A Child's Journey Flashcards
1
Q
what are the Recognised phases of childhood?
A
- Neonate (<4w)
- Infant (<12m/1y)
- Toddler (~1-2y)
- Pre-school (~2-5y)
- School age
- Teenager/ Adolescent
2
Q
What are the main childhood objectives?
A
- To grow
- To develop and achieve their potential
- To attain optimal health
- To develop independence
- To be safe
- To be cared for
- To be involved
3
Q
what is development?
A
- Gaining functional skills throughout childhood
- A gradual yet rapid process
- Cell growth, migration, connection, pruning, and myelination (Use it or lose it)
- Sequence of events in each domain
- School - Cognitive and thought development (early skills become more refined)
4
Q
when does development occur?
A
- Typically birth to 5y (but brains develop in utero)
- Fairly consistent pattern but rate will vary
5
Q
Getting Wired up…
What is happening in the brain in fascinating
Born with connections and up until 2 forms billions of connections
A
Use it or Lose it….
Then there’s a pruning back process at 15
6
Q
what are the key development fields?
A
4 main key areas
2 parts of motor separate
Hearing and vision may not get listed separately
All these areas do interact and overlap with each other
7
Q
evolution of childs level of physical development
A
8
Q
evolution of childs level of mental and social development
A
Understand the sequence
It’s a progression of skills over a period of time
9
Q
when thinking about a childs development, what are important things you need to think about?
A
What has come before? What is coming next?
- Think of the sequence within each domain
- If what you see is normal - Chances are what follows will be normal
- If what you see is abnormal - What came before and what comes after may well be abnormal
10
Q
what are Milestones?
A
- Achievement of key development skills
- Social smile, sitting, walking, first words
- Variation of what is normal
11
Q
when should a child be refered if milestones are not met?
A
- Refer if not achieved by limit age (2 SDs from mean)
- Correct for prematurity until 2y (born early, should be caught up by 2 years old)
- Example: Walking
- Some may walk at 9-10 months
- 50% by 12m (median age)
- Refer if not walking by 18m (limit age)
- Beware bottom shufflers and commando crawlers
12
Q
Why is Development Important?
A
- Learning functional skills for later life (often things you take for granted)
- Hone skills in a safe environment
- Allow our brain’s genetic potential to be fully realised
- Equip us with tools needed to function as older children and adults
- Many are completely automatic
Critical for who you become when you are older
13
Q
what are influencing factors of development?
A
- Genetics (Family, race, gender)
- Environment
- Positive early childhood experience
- Developing brain vulnerable to insults - Antenatal, Post natal, Abuse and neglect
14
Q
Adverse Environmental Factors affecting development:
what are some Antenatal factors?
A
Infections (CMV, Rubella, Toxoplasmosis, VZV)
Toxins (Alcohol, Smoking, Anti-epileptics)
15
Q
Adverse Environmental Factors affecting development:
what are some Postnatal factors?
A
Infection (Meningitis, encephalitis)
Toxins (solvents mercury, lead)
Trauma (Head injuries)
Malnutrition (iron, folate, vit D)
Metabolic (Hypoglycaemia, hyper + hyponatraemia)
Maltreatment/under stimulation/domestic violence
Maternal mental health issues
16
Q
Developmental Assessment- Why?
A
- Reassurance and showing progress
- Early diagnosis and intervention
- Discuss positive stimulation/parenting strategies
- Provision of information
- Improving outcomes (pre-school years critical)
- Genetic counselling
- Coexistent health issues
17
Q
Developmental Assessment - how are patients assessed?
A
- Child surveillance v.s. developmental screening v.s. developmental assessment
- Specific groups (premature, syndromes, events)
Surveillance being the process by which all children are kept under review. developmental screening is the points at which kids get seen at set ages And there’s that snapshot to take a look at where they’re at. And developmental assessment is more a more detailed process where there’s maybe a few issues flagged up at screening, and then you have a more detailed assessment looking at a wider range of skill sets
18
Q
Developmental Assessment - Who are the assessors?
A
Parents and wider family
Health visitors, nursery, teachers
GPs, A+E, FYs, STs, students
Paediatricians and community paediatricians
19
Q
Developmental Assessment - What is it?
A
- Healthy Child Programme (HCP) UK
- Screening may not always be sensitive/specific
- Listen to parental concerns/videos on phone
- Opportunistic questions - target the right area
- Review the red book
- Good observation of play and activity
- Medical history and examination
- Most common mistake is not thinking about it!
20
Q
Developmental Assessment - How is it done?
A
A simplified way to think about this is;
- How do they move their body around? (gross motor skills)
- What do they do with their hands? (fine motor skills)
- How do they communicate? (language skills)
- What can they do for themselves? (social and self help skills)
- Use basic toys (Bricks, crayons, balls, tea sets, picture books)
- Watch carefully and let the parents help
21
Q
Deciding what is normal is not always easy, how should you do it?
A
- Think about each developmental field (deficiency may predominantly affect one area)
- What sequence/pattern has come before?
- What skills have been achieved?
- What has not yet been achieved?
- Is one field falling behind the other? - Global delay v.s. specific developmental delay
- Are the skills gained age appropriate? (the older you get, the wider the age of what we would think of is okay is okay)
22
Q
Recognise Normal Variation - what variation should you look out for?
A
- Early developers and Late normal
- Bottom shufflers - walking delay
- Bilingual families- apparent language delay (total words may be normal)
- Familial traits
23
Q
it is important to recognise red flags, what are they?
A
- Loss of developmental skills (urget referral to hospital)
- Parental/professional concern re. vision (simultaneous referral to paediatric ophthalmology)
- Hearing loss (simultaneous referral for audiology/ENT)
- Persistent low muscle tone/floppiness
- No speech by 18 months, esp if no other communication (simultaneous referral for urgent hearing test)
- Asymmetry of movements/increased muscle tone
- Not walking by 18m/Persistent toe walking
- OFC > 99.6th / < 0.4th / crossed two centiles/ disproportionate to parental OFC
- Clinician uncertain/thinks that development may be disordered
24
Q
What do you need to know:
- The usual sequence of the key ____ areas
- The expected skills for key ____ (6m, 12, 2y, 3y)
- ___ _____ for developmental delay
- How to assess ________ (as a non-specialist)
- What to do when there are concerns (how to _____)
- Recognition of normality (wide spectrum of ______)
A
skill
ages
Red flags
development
refer
normal
25
Summary - Important Points:
* Think about it in every health care contact
* Parents with concerns are usually \_\_\_\_\_\_
* Parents are better aware of _____ milestones than language/speech/social
* \_\_\_\_ of skills/regression is v. worrying and needs further referral and investigation
* Screening tools can help but not usually needed outwith a _________ setting
correct
motor
Loss
specialist
26
what is child health screening?
| (overview of health and development)
* UK- Healthy Child Programme
* Child Health Programme (Scotland) based on HAL4
* Based in primary care (GP, HV, MW)
* Main components - Health promotion, Developmental screening (including hearing), Immunisation
* Parental (carer) observations and concerns crucial
* Record, advise, refer as appropriate
27
what is involved in the Child Health Programme?
* New-born exam and blood spot screening (Spot of blood taken from heel, put onto a card and sent to a lab for monitoring for a list of conditions)
* New-born hearing screening (by Day 28)
* Health Visitor First Visit
* 6-8w Review (Max 12w)
* 27-30 month Review (Max 32m)
* Orthoptist vision screening (4-5y)
* If needed - Unscheduled review, Recall review
28
what is done at the 6-8w Review (GP and HV)?
* Identification data (Name, address, GP)
* Feeding (breast/bottle/both)
* Parental concerns (appearance, hearing; eyes, sleeping, movement, illness, crying, weight)
* Development (gross motor, hearing + communication, vision + social awareness)
* Measurements (Weight, OFC, Length)
* Examination (heart, hips, testes, genitalia, femoral pulses and eyes (red reflex))
* Sleeping position (supine, prone, side)
29
what is done at the 27-30m Review (HV)?
* Identification data (name, address, GP)
* Development
- Social, behavioural, attention and emotional
- Communication, speech and language
- Gross and fine motor
- Vision, hearing
* Physical measurements (height and weight)
* Diagnoses/other issues
Around 2.5 years old
Focus on social and communication aspect
Has the parents observed any problems
By 2 no longer need to measure head and move from measuring length to height
30
what does the healthy child programme include?
* Antenatal
* Birth -1w (Feeding, hearing, examination, Vit K immunisations (reduce haemorrhage), blood spot
* 2w (Feeding, mat mental health, jaundice, SIDS)
* 6-8w (Exam, Imms, measure, mat mental health)
* 1y (Growth, health promotion, questions)
* 2-2.5y (development, concerns, language)
* 5y (Imms, dental, Support, hearing, vision, dev)
31
Health Promotion is also invled in the Healthy Child Programme (Other)
what things may be promoted?
Smoking
Alcohol/ Drugs
Nutrition
Hazards and safety
Dental Health
Support services
32
why immunisations?
* Highly effective public health measure
* Reduction and eradication of diseases
* No live vaccines (e.g. MMR) if child is immunocompromised (except HIV)
* Egg allergy is NOT a contraindication to MMR
33
who gets vaccinations?
* All children (additional if “at risk”)
* Chronological age (i.e. don’t correct prems)
* Postponed if unwell (fever, systemic symptoms) -Only defer if unwell and been sick and fever
34
what is important to gather in immunisation history taking?
* Frequently updated schedule
* Different schedules in different countries
* Older children may not have been immunised against the “current list”
* Check with the parents and red book (but they may just say “they’re up to date”)
* Mild temp, discomfort, swelling - common
* Anaphylaxis - rare
* No link with Autism
35
Growth monitoring - Physical measurements of 3 key parameters:
what are they?
Weight (grams and Kgs)
Length (cm) or height (if \>2y)
Head circumference (OFC) (cm) (Head up till around 2)
36
growth monitoring - Derived (Not routine but may be done)
Weight for age
Length (height) for age
Body mass index (BMI) …. Kg / m2
Weight for length
Rate of weight gain … g / kg / day (infants only)
37
Reference charts vs. WHO Standard charts
whats the difference?
A growth reference simply describes the growth of a sample of individuals, whereas a standard describes the growth of a 'healthy' population and suggests an aspirational model. WHO growth charts are growth standards
Taking info and putting it on growth chart to see where they fit into the rest of the population
Population derived references
38
Useful reference values to remember for weight, length and OFC
Unlikely to get asked in exams
What age does your head circumference double by? - it doesnt
39
Understanding Centiles - how do they work?
* ‘Centile’ – % divisions of the reference population sampled
* 50th Centile - “If you take the average 100 healthy children 50 are above this point and 50 are below” - “About half the kids in class are smaller…”
* 0.4th Centile - “If you take the average 1000 healthy children 4 are below this point 996 are above”
* No single measurement abnormal but pattern, progress, history are crucial
40
Failure to thrive (FTT)/ Weight Faltering - what is it?
* Child growing too slowly in form and usually in function at the expected rate for his or her age
* Significantly low rate of weight gain - Crossing centile spaces
* Not a diagnosis but a description of a pattern
41
Cause of failure to thrive in early life - Deficient intake - maternal causes?
Poor lactation
Incorrectly prepared feeds
Unusual milk or other feeds
Inadequate care
42
Cause of failure to thrive in early life - Deficient intake - infant causes?
Prematurity
Small for dates
Oro palatal abnormalities (e.g. cleft palate)
Neuromuscular disease (e.g. cerebral palsy)
Genetic disorders
43
Cause of failure to thrive in early life - Increased Metabolic demands causes
* Congenital lung disease
* Heart disease
* Liver disease
* Renal disease
* Infection
* Anemia
* Inborn errors of metabolism
* Cystic fibrosis
* Thyroid disease
* Crohn’s/ IBD
* Malignancy
44
Cause of failure to thrive in early life - Excessive nutrient loss causes
* Gastro oesophageal reflux
* Pyloric stenosis
* Gastroenteritis (post-infectious phase)
* Malabsorption
- Food allergy
- Persistent diarrhoea
- Coeliac disease
- Pancreatic insuffiency
- Short bowel syndrome
45
Failure to thrive – Non medical causes (non-organic causes)
* Poverty/socio-economic status
* Dysfunctional family interactions (especially maternal depression or drug use)
* Difficult parent-child interactions
* Lack of parental support (eg, no friends, no extended family)
* Lack of preparation for parenting/ education
* Child neglect
* Emotional deprivation
* Poor feeding or feeding skills disorder
46
summary of how to deal with a child who has failure to thrive
Diet part of history is most important
