toluene (solvent abuse) Valproate Vitamin D Warfarin (Coumadin)

EFFECT ON FETUS Congenital cardiac, CNS, limb anomalies; IUGR; developmental delay; attention deficits; autism Congenital heart disease, IUGR, withdrawal Spina bifida, possible neurodevelopmental delay Cerebral atrophy, microcephaly, seizures Deafness Low birthweight for gestational age Microcephaly, LBW, IUGR, behavioral disturbances Multiple malformations Virilization Masculinizaition of female fetus Spina bifida Minamata disease, microcephaly, deafness, blindness, mental retardation Minamata disease, microcephaly, deafness, blindness, mental retardation Congenital anomalies, IUGR, neuroblastoma, bleeding (vitamin K deficiency) Oral clefts Masculinization of female fetus Abortion, thrombocytopenia, deafness IUGR, limb deficiencies, VACTERAL Vaginal adenocarcinoma in adolescence Deafness Retarded skeletal growth, pigmentation of teeth, hypoplasia of enamel, cataract, limb malformations Phocomelia, deafness, other malformations Craniofacial abnormalities, prematurity, withdrawal symptoms, hypertonia CNS, facial and cardiac anomalies, limb defects, impaired neurologic function Supravalvular aortic stenosis, hypercalcemia Fetal bleeding and death, hypoplastic nasal structures

III. PERIODS OF DEVELOPMENT (a-b)

a. THREE PHASES OF INTRAUTERINE LIFE - OVULAR (first 2weeks of life) Fertilization to zygote; from fertilized ovum to implantation - EMBRYONIC (2weeks to 2months) Rapid Organogenesis occurs - FETAL (week 8 to 40) Elaboration/refinement of functions b. TWO GROWTH PERIODS - PRENATAL [0-280 days] ovumembryofetus Ovum 0-14 days AOG Embryo 14days 9weeks Fetus 9weeks birth o Early 2nd term (4-6months) o Late 3rd term o Premature week 27-37 o Term week 38-42 o Post Term more than 42 weeks - POSTNATAL Infancy 1-2 years of life st o Neonate 1 4weeks of life st o Middle 1 year of life o Toddler/Late 1-2 years of life Childhood 2-12 years of life o Early 2-6 years of life (preschool period) o Late 6-12 years of life (school age period) Adolescence o Female 10-18 years of life o Male 12-20 years of life

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IV. ORGAN GROWTH CURVES (a-d)

a.

GENERAL - Development of the organ system (respiratory and digestive) other than the lymphoid, neural and genital - rapid development(due to hormonal surge): infancy and adolescence; - Slow period is during childhood- plateau of curve b. GENITAL - Reproductive system - Adolescent stage; rapid development due to the development of secondary sexual characteristics - Slow to almost no growth UNTIL adolescence c. NEURAL - Central Nervous System - Rapid development of brain and spinal cord during the first 2 years of life (infancy) - Brain development MYELINIZATION - Slows down during early-late childhood - During growth silent increments (adulthood and adolescence) d. LYMPHOID - Includes spleen, lymph node and liver - rapid development during childhood (8-12 years of life) - Prone to infection because of hypertrophy of the adenoids and tonsils; the glands will eventually shrink to their normal size - Curve that accelerates the fastest - Slow OR decrease during late adulthood and adolescence - *prone to infections, tonsillitis, diarrhea due to the rapid development of the lymphoid system

V. ORGAN SYSTEMS DEVELOPMENT (a-i)

A. MUSCULAR SYSTEM - Derived from the mesoderm th - bulk of development occurs at the 4 month AOG (largest increase) th - slow growth before the 4 month - muscle size: 1/6 of TBW (total body weight) of fetus at mid-pregnancy to 1/5of TBW at birth 1/3 of TBW at adolescence 2/5 of TBW at early adulthood Strength doubles: 12-16 years B. SKELETAL SYSTEM - Derived from ectoderm - Calcification of the fetal skeletal system depends on Maternal levels of Ca, Phosphorus, Vit. D and proteins i. Important to be kept at optimum levels during pregnancy Status of thyroid, parathyroid and kidneys of the fetus - Can be used for aging methods (skeletal aging) 0-5 y/o have ossification centers 5-14 y/o have calcification of cartilaginous areas 14-25 y/o have epiphyseal fusion 25 y/o completely fused ** at birth: Face and shoulders Barrel chest: AP and lateral diameter of the chest are the same Neck hardly seen Shoulders elevated (because cervical spines are not yet fully developed) ** 3-10 years old: Face, neck (longer development of cervical spine), shoulders Chest becomes broader and flatter: Lateral Diameter > AP as child gets older Ribs sloped down Manubrium goes down

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- Spines At birth: Thoracic and Sacral well developed 3 months of age: Cervical spine is fully developed 3 years old: Lumbar spine is well developed C. NERVOUS SYSTEM st - Development starts at 4-6 week AOG (1 trimester) to 2 years in cephalocaudal pattern - Myelinization occurs at 6-12 months old and continues up to 2 years old cephalocaudal pattern- due to myelinization of nervous system - Size of brain in relation to body weight decreases with progress At 2 months AOG it is 50% of the body mass (TBW) At birth 10% TBW i. E.g 3kg baby: size of brain = 0.3 At 5 years AOG 5% TBW Adulthood 2% TBW - Pineal gland calcifies at 10 years (can already be seen in x-rays) - Examining the CSF: Normally clear and colorless o Xanthochromic (yellowish) at 1st month is Normal (yellowish CSF beyond 1st mo: abnormal) Pandys Reaction- reaction of CSF to protein (high protein count- TB or viral infection); Positive for about 50% of births, it is normal up to 6 months old Protein levels differ: o Newborns: 40-80mg/dl (normal) o Premature: 60-180mg/dl (normal) o Beyond 1 month: 20-40mg/dl (normal) o Neonatal cells: 20-30/hpf- normal as long as they are all lymphocytes >30/hpf, all lymphocytes still considered normal D. SENSORY SYSTEM - Tactile Development of cephalocaudal st During the 1 hours of life, there could be no pain sensation (relative hyposthesia until 1week old) - Response to pain 1-2 months: generalized movement and crying 7-9 months: can localize and withdraw 12-16 months: shoves pain stimulus away, scratches and brings hand to irritated area - Visual At birth: not developed 1st month: has regard for shape 2nd month: smiles 3rd month: recognizes face 16 weeks: clear vision (4th month) 7 years old: 20/20 visual acuity - Auditory Can localize sound at 6 months old Remember that babies can already hear at birth, they can hear clearer at 6 months old - Taste Can discriminate taste at 3 months old E. RESPIRATORY SYSTEM - Derived from endoderm - Right bronchus is larger (shorter and wider) and more obtuse than the left. (more prone to aspiration) - Stimuli for respiratory at birth: Decreased O2 Decreased CO2 Decreased pH Tension pressure Tactile stimulation (slapping/scratching the sole of the foot, rubbing the back at the level of the spine) - Change in temperature (normal: 37.5-38oc, intrauterine 36.5-37.5oc) - Surfactant Phospholipids prevents collapse of the lungs Produced at 20weeks AOG but amounts are still inadequate for life Increasingly produced until 3rd term of pregnancy Upon, birth, decreases surface tension expansion of lungs Respiratory Distress Syndrome: inadequate surfactant - Neonatal Breathing Abdominal Breathers; rapid RR [RR decreases as baby grows] Usually rapid than older babies, abdominal in nature, periodic breathing Periodic breathing- With short pauses (5-10seconds) then rapid respiration (10-15seconds) will last for 1-2 months, disappears with age, usually on the 2nd month; NORMAL if the heart rates are normal and NO discolorations If there is pallor, cyanosis, and change in cardiac rate= apnea Normal: 40-60 cycles/min; >60 : tachypnea/pneumonia Apnea: baby suddenly stops breathing (pathologic condition); also with pauses in breathing but baby changes in color (cyanotic) Periodic Breathing: normal findings in new born, can last for around 1month

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F.

DIGESTIVE SYSTEM - Derived from the yolk sac - Area PROXIMAL to yolk sac Duodenum, Jejenum and Proximal Ileum - Area DISTAL to yolk sac Distal Ileum and Large Intestines - Meckels Diverticulum (painless rectal bleeding): persistent yolk stalk at birth - Umbilical Hernias or Omphalocoele (extrusion of abdominal contents) may be present due to abdominal wall deficiency - Atresia: canals of digestive system fails to recanalize - Stenosis: partial recanalization - E.g pyloric stenosis; duodenal atresia; jejenal atresia - Gastric Capacity Birth: 30-90ml (30ml=1oz) 1month: 90-150ml (3-5oz) 1year: 210-360ml 2years old: 500ml Late Childhood: 750-900ml - Gastric Emptying Time: 2-6hours (feed baby every 2hours) - Activity of Digestive Enzymes at birth Renin and Trypsin = normal Amylase and Lipase = low - Absorption Protein and sugar = good Complex carbohydrates and fats = poor - Weak and thin abdominal muscles; intestines, kidneys and liver are easily palpable - Liver normally palpable; 1-2cm below RSCM - Passage of food: SLOW in small intestines, FAST in large intestines - Globular shaped abdomen - Stool Development: Day 1-3 : Meconium (blackish- greenish, odorless) Day 4-7 : Transitional stool (yellowish green) 1week : proximate adults stool (yellow) 2years : adults stool - Daily Water Requirement = 120-150 ml/kg/day (inclusive of milk formula) [ : goes to urine; : insensible loss skin, lungs] - Total Caloric Requirement = 110cal/kg/day (20cal = 1oz) G. CIRCULATORY SYSTEM - PDA aorta and pulmonary artery - Younger Child faster HR; low BP - Normal BP at birth: systolic 70 - Normal BP at 9 years old: systolic 97 - Cardiac Rate: 140-160/min [newborn] **as one ages, BP INCREASES; Cardiac Rates and Respiratory Rates DECREASES** FUNCTIONAL CLOSURE ANATOMIC CLOSURE DUCTUS VENOSUS Birth 3weeks FORAMEN OVALE Birth 4months 8-12 weeks after birth [cardiac DUCTUS ARTERIOSUS 2months murmur is normal] MEAN BLOOD PRESSURE OF FILIPINO INFANTS AND CHILDREN MEAN SYSTOLIC 2SD MEAN DIASTOLIC 0-1 months 72.00 0.6 2-11months 81.66 0.6 1 year 87.30 0.8 56.40 0.6 2 years 88.20 1.2 63.15 0.6 3 years 87.47 1.8 55.50 1.2 4 years 87.37 1.2 56.45 1.4 5 years 93.90 1.2 59.80 0.8 6 years 93.84 1.2 60.05 1.0 7 years 96.56 1.0 61.55 1.0 8 years 98.50 1.2 60.06 1.0 9 years 97.00 1.2 57.30 0.4 10 years 98.95 2.2 61.50 0.8 11 years 98.80 2.6 74.40 2.8 12 years 101.55 1.8 67.55 1.8 13 years 106.95 3.0 65.70 1.0 14 years 108.00 1.2 71.50 0.6 15 years 104.05 1.8 86.85 1.6

SD

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AVERAGE CARDIAC RATE OF FILIPINO INFANTS AND CHILDREN AND SEX MALES FEMALES Mean CR 2 SD Mean CT 2 SD 0-1 month 147 30.5 145 26.2 2-6 months 139 31.4 141 33.5 7-12 months 133 32.4 134 31.9 13-24 months 128 34.1 129 34.3 2-4 years 109 32.6 110 29.5 5-9 years 93 23.7 92 23.2 10-14 years 86 20.4 86 20.7 H. URINARY SYSTEM - Normal Urine Output : 1-2cc/kg/hr - Monitor childs hydration; poor hydration, poor circulation - Insensible water loss: Preterm (2 cc/kg/hr), At term (1 cc/kg/hr), Adult (0.4 cc/kg/hr) - Mature kidneys functions occurs at 6-7 years old - Susceptible hydration because glomerular function precedes tubular function so fluid turnover is 7x that of adults - Proteinuria is normal in neonates - Hypotonic Urine LOW specific gravity, large volume, low osmolality, poorer response to ADH - More ECF compared to adults; 2x of adults - Blood: low pH, low HCO3; high Na, Cl, PO4 - Urine: proteinuria; urea [pink stains on diapers = normal in newborns] I. DENTITION - Not absolute - First tooth to erupt: lower central incisors - First permanent tooth to erupt: first molar - Number of teeth = age in months 6 [ex. 12months 6 = 6 teeth] - Age of eruption of deciduous teeth CHRONOLOGY OF HUMAN DENTITION OF PRIMARY OR DECIDUOUS AND SECONDARY OR PERMANENT TEETH CALCIFICATION AGE AT ERUPTION AGE AT SHEDDING BEGINS AT COMPLETE AT MAXILLARY MANDIBULAR MAXILLARY MANDIBULAR ~~~~~~~~~~~~~~~~~~~~PRIMARY~~~~~~~~~~~~~~~~~~~~ CENTRAL 5th fetal month 18-24 months 6-8 months 5-7 months 7-8 years 6-7 years INCISORS LATERAL 5th fetal month 18-24 months 8-11 months 7-10 months 8-9 years 7-8 years INCISORS CUSPICS 6th fetal month 30-36 months 16-20 months 16-20 months 11-12 years 9-11 years [CANINES] th FIRST MOLARS 5 fetal month 24-30 months 10-16 months 10-16 months 10-12 years 10-12 years SECOND 6th fetal month 36 months 20-30 months 20-30 month 10-12 years 11-13 years MOLARS ~~~~~~~~~~~~~~~~~~~~SECONDARY~~~~~~~~~~~~~~~~~~~~ CENTRAL 3-4 months 9-10 years 7-8 years 6-7 years INCISORS MAXILLARY 10LATERAL 12 months 10-11 years 8-9 years 7-8 years INCISORS MANDIBULAR 3-4 months CUSPICS 4-5 months 12-15 years 11-12 years 9-11 years [CANINES] FIRST PREMOLARS 18-21 months 12-13 years 10-11 years 10-12 years [BICUSPIDS] SECOND PREMOLARS 24-30 months 12-14 years 10-12 years 11-13 years [BICUSPIDS] FIRST MOLARS Birth 9-10 years 6-7 years 6-7 years SECOND 30-36 months 14-16 years 12-13 years 12-13 years MOLARS MAXILLARY 7THIRD 9years 18-25 years 17-22 years 17-22 years MOLARS MANDIBULAR 8-10 years

***********************END OF TRANX*********************** God bless people and study well! Transcription was lifted from powerpoint, previous tranx and recording of the lecture ().

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