Child Development I Flashcards
Growth
Growth refers to increase in physical size and dimensions, i.e. gain in ht, wt, and head circumference with advancement in age.Transient shifts may occur between 4-18 months but a child should reach a stable rate by 1.5 years of age.
What can cause Asymmetric Growth
Brachial plexus paralysis – leading to limb shortening.
Congenital varicella syndrome or myleodysplasia.
Upper motor neuron lesions.
Growth in Relation to Health
The rate of growth rather than absolute size is a sensitive indicator of health or disease. Therefore, all parameters should be measured in a serially consistent manner and recorded in a growth chart. If a child has values outside ± 2 SD range on a normal distribution curve or a continued and unexplained shift in growth trend indicates a need for evaluation.
Certain childhood illnesses or conditions may affect growth:
‐Neurologic impairment/CP ‐Oro-‐motor dysfunction (leading to FTT) ‐Endocrine dysfunction ‐Skeletal disease ‐Genetic condition (like Down Syndrome)
Children with Down Syndrome are typically at or near 3rd percentile for general population. Their average adult height is 5 ft for men, 4.5 ft for women.
The Importance of Head Circumference
The average head circumference is 34-35 cm at birth. It increases by 12 cm in the first year (46-47 cm).
Head circumference should be measured up until 3 yrs of age and thereafter if CNS pathology is suspected. A rapid increase in head size during the first year reflects normal growth and maturation of brain.
When do Fontanels and Sutures harden and close?
Fontanels are closed between 12-18 months. Sutures do not unite firmly until puberty
Height
The average length of FT is 50 cm. Length increases by 50% in first 12 months. The average growth is 12 cm in the 2nd year and 6-8 cm annually from 3-5 years of age. Adult height can be estimated by doubling the length at 2 years of age.
Changes in Height: Boys vs Girls
Girls attain maximal growth velocity before menarche and attain ultimate height 2 years after menarche. Boys grow fastest in late puberty concurrent with appearance of facial hair.
Height Predictions in Children with Defects
For children with marked deformity of the spine or lower extremity, height prediction can be obtained by measuring arm span. With significant bilateral atrophy of lower extremities due to lower motor neural lesion, a sitting height may be a better indicator of general growth than total height.
Height/Stature Progression
xx
Weight
Average FT neonate weighs approximately 3400 gm (range 2500/4600 gms). < 2500 gm are classified as low-birth-weight infants.
Babies lose up to 10% of body weight during 1st week of life. Weight Gain after 2nd week is about 1 oz every day during first 3 – 4 months. Weight is doubled by 5 – 6 months and tripled by 1 year of age.
During 2nd year of life average weight gain is about 2.5 kg (5.5 lbs) and 2 kg (4.5 lbs) annually from 3 – 5 years of age
Low Birth Weight
LBW:
- < 37 wks – Premature
- > 37 wks FT – small for gestational age
Development
Development refers to neuro-maturation, i.e. achievement of systemic functional milestones relative to advancing age.
Development is the acquisition and refinement of the advancing skills. The neurophysiologic basis of achievement of milestones in CNS maturation.
Variations in Development
Under normal circumstances achievement of milestones has a predictable pattern. Individual variations may occur in the timing than in the process of sequences. Delays in milestones and areas of involvement will guide you to a diagnosis and management
Development Milestone: 1 month
Eyes follow to midline
Development Milestone: 2 months
Has responsive smile
Development Milestone: 3 months
Coos and chuckles (vocal/social response)
Development Milestone: 4 months
Holds head steady in seated position and can lift head 90° when prone
Development Milestone: 5 months
Grasps cube on contact
Development Milestone: 6 months
Can sit on chair erect
Development Milestone: 7 months
Can sit erect momentarily (on hard surface)
Development Milestone: 8 months
Crawls by dragging rest of body/pelvis on floor
Development Milestone: 9 months
Stands holding on
Development Milestone: 10 months
Creeps (hands and knees on floor with feet and trunk raised) 4-point reciprocal
Development Milestone: 11 months
Cruises (both hands holding on and moving sideways)
Development Milestone: 12 months
Walks (one hand held)
Newborn Period:
Muscle tone is predominantly with semiflexion of the extremities. When in prone position head turns from side to side with neck hyper extension. Sweeping mouth against the surface.
Most movements in this period are involuntary and purposeless. Primitive Reflexes are present
If you put them in sitting position, full support is required, the back is rounded and head falls forward. Hands are loosely fisted and grasp reflexes can be elicited.
Temperament characteristics are discernible during first few months and contribute to parent child interaction
Infantile Reflex Development
Motor behavior in infancy is influenced by primitive reflexes (as CNS is immature). The reflexes produce a predictable and stereotypic movement. As neuromaturation occurs these primitive reflexes are suppressed and become part of mature reflex system.
T/F: Obligatory or persistent primitive reflexes are the earliest indicator of neuro-abnormality
True
Moro
Stimulated by sudden neck extension
Response is shoulder abduction, shoulder, elbow and finger extension followed by arm flexion adduction.
Suppressed at 4-6 mo
Startles
Stimulated by sudden noise, clapping
Response is shoulder abduction, shoulder, elbow and finger extension followed by arm flexion adduction.
Suppressed at 4-6 mo
Rooting
Stimulated by stroking lip or around mouth
Response is head and mouth moving toward stimulus in search of nipple
Suppressed at 4 mo
Positive Supporting
Stimulated by light pressure or weight bearing on plantar surface
Response is legs extended for partial weight bearing support
Suppressed at 3-5 mo
Asymmetric Tonic Neck
Stimulated by turning head to side
Response is extremities on face side extend, extremities on occipital side flex
Suppressed at 6-7 mo
Symmetric Tonic Neck
Stimulated by extension/flexion of the head
Response is arms flex, legs extend; legs flex arms extend.
Suppressed at 6-7 mo
Palmar Grasp
Stimulated by touch or pressure on palm or stretching finger flexors.
Response is flexion of all fingers, hand fisting
Suppressed at 5-6 mo
Plantar Grasp
Stimulated by touch or pressure on sole to distal metatarsal heads.
Response is flexion of all toes
Suppressed at 12-14 mo when walking is achieved.
Automatic Neonatal Walking
Stimulated by vertical support, plantar contact and passive tilting of body forward and side to side.
Response is alternating automatic steps with support
Suppressed at 3-4 mo
Placement or Placing
Stimulated by tactile contact on dorsum of foot or hand
Response is extremity flexion to place hand or foot over an obstacle
Suppressed before the end of the first year.
Gross and Fine Motor Development in Pre School Years: 2 years
o Walks up and down stairs one step per tred o Can walk backwards o Throws ball over hand o Kicks ball forward o Scribbles
Gross and Fine Motor Development in Pre School Years: 2 1/2 years
o Can walk on tiptoe o Jumps with both feet in place o Helps dress and undress o Copies a crude circle o Can imitate vertical and horizontal lines
Gross and Fine Motor Development in Pre School Years: 3 years
o Can run but stumbles occasionally o Throws a ball without loosing balance o Rides tricycle o Can copy a circle o Can use scissors to cut paper
Gross and Fine Motor Development in Pre School Years: 3 ½ years
o Runs smoothly with acceleration and decleration
o Briefly hops on one foot
o Catches a bounced ball
o May copy a crude square
Gross and Fine Motor Development in Pre School Years: 4 ½ years
o Hops on non dominant foot
o Dresses himself except for tying shoes
o Copies a triangle
Gross and Fine Motor Development in Pre School Years: 4 years
o Balances on one foot for 4 – 8 seconds
o Skips on one foot
o Copies a square
o May button and unbutton
Gross and Fine Motor Development in Pre School Years:5 years
o Catches with two hands
o Skips rope
Asymmetric tonic neck reflex (ATNR)
Flexion of the arm and leg on the occipital side and extension on the chin side create the “fencer position.”
Development of head control on the pull-to-sit maneuver
At 1 month of age, the head lags after the shoulders
At 5 to 6 months, the child anticipates the movement and raises the head before the shoulders
Development of sitting posture
At 3 to 4 months, support in the lumbar area is required to sit
At 5 to 6 months of age, the infant holds the head erect and the spine straight
Crawling, Creeping, Cruising and Walking
Crawling implies that the belly is still on the ground
Creeping refers to mobility with the child on hands and knees (quadruped)
Cruising refers to standing with two-handed support on stationary objects before moving with steps
Early, free walking
Development of skill at drawing a person
To calculate an age equivalent, the child earns ¼ year for each of the five features, added to a base age of 3 years.
Scissoring
Excessive pull of the hip adductors and internal rotators in a child of 3 years results in his legs crossing in a scissor-like pattern while he is supported in vertical suspension.
Milestones of Language Development: 1 month
Alerts to sounds
Milestones of Language Development: 2 months
Smiles socially
Milestones of Language Development: 3 months
Quiets when hears speech. Produces cooing sounds (produces long vowel sounds in a musical fashion)
Milestones of Language Development: 4 month
Laughs out loud & Orients to voice
Milestones of Language Development: 6 months
Babbles, ah-goo, ma, da, ba & Lateral orientation to bell
Milestones of Language Development: 9 months
Says mama, dada indiscriminately, Gestures, waves bye-bye & Understands no.
Milestones of Language Development: 12 months
Uses mama, dada specifically, Uses two words other than mama, dada, Speech like jargon & Follows one step command with gestures
Milestones of Language Development: 15 months
Vocabulary of 4 – 6 words. Follows one step commands without gesture.
Milestones of Language Development: 18 months
Vocabulary of 7 – 10 words. Mature jargon. Knows 5 body parts.
Milestones of Language Development: 24 months
Vocabulary of 50+ words. Uses pronouns (I, you, me) inappropriately.
Milestones of Language Development: 36 months
Vocabulary of 250 words minimum. 3 words in a sentence. Knows pronouns, uses plurals.
Milestones of Language Development: 4 years
1000+ vocabulary. 4 words in a sentence. Knows colors. Sings songs from memory. Ask questions.
Milestones of Language Development: 5 years
Prints first name. Asks what does a word mean.
Milestones of Social Development: 2 Months
Social Smile
Milestones of Social Development: 4-8 Months
Seeks Primary Caregiver
Milestones of Social Development: 8-12 Months
Stranger Anxiety
Milestones of Social Development: 10-15 months
Displays two or more recognizable emotions
Milestones of Social Development: 11-20 months
Explore play-by-self
Milestones of Social Development: 19-36 months
Cooperative play in small groups
Colic
Severe and paroxysmal crying in an otherwise healthy
2-3 month-old
Colic “Rule of 3’s”:
- > 3 hours/day
- > 3 days/week
- > 3 weeks
Colic Presentation
Knees drawn up, fists clenched, pained facial expression, expel flatus, minimal response to soothing. Usually in late afternoon.
Begins in the first few weeks of life; peaks at 2-3 mos; persists into 4th and 5th months in 30-40%.
Colic Treatment
Parent education (discuss behavioral states) & reassurance
Temper Tantrums
Crying, throwing self down, kicking, screaming, striking out at people or objects in the room, stamping. Common between ages 12 mos and 4 yrs. Occur at least once/wk in 50–80% of 2-3 yos. 20% have daily tantrums
Management of Temper Tantrums
Address contributing factors, educate parents, childproof home, allow choices, provide routines, adjust to temperament, chose battles, ignore when possible, prevent harm, use constructive language
Breath-Holding Spells
Involuntary cessation of breathing in response to a noxious, painful, or frustrating stimulus
Types:
- Cyanotic: Short burst of crying ( involuntary holding of the breath in expiration -> cyanosis
- Pallid: Fright or minor trauma -> no crying or single cry -> pallor and limpness. Hyperresponsive vagal response -> bradycardia -> pallor, LOC
Breath-Holding Spells
-25% of children; positive FH in 25% of cases. Most common in 1 to 3 year-olds.
50% resolve by 4 à 90% by 6 yo
Treatment: Parent education
Parasomnias
Night Terrors & Nightmares
Night Terrors
Occur in 3% of children. 3-12 year-old (median onset 3.5).
Occur 15-60 minutes after going to sleep. Non-REM sleep.
Presentation: Poorly consolable, amnesia for event
Prevention/Treatment: Reassurance, Environmental measures, Scheduled awakening
Nightmares
25-50% of 3-5 year olds. Onset in latter part of the night. REM sleep.
Presentation: frightened but consolable, recalls dream and resists going back to sleep.
Prevention/Treatment: Accept child’s fear, Comfort and stay with child & Transitional objects
Developmental Disorders Prevalence:
12-22% of American children with 70%-80% not detected in primary care.
Providers ideally should refer (~ 1 of 6 pts)
HOW to assess development?
Surveillance, Screening (Denver, ASQ), Evaluation (refer for specific evaluation), Diagnosis
Parachute Reflex
As the examiner allows the child to free fall in ventral suspension, the child’s extremities extend symmetrically to distribute his weight over a broader and more stable base on landing.
Feeding disorders
The common denominator of feeding disorders is usually food refusal. Infants and young children may refuse to eat if they find eating painful or frightening. They may have had unpleasant experiences (emotional or physiologic) associated with eating, they may be depressed, or they may be engaged in a developmental conflict with the caregiver that is being played out in the arena of feeding.
The infant may refuse to eat if the rhythm of the feeding experience with the caregiver is not harmonious.
Management of Feeding Disorders
The goal of intervention is to identify factors contributing to the disturbance and to work to overcome them. The parents may be encouraged to view the child’s behavior differently and try not to impose their expectations and desires. Alternatively, the child’s behavior may need to be modified so that the parents can provide adequate nurturing.
When the chief complaint is failure to gain weight, a different approach is required.
Excessive weight loss may be due to:
Malnutrition, vomiting or diarrhea, to malabsorption, or to a combination of these factors.
The Denver Developmental Screening Test (DDST)
A widely used assessment for examining children 0-6 years of age as to their developmental progress. The scale reflects what percentage of a certain age group is able to perform a certain task. A subject’s performance against the regular age distribution is noted. Tasks are grouped into four categories (social contact, fine motor skill, language, and gross motor skill) .
When should a stable rate of growth be reached?
1.5 yo
LBW in grams
<2500 gm is classified as LBW
Weight Gain in Infants
Should double in 5-6 mo and triple in 1 yr. (1 oz per day for first 3-4 mo)
What is the earliest indicator of neuro-abnormality?
obligatory or persistent primitive reflexes
Cerebral Palsy
Cerebral palsy is a disorder of movement, muscle tone or posture that is caused by an insult to the immature, developing brain, most often before birth.
Symptoms of Cerebral Palsy
Variations in muscle tone, such as being either too stiff or too floppy
Stiff muscles and exaggerated reflexes (spasticity) or normal reflexes (rigidity)
Lack of muscle coordination (ataxia)
Tremors or involuntary movements/Slow, writhing movements (athetosis)
Favoring one side of the body, such as reaching with only one hand or dragging a leg while crawling
Excessive drooling or problems with swallowing
Diagnosis of Cerebral Palsy
Developmental Monitoring, Developmental Screening & Developmental and Medical Evaluations
Treatment of Cerebral Palsy
Cerebral palsy can’t be cured, but treatment will often improve a child’s capabilities. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed.
THERAPY
Prognosis of Cerebral Palsy
50% can’t walk by them selves
T/F: Cerebral palsy is the most common motor disability in childhood.
True
