Community Flashcards
6 weeks - gross motor + fine motor / vision
GM: Briefly holds head in ventral suspension + some lag. Primitive reflexes. Symmetrical limb movement.
FM / vision: Holds fists closed. Turns to light. Fixes + follows through 90° (especially face).
6 weeks - language + hearing, social + self care
Cries. Responds to mothers voice + startles to noise.
Smiles
3-4 months - gross motor + fine motor / vision
GM: No head lag. Raises chest (resting on elbows) when prone. More vigorous limb movements.
FM/V: Holds object placed in hand. Reaches for objects Fixes + follows though 180°.
3-4 months - language + hearing, social + self-care
Cooing. Quietens to mothers voice. Turns towards sound.
Laughs
5-6 months - gross motor + fine motor / vision
GM: Sits unsupported / supported with curved back. Lifts chest on extended arms when prone. Rolls front to back (later: back to front)
FM/V: Brings objects to midline. Transfers between hands. Consciously releases objects + starts mouthing objects.
5-6 months - language + hearing, social + self-care
Early babbling (with consonants). 2 syllables e.g. ‘adah’ ‘erieh’ – 6 months
Screams (happy). No stranger anxiety
8-9 months - gross motor, fine motor / vision
GM: its unsupported with straight back. May crawl / bum shuffle.
FM/V: Early pincer grip. Looks for fallen objects.
8-9 months - language + hearing, social + self-care
Developed babbling: repetitive consonants. ‘mama’ + ‘dada’ non-specifically.
Stranger anxiety develops. Plays peekaboo.
10 months - gross motor, fine motor / vision
GM: Pulls to stand. Cruising.
FM/V: Developed pincer grip – grains of rice off floor.
10 months - language + hearing, social + self care
Understands ‘no’
Understands ‘bye-bye’
12 months - gross motor, fine motor / vision
Early walking (unsteady broad-based gait). Note: unsupported walking 13-15 months.
FM/V: Bangs objects together. Casts objects. Object permanence (looks for hidden toys). Points at things.
12 months - language + hearing, social + self care
Few individual words. Imitates sounds + speaks jargon with conversational intonation. Understands names + simple objects.
Finger feeds. Can hold spoon + attempt use. Waves bye-bye. Claps. Points to convey desire, shortly followed by pointing for excitement.
15 months - gross motor, fine motor / vision
GM: More confident walking.
FM/V: tower of 2 or 3 bricks. turns thick cardboard pages.
15 months - language + hearing, social + self care
Obeys simple commands. Identifies common objects.
Uses cup + spoon.
18 months - gross motor, fine motor / vision
GM: Squats to pick up objects. Running.
Builds tower of 2 or 3 bricks. To + fro scribble. Points to pictures in books. Turns pages in book a few at a time.
18 months - language + hearing, social + self care
10-20 common words including common objects. Common two word phrases e.g. ‘all gone’. Points to body parts.
Removes socks/shoes. Imitative play / domestic mimicry (copies parents’ actions at home).
2 years - gross motor, fine motor/vision
Jumping. Kicks ball. Climbs stairs two feet per step / holding on.
Circular scribble. Draws straight line (at 2.5 years). Builds tower of 6 blocks.
2 years - language + hearing
50+ words (200 at 2 ½). Links words together to make 2 or 3 word sentences. Understands functions of object (e.g. which do you eat with? Fork vs pencil) + verbs. Obeys two-part commands.
2 years - social + self care
Feeds with fork & spoon. Starts toilet training. Temper tantrums. Plays alongside other children (parallel play). Symbolic play.
3 years - gross motor
Rides tricycle. Upstairs one foot per step & downstairs 2 feet per step.
3 years - fine motor
Copies a circle. Builds a tower of 9 bricks. Copies a bridge & stairs with 6 bricks.
3 years - language + hearing
Knows several nursery rhymes. Complex 4-5 word sentences. States first & last name. ‘What’ & ‘who’ questions. Understands prepositions e.g. under / behind. Understands sizes e.g. big / little / tall.
3 years - social + self care
Washes hands. Plays with other children. Pretend play. Understands sharing.
4 years - gross motor
Hops. Up & down steps like adult.
4 years - fine motor / vision
Copies a cross. Copies stairs with 10 bricks.
4 years - language + hearing
Can tell descriptive account of events. Uses ‘why’ ‘when’ ‘how’. Understands negatives (e.g. which one is not..) & 3 part commands.
4 years - social + self care
Undresses, but cannot dress independently. Understands turn-taking.
5 years - gross motor
Skips. Catches ball.
5 years - fine motor / vision
Copies triangle / square.
5 years - language + hearing
Tells complex story using all tenses: future & past.
5 years - social + self care
Dresses, including buttons and zips. Eats with knife & fork. Imaginative play including role playing and made up stories.
When to refer for developmental milestones?
6-8 weeks: asymmetrical moro reflex, no fix & follow, no smile, excessive head lag, no startle to sound.
12 weeks: persistent squint
8 months: persistent primitive reflexes, not vocalising.
1 year: Hand preference, not responding to own name.
18 months: not walking
2 years: no or few words spoken.
3 years : not speaking in sentences, not interacting with other children, not following simple commands. Unable to use toilet or spoon.
What is the healthy child program?
DOH 2009
Feeding, growth + development monitored until 5 years.
Red Book: vaccination record, early midwife + health visitor assessments, growth charts, general advice regarding care. Plotting weight on growth chart is frequent through 1st year then may become less frequent.
What are the 5 steps of the healthy child program?
- Newborn Examination (paediatrician or midwife)
Abnormalities, red reflex, feeding, urine / bowels, weight, head circumference, hips, heart, newborn hearing screen, ensure parents basic understanding of how to care for baby and when to seek help - Early newborn review: 7-14 days (health visitor or midwife): adequate feeding, parental anxieties or mental health concerns. GUTHRIE TEST.
- 6-8 week review (GP): similar to newborn assessment, particular focus on eyes, hips, heart, testicles. General matters of concern.
- 8-12 months (GP): full developmental check, growth & feeding.
- 2 – 2 ½ years (health visitors): full developmental check. Social development concerns that may affect child’s ability to access the educational curriculum are usually more obvious at this age. Any children with concerns will be referred for specialist assessment.
How is vision assessed throughout development?
Routine screening using red reflex at newborn, and 6-8 week checks. Then at pre-school or during school entry at 4-5 years old. Concerns outside these checks referred to optometrist, ophthalmologist or an orthoptist.
Cardiff Acuity Test: 1-3 years: those with developmental delay (based on preferential looking e.g. object vs plain image)
Stycar Letter Matching Test: 3-5 years
Snellen Chart: 5 years +
What visual problems may be detected in young children / what is normal visual development?
Squints: neonatal misalignment common in first 2 months (eyes don’t focus on same spot) but usually reduces in 2nd month: if persists at 10-12 weeks, referral as may be a squint. Earlier detection + referral = more likely corrected (corrected squint allows binocular vision & depth perception to develop as normal & prevents amblyopia).
Red reflex: cataracts + retinoblastoma (leukocoria) – absence of reflex needs urgent referral (ophth or paeds)
Fixing + following: across midline up to 180° by 3 months, visual pathway then continues developing during infancy (rapidly improving acuity first 6 months, adult levels ~12 months), colour vision well developed by 6 months
How is hearing assessed throughout development?
Critical age for intervention in SNHL is <6 months, therefore, UK Hearing Screen (2006) introduced: if child fails or has certain risk factors, referral to audiologist
Otoacoustic emissions (OAE): from birth (1st line: neonatal screening, record sounds produced by inner ear in response to noise – misses SNHL if cochlear function normal)
Auditory brainstem responses: from birth (if OAE fails, clicks presented to each ear, electrodes on scalp pick up responses; does not distinguish between CHL & SNHL and cannot carry out if infant is moving)
Distraction testing: 6-9 months but can be used up to 24 months (one examiner gains child’s attention, whilst other makes noise behind: child should move head towards the noise)
Performance testing (2 years): responding to instructions at various frequencies / volumes. Needs appropriate receptive language development + careful interpretation.
Discrimination testing (2 years): identify objects / pictures with similar sounding words
Pure tone audiometry (4 years): headphones; different volumes + frequencies – child says when they hear a noise and on which side (differentiates CHL + SNHL)
Tympanometry (all ages): middle ear pathology – measure amount of sound reflected back - compliance determined by repeating at varying pressures -> graph
What is global developmental delay?
Usually describes children <5 with delay in 2 or more domains
What could cause global developmental delay?
Split answer into antenatal and postnatal
Antenatal
• Early maternal infection e.g. rubella, toxoplasmosis, CMV
• Late maternal infection e.g. varicella, malaria, HIV
• Toxins e.g. alcohol, pesticides, radiation, smoking
• Drugs e.g. cytotoxics, anti-epileptics
Postnatal
• Infections e.g. meningitis, herpes encephalitis, CMV
• Metabolic e.g. hypoglycaemia, hypernatraemia or hyponatreamia e.g. dehydration
• Toxins e.g. lead, mercury, arsenic
• Trauma especially head injury
• Severe under stimulation, maltreatment or domestic abuse
• Malnutrition (iron, folate, vitamin D)
• Maternal mental health concerns especially depression
What factors influence development of gross + fine motor skills, communication skills, problem solving skills and personal / social skills?
(social factors / family etc)
Gross motor: space to play, tummy time, bicycles or outside space
Fine motor: appropriate toys, books, self-feeding
Communication: being talked to, nursery rhymes, books, turns taking games, maternal mood
Problem solving: opportunity to practice, understanding place in environment, repetition
Personal Social: time & repetition, parental expectations, family structure, attachment and attunement, maternal mood
What are causes of developmental delay (think in terms of body systems)
Neurological: congenital (embryological or antenatal vascular event), static acquired (HIE, IVH, hypoglycaemia, TBI, stroke) or progressive acquired (brain tumour, SSPE)
Neuromuscular e.g. Duchenne
Endocrine e.g. hypothyroidism
Genetic e.g. Down’s syndrome, phenylketonuria
Pervasive developmental disorders e.g. autism
Nutritional e.g. vitamin deficiencies, malnutrition
Isolated speech & language delay
Prematurity
Metabolic disorders
Idiopathic
First line investigations for global developmental delay?
FBC + haematinics: IDA, folate, B12 – developmental delay + learning difficulties
U&Es: renal failure & hyponatraemia can both cause poor growth, renal osteodystrophy can cause gross motor delay, baseline also useful for future tests
CK: early detection of Duchenne
TFTs: hypothyroid causes developmental & intellectual delay – if treatment delayed effects are irreversible
LFTs: abnormalities may suggest further Ix e.g. for underlying metabolic disorder
Bone profile (+ Vitamin D): Vit D deficiency can cause motor delay, hypocalcaemia can represent this or another underlying disorder with delayed development (e.g. 22q11 deletion)
Hearing test: speech + language delay may be due to hearing defect, but genetic disorders with global delay may also have conductive or sensorineural hearing loss
Second line / additional investigations for global developmental delay?
Karyotype: may identify trisomy disorders or Turner’s
DNA testing: FMR1 DNA test determines Fragile X syndrome, can cause developmental delay, without necessarily showing obvious dysmorphism early on
Array comparative genomic hydridisation (CGH): can identify chromosomal microdeletions or microduplications & may explain previously unknown causes of developmental delay without necessarily showing obvious dysmorphism early on
Metabolic screen: inborn errors of metabolism e.g. mucopolysaccharide or peroxismal disorders (both usually dysmorphic), organic and aminoacidaemias, mitochondrial disorders – found in just ~1% of developmental delay
Lead: toxicity possible with no other symptoms, treatable
Biotinidase: deficiency can present as delay as its only sign, treatable
Brain MRI: structural abnormality or damage from a static event (e.g. infection, trauma etc). or a progressive neurological disorder, this may require a general anaesthetic in younger child
EEG: if developmental regression, or associated seizures, EEG may show typical features of an epilepsy syndrome e.g. West syndrome, Landau-Kleffner syndrome
What are the mechanisms of Down’s syndrome?
1 in 1000 live births. Three mechanisms:
Nondisjunction (~95%): 3 full copies inherited due to meiotic nondisjunction during gametogenesis – higher incidence in older parents (particularly women).
- Translocation (3-5%): 3 copies of chromosome 21 in each cell, with 3rd copy being attached to a different chromosome (usually 14) – unbalanced Robertsonian translocation (often occurs if one parent has balanced Robertsonian translocation i.e. translocation carrier)
- Mosaicism (1-4%): nondisjunction occurs after zygote formation (during mitosis), ∴ some cells normal + others have T21. Very variable phenotype but often less severe. Offspring only affected if gamete-producing cells carry defect.
What are possible physical features of Downs syndrome?
Low birth weight
Hypotonia (may cause feeding / swallowing difficulty)
Brachycephaly (flattening) from early fusion of coronal sutures
Facial features: epicanthic folds, upslanting palpebral fissures, depressed nasal bridge, low set ears, large protruding tongue
Hands: Single palmar crease, clinodactyly of 5th digit
Brushfield spots (periphery of iris)
Sandal gap
Special growth charts as often slower rate of growth
How is Down syndrome investigated (diagnosed)
All women offered triple test (11-14 weeks) – combined screening involves USS for nuchal translucency, blood test for ↑βhCG, ↓PAPP-A.
Followed by structural anomaly USS at 22 weeks (may show cardiac disease or duodenal atresia).
Later in pregnancy, ‘quadruple test’ possible based on bloods alone (AFP, βhCG, inhibin-A, oestradiol).
If screening test determines high risk, parents offered pre-natal testing using amniocentesis (15-20 weeks) or chorionic villus sampling (<15 weeks).
Postnatal diagnosis by blood tests: FISH detects no. of chromosomes or chromosome segments, can be performed quickly (within 48 hours) to show T21. Karyotyping: grows cells + chromosomes extracted + sorted: number & structure of each set of chromosomes. Results can take ~10 days due to time to culture cells.
What immediate complications of DS are screened for? (neonatal + infancy)
ECHO: structural cardiac abnormalities
FBC or spun packed cell volume (PCV): neonatal polycythaemia
TFTs
Normal screening throughout infancy, but with additional checks: 8 month hearing screen, vision screen throughout childhood: cataracts, nystagmus & squint
How is DS managed?
Inform parents of suspicion before genetic investigations, if confirmed inform ASAP in supportive environment, offer advice about: aetiology, physical features, medical complications, management. Many adults active, mobile + lead semi-independent lives, however, more likely to have special educational needs + additional support in school – MDT throughout formative years + many support groups available e.g. Down Syndrome Association. SALT referral post-delivery (feeding support + later for language delay) + physio if mobility or delayed gross motor development.
Ongoing Management (Community MDT) o Dieticians o Physiotherapists o OTs o Community paediatrician o SALT
Other specialists depending on complication: ?ENT/resp, sleep apnoea common (sleep studies, CPAP trials). Genetics referral may help assess risk for future children.
If >18, annual health screening program with GP done routinely in UK (go through each body system to check for complications) and provided with Personal Health Action Plan to identify any needs + a review date.
What are the complications of Down’s syndrome?
Cardiac: structural ab. (40%) – AVSD most common
Resp: recurrent infections, (especially otitis media), often enlarged adenoids + tonsils, + small upper airways due to face shape –> OSA. Secretory otitis media can cause conductive hearing loss
GI: structural ab (6%): duodenal atresia, Hirschsprung’s
Infection: generalised increased susceptibility
Autoimmune: T1DM, coeliac disease
Neuro: seizure disorders more common, Alzheimer’s in majority by 5th decade
Haematological: leukaemia, especially ALL + AML
Endocrinological: hypothyroidism
Musculoskeletal: short stature + atlanto-axial instability
Ophthalmological: cataracts (3%) + visual impairment
Developmental delay: learning difficulties evident as child gets older
Poor feeding: sucking + swallowing difficulties
Psychological: anxiety, depression and other disorders (higher incidence)
What is the prognosis of DS?
Marked variability, some adults lead active and at least semi-independent lives (e.g. further education, gaining employment), life expectancy for children born with Down syndrome has improved greatly over last 30 years, today majority will live to be >60.
What is Turner’s syndrome (mechanism)?
1 in 2500 live female infants. One set of genes absent from short arm of an X chromosome.
- Most have karyotype 45,X (most are missing paternal X chromosome due to meiotic nondisjunction during gametogenesis). Parents are not affected.
- Mosaic Turner syndrome: when % of cells are 46,XX + others 45,X due to mitotic nondisjunction very early in foetal life (offspring cell does not undergo apoptosis but continues replicating to form part of foetus).
- Rarely, children may have 46,XXiq, where short arm of X chromosome is missing – these cases can be inherited from parents with Turner’s syndrome.
Physical features of Turner’s syndrome?
- Short stature
- Broad / webbed neck with low hairline
- Shield-shaped chest with widely spaced nipples
- Wide carrying angle of arms (cubitus valgus)
- Hypoplastic nails
- High arched palate
Lymphoedema of hands & feet may be only sign in newborn babies. Disappears rapidly after birth & can be easily missed.
What problems are associated with Turner’s syndrome?
CV abnormalities: particularly coarctation of the aorta + less commonly hypoplastic left heart syndrome, aortic dissection & aortic aneurysms. Also associated with bicuspid aortic valve + hypertension.
Gonadal development: streak ovaries (aplasia) often causing primary ovarian failure + infertility. As patients age, usually have short stature + absent adolescent growth spurt. However, due to ovarian failure, usually amenorrhoea + absent breast development
Other abnormalities:
Eyes: myopia, usually minor + corrected by glasses
Ears: e.g. otitis media in early childhood which may lead to hearing loss
Renal abnormalities: e.g. horseshoe kidneys, renal aplasia, duplex kidneys
Intellectual function is mostly normal.
Immunisations - add in the OSCE stuff.
Immunisations - add in the OSCE stuff.
Birth immunisations?
BCG / Hep B if risk factors
2 month immunisations?
6 in 1: diptheria, tetanus, whooping cough, polio, Hib, Hep B
Oral rotavirus
PCV
Men B
3 month immunisations?
6 in 1: diptheria, tetanus, whooping cough, polio, Hib, Hep B
Oral rotavirus
4 month immunisations?
6 in 1: diptheria, tetanus, whooping cough, polio, Hib, Hep B
PCV
Men B
12-13 month immunisations?
Hib / MenC
MMR
PCV
Men B
2-8 year immunisation?
annual flu vaccine
3-4 year immunisation?
4 in 1 pre-school booster: diptheria, tetanus, whooping cough, polio
MMR
12-13 year immunisation
HPV girls
13-18 years
3 in 1 teenage booster: tetanus, diptheria polio
Men ACWY
