Development Flashcards
What is global developmental delay?
Global developmental delay refers to a child displaying slow development in all developmental domains.
What might global developmental delay suggest as an underlying diagnosis?
Down’s syndrome
Fragile X syndrome
Fetal alcohol syndrome
Rett syndrome
Metabolic disorders
What is gross motor delay?
A delay that is specific to the gross motor domain
What might gross motor delay suggest as an underlying diagnosis?
Cerebral palsy
Ataxia
Myopathy
Spina bifida
Visual impairment
What is fine motor delay?
A delay that is specific to the fine motor domain
What might fine motor delay suggest as an underlying diagnosis?
Dyspraxia
Cerebral palsy
Muscular dystrophy
Visual impairment
Congenital ataxia (rare)
Language delay - A delay that is specific to the speech and language domain may indicate what underlying diagnosis?
Specific social circumstances, for example exposure to multiple languages or siblings that do all the talking
Hearing impairment
Learning disability
Neglect
Autism
Cerebral palsy
Management of language delay
Management of language delay involves a referral to speech and language, audiology and the health visitor.
Referral to safeguarding is required if neglect is a concern.
Personal and Social Delay - a delay that is specific to the personal and social domain may indicate what?
Emotional and social neglect
Parenting issues
Autism
What is the legal framework for child safegaurding?
The legal framework for child safeguarding is the Children Act 1989
What is meant by ‘a child of need’?
A child is need refers to a child that is likely to need supportive services to maintain their health and development, or is disabled.
What is meant by child protection?
Child protection involves the process of protecting a child that is at risk of or suffering harm.
Types of abuse
Physical
Emotional
Sexual
Neglect
Financial
Identity
Risk factors for abuse?
Domestic violence
Previously abused parent
Mental health problems
Emotional volatility in the household
Social, psychological or economic stress
Disability in the child
Learning disability in the parents
Alcohol misuse
Substance misuse
Non-engagement with services
Signs of abuse in children?
Change in behaviour or extreme emotional states
Dissociative disorders (feeling separated from their thoughts or identity)
Bullying, self harm or suicidal behaviours
Unusually sexualised behaviours
Unusual behaviour during examination
Poor hygiene
Poor physical or emotional development
Missing appointments or not complying with treatments
What measures can help support families with children with safegaurding concerns?
Home visit programmes to support parents
Parenting programmes to help parents develop parenting skills and manage their child’s behaviour
Attachment-based interventions to help parents bond and nurture their child
Child–parent psychotherapy
Parent–child interaction therapy
Multi-systemic therapy for child abuse and neglect (MST-CAN)
Cognitive behavioural therapy for children that have suffered trauma or sexual abuse
Managing safegaurding concerns
All NHS organisations should have a safeguarding team or safeguarding lead that should be available to assist with safeguarding concerns. Once a safeguarding concern is identified the person that identifies it is responsible for escalating it to someone that can take action on it. It is generally not the role of the doctor or nurse to investigate or manage the concern, but it is their responsibility to refer or pass this on to someone trained and in a position to investigate further and take action.
Generally safeguarding cases are referred to children’s services (social services) who can investigate further and decide what action needs to be taken. Most safeguarding cases don’t involve children being removed from their parents. Usually social services are able to put in extra support and services and follow up over time. If the child is in immediate danger the police may need to be involved. If they are acutely unwell or need a place of safety they should be admitted to hospital.
Maintaining a professional, open, honest and trusting relationship with parents or carers is important, even when they are responsible for the abuse. This will make all aspects of any investigation and management easier, and lead to better outcomes.
What issues with breastfeeding may lead to inadequete nutrition for the neonate?
Poor milk supply
Difficulty latching
Discomfort or pain for the mother
When is overfeeding more common in babies?
Both breast and bottle feeding can lead to overfeeding, however overfeeding is more common in bottle-fed babies.
The world health organisation recommend exclusive breastfeeding how long?
for the first 6 months of life
Benefits of breastfeeding?
Breast milk contains antibodies that can help protect the neonate against infection.
Breastfeeding has been linked to reduced infections in the neonatal period, better cognitive development, lower risk of certain conditions later in life and a reduced risk of sudden infant death syndrome.
Body composition appears to be slightly different between breast and bottle-fed babies and children and adolescents that were breastfed appear to have less obesity.
There is evidence that breastfeeding can reduce breast cancer and ovarian cancer risk in the mother.
Feeding Volumes in Babies
On formula feed, babies should receive around 150ml of milk per kg of body weight. Preterm and underweight babies may require larger volumes. This is split between feeds every 2-3 hours initially, then to 4 hours and longer between feeds. Eventually babies and infants transition to feeding on demand (when they are hungry).
60mls/kg/day on day 1
90mls/kg/day on day 2
120mls/kg/day on day 3
150mls/kg/day on day 4 and onwards
How much weight is it acceptable for a baby to lose in the first 5 days of life?
It is acceptable for breast fed babies to loose up to 10% and formula fed babies to loose up to 5% of their body weight by day 5 of life
Most common cause excessive weight loss or not regaining weight in new borns?
The most common cause of excessive weight loss or not regaining weight is dehydration due to under feeding, even when they do not clinically look dehydrated. The most reliable sign of dehydration in babies is weight loss.
Weaning
Weaning refers to the gradual transition from milk to normal food. Weaning usually starts around 6 months of age. It starts with pureed foods that are easy to palate, swallow and digest, for example pureed fruit and “baby rice”.
Over 6 months this will progress towards a healthy diet resembling an older child, supplemented with milk and snacks to 1 year of age.
What is included on a child’s growth chart?
Growth charts are used to plot a child’s weight, height and head circumference against the the normal distribution for their age and gender. The child’s measurements are plotted on a graph using a dot. The age is plotted on the x-axis and the weight, height and head circumference are plotted on the y-axis.
Centiles (cent– meaning hundred) indicate where a child’s growth compares to the normal distribution for their age and sex.
What is important to establish when there are concerns re a childs growth chart?
The important thing when assessing a child where there are concerns about not gaining weight or height is to establish whether they are maintaining their centile. If a child is on the 9th centile, but they have always been on the 9th centile, that is much less concerning than a child that was on the 91st centile and is now on the 9th.
What are the three phases of growth?
First 2 years: rapid growth driven by nutritional factors
From 2 years to puberty: steady slow growth
During puberty: rapid growth spurt driven by sex hormones
What is defined as obese/overweight in children
Overweight is defined as a body mass index (BMI) above the 85th percentile and obese as above the 95th percentile
Why is childhood obesity increasing?
Obesity in children results from consuming more calories than are expended through activity and growth. Recently, access to readily available, affordable, hyper-palatable, high calorie foods has lead to the overconsumption of calories. There has been a shift from physical activities and outdoor play to sedentary activities such as video games and screens. This has contributed to an increase in childhood obesity.
Obesity in children: height considerations
Obese children are often tall for their age and come from overweight families. If children are short and obese, consider endocrine investigations for an underlying cause, such as hypothyroidism. A pathological cause is rare.
Effects of obesity in children
Bullying
Increased likelihood of it continuing into adulthood
Risk later in life of:
Imapired glucose tolerance
T2DM
CVD
Arthritis
Cancer
What is failure to thrive?
Failure to thrive refers to poor physical growth and development in a child.
What is faltering growth?
Faltering growth is defined in the 2017 NICE guidelines on faltering growth in children as a fall in weight across:
- One or more centile spaces if their birthweight was below the 9th centile
- Two or more centile spaces if their birthweight was between the 9th and 91st centile
- Three or more centile spaces if their birthweight was above the 91st centile
What is a centile space?
Centile spaces are the distance between two centile lines on a growth chart.
The distance between the 75th and 50th centile lines is a centile space.
A weight that falls this distance is a drop across one centile space.
For example, if the initial weight of a child is plotted halfway between the 9th and 25th centile lines and several months later is plotted halfway between the 2nd and 9th centile lines, they have dropped a full centile space.
Anything that leads to inadequate energy and nutrition can lead to failure to thrive. The causes can be categorised how?
Inadequate nutritional intake
Difficulty feeding
Malabsorption
Increased energy requirements
Inability to process nutrition
Failure to thrive: inadequate nutritional intake causes
Maternal malabsorption if breastfeeding
Iron deficiency anaemia
Family or parental problems
Neglect
Availability of food (i.e. poverty)
Failure to thrive: caused by difficulty feeding
Poor suck, for example due to CP
Cleft lip or plate
Genetic conditions with an abnormal facial structure
Pyloric stenosis
Failure to thrive: causes of malabsorption
Cystic fibrosis
Coeliac disease
Cows milk intolerance
Chronic diarrhoea
Inflammatory bowel disease
Failure to thrive: causes of increased energy requirement
Hyperthyroidism
Chronic disease - e.g. congenital heart disease, CF
Malignanacy
Chronic infections e.g. HIV or immunodeficiency
Failure to thrive: inability to process nutrients properly
Inborn errors of metabloism
T1DM
Failure to thrive - key areas to assess
Pregnancy, birth, developmental and social history
Feeding or eating history
Observe feeding
Mums physical and mental health
Parent-child interactions
Height, weight and BMI (if older than 2 years) and plotting these on a growth chart
Calculate the mid-parental height centile
How is BMI calculated
BMI is calculated as: (weight in kg) / (height in meters)2.
Feeding history
A feeding history involves asking about breast or bottle feeding, feeding times, volume and frequency and any difficulties with feeding. An eating history involves asking about food choices, food aversion, meal time routines and appetite in children. Asking the parent to keep a food diary can be helpful.
What BMI might indicate inadequate nutrition or a growth disorder?
BMI below the 2nd centile
What BMI might indicate inadequate nutrition or a growth disorder?
BMI below the 2nd centile
What mid-parental height might indicate inadequate nutrition or a growth disorder?
Height more than 2 centile spaces below the mid-parental height centile
How is mid parental height calculated
Mid parental height is calculated as: (height of mum + height of dad) / 2.
NICE reccomendations on investigating faltering growth?
Urine dipstick, for urinary tract infection
Coeliac screen (anti-TTG or anti-EMA antibodies)
Further investigations are usually not necessary where there are no other clinical concerns. Focused investigations should be considered where additional signs or symptoms suggest an underlying diagnosis, such as cystic fibrosis or pyloric stenosis.
Management of failure to thrive?
Management depends on the cause and may involve input from the multidisciplinary team. All children with faltering growth should have regular reviews to monitor weight gain. Reviews that are too frequent can increase parental anxiety.
Where difficulty with breastfeeding is the cause, there are lots of ways for the mother to get support, including midwives, health visitors, peers groups and “lactation consultants”. Supplementing with formula milk is likely to successfully improve growth, however it often results in breastfeeding stopping. Mother should be encouraged to feed with breastmilk prior to top-up feeds, and express when not breastfeeding to encourage lactation to continue.
Where inadequate nutrition is the cause there are several management options based on individual circumstances:
Encouraging regular structured mealtimes and snacks
Reduce milk consumption to improve appetite for other foods
Review by a dietician
Additional energy dense foods to boost calories
Nutritional supplements drinks
Where other measures fail and there are serious concerns the multidisciplinary team may consider enteral tube feeding. This needs to have clear goals and a defined end point.
In paediatrics, what is short stature?
Short stature is defined as a height more than 2 standard deviations below the average for their age and sex. This is the same as being below the 2nd centile.
Calculating a child’s predicted height?
Boys: (mother height + fathers height + 14cm) / 2
Girls: (mothers height + father height – 14cm) / 2
Causes of short stature (below 2nd centile) in children?
Familial short stature
Constitutional delay in growth and development
Malnutrition
Chronic diseases, such as coeliac disease, inflammatory bowel disease or congenital heart disease
Endocrine disorders, such as hypothyroidism
Genetic conditions, such as Down syndrome
Skeletal dysplasias, such as achondroplasia
What Is Constitutional Delay In Growth and Puberty?
Constitutional delay in growth and puberty (CDGP) is considered a variation on normal development. It leads to short stature in childhood when compared with peers but normal height in adulthood. Puberty is delayed and the growth spurt during puberty lasts longer. They ultimately reach their predicted adult height.
What objective feature will be present in CDGP
A key feature of CDGP is delayed bone age. It is possible to estimate the age of a child using xray images of their wrist and hand by assessing the size and shape of the bones and the growth plates. Children with CDGP will have a delayed bone age compared with the reference for their age and sex.
CDGP: diagnosis and management
Diagnosis is based on a suggestive history and examination and can be supported by an xray of the hand and wrist to assess bone age. Management involves excluding other causes of a short stature and delayed puberty, reassuring parents and the child and monitoring growth over time.
What are the four major domains of child development?
Gross motor
Fine motor
Language
Personal and social
What is gross motor development and in what pattern does it develop?
Gross motor refers to the child’s development of large movements, such as sitting, standing, walking and posture. Development in this area happens from the head downwards
Gross motor milestone: 4 months
Child able to support their head and keep it in line with the body
Gross motor milestone: 6 months
Child can keep their trunk supported by their pelvis (maintain a sitting position)
However they may lack the BALANCE to do so
Gross motor milestone: 9 months
Child able to sit unsuported
Crawling
Able to keep their trunk and pelvis supported on their legs (maintain a standing position) and bounce on their legs when supported
Gross motor milestone: 12 months
Should stand and being cruising (walking whilst holding furniture)
Gross motor milestone: 15 months
Walk unaided
Gross motor milestone: 18 months
Child should be able to squat and pick things up from the floor
Gross motor milestone: 2 years
Run, kick a ball
Gross motor milestone: 4 years
Hop, climb and descend stairs like an adult
Fine motor - early milestones:
8 weeks
Fixes their eyes on an object 30 centimetres in front of them and makes an attempt to follow it
They show a preference for a face rather than inanimate object
Fine motor - early milestones:
6 months
Palmar grasp objects (wraps thumb and fingers around the object)
Fine motor - early milestones:
9 months
Scissor grasp of objects (squashes it between thumb and forefinger).
Fine motor - early milestones:
12 months
Pincer grasp (with the tip of the thumb and forefinger).
Fine motor - early milestones:
14-18 months
They can clumsily use a spoon to bring food from a bowl to their mouth.
Fine motor: drawing skills:
12 months
Holds crayon and scribbles randomly
Fine motor: drawing skills:
2 years
Copies vertical line
Fine motor: drawing skills:
2.5 years
Copies a horizontal line
