INDIAN VOL. 23
JOURNALOF
PEDIATRICS
1956
No. 101
AUGUST,
SYMPOSIUM ON GROWTH AND DEVELOPMENT 1 GROWTH AND DEVELQPMENT* N. PURSHOTTAM
Bombay After m a n y hours of concentrated attention on your part to problems of pathologic physiology in infancy and childhood, I a m appearing before you to introduce a subject which is without doubt a basic and fundamental part of pediatrics and which has always been the last and the least to be considered in most of the pediatric meetings in which I have had the opportunity to take part. Combined with the news that we have now the first Institute of Child Health at Calcutta functioning as of J a n u a r y 23rd, 1956, and the various statements of plans for a national school health and other preventive pediatric programs in our country of more than 150 million children, I make bold to stray from theoretical considerations of growth, which is a very- vast and complicated subject to be covered in quarter ef an hour, in any case, to certain specific matters connected with that fundamental area of growth and development of children which we in India can undertake right at this stage of our pediatric development. You m a y wonder why and how a person working in occupational health in one of our active industrial organisations can be interested in the growth and development of children. I have been asked this question at the office and factories where I function. These two fields of medical endeavour have so much in common that I cannot help expressing them before I go on to practical matters. Occupational health and pediatrics--at least the pediatrics that we would all like to practise, viz. that encompassing not only attention to sick children but also to promotion of health and prevention of disease and unhappiness to them, are no definite specialties in the strict sense of the t~rm but are areas of medical knowledge wherein the interest is toward an age group rather than a system or part of the body and wherein the attitude is very muc h one of prevention of illness and active promotion of health--which in industrial medical p a r l a n c e - - w e have come to denote as Constructive Medicine. I f you will agree that preventive medicine is the medicine of the future, then we in these two fields of medical work are really in the forefront of that evolutionary pattern in medicine. I think it is significant that of all the groups that are so definitely preventive minded, * Paper read at the Seventh All-India Pediatric Conference,Indore, on February 25, 1956,
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the pediatricians lead the profession and have actively filled great roles in the social and public health profession. Having taken that share of credit, it needs to be pointed out however, that we, pediatricians, have not been so alert in realising the value of basic knowledge of growth and development of children or active in obtaining such fundamental data through research into child life. Even in the United States, which leads in the matter of growth and development research and translation of that knowledge to the practice of pediatrics to an increasing extent, pediatricians began to take interest in fundamental explorations of growth only since the Firat White House Conference called by President Roosevelt in the early thrities. We are actually "Johnny come latelies" to the field and owe much of our knowledge in growth to other scientific workers such as the physical anthropologists, biologists, dentists, physiologists, psychologists and members of the teaching profession. It is high time that medical men claiming to be child specialists began taking an active role in observation, recording, reflection and analysis of normal childhood with its vastly intriguing dynamic morphological and other changes. Such knowledge is going to be needed rather quickly if we are to guide the various school health or child health programmes that are ever in the news. We are facing the problem of lack of basic human biological data and norms for comparison or guidance in constructive medical programmes in industry already and there is no doubt that pediatricians will be asked squarely and fairly what norms they consider recommending to school health workers and in child health programmes in the very near future. Divorce from normal human biological research is the most serious development of curative medicine and if we have to withstand the criticism as well as competitions from other systems of medicine in India, it is high time we paid attention to human life studies and start regular observations, recording and analysis of growth material. If one were to summarize quickly the broad generalisations of growth research and understanding obtained during the past few decades, he may observe that the rate of growth of the body as a whole varies with age. Growth is most rapid during the first year after birth when there is about a three-fold increase in weight. The first period of rapid growth is fairly steady. The second period of rapid growth occurs during puberty, after which the rate gradually levels off until maximum growth is reached. Girls go through their pubertal growth spurt earlier than boys, so that girls between eleven and fourteen are taller and heavier on the average than b@s o~ the same age. The growth of various parts of the body also follows characteristic patterns at different ages. The genital and e n d o q i n e tissues shrink in size during early infancy and then grow hardly at all until the sharp prepubertal and pubertal spurt. The brain and other nervous tissue present the opposite type of pattern with ninety per cent of their total growth occurring during the first six years of life on this ear~th. The lymphoid tissues have their own distinct pattern of increase in size, attaining their greatest size during early school years.
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The varied patterns of growth of tissue systems have many practical implications as you readily see. Unless this factor is brought to the attention of school medical inspectors, a large percentage of children may be sent to surgery and other referrals, purely on the belief of an idealized size of tonsillar or otb.er tissue. The rapid growth of neural tissues before six years of age is a ~possible indication of the extremely rapid development of behaviour patterns and the greater emotional stresses during this period of life. The growth of children varies not only according to sex; race, nationality, socio-economic status and geographic area are also significant factors. Growth also varies with season and according to various ecological factors of the environment. There is further the intricate relationship of part to total length and differences in various regions of the body. Some of these factors have been fruitfullv analysed in various growth studies amongst which some may be taken up for consideration by my colleagues on this symposium. Ahhough we cannot state that our knowledge of growth and development is very extensive and entirely satisfactory, certain positive principles have been discovered on which extended applications in child health services are called for. The first such dictum is that healthy growth progresses naturally and regularly according to certair> patterns and stages. The infant is not a miniature child, nor the school child a miniature adult. So what is proper or good advice for a child need not be so for the infant and so on in the higher age scale. The second principle is that within this general pattern of h u m a n growth each individual charts his own unique course, a course consistent for himself but differing from those of his peers. One cannot apply a rule of thumb and expect children of different ages to come up to or conform to narrow ranges of certain arbitrary norms. There is thus a wide range of human variation within the "broad highway" of human growth patterns, whether it be in total or partial lengths, circumthrences or weight or any other measure. This may seem obvious but is quite a difficult concept all the same for such of those who are to assess children and even more difficult to explain to mothers and teachers interested in any individual child's progress. The third principle of child development always to be kept in view is that all aspects of growth, physiological, chemical, emotional, social and any other descriptive adjective that can be thought o f ~ a l l aspects are interdependent and interrelated in more ways than we can begin to comprehend. The close inter-relationship of the growth process is a stern challenge to our synthetic understanding of biologic phenomen'a for which present day scientific and medical training woefully befits us. There are innumerable levels of understanding or perception of growth phenomena and all the levels contribute to a certain core of knowledge on which alone our programmes of infant, child or school health will be firmly based and helpful. 1 hope that I have not given the impression that the study of child development is gome.thing of the nature of a superspecialty, as I want to impress at the same time that knowledge in this area has come from varied disciplines and observers of all kinds. Almost any one
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coming into close and repeated contact with children with proper training in observation and recording can contribute to the field and has done so in the past. I have already alluded to the late appearance of the pediatrician at this scene. This is a complex field but by no means an exclusive field for the child specialist only. In this century of the child, increasing numbers of people are not only coming to believe that we should know more a b o u t the dynamics of human growth and development but also that we can know more if we apply certain methods of study to the involved problem. O f these methods, I shall touch upon two broack types of child study in their chronologic order. Early students of child research were captivated by what are known as "cross-sectional" or mass observations, in which 1arge numbers of children of similar chronologic age were measured and examined in other ways and from such collections of data averages and spread around the central tendency were worked out. The hope was that within a short time we can obtain norms rather quickly by recourse to large samples and reach the requisite norms, for assessment of individual children against such group values. The matter of growth and development is not so simple and the field demands that we must with all our limitations of life and resources, extend our studies on the same~.children, even if they be not in large numbers, to a number of years 'longitudinally' as the expression goes and institute what are known as seriatim recording or human life studies following the same child or children over successive decades from birth. The old idea of extensive cross-sectional norms or averages has been discarded and instead a sample is taken for a much more intensive serial or longitudinal analysis. The averages derived in these seriatim studies are in reality the expressions of so many individual paths of growth. An important result of this changed approach has been to free the individual child from the unnatural adherence to arbitrary height-weight or other rigid norms of bodily development. Thus, as PROF. WILTON MARION KROGMAN puts it graphically, "'We no longer force the child to walk the straight and narrow path of the mean; rather, we permit him to saunter, as his own growth potential will, along the broad highway of an acceptable range of variability." There are at least four such studies in progress in the United States at the present time, many having been terminated at one stage or another previously. A long-term study of physical and mental development started in London in 1951 and recently similar studies have been u~ndertaken in Paris (France), Brussels (Belgium) Stockholm (Sweden) and Zurich (Switzerland). The unusual features of these western European studies are that they are all correlated and observations made at one of these national centres are comparable at least in certain basic measures with others in the area; and recently there has been se,t up a co-ordinating council of child growth studies under the aegis of the International Children's Centre whose guidance and deliberations will be of utmost value to all who are actively concerned with the promotion of that central objective, viz. "a sound
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unfolding mind in a sound growing body," wherever we m a y work toward that objective. The question m a y arise as to the need and value of carrying out such painstaking, long and arduous as well as expensive research studies of a longitudinal nature in our country. Why not utilize the information that has been obtained abroad and compare our children to theii~ optimal standards ? Unfortunately such a procedure is not possible as it has been already indicated that innumerable factors of race, climate, nationality, socio-economic factors, nutritional practices and m a n y other variables enter into the development of norms of child growth and it becomes difficult even to use the norms worked out at one region of the same comparatively homogeneous country like the U.S.A. to children of another region with m a n y similar circumstances. Especially in a variegated nation like ours where there are differing ways of life and social mores, it becomes imperative that we work out separate standards for comparison and guidance in different parts of the country. We, however, have a great deal of spade work details that can be utilized from the experience of both cross-sectional and longitudinal growth studies in western countries, especially the U.S.A. where growth studies have been carried on for over 30 years. ~O n e can choose to avoid or discard m a n y time consuming and expensive projects on the basis of such experience and concentrate on essentials for this purpose. T h e prog r a m m e in Western Europe, co-ordinated at the International Children's Centre level is also of m u c h interest and value to us. I would like to suggest here th~/t we establish some liaison with that body even at a preliminary planning stage and co-operate and co-ordinate our efforts with them right from the beginning. O f course there is a definite need for co-ordination between any studies that m a y be started in different regions within India itself. Especially as there is going to be much more free travel and migration of different states and language groups in the future, one should look ahead and attempt to use at least a basic pattern for these rather time consuming and costly projects. I understand that the European studies have agreed to collect a m i n i m u m n u m b e r of essential measurements in about a similar manner and have left further explorations and additions to the interest of individual study groups. They are again coming together annually to comp a r e notes and progress and in such ways promote the common pool of information and objectives. Without taking any more of your time, I would like to suggest~ the formation of a Committee or working party to work out details of'such nature for the guidance of those setting out to collect information on growth of children in India, which knowledge we will be called upon to produce at very-short and impossible notice by those who have the good intentions but; not the insight. Let us be alert to our responsibility in proper time.
