Case 16- Development and Vaccination Flashcards
The domains of child development
- Gross motor
- Fine motor and visions- how we use our hands to manipulate stuff
- Speech, language and hearing
- Social and emotional- how we relate to ourselves and others
How development should progress
Development should always follow the same pattern. The rate at which each development milestone is achieved can be different between children
Define development milestones
• The median age a skill is achieved
OR
• The upper limit of normal (98% of children will have developed this milestone by this time)
The primitive reflexes
- Moro
- Sucking
- Asymmetric tonic neck
- Stepping
- Routing
- Palmar-grasp
Factors influencing child development
- Health- have they spent a lot of time in hospital or bed
- Parenting- neglect
- Deprivation- emotional or physical deprivation
- Attachment- someone who the child feels secure with
- Opportunity to practise a skill- for speech and language development especially
- Neglect
- Prematurity- may develop at a slower rate or it may be delayed, we correct for prematurity up to two years to gestational age
What do you need to losse in order to develop properly
You need to lose your primitive reflexes before you move on to the next stage of development. You develop from head to toe i.e. you first develop neck, also from in to out
Stages of gross motor development up to a year
- 6 weeks - head control developing, primitive reflexes present
- 3 months - lifts head and shoulders onto forearms when on tummy, no head lag
- 6 months - rolls over, holds head when sitting, sits with support
- 9 months- sits well unsupported and pulls up to stand
- 12 months - gets up to sitting position on own, pulls to stand at furniture, cruising (walking between furniture), crawling. Not all children crawl, some just shuffle their bottom along
Stages of gross motor development after a year
- 18 months - walks alone, crawls up stairs. Pushes or pulls toys while walking
- 2 years - walks backwards, kicks a ball, walks up stairs 2 feet per step
- 3 years - stands on one foot briefly, stairs, tricycle, jumps
- 4 years - down stairs alternate feet, walks in a straight line. Stands on one foot for more then 3 seconds. Very active, can climb on play structures. Jump
Stages of fine motor and vision development (up to a year)
- Birth - primitive reflexes
- 6 weeks - momentarily holds objects, rolls (till 2 months), fixes and follows (can follow a bright object with their eyes)
- 3 months - palmer grasp, hold and shakes rattle
- 6 months - reaches for toys, hand-hand transfer, opens mouth for spoon, finger feeds
- 12 months – between 9-12 months you develop the pincer grasp, picks up and eats finger food, holds cup with 2 hands
Stages of fine motor and vision development- after a year
- 18 months - helps with dressing, stacks 2 blocks, scribbles, turns pages in book
- 2 years - takes off shoes, stacks 5 blocks, eats with spoon, draws line
- 3 years - dress/undress with help, copies a circle
- 4 years - correctly holds crayon, buttons, scissors, dresses
- 5 years - draws shapes and stick people, knife and fork
How might a child communicate if they cant hear
Through gesturing i.e. pointing. If children arent trying to communicate that is a red flag
Receptive and Expressive language
1) Expressive language- what we can say
2) Receptive language- what we can understand i.e. can you get your shoes
Children are more likely to have issues with expressive language then receptive language
Stages of speech, language and hearing development
- 6 weeks – smiles (4 weeks), cooing, startles to loud noise
- 6 months - babbling
- 12 months - 1-2 words, pointing
- 2 years - joins 2 words
- 3 years - 3-4 word sentences
- 4 years - tells stories in past tense, counts 1-20
- 5 years - knows colours / age/ address, strangers can understand what they are saying
Stages of social and emotional development
- 12 months - stranger anxiety
- 18 months - symbolic play- copies actions they see around them like feeding dolly
- 2 years - tantrums
- 3 years - toilet trained, sharing
- 4 years - parallel play (play with other kids)
- 5 years - takes turns, plays games with rules
How you start learning to talk
Vowels start first from the back of the mouth i.e. ohh. Babble then Raspberries. Noises that sound like pretend conversations. Harder sounds p, m, t. Single words with meaning, putting words together.
Children and emotions
Children have different temperaments. However, they should be interested in interacting with some of the people around them. How do they respond to other peoples emotions i.e. concerns if someone is hurt. Can they regulate their own emotions i.e. shouldn’t be having tantrums at 5.
Red flags for child development
Loss of skill at any age
Parental concern
Red flags for child development= 0-8 moths
Gross motor= Primitive reflexes (6m), Head lag
Fine motor= Not fixing, Hand preference (6m)
Social= No smile (8w), little interest in people
Red flags for child development= 8-18 months
Gross motor= No sit (9m), walk (18m)
Fine motor= No pincer grasp (12m)
Speech language= Absence of babbling (12m)/speech
Red flags for child development= 8-18 months
Gross motor= No sit (9m), walk (18m)
Fine motor= No pincer grasp (12m)
Speech language= Absence of babbling (12m)/speech
Red flags for child development= 18-24 months
Absence of speech
Red flags for child development 2-3 years
Gross motor= unstable walking
Fine motor= Avoids crafts
Speech language= No 2-3 word sentences
Social= No pretend play
What is a vaccine
A biological preparation that improves immunity to a particular disease
What does a vaccine contain?
• An agent that resembles a disease causing microorganism
• Is made from attenuated or killed forms of the microbe
• The toxins or surface proteins of the microbe
It stimulates the immune system to recognise the agent as foreign and provides immune memory
Properties of the ideal vaccine
1) Broadly protective against all variants of the organism
2) Prevents disease transmission
3) Induce effective immunity rapidly
4) Be effective in all vaccinated subjects
5) Transmits maternal protection to fetus
6) Cheap and stable
7) Limited side effects
8) Requires few immunisations to induce protection
Immunological prinicpals behind vaccinations
Induces effector mechanisms in the immune system that control or destroy pathogens and related toxic componenets
The main mechanisms of vaccination are activated by
- B cells- antibody production
- CD4+ T-cells- cytokine production causes maintenance of B-cell and CD8+ cell response
- CD8+ lymphocytes- limits infection spread by killing infected cell or releasing antiviral cytokines
B cell response to vaccines- antibody production
- Dendritic cells recognise foreign antigens
- Becomes activated
- Migrates to lymph node
- Activates B cells in lymph node follicules
- Plasma B cells produce and secrete antibodies
- Typically IgM
- IgG is also produced from long lived plasma B cells which require T helper cells, long lived plasma cells are generated in the germinal centre of the lymph node
- Central B memory cells also develop
- These generate long lasting immunity
What can antibodies do to prevent infection?
- Bind to the active sites of toxins or stop diffusion
- Neutralising viral replication
- Opsonisation
- Complement activation
T cell response to vaccines
- Dendritic cell recognises foreign antigens
- Migrates to lymph nodes
- Activates T cells
- T cells differentiate into CD4+ cells
- These produce cytokines and maintain B cells
- Also, differentiates in to CD8+ T cells
- These kill infected cells - therefore only works in live vaccines
- Also some T memory cells which provide long lasting immunity
Types of vaccines available
- Inactivated- toxoids i.e. bacterial toxins, viral like particles, killed bacteria or viruses, peptides or polysaccharide units, viral like particles (VLP), RNA vaccines.
- Live- attenuated, virulent
Adjuvants
Chemical additives added to vaccines in combination with the antigen to improve effectiveness and produce a more robust immune response
When are adjuvants used
- Typically used in inactivated vaccines
- And weak immunogenicity vaccines
- Enhances the speed and duration of the immune response
- Decreasing the dose of antigen required
- Enhances the immune response in immunologically immature patients
Polysaccharide derived vaccines
Derived from the bacterial polysaccharide in the cell envelope. Poorly immunogenicity. Not all that effective especially in infants and young children (18-24 months). Some do work. PS vaccines rarely induce a T-cell response. Solution = produce a conjugate vaccine, combining it to a strong immunogenic protein.
Properties of a live vaccine
Route- Natural/injection Doses- few Adjuvant- no Protection- long term T-cell response- good Side effects- mild symptoms
Properties of inactivated vaccine
Route- injection Doses- many Adjuvant- yes Protection- short term T-cell response- weak Side effects- site of injection pain
Rationale of vaccination programmes
Saves millions in healthcare costs, provides herd immunity. However, vaccine development is time consuming and costly and not always successful.
How do we choose what to vaccinate against?
- Chose agents which cause significant illness
- Agents whose infection can be blocked by antibodies
- Agents which dont have oncogenic protection
- Agents which exist as only one serotype
- Vaccine is heat stable
Common side effects of any vaccine include
- Injection site reactions (pain, swelling and redness)
- Mild fever
- Shivering
- Fatigue
- Headache
- Muscle and joint pain
- Rare- anaphylaxis
Vaccines at 8 weeks
6 in 1 vaccine
1) Diptheria
2) Tetanus
3) Whooping cough (pertussis)
4) Polio
5) Haemophilus influenzae type B
6) Hepatitis B
7) Pnemococcal (PCV) vaccine
8) Rotavius vaccine
9) MenB vaccine
12 week vaccine
6 in 1
Rotavirus
16 weeks vaccines
6 in 1
Pneumococcal (PCV)
MenB
1 year vaccines
Hib MenC MMR Pneumococcal (PCV) MenB
3 year and 4 months vaccines
MMR 4-in 1 pre-scholl booster Diptheria Tetanus Whooping cough Polio
12-13 year vaccine
HPV vaccine
14 year vaccine
3-in 1 teenage booster Diptheria Tetanus Polio MenACWY
Vaccine 65+
Flu vaccine- every year
70 years vaccine
Shingles
Development
The process by which a child evolves from helpless infancy to independent adult
Developmental delay
The slow aquisition of a skill, in children 0-5 years. Can be:
Global- significant delay in more then 2 domains, usually presents in the first two years of life
Specific- significant delay in 1 domain
What happens to the developmental delay over time
The gap between normal and abnormal development becomes greater with increasing age
Biological factors for gross motor skill delay
1) Duschenne muscular dystrophy
2) Cerebral palsy
3) Dyspraxia
4) Spinal cord lesions i.e. spina bifida
Biological causes for speech, language and hearing delays
1) Deafness
2) Cerebral palsy
3) Autism spectrum disorders
4) Cleft palate
5) Isolated speech and language delay
Biological causes- Fine, motor skills and vision
1) Squint
2) Refractive errors i.e. astigmatism, short/long sighted
3) Severe visual impairment i.e. congenita cataracts
4) Cerebral palsy
Biological causes of social, emotional and behaviour delays
Autism spectrum disorders
Prenatal causes of a developmental delay
1) Genetic disorders: e.g. Down’s syndrome, Fragile X syndrome, Duchenne muscular dystrophy
2) Neurological: Microcephaly, stroke
3) Metabolic: Hypothyroidism, phenylketonuria
4) Teratogenic: Foetal alcohol syndrome, teratogenic drugs, radiation
5) Congenital infection: toxoplasmosis, rubella, cytomegalovirus, HIV
Perinatal causes of developmental delay
1) Extreme prematurity: intraventricular haemorrhage
2) Birth asphyxia: hypoxic-ischaemic encephalopathy and cerebral palsy
3) Metabolic: kernicterus, symptomatic hypoglycaemia
Postnatal causes of developmental delay
1) Infection: meningitis, encephalitis
2) Trauma: Head injury – accidental or non-accidental injury (NAI)
3) Metabolic: hypoglycaemia
4) Vascular: stroke
5) Sociological: Abuse and emotional neglect
Red flags for developmental delay
1) Extremes of occipito-frontal circumference percentile or rapid change in percentile
2) Developmental regression
3) Squint
4) Parental concern
The multi-disciplinary tea for a child with a developmental delay
1) Physiotherapist
2) Speech and language therapist
3) Paediatrician
4) Educational psychologist
5) Clinical psychologist
6) Social worker
7) Dietician
8) Specialist health visitor
9) Occupational therapist
Factors which can cause a delay in normal speech and language development
1) Hearing loss
2) Global developmental delay
3) Difficulty in speech production due to anatomical deficit
Interaction with other types of delay i.e. cleft palate
4) Environmental deprivation or lack of opportunity for social interaction
5) Normal variants and family patterns e.g. family history of speech delays
Factors which cause a disorder in speech and language development
1) Language comprehension and expression disorders
2) Intelligibility e.g. stammering, dysarthria
3) Social communication skills e.g. Autistic Spectrum Disorder
Language expression disorder
Inability or difficulty in producing specch whilst knowing what is needed to be said
Dysarthria
Difficult or unclear articulation of speech that is otherwise linguistically normal
What is the initial step if the child has abnormal speech and language development
A hearing test and assessment by speech and language therapists are the initial steps
Define learning difficulty and disorder
Learning difficulty- used in relation to children of school age, may be cognitive/physical/both
Disorder- maldevelopment of a skill
Define Impairement, Disability and Disadvantage
Impairement- loss or abnormality in physiological function or anatomical structure
Disability- any restriction or lack of ability due to impairment
Disadvantage- this results from the disability and limits or prevents fulfilment of a normal role
Cerebral palsy
Abnormality of movement and posture causing activity limitation due to non progressive disturbance that occurred in the developing fetal/infant brain
Causes of cerebral palsy
Antenatal (80%)- structural maldevelopment, vascular occlusion, genetic syndromes During delivery (10%)- Hypoxic-iscaemic injury Postnatal (10%)- Meningitis, encephalitis, head trauma, hypoglycaemia
Early clinical features of cerebral palsy
1) Abnormal limb and or/trunk posture and tone with delayed motor milestones
2) Feeding difficulties (oromotor incoordination) – slow feeding, gagging, vomiting
3) Abnormal gait
4) Asymmetric hand function i.e. hand dominance before 12 months of age
