Child Development

Question 1

What is the development of fine motor and vision?

Answer 1

• Fixes: 1 month, follows: 2 months
• Holds rattle in one hand for 3 months
• Holds objects in one hand at 5 months
• Transfers objects between hands at 6 months
• Crude palmer grasp - 6 months
• Pincer grasp at 9-10 months
• 13 months - 2 blocks, 18 months - 3 blocks, 2yrs - 5 blocks
• 3yrs - bridge, 4yrs - train, 5 yrs - stairs

Question 2

What is the development of speech and hearing?

Answer 2

• Vocalises at 3 months
• Imitates 6-7 months - baba, dada
• 1 word by 11 months
• 2-3 words by 12 months
• Sentence by 2yrs
• Full name by 2.5yrs
• Turns to sound at ear level by 3 months
• Turns up to sound above ear level by 8 months

Question 3

What is the development of social skills?

Answer 3

• Social smile at 6-8 weeks
• Laughs at 4 months
• Stranger wary by 7-9 months
• Peek a boo - 9-10 months
• Object permanence by 9-11 months
• Drinks from cup by 15 months
• Can use a spoon - 18 months
• Toilet training achieved around 3yrs

Question 4

What is Down’s Syndrome?

Answer 4

• Genetic condition causing learning difficulties and is associated with severe physical characteristics
• Condition can be diagnosed antenatally between 11-14 weeks of gestation. Typically - increased fluid under skin at back of neck of foetus (increased nuchal translucency)
• Options of blood tests antenatally along with invasive tests like CVS or amniocentesis to get a confirmed diagnosis
• Some cases are diagnosed postnatally (examination and chromosomal analysis)
• Risk of Down’s increased with maternal age, especially >35yrs

Question 5

What are the orthopaedic problems associated with Down’s Syndrome?

Answer 5

• Hypotonia: delayed motor milestones, respiratory problems
• Hypotonia, ligamentous laxity and skeletal dysplasias may predispose to other problems: patellar instability; scoliosis; subluxation and dislocation of hips; and pes planus and metatarsus varus.

Question 6

Why is there upper airway obstruction and obstructive sleep apnoea associated with Down’s Syndrome?

Answer 6

• Narrow airways and tongue hypotonia are common contributory factors: growth retardation, poor developmental progress, tiredness and lethargy
• Significant hypoxia and pulmonary hypertension can result
• Symptoms: sleep disturbance, snoring, drooling and swallowing
• Some children require adenotonsillectomy

Question 7

What are the problems with vision in Down’s Syndrome?

Answer 7

• High prevalence of ocular disorder
• 10 fold increase in congenital cataract and infantile glaucoma can occur
• Refractive errors +/or squint may be present from an early age and persists in childhood, decreased accommodation

Question 8

What are the problems with growth in Down’s Syndrome?

Answer 8

• Mean adult height is 145cm for females and 157cm for males
• Cause of growth retardation is not known
• However, poor growth may be an indicator of: congenital heart disease, upper airway obstruction, coeliac disease, hypothyroidism
• In older children obesity is normal however it is not an inevitable consequence
• Excessive weight gain should be thoroughly assessed and advice on nutrition and exercise offered.

Question 9

What are the problems with sexual development in Down’s Syndrome?

Answer 9

• Mainly proceeds same as general population and most adolescents cope well with puberty
• Some boys have small genitalia
• Sub-fertility occurs in both sexes but more so amongst men
• 50:50 risk of Down’s in pregnancy where one parent has the syndrome

Question 10

What are the problems with the GI system in Down’s Syndrome?

Answer 10

• 10% have congenital malformations: atresia of jejunum, duodenum, oesophagus and anus
• There are less severe forms e.g. anal or duodenal stenosis where symptoms are milder and may go unrecognised for a long time
• Children with Down’s should not be denied treatment for surgically correctable conditions on the grounds they have Down’s

Question 11

What are common blood disorders associated with Down’s Syndrome?

Answer 11

• Immune deficiencies - very variable (immunisation important)
• Transient abnormal myelopoesis
• AML - 150x risk of general population
• ALL

Question 12

What are common dental problems in Down’s Syndrome?

Answer 12

Related to tooth morphology:

• Decreased root to crown ratio
• Decreased tooth size
• Hypodontia or partial anodontia
• Delayed eruption

Question 13

What are the signs of Down’s syndrome?

Answer 13

• Incurved little fingers (clinodactyly)
• Single palmar crease
• Brushfield spots on iris
• Epicanthic folds (around eyes)
• Fissured tongue (protruding)
• Gap between 1st and 2nd toes
• Duodenal atresia
• Small ears
• Upward slanting eyes
• Flat round face
• Cardiac defects

Question 14

What is cerebral palsy and what are the types?

Answer 14

• Lifelong condition that affects movement and coordination
• There are several causes. Most commonly it is caused by lack of oxygen supplied to the brain around birth, bleeding in the brain, meningitis, serious head injury
• Broadly 4 different types: spastic, dystonic, ataxic and mixed

Question 15

What are the complications in managing cerebral palsy?

Answer 15

• Prone to MSK problems like hip dislocation, muscle contractures, scoliosis
• Drooling
• Recurrent chest infections
• Seizures
• Different vascular access
• Spasticity and hypertonia
• Feeding challenges and requirement of PEG feeding

Question 16

What is the management for cerebral palsy?

Answer 16

• Screening for hip subluxation +/- dislocation which can be extremely painful, 60-98% of children with GMFCS score of 4-5 have dislocated hip
• Normal hip at birth
• Hip displacement explained by abdominal shape of proximal femur as a result of delayed/limited/absent walking
• Poor development of neck to shaft angle of femur
• Increase in MP; mean 4.6% per annum
• Rate of displacement increases when MP >50%
• Treatment is supportive and preventative - physiotherapy, OT

Question 17

What alerting features may lead you to consider or suspect child maltreatment?

Answer 17

• Physical features
• Sexual abuse
• Neglect
• Emotional, behavioural, interpersonal and social functioning
• Clinical presentations
• Fabricated or induced illness
• Parent or carer-child interactions

Question 18

What bruises are suspicious?

Answer 18

Bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement. Bruising or petechiae not caused by medical condition, with an unsuitable explanation:

• In a child who is not independently mobile
• Where there are multiple, in clusters of similar shape and size
• On non-bony parts of the face or body, including the eyes, ears and buttocks
• On the neck that look like attempted strangulation
• On the ankles and wrists that look like ligature marks

Question 19

What thermal injuries are suspicious?

Answer 19

Suspect burns or scald injuries:

• If there is an absent or unsuitable explanation
• The child is not independently mobile
• On soft tissue areas not expected to come into contact with a hot object e.g. backs of hands, soles of feet, buttocks, back
• In the shape of an implement e.g. cigarette or iron
• That indicate forced immersion e.g. scalds to buttocks, perineum and lower limbs, to limbs in a glove/stocking or symmetrical distribution or with sharply delineated borders.

Question 20

When are fractures suspicious?

Answer 20

There is no medical condition that predisposes to fragile bones or the explanation is absent or unsuitable, including:

• Fracture of different ages
• XR evidence of occult fractures e.g. rib fractures in infants

Question 21

What other physical features can be suspicious?

Answer 21

Suspect if there is no major confirmed accidental trauma or medical explanation:

• Retinal haemorrhages or injury to the eye in a child
• Signs of spinal injury in a child
• Intra-abdominal or intrathoracic injury in a child with an absent or unsuitable explanation or with a delay in presentation. There may be no external bruising or other injury.

Question 22

What do you do in suspected child maltreatment?

Answer 22

• Discuss with the team first

- Discuss with social care or senior GP or paediatrician as relevant

Question 23

What are other features common in Down’s syndrome?

Answer 23

• Glue ear is common and sensorineural hearing loss
• Thyroid dysfunction: prevalence increases with age
• Eczema, vitiligo, alopecia

Question 24

What are more difficult forms of child maltreatment to spot?

Answer 24

• Cold injuries: left outside, hypothermia
• Neglect: parents or carers who repeatedly fail to attend essential follow-up appointments that are necessary for the health and wellbeing of the child. Suspect also if the child is smelly and dirty.

Question 25

What are the developmental milestones?

Answer 25

• 6 weeks: smiling, fixing, following
• 6 months: transfer object from one hand to another
• 8 months: scared of stranger, sit without support
• 12 months: walk around holding onto furniture (cruise)
• 2yrs: constant questions
• 2 1/2-3yrs: dry in day
• 3yrs: ride a trike, know their gender