Community Flashcards
Gross motor development at 1 month
Symmetrical movements in all limbs
Normal muscle tone
Head lag when pulled up
Gross motor development at 3 months
Almost no head lag when pulled to sit
Lifts head and chest when prone
Gross motor development at 6 months
Rolls from back to front
When held, stands and sits with straight back
Bears most of own weight
Gross motor development at 9 months
Sits without support
Stands holding onto furniture
Moves around the floor - wriggling, commando crawling
Gross motor development at 12 months
Stands without support
Crawls, bottom shuffles or bear walks
Cruises along furniture
May walk unsteadily
Gross motor development at 15 months
Generally walks without support
Crawls upstairs
Gross motor development at 18 months
Walks steadily, stopping safely
Squats to pick up a toy
Climbs stairs holding hand or rail
Gross motor development at 24 months (2 years)
Runs safely
Throws ball overhand
Wlaks up and down stairs, both feet on each step
Gross motor development at 30 months
Jumps on 2 feet
Kicks ball
Gross motor development at 36 months (3 years)
Walks backwards and sideways
Rides tricycle
Catches large ball with arms outstreched
Gross motor development at 48 months (4 years)
Stands, walks and runs on tiptoes
Runs up and down stairs
Gross motor development at 5 years
Hop
Catches ball
Heel-toe walking
May ride a bike
Fine motor development at 1 month
Grasps finger when placed in the palm
Fine motor development at 3 months
Watches their own hands
Brings hands to their mouth
Holds toy brieftly
Fine motor development at 6 months
Palmer grasp
Reaches for toys
Puts objects in mouth
Fine motor development at 9 months
Passes toys from one hand to tht other
May have pincer grip
Fine motor development at 12 months
Fine pincer grip
Points to objects of interest
Releases objects intentionally
Fine motor development at 15 months
Imitates to and fro scribbles
Builds tower of 2 cubes when demonstrated
Fine motor development at 18 months
Makes tower of 3 blocks
Fine motor development at 24 months (2 years)
Builds a tower of 6 blocks
Draws horizontal lines with preferred hand
May draw vertical lines
Turns pages of book individually
Fine motor development at 30 months
Can thread bead on a string
Makes a tower of 7 or more blocks
Holds pencil in tripod grip
Fine motor development at 3 years
Builds bridge using blocks
Draws circle
Draws person with a head
Fine motor development at 42 months (3.5 years)
Draws a cross
Fine motor development at 4 years
Build stepts using blocks
Draws a square
Draws a person with head/face, arms and legs
Fine motor development at 5 years
Uses knife and fork competently
Draws triangle
Copies alphabet letters
Define speech
Actual sounds of spoken language
- produced by co-ordinated action of the muscles of the tonuge, lips, jaw and vocal tract
Define language
Systems of words and symbols
- use to communicate with each other
- encompassess written, verbal and non-verbal communication
Speech/language development a newborn
Cries
Speech/language development at 6-8 weeks
Coos
Speech/language development at 3 months
Laughs
Vocalises
Speech/language development at 6 months
Understands words such as mama, dada or bye-bye
Babbles spontaneously - initially monosyllables
Uses tuneful, singsong voice
Speech/language development at 9 months
Imitates adult sounds, such as coughs
Understands simple commands
Understands no
Speech/language development a 12 months
Knows and responds to own name
Uses 2-6 words and understands many more
Speech/language development at 18 months
Uses 6-40 recognisable words
Can point to parts of the body when asked
Tries to sing
Speech/language development at 24 months (2 years)
Speaks over 200 words, understands many more
Joins words together
Omits opening or closing consonants
Speech/language development at 30 months
Continually asks questions
Speech/language development at 36 months (3 years)
Can name 2/3 colours
Knows and repeats songs and nursery rhymes
Counts by rote up to 10
Has simple conversations
Speech/language development at 48 months (4 years)
Talks fluently
Counts by rote to 20
Enjoys jokes
Speech/language development of at 60 months (5 years)
Fluent in speech and mostly grammatically correct
Interested in reading and writing
Social, emotional and behavioural development of a newborn
Responds to being picked up
Enjoys feeding and cuddling
Social, emotional and behavioural development at 6 weeks
Gazes at adult faces
Social smiles
Social, emotional and behavioural development at 3 months
Smiles at familar faces and strangers
Social, emotional and behavioural development at 6 months
Feeds self with fingers
Shows stranger fear
Social, emotional and behavioural development at 9 months
Waves bye
Plays peek-a-boo
Shows likes and dislikes
Social, emotional and behavioural development at 12 months
Drinks from a cup with 2 hands
Has seperation anxiety
Social, emotional and behavioural development at 18 months
Uses a spoon
Plays contentedly alone, near familar adult
Eager to be independent
Social, emotional and behavioural development at 24 months (2 years)
Displays frustration - temper tantrums
Dresses self
Begins to express feelings
Social, emotional and behavioural development at 30 months
Eats skillfully with spoon, may use fork
May use toilet independently
Plays alone and alongside other children - parallel play
Enjoys pretend play
Social, emotional and behavioural development at 36 months (3 years)
Shows affection for younger siblings
Probably toilet-trained - may still be wet at night
Enjoys helping adults, imitating household tasks
Has friends
Social, emotional and behavioural development at 48 months (4 years)
Eats skillfully with fork and spoon
Brushes own teeth
Shows sensitivity to others
Takes turns
Social, emotional and behavioural development at 60 months (5 years)
Very definite likes and dislikes
Shows sympathy and comforts friends
Dressess without help - except laces
Engages in co-operative and imaginative play, observing rules
Hearing and vision development of a newborn
Fascinated by human faces
Turns head towards light
Startled by sudden noises
Hearing and vision development at 1 month
Turns head towards diffuse light and stares at bright objects
Startles to loud noises
Hearing and vision development at 3 months
Focuses eyes on same point
Moves head deliberately to gaze around them
Prefers moving objects to still ones
Hearing and vision development at 6 months
Adjusts position to see objects
Turns towards the source of sounds
Hearing and vision development at 12 months
Sees almost as well as an adult
Knows and responds to own name
Hearing and vision development at 18 months
Recognises themselves in a mirror
Hearing and vision development at 24 months (2 years)
Recognises familiar people in photographs
Listens to conversations with interest
Hearing and vision development at 30 months
Recognises self in photographs
Recognises small details in picture books
Hearing and vision development at 48 months (4 years)
Matches primary colours
Listens to long stories with attention
Hearing and vision development at 60 months (5 years)
Can match 10 colours
Define Autism Spectrum Disorder
Neurodevelopmental disorder that affects a person’s social interaction, communication and behaviour
- usually diagnosed in adulthood
- key symptoms being present from age of 3
Epidemiology of ASD
1%
More common in boys than girls
More prevenlent in premature children
Pathophysiology of ASD
Genetic syndromes - fragile X syndrome, tuberous sclerosis and Angelmann syndrome
Gentic aetiology - chromosonal analsysis gives a diagnosis in around %
Structural changes in the brain
Clinical featrues of ASD
Abnormality of social interaction
- poor eye contact, failure to use facial expression of body language
- problems making friends, difficulty reading social situations
Impaired social communication
- delay or failure to develop social language
- failure to initiate or continue conversations
- abnormal use of language
Restrictive or repetitive activities
- preoccupations with unusual subjects/atypical way
- need for routine - upset if disrupted
- motor mannerisms - hand flapping
Signs for look for on examination in ASD
Skin stigmata of neurofibromatosis or tuberous sclerosis
Signs of injury - self-harm or child maltreatment
Congenital abnormalities and dysmorphic features
Differential diagnosis of ASD
Learning difficulties Attachment disorders Rett's syndrome - regression of skills at 18 months, most common in females Schizophrenia Specific language disorders
Investigations for ASD
Clinical diagnosis made by MDT team
- symptoms should be persistent in different environments - both home and school
Management for ASD
For milder end diagnosis alone
- allows families to access certain modes of support - parent support groups, community-based services
No medications
Behavioural management strategies - visual timetables, preparation and explanation for changes in routine
Educational measures - diagnosis needed for and Education, Health and Care Plan so school can access extra funding
- most educated in main school streaming
Define ADHD
Attention Deficit Hyperactivity Disorder Neurobehavioral disorder that is characterised by - hyperactivity - inattention - impulsivity
Epidemiology of ADHD
7%
More common in boys than girls
Up to 50% have co-morbid condition - ASD, learning difficulties, communication disorders, depression, anxiety, Tourette Syndrome
Pathophysiology of ADHD
Evidence suggests structural and functional changes in brain as well as changes in levels of dopamine
Genetic component
Clinical features of ADHD (ICD-10)
Early onset - before 6 years Main features - impaired attention - over-activity Disinhibition, recklessness and lack of adherence to social norms may be present but not necessary for diagnosis
DSM-V criteria for ADHD
3 subtypes - combined, predominantly inattentive, predominantly hyperactive
Diagnosis made when at least 6 criteria from either category are met and present from before age of 12 for at least 6 months
- must be present in more than one setting
Differential diagnosis for ADHD
Auditory processing disorder - brain has difficulty interpreting sounds and information heard
Oppositional-defiant disorder - features of anger, vindictiveness and being argumentative
Conduct disorder - marked features of aggression
- those with ADHD tend to not want to get into trouble
Investigations for ADHD
Conner’s questionnaire
School observation
Management of ADHD
Pre-school - medication not recommended - parent training/education programme Mild/moderate - 1st line is behavioural strategies - parent education, CBT, social skills training, teacher education Severe - Medication 1st line
Medications used in ADHD
Methylphenidate - stimulant
- immediate and mixed preparations
- start small dose and titrate up
Atomoxetine
- used if methylphenidate not effective, associated tic or anxiety disorder, risk of stimulant abuse
- SE of liver damage
Lisdexamfetamine - newer stimulant medication
- used when methylphenidate not effective at max dose
Guanfacine - non-stimulant
- used when stimulant not suitable, not tolerated or not effective
Antipsychotics - should not be used in children
Aim of medication in ADHD
Improve attention and concentration to allow them to achieve their educational potential
SE of ADHD medication
Raised BP Palpitations Disturbed sleep Impaired growth and appetite suppression Problems with aggression or increased emotion - anxious or depressed
Define child protection
Process of protecting individual children identified as either suffering, or likely to suffer, significant harm as a result of abuse or neglect
- involves measures and structures designed to prevent and respond to abuse and neglect
Types of child abuse
Physical - especially children under 2 Sexual Emotional Neglect
Risk factors for child abuse
Child factors - unable to fulfil parental expectations - crying persistently - children under 4 - disability - low birth weight - chronic ill health - prematurity - being unwanted Adult factors - mental illness - postnatal depression - lack of support network - drugs - own child abuse - alcohol misuse - learning disability - criminal activity - financial difficulties
Features of non-accidental injuries
Mechanism of injury not compatible with injury sustained
Child’s developmental stage inconsistent with the injury presented
Child sustained significant injury with little or on explanation
Inconsistent histories given
Delay in presenting child to health care providers
Recurrent injuries
Parents reaction not appropriate to the situation
Presentations of physical abuse
Bruising - coagulation screen - FBC Fractures - full skeletal survey - CT scan - bone biochemistry Presentation in under 2 years - full skeletal survey - CT head - expert ophthalmological examination - coagulation screen
Differential diagnosis for bruising
Bleeding disorder Birthmark Vasculitic disorders Infection - meningococcal septicaemia Drug related - NSAIDs Erythema nodosum Malignancy Striae Contact dermatitis
Differential diagnsosis of fractures
Birth injury - clavicular fracture Infection - osteomyelitis Malignancy Osteogenesis imperfecta Nutritional - vitamin D deficiency Copper deficiency
What is a HEADSSS assessment
Tool used to structure the assessment of an adolescent patient
- Home
- Education/Employment
- Activities
- Drugs
- Sex and relationships
- Self harm and depression
- Safety and abuse
Define adolescence
Transition period where child becomes an adult
- physical changes of puberty
- psychological and sociological changes associated with finding your identity and gaining independence from parents/carers
Presentation of neglect
Medical
- unimmunised
- failure to attend appointments
- poor compliance with medication
- failure to seek appropriate timely medical advice
Nutritional
- faltering growth due to failure to provide an appropriate and or sufficient diet
- obesity due to failure to control diet and lifestyle
Emotional
- poor school attendance
Physical
- inadequate hygiene
- severe and or persistent infestations/infections
- inappropriate clothing for childs size and weather
Failure to supervise
- frequent A&E attendances
- injury that suggests lack of care such as sunburn, scalds, burns, falls
- ingestion of harmful substances
Symptoms of emotional abuse in an infant
Developmental delay Poor sleep Feeding difficulties Persistent Crying Irritable
Symptoms of emotional abuse in a toddler
Difficult/violent behaviour
Delayed social and language skills
Symptoms of emotional abuse in a school child
Poor attendance
Truancy
Antisocial behaviour
Academic failure
Symptoms of emotional abuse in an adolescent
Depression Self harm Relationship difficulties Substance abuse Criminal activity Eating disorders Aggressive behaviour
Presentation of sexual abuse
Allegation Pregnancy STI Ano-genital injury Unexplained vaginal bleeding Unexplained rectal bleeding Recurrent vaginal discharge Soiling, bowel problems, enuresis Behavioural difficulties Any children close proximity with an adult identified as a risk to children When perpetrator is child
Consequences of child abuse
Attachment disorder PTSD Somatic symptoms Sexual dysfunction Emotional disorders Self-harm Alcohol misuse Drug abuse Antisocial personality Aggressive behaviour
Medical professional response to concerns of child abuse
Document everything clearly in the patients notes - Clearly attribute who said what/when plus actions taken – including any discussions at handover
Sign, date and time all entries
Seek advice from senior colleague/consultant on how to proceed
If you are unhappy with the advice given consult further – go up a level of seniority or contact the named doctor/nurse for safe guarding
Communicate with nursing staff
Keep the child safe
DON’T DO NOTHING
Medical professional responding to disclosure of child abuse
Try not to look shocked Let the child know you believe them Tell them they are not in trouble Listen to what they have to say, don’t make an excuse to leave Don’t ask leading questions – this may affect the case if it goes to court Don’t make promises you cant keep Be honest at all times Inform your senior
Define life limiting conditions
Conditions for which there is no reasonable hope of cure
- from which children/young people will die
- include life-threatening for which curative treatment may be feasible but can fail
Define life threatening conditions
Curative treatment may be feasible but can fail
- palliative care services may be necessary when treatment fails or during an acute crisis
- cancer
Define conditions where premature death is inevitable
May be long periods of intensive treatment aimed at prolonging life and allowing participation in normal activities
- cystic fibrosis
- duchenne muscular dystrophy
Define progressive conditions without curative treatment options
Treatment is exclusively palliative and may commonly extend over many years
- Batten disease
- mucopolysaccharidoses
Define irreversible but non-progressive conditions causing severe disability, leading to suceptilbitly to health complications and likelihood of premature death
Children have complex health care needs and are at high risk of an unpredictable life-threatening event or episode
- cerebral palsy
- spinal cord injury
Key differences of child vs adult palliative care
Small number of children die
Many conditions rare and genetic
May only be needed for short period of time and may be on and off for a number of years
Importance of physical, emotional and cognitive development
Provision of play and education vital
Features of advanced care planning
Helps create advance statements about wishes and preferences such as preferred place of care, withdrawal of treatment and resuscitation status
DNACPR forms in paediatrics
Lots of controversy and misunderstanding over their design, use and limitations
Features of ReSPECT forms
Recommended Summary Plan for Emergency Care and Treatment
- process supports the creation of these recommendations by initiating conversations to ensure a shared understanding of the condition, current issues and future outlook
- child/families preferences for care and realistic future emergency treatment
- making and recording agreed clinical recommendations for care
Key pillars of ethics
Autonomy - right to self-determination
Non-maleficence - need to avoid harm
Beneficence - ability to do good
Justice
Ethical issues related to paediatrics
Children represent spectrum from non-verbal infant to fully conversant adolescent striving for independence and self-identity
Child’s ability to make informed choices depends on level of development and life experience
Even young children have the right to be informed
As children’s competence increases so should their involvement in decision making
Normal growth
Acceptable for breastfed babies to lose 10% of birthweight and bottle-fed 5% in first 10 days of life
Babies should have doubled weight by 4 months and tripled by 1 year
Red flags for gross motor control
No head control at 6 months Cannot sit unsupported at 12 months Not weight bearing at 12 months Not walking at 18 months Not running by 2.5 years
Red flags for fine motor and visual skill
Does not hold objects in hand at 5 months
Red flags for speech and language skills
No response to stimuli at 3 months No babble at 9 months No words at 18 months Cannot join 2 words at 2 years Cannot speak in full sentences at 3 years
Red flags for social skills
No gestures at 12 months
No symbolic play at 18 months
Causes of developmental delay
Antenatal - Genetic - down syndrome, duchenne muscular dystrophy - metabolic/endocrine - hypothyroidism, PKU - toxins - drugs and alcohol Peri and postnatal - infection - trauma/brain injury -> cerebral palsy - neglect
Vaccination schedule
8 weeks: - 6 in 1 vaccine (diphtheria, tetanus, pertussis, polio, haemophilus influenzae type B (Hib) and hepatitis B) - Meningococcal type B - Rotavirus (oral vaccine) 12 weeks: - 6 in 1 vaccine (again) - Pneumococcal (13 different serotypes) - Rotavirus (again) 16 weeks: - 6 in 1 vaccine (again) - Meningococcal type B (again) 1 year: - 2 in 1 (haemophilus influenza type B and meningococcal type C) - Pneumococcal (again) - MMR vaccine (measles, mumps and rubella) - Meningococcal type B (again) Yearly from age 2 – 8: - Influenza vaccine (nasal vaccine) 3 years 4 months: - 4 in 1 (diphtheria, tetanus, pertussis and polio) - MMR vaccine (again) 12 – 13 years: - Human papillomavirus (HPV) vaccine (2 doses given 6 to 24 months apart) 14 years: - 3 in 1 (tetanus, diphtheria and polio) - Meningococcal groups A, C, W and Y
Types of vaccines
Inactivated
- polio
- flu
- hep A
- rabies
Subunit and conjugate
- Pneumococcus
- Meningococcus
- Hepatitis B
- Pertussis (whooping cough)
- Haemophilus influenza type B
- Human papillomavirus (HPV)
- Shingles (herpes-zoster virus
Live attenuated - still capable of causing infection particularly in immunocompromised patients
- Measles, mumps and rubella vaccine: contains all three weakened viruses
- BCG: contains a weakened version of tuberculosis
- Chickenpox: contains a weakened varicella-zoster virus
- Nasal influenza vaccine (not the injection)
- Rotavirus vaccine
