5 - Surveillance and Development Flashcards
WHO encourage exclusive breast-feeding for the first 6 months of life. What are the benefits of this?
Child
- Immunity
- Lower risk of obesity
- Less risk of overfeeding
- Lower risk of SIDS
- Lower risk of NEC
Mother
- Lower risk of breast cancer
- Lower risk of ovarian cancer
Start weaning at 6 months with pureed food and baby rice, then normal diet by 1 year
How much should a baby be fed in the first part of life?
- 60mls/kg/day on day 1
- 90mls/kg/day on day 2
- 120mls/kg/day on day 3
- 150mls/kg/day on day 4 and onwards
Split between feeds every 2-3 hours then gets longer as time goes on
How much weight loss in the first week of life is normal?
By day 5 normal to lose 10% weight in breast-fed and 5% bottle fed
Should be back to birth weight by day 10
If lose more weight than this or do no regain weight by day 14 need hospital admission and investigations
How do you plot a growth chart?
Male and Female have separate charts. Use UK-WHO from 0-4 and UK1990 from 4 upwards
X-Axis: Age
Y-Axis: Head circumference, Weight, Height
How do we interpret growth charts?
Based on centiles
50% is average
e.g 91% height means child is taller than 91% of people their age
Worrying if child is not maintaining centiles!!!
How do we measure a child to plot their growth chart?
Length Board: before 2 years, do without nappy or footwear
T piece or Stadiometer: eyes and ears at 90 degrees, no foot wear, measure on expiration
How often do we need to weigh babies?
- First week and thereafter if necessary
- 8th week
- 12th week
- 16th week
- 1 year
- At routine immunisations
How do we work out percentage weight loss from a growth chart?
How do we work out adult height from centiles?
Take centile at 2-4 years and plot
What BMI centile represents obesity?
Over 91%
If over 98% morbidly obese
If over 85%overweight
Can only do this from age 2 up
What syndromes may need GH treatment by assessing their growth charts?
What are the three phases of growth in childhood and what are they driven by?
- First 2 years: rapid growth driven by nutritional factors (5-7cm/year)
- From 2 years to puberty: steady slow growth by growth hormone (5cm/year)
- During puberty: rapid growth spurt driven by sex hormones (12cm/year)
If a child is short and obese what do you need to consider?
Endocrine disorder e.g hypothyroidism, GH deficiency
Obese children are usually tall for their age if due to overconsumption
What is the management for obese children?
- What has been tried before? It is important to involve the whole family
- The primary treatment is dietary modification and exercise
- Referral to a dietician
- Aim for moderate exercise of at least 60 minutes per day. Exercise not only increases energy expenditure but also increases self-esteem and helps sleep
- The MEND programme (Mind, Exercise, Nutrition…Do it)
What is the definition of ‘faltering growth’ or ‘failure to thrive’?
- One or more centile spaces if their birthweight was below the 9th centile
- Two or more centile spaces if their birthweight was between the 9th and 91st centile
- Three or more centile spaces if their birthweight was above the 91st centile
What are some causes of failure to thrive?
- Inadequate nutritional intake
- Difficulty feeding
- Malabsorption
- Increased energy requirements
- Inability to process nutrition
What parts of the history do you need to emphasise when looking at a child with failure to thrive?
- Pregnancy, birth, developmental and social history
- Feeding or eating history
- Observe feeding
- Mums physical and mental health
- Parent-child interactions
- Height, weight and BMI (if older than 2 years) and plotting these on a growth chart
- Calculate the mid-parental height centile
How do we calculate mid-parental height and interpret this?
(height of mum + height of dad) / 2
Outcomes from the assessment that would suggest inadequate nutrition or a growth disorder are:
- Height more than 2 centile spaces below the mid-parental height centile
- BMI below the 2nd centile
What are two important investigations NICE recommends when a child has failure to thrive?
- Urine dipstick, for urinary tract infection
- Coeliac screen (anti-TTG or anti-EMA antibodies)
Look for signs of underlying conditions e.g Pyloric Stenosis, Cystic Fibrosis
How is failure to thrive managed?
- Breastfeeding support and top-up with formula
- Encouraging regular structured mealtimes and snacks
- Reduce milk consumption to improve appetite for other foods
- Review by a dietician
- Additional energy dense foods to boost calories
- Nutritional supplements drinks
How can we predict the height of a child as and adult using their parent’s height?
- Boys: (mother height + fathers height + 14cm) / 2
- Girls: (mothers height + father height – 14cm) / 2
What is the definition of short stature and some reasons for this?
Height below 2nd percentile for their age (2 SD from average)
- Familial short stature
- Constitutional delay
- Malnutrition
- Chronic diseases, such as coeliac disease, IBD or congenital heart disease
- Endocrine disorders, such as hypothyroidism
- Genetic conditions, such as Down syndrome
- Skeletal dysplasias, such as achondroplasia
How can we determine short stature as a constitutional delay?
History and examination and can be supported by an xray of the hand and wrist to assess bone age. Management involves excluding other causes of a short stature and delayed puberty, reassuring parents and the child and monitoring growth over time
Child will grow to normal adult height as puberty will last longer for them, they are short due to delayed bone age
Apart from growth, what are the four domains we can measure development in children?
- Gross motor
- Fine motor
- Language
- Personal and social
What are the gross motor developmental milestones?
Development of large movements, such as sitting, standing, walking and posture. Development happens from head downwards:
- 4 months: Support own head
- 6 months: Unsupported sitting
- 9 months: Crawling and stands holding on
- 12 months: They should stand and begin cruising
- 15 months: Walk unaided.
- 18 months: Run
- 2 years: Run. Kick a ball.
- 3 years: Climb stairs one foot at a time. Ride a tricycle.
- 4 years: Hop. Climb and descend stairs like an adult.
What are the fine motor developmental milestones?
Development of precise skilled movements, visual development and hand-eye coordination:
- 6 weeks: tracks object/face
- 6 months: palmar grasp, transfer hand to hand
- 9 months: object permanence and scissor grip
- 12 months: pincer grip, stack 2 bricks. Casting bricks which should stop by 18m, casting beyong 18m is abnormal.
What are the language developmental milestones?
- 6 weeks: Startles to noise
- 6 months: Turns head to loud sounds, understands ‘bye bye’
- 9 months: Responds to own name and babbles
- 12 months: Single words
- 18 months: Speak 6-10 words, understand Nouns e.g show me the spoon
- 2 years: Can join 2 words together, speak 50 words, understand verbs e.g show me what you eat with
- 2.5 years: 3-4 words joined together, understand prepositions in/on e.g put the spoon in the cup
- 3 years: understands negatives, understand adjectives e.g what is bigger? which is red?
- 4 years: understands complex instructions e.g. ‘before you put the book down can you give the pen to mummy’
What is an easy way to remember how many words a child can respond to at their age?
What are the social and behavioural developmental milestones?
Child’s development of interacting, communicating, playing and building relationships:
- 6 weeks: Smiles
- 3 months: Laughs
- 6 months: Curious and engaged with people
- 9 months: They become cautious with strangers, wave bye
- 12 months: Engages with others by pointing and handing objects. Claps hands.
- 18 months: Imitates activities such as using a phone
- 2 years: Extends interest to others beyond parents, such as waving to strangers. Plays next to but not necessarily with other children (parallel play). Usually dry by day.
- 3 years: They will seek out other children and plays with them. Bowel control.
- 4 years: Has best friend. Dry by night. Dresses self. Imaginative play.
What are the developmental milestones for brick building and drawing with a pencil?
What are some red flags for developmental delay at 6, 9, 12, 18 and 24 months?
- Lost developmental milestones
- Not able to hold an object at 5 months
- Not sitting unsupported at 12 months
- Not standing independently at 18 months
- Not walking independently at 2 years
- Not running at 2.5 years
- No words at 18 months
- No interest in others at 18 months
How do you take a developmental history?
-Consider child’s age and focus questions based on milestones
-Offer child suitable toys to assess skills
-Observe how the child plays and interacts with others
What are some causes of developmental delay in the following areas:
- Global
- Fine motor
- Gross motor
Global
- Down’s syndrome
- Fragile X syndrome
- Fetal alcohol syndrome
- Rett syndrome
- Metabolic disorders
- Extreme prematurity
Fine motor
- Dyspraxia
- Cerebral palsy
- Muscular dystrophy
- Visual impairment
- Congenital ataxia (rare)
Gross motor
- Cerebral palsy
- Ataxia
- Myopathy
- Spina bifida
- Visual impairment
What are some causes of developmental delay in the following areas:
- Language
- Behavioural and Social
Language
- Specific social circumstances, for example exposure to multiple languages or siblings that do all the talking
- Hearing impairment e.g glue ear
- Learning disability
- Neglect
- Autism
- Cerebral palsy
Social
- Emotional and social neglect
- Parenting issues
- Autism
What screening is done on the NHS Healthy Child Programme?
- Antenatal screening
- APGAR
- Newborn Hearing Screening Programme
- Newborn assessment by 72 hours
- Blood spot Screening at 5-8 days
- 6 week repeat newborn assessment
- Visual and Hearing Screen by 5 years
What are some causes of obesity in childhood?
Organic: Hypothyroidism, Prader-Willi Syndrome, GH deficiency
What children are at risk of poor social and educational outcomes?
- Young parents
- Both parent’s not in work
- English not first language of parents
What children have protective factors against poor social and educational outcomes?
What immunisations do babies have in the first year of their life? (not including 1 year)
What immunisations do babies have at 1 years old?
What immunisations do children have from 1 to 15 years?
What does the healthy child programme review as a whole?
Important image
- Screening
- Encouraging breast feeding
- Developmental assessment
- Parental support
What are the principles of parenting programmes?
- consider the whole family
- focus on parents’ strengths
- focusing on empowering parents
- the ability to promote attachment, laying the foundations for a child’s trust in the world,
- involving fathers
- recognising and addressing mental health problems in either parent
What are some of the principles of obesity prevention laid out by the government?
- Assessment at 12 weeks of pregnancy, and advice on healthy weight gain during pregnancy
- Make breastfeeding the norm (breastfeeding reduces risk of excess weight in later life)
- Delaying weaning until around six months of age, introducing children to healthy foods and controlling portion size
- Identifying early those children and families who are most at risk (e.g. where either the mother or the father is overweight or obese)
- Encouraging an active lifestyle
How is breast feeding promoted through the healthy child programme?
- Peer support
- Involving and informing father’s
- Raise the topic of breastfeeding at every antenatal appointment
What advice can you give to parents on dental health?
How do you explain to a mother how to breast feed?
- Ensure baby’s shoulders and head facing breast
- Avoid forcing the nipple into the mouth. Tease baby to open mouth by brushing nipple on lip and pulling away
- Mouth wide open, and chin touching the breast (nose hardly touching). The baby should be seen to be drawing in breast, not just nipple. Lower lip curled back, maximally gobbling the areola
- Slow, rhythmic, and deep jaw movements, as well as sucking movements. The 1st few sucks may be fast, shallow, and non-nutritive to stimulate let down reflex
Why is breast feeding good for mothers and babies?
What are some causes of hypotonia in children?
