GROWTH AND

DEVELOPMENT
ASSESSMENT
FORMAT
 ASSESSMENT OF PRETERM / NEWBORN
BASELINE DATA:
Name of the child/mother:
Date of Birth: Time of birth:
Age:
Gender:
Father’s name:
Address:
Maternal history
Name: EDD:
Dr. Incharge (Mother):
Dr. Incharge (baby):
Age: G: P: A: _ L:
Gestational age:
Married: yes/no
Prenatal care began: 1st tri/2nd tri/3rd tri
Chronic medical problem: Y/N
Substance use: Y/N
Other:
Labs:
HIV: Positive/negative/Unknown HBsp Ag: Positive/negative/Unknown
TORCH: Positive/negative/Unknown Blood gr.:
Prenatal USG:
Labour and delivery history
AROM/PROM (Date/time): Clear/Meconium:
Maternal antibiotics: Y/N First dose (time):
Induction: Y/N Reason:
Vaginal/CS: Reason:
Forceps/Vaccum/NA: Reason:
Complications:
 Labour and delivery history
AROM/PROM (Date/time):
Clear/Meconium:
Maternal antibiotics: Y/N First dose (time):
Induction: Y/N Reason:
Vaginal/CS:
Reason:
Forceps/Vaccum/NA:
Reason:
Complications:
Resuscitation: Y/N Oxygen: Y/N L/min
Blow/CPAP/BMV
APGAR: 1 min 5 min 10 min
Stool: Y/N Void: Y/N
Paediatrician/other provider at delivery: Y/N
Reason:

GENERAL MEASUREMENTS:
S. N. Vital parameters Findings of the Baby Normal Value Inference
1 Birth weight
2 Current weight
3 Length
4 Head Circumference
5 Chest Circumference
6 Temperature
7 Heart rate
8 Respiration
Immunization status:
S. Vaccine Time of Date of Remark
N. administration administration
1
2
3
4

GENERAL ASSESSMENT:
A. General appearance:
• Posture: Flexion of the head and extremities, extended legs and abducted thighs
• Activity: Active, dull
• Body built: Thin, well built
B. Skin:
• Colour: Pale, pink, jaundiced, cyanosed
• Texture: Smooth dry
• Turgor: Normal, lost
• Vernix caseosa
• Lanugo
• Edema: eye, face etc.
• Milia
• Strawberry nerves/Hemangioma
• Harlequin phenomena
• Mongolian spots
C. Head:
• Size: normal, micro, macro
• Shape: Normal abnormal
• Anterior fontanel: palpable, depressed, bulging
• posterior fontanel: palpable, depressed, bulging
• Caput succedaneum
• Cephalohematoma
• Craniosynostosis
• Fused sutures
• Overlapping of sutures
• Widened sutures
• Moulding
• Scalp: Abrasions, lacerations,
• Hairline
D. Eyes:
• Lids: edematous
• Iris colour: Slate gray, blue, brown
• Fixation on objects
• Sclera: white, blue, yellow
• Subconjunctival hemorrhage
• Epicanthal folds
• Mongoloid slanting
• Hyper or hypo telorism
• Congenital cataract
E. Ears:
• Pinna: in line with eyes
• Patent ear canal
• Pinna flexible
• Cartilage present
• Skin tags
• Hairy ears
• Irregular shape/size
F. Nose:
• Patent nostril
• Nasal discharge
• Nasal septal deviation
• Larger philtrum
• Flaring of nares
• Bruised
G. Mouth and external observations:
• Throat: asymmetric while crying
• Intact lips and palate
• Shape: Normal/abnormal
• Internal observations:
• Ovula in nidline
• Frenulum of tongue upper present
• Natal teeth
• Micro/macro glossia
• Epstein pearls
• Oral thrush
H. Neck:
• Short
• Thick and skin folds
• Wry neck
I. Chest:
• Symmetric
• AP and lateral diameter equal
• Sternal retraction
• Xiphoid process evident
• Breast enlargement
• Supernumerery nipples
• Witch milk
• Wide spaced nipples
J. Respiratory system:
• Inspection: chest colour
• Expansion: unilateral/bilateral
• Palpation: Skin temperature, nodules, tumours
• Percussion: resonance sound
• Auscultation: normal/abnormal sounds
K. Cardiovascular:
• Inspection: chest colour, any visible pulsation, an lesion, edema etc.
• Palpation: palpable pulses, any abnormal mass
• Auscultation: S1, S2 sounds, murmurs
L. Abdomen:
• Cylindric shape
• Distended
• Umbilical hernia
• Vessels in cord
• Femoral pulses
• Distended veins
• Cord bleeding
M. GI System:
• Inspection: any scar noted, visible peristalstic movement noted
• Palpation: enlargement of liver, spleen any mass is noted
• Percussion: Tympany heard
• Auscultation: Bowel sounds
• Rectum: imperforate anus, patent and opening
N. Female genitalia:
• Labia majora larger than minora
• Labia and clitoris edematous
• Patent vagina
• Imperforate hymen
• Ambiguous genitalia
• Pseudo menstruation
O. Male genitalia:
• Urethral opening centre
 • Descended testis
• Deep pigmented scrotum
• Smegma
• Hypospadias/Epispadias
• Congenital hydrocele
• Inguinal hernia
P. Spine:
• Spine intact
• Abnormal curvature
• Spina bifida
Q. Extremities:
• Hands touches upper thigh
• Full ROM
• Pink nail buds
• Capillary refill 2-3 seconds
• Flat sole
• Symmetry of extremities
• Equal muscle tone
• Polydactyl, syndactyl
• Hip dislocation
• Club foot
R. Neuromuscular system:
• Glass coma scale of applicable
• Cry: loud, lusty, weak, high pitched
• Flexion of extremities
• Extension of extremities
• Head lag while seating
• Turn head from side to side
• Sign of paralysis
• Myoclonic jerks
 • Head lag in all positions
Assessment of reflexes:
Reflex Description Present / absent / Remark
sluggish
Eyes:
Blinking
Pupillary
Dolls eye
Nose
Glabellar
Sneezing
Mouth and throat
Sucking
Gag
Rooting
Yawn
Cough
Extrusion
Extremities
Palmer Grasp
Plantar grasp
Babinski’s
Ankle clonus
Mass reflexes
Moro reflex
Startle
Perez
Tonic neck reflex
Galant
Dancing/stepping
 Crawl
Placing

Assessment of gestational age (For preterm)

BALLARD SCORE
A) PHYSICAL MATURITY

B) NEUROMUSCULAR MATURITY

Baby’s Maturity Score:

Physical maturity Score

Neuromuscular maturity
Total Maturity Score
 Maturity Rating:

Score -10 -5 0 5 10 15 20 25 30 35 40 45 50
Weeks 20 22 24 26 28 30 32 34 36 38 40 42 44

1st Exam 2nd Exam

Estimating gestational weeks weeks
age by maturity score
Time of exam Date Date
Hour am/pm Hour am/pm
Age at exam Hours Hours
Signature of examiner
Any other observations made:
Summary:
 ASSESSMENT OF GROWTH AND DEVELOPMENT - INFANT
I. Introduction
II. Demographic profile
Name of the child:
Date of Birth: Age: Gender:
Father’s name:
Address:
Reason for hospitalization
III. History:
a) Past history
b) Present history
c) Family history
d) Antenatal history
e) Natal history
f) Post natal history
g) Immunization history
IV. Growth and development assessment:
a) Biological development
S. N. Vital parameters Findings of the Baby Normal Value Inference
1 Birth weight
2 Current weight
3 Length
4 Dentition
5 Head Circumference
6 Chest Circumference
7 Temperature
8 Heart rate
9 Respiration
b) Reflexes:
1. Labyrinth righting (head/ back/ abdomen development)
2. Tonic neck reflex
3. Parachute reflex (use during rotation)
4. Landau reflex (swimming)
c) Sensory changes:
1. Vision:
• Able to follow in range of 90°
• Has binocular vision
• Looks at hand while lifting or lying on back
• Has developed colour preference
• Has hand- eye coordination
• Able to fixate on very small objects
• Follows rapidly moving object
2. Hearing:
• Turns head to side when sound is made
• Imitates sounds
• Respond to own name
• Localises sounds
• Knows several words and meaning
d) Motor development:
1. Fine motor development:
• Desires to grasp
• Looks from the hands to the object and back
• Transfer objects from one hand to other
• Explores movable parts of the toy
• Able to put objects into a container
2. Gross motor development:
• Head control:
Ø Able to lift the head and front portion of the chest about 90° of the table
Ø Able o raise chest and upper part of the abdomen
Ø Can bear weight on one hand while exploring with other
• Rolling over:
 Ø Rolls from back to side
Ø Rolls from abdomen to back
Ø Rolls from back to abdomen
• Sitting:
Ø Sits with good head control with support
Ø Sits alone leaning on hands for support
Ø Sits alone without support
• Locomotion:
Ø Moves from seating to kneeling and standing position
Ø Crawls with abdomen on floor
Ø Stand holding on furniture
Ø Takes deliberate steps
Ø Creeps on hands and knees
Ø Walks with support of one hand
e) Vocalization:
• Imitates sounds
• Laughs aloud
• Takes pleasure on hearing sounds
• Produce words without meaning
• Comprehends the meaning of simple words
f) Social development:
• Has social smile
• Recognises parents
• Has fear of strangers
• Holds arm out to be picked
• Imitates others
• Has definite likes and dislikes
• Searches for dropped objects
• Has frequent mood swings
g) Developmental theories:
 Ø Psychosocial developmental theory
Ø Psychosexual developmental theory
Ø Cognitive developmental theory
Ø Use of reflex – sucking and swallowing
Ø Primary circular reactions
Recognizes stimulus that produce a response
Engages in an activity for the pleasure
Recognizes orderly sequence of an event
Secondary circular reactions
Recognizes symbols
Imitates sounds
Ø Coordination of secondary schemes and their application to new situations
Associates symbols with events
Distinguishes objects from related activity
Has concept of object permanence
Ø Moral developmental theory
Ø Spiritual developmental theory
h) Play:
• Plays alone
• Plays with toys
i) Nutrition:
j) Needs of child:
k) DDST if applicable:
l) Health education:
m) Conclusion:
 ASSESSMENT OF GROWTH AND DEVELOPMENT - TODDLER
I. Introduction
II. Demographic profile
Name of the child:
Date of Birth: Age: Gender:
Father’s name:
Address:
Reason for hospitalization
III. History:
a. Past history
b. Present history
c. Family history
d. Antenatal history
e. Natal history
f. Post natal history
g. Immunization history
h. Growth and development assessment:
a) Biological development
S. N. Vital parameters Findings of the Baby Normal Value Inference
1 Birth weight
2 Current weight
3 Length
4 Dentition
5 Head Circumference
6 Chest Circumference
7 Abdominal Circumference
8 Mid arm Circumference
9 Temperature
10 Heart rate
11 Respiration
b) Sensory changes:
 • Able to identify geometric figures
• Displays interest in pictures
• Accommodation well developed
d) Motor development:
1. Fine motor development:
• Scribbles spontaneously
• Constantly casting objects to floor
• Able to use cup well but rotates spoon
• Able to turn pages in a book 2-3 at a time
• Makes strokes initially while drawing
• Able to manage spoon without rotation
• Has a good hand – finger coordination
• Able to institute vertical or circular stroke
• Able to unscrew the lid
• Able to move the finger independently
2. Gross motor development:
• Able to walk
• Able creep upstairs
• Able to kneel with support
• Able to stand without support
• Can throw ball without falling
• Able to go up and down stairs with two feet on each stair
• Able to run but falls often
• Able to walk upstairs with one hand held
• Able to pull and push toys
• Able to jump in place with both feet
• Able to sit self on chair
• Able to pick up objects without falling
• Able to jump from chair
• Able to stand on one feet momentarily
 • Able to take a few steps on tip toe
e) Vocalization:
• Uses expressive jargon
• Asks for objects by painting
• Able to understand simple commands
• Able to point out body parts
• Able to understand direction
• Refers by self name
• Verbalises need for toileting, food or drink
• Uses pleural
• Able to name one colour
f) Socialization development:
• Tolerates separation from parents
• Less likely to fear strangers
• Imitates parents
• Able to feed self using a cup with little spilling
• Kisses and hugs parents
• Kisses pictures in book
• Has temper tantrums
• Has awareness of ownership
• Demonstrates dependancy on transitional objects
• Has sustained attention span
• Uses parallel play
• Able to dress self in simple clothing
• Knows own sex
• Begins to notice sex differences
g) Developmental theories:
Ø Psychosocial developmental theory
Ø Psychosexual developmental theory
Ø Cognitive developmental theory:
 Has a concept of object permanence
Curiosity about environment
Imitates words/sounds
May follow simple directions
Ø Moral developmental theory
Ø Spiritual developmental theory
i. Play:
j. Nutrition:
k. Needs of child:
l. DDST if applicable
m. Health education
n. Conclusion
 ASSESSMENT OF GROWTH AND DEVELOPMENT - PRESCHOOLER
I. Introduction
II. Demographic profile
Name of the child:
Date of Birth: Age: Gender:
Father’s name:
Address:
Reason for hospitalization
III. History:
a. Past history
b. Present history
c. Family history
d. Antenatal history
e. Natal history
f. Post natal history
g. Immunization history
Growth and development assessment:
a) Biological development
S. N. Vital parameters Findings of the Baby Normal Value Inference
1 Birth weight
2 Current weight
3 Height
4 Head Circumference
5 Chest Circumference
6 Mid arm Circumference
7 Temperature
8 Heart rate
9 Respiration
b) Motor development:
1. Fine motor development:
• Place small pellets in narrow necked bottles
• Can copy a circle, square, cross, diamond and triangle
• Able to use scissors
• Ties shoe laces
• Buttons and unbuttons dress
2. Gross motor development:
• Rides tricycle
• Jumps from bottom steps
• Tries to dance, but has inadequate balance
• Able to stand on one foot for few seconds
• Catches ball
• Walks downstairs using alternate foot
e) Language:
• Uses complete sentences of 3 to 4 words
• Talks regardless of whether anyone is playing attention
• Constantly asks questions
• Knows simple rhymes (songs)
• Name colours
• Count up to 10
f) Socialization development:
• Has increased attention span
• Has fear of darkness
• Has selfishness and is impatient
• Shows physically and verbally aggressive behaviour
• Participates in parallel and associative play
h) Developmental theories:
Ø Psychosocial developmental theory
Ø Psychosexual developmental theory
Ø Cognitive developmental theory
Ø Has social awareness
Ø Understands time
Ø Uses time oriented expressions
Ø Understands space
Ø Thinks an idea at a time
Ø Understands conservation of size, shape and length
Ø Communicates in egocentric way
Ø Has magical thinking
Ø Obeys to set limits of parents
Ø Understands other perspective
Ø Moral developmental theory
Ø Spiritual developmental theory
h. Play:
i. Nutrition:
j. Needs of child:
k. DDST if applicable
l. Health education
m. Conclusion
ASSESSMENT OF GROWTH AND DEVELOPMENT – SCHOOL AGE CHILD
I. Introduction
II. Demographic profile
Name of the child:
Date of Birth: Age: Gender:
Father’s name:
Address:
Reason for hospitalization
III. History:
a. Past history
b. Present history
c. Family history
d. Antenatal history
e. Natal history
f. Post natal history
g. Immunization history
Growth and development assessment:
a) Biological development
S. N. Vital parameters Findings of the Baby Normal Value Inference
1 Current weight
2 Height
3 Temperature
4 Heart rate
5 Respiration
6 Blood pressure

b) Motor development:
1. Fine motor development:
• Draws a person with 12 to 16 parts
• Writes with running hand writing
 • Uses brushes and paints
• Likes to eat with fingers
2. Gross motor development:
• Dresses self
• Jumps, skips and climbs
• Rides bicycle
• Throws ball skilfully
c) Language:
d) Socialization development:
• Cooperate better with others
• Often jealous of young brother or sister
• Imitates adults doing
• Cheats to win game
• Giggles a lot
• Easy to get alone at home/better behaved
• Dramatizes
• Likes the reward system
• Steals money or attractive items
• Likes to please mother in many ways
• Respect parents
• Talks about friends constantly
• Choose friends selectively
• Loves conversation
• Has beginning interest in opposite sex
e) Adoptive behaviour
• Takes bath without supervision
• Performs bedtime activities alone
• Combs hair acceptably without help
• Helps with routine house hold tasks Ex- Dusting, sweeping
• Likes school
• Does easy repair work
• Produces simple painting/drawing
f) Developmental theories:
Ø Psychosocial developmental theory
Ø Psychosexual developmental theory
Ø Cognitive developmental theory
Ø Knows whether morning or afternoon
Ø Define common objects in terms of their use
Ø Shows right hand and left ear
Ø Says which is pretty and ugly of series of drawings of a face
Ø Reads from memory
Ø Identifies certain missing parts of picture
Ø Copies diamond
Ø Reads ordinary clock or watch correctly
Ø More mechanical in reading, does not stop at the end of the sentence
Ø Gives similarities and differences between things from memory
Ø Counts backward from 20 to 1
Ø Repeats the weeks and months in order
Ø Enjoys comics
Ø More aware of time( can be relied on to get school on time)
Ø Afraid of failing or ashamed of low grades
Ø Write occasional short letters to friends, relatives on own initiative
( mailing)
Ø Reads library books, adventure or animal stories
Ø Engage themselves in social network (Social network sites)
Ø Moral developmental theory
Ø Spiritual developmental theory
h. Play:
i. Nutrition:
j. Needs of child:
k. Health education
l. Conclusion
ASSESSMENT OF GROWTH AND DEVELOPMENT – ADOLESCENT CHILD
I. Introduction
II. Demographic profile
Name of the child:
Date of Birth: Age: Gender:
Father’s name:
Address:
Reason for hospitalization
III. History:
a. Past history
b. Present history
c. Family history
d. Antenatal history
e. Natal history
f. Post natal history
g. Immunization history
Growth and development assessment:
a) Biological development
S. N. Vital parameters Findings of the Baby Normal Value Inference
1 Current weight
2 Height
3 Temperature
4 Heart rate
5 Respiration
6 Blood pressure

b) Appearance of secondary sexual characteristics

• Has hair growth over body
• Has increase in size of breast ( In females)
• Others
c) Identify:
• Preoccupied with rapid body changes
• Tries out of various roles
• Very self centred
• Has a rich fantasy life
• Able to perceive future implications
• Comfortable with physical growth
d) Sexuality
• Has limited outing
• Has limited intimate relationship
• Has multiple pleural relationship
• Has feeling of being in love
• Forms stable relationships and attachment to another
e) Emotional relationship
• Relationship with parents
Ø Has strong desire to remain dependent on parents
Ø Has major conflicts over independence and control
Ø Has complete emotional and physical separations from parents
• Relationship with peers
Ø Has strong need to identify to affirm self image
Ø Feels acceptance by peers extremely important
Ø Explores ability to attract the opposite sex
• Emotionality
Ø Has wide mood swings
Ø Has intense day dreaming
Ø Has feeling of inadequacy
Ø Anger expressed with moodiness and temper out burst
g) Developmental theories:
Ø Psychosocial developmental theory
Ø Psychosexual developmental theory
Ø Cognitive developmental theory
Ø Knows whether morning or afternoon
Ø Define common objects in terms of their use
Ø Shows right hand and left ear
Ø Says which is pretty and ugly of series of drawings of a face
Ø Reads from memory
Ø Identifies certain missing parts of picture
Ø Copies diamond
Ø Reads ordinary clock or watch correctly
Ø More mechanical in reading, does not stop at the end of the sentence
Ø Gives similarities and differences between things from memory
Ø Counts backward from 20 to 1
Ø Repeats the weeks and months in order
Ø Enjoys comics
Ø More aware of time( can be relied on to get school on time)
Ø Afraid of failing or ashamed of low grades
Ø Write occasional short letters to friends, relatives on own initiative
( mailing)
Ø Reads library books, adventure or animal stories
Ø Engage themselves in social network (Social network sites)
Ø Moral developmental theory
Ø Spiritual developmental theory
h. Play:
i. Nutrition:
j. Needs of child:
k. Health education
l. Conclusion