Development and malnutrition

Question 1

What are the four domains of development?

Answer 1

Gross motor
Fine motor and vision
Hearing and speech
Social

Question 2

What would you expect a child to be able to do at 6-8 weeks old?

Answer 2

GM - Might be making attempts at holding head (raise to 45 degrees)
FM+V - Fixing and following
H+S - Startle to loud noises
S - SMILING

Question 3

What might you expect a child to be able to do at 3-4 months old?

Answer 3

GM - Support own head, look up when lying on abdomen, held sitting with curved spine
FM+V - Reaching out for toys
H+S - Single syllable vocalisation when alone or when spoken to
S - Laughs, enjoys friendly handling

Question 4

What might you expect a child to be able to do at 6-8 months old?

Answer 4

GM - Roll over, sit without support, held sitting with straight spine, pull to standing
FM+V - Palmar grasp, might transfer from hand to hand and have immature pincer grip
H+S - Double syllable babbling and responding to own name, shouts
S - Not shy

Question 5

What might you expect a child to be able to do at 9 months old?

Answer 5

GM - Crawling (not all), sit without support
FM+V - pincer grip
H+S - Respond to name
S - Stranger anxiety

Question 6

What might you expect a child to be able to do at 10-12 months old?

Answer 6

GM - Cruising (10/12), First steps
FM+V - Points, mature pincer, looks for fallen objects, casting, banging objects together
H+S - 2-3 recognisable words
S - waving, clapping, drinking from beaker

Question 7

What might you expect a child to be able to do at 12-18 months?

Answer 7

GM - walk steadily and possibly run at 18/12, squats at 15/12, stairs 2 feet
FM+V - 12/12 - 2 cubes, 18/12 - 4 cubes,
H+S - Repeat name, knows 6-10 words, might know body parts at 18/12
S - Eats with spoon by self

Question 8

What might you expect a child to be able to do at 2-2.5 years?

Answer 8

GM - Run, jump and kick ball
FM+V - 6-8 cubes in tower,
H+S - use 2 words together, use pleurals and verbs
S - Become skilful with spoon

Question 9

What might you expect a child to be able to do at 3-3.5 years?

Answer 9

GM - Rides a tricycle, uses stairs with handrail
FM+V - Can make a bridge or tower of 9
H+S - Sentences, gender, adjectives and colour, count to 10
S - Use fork and spoon, dress self under supervision, continence and plays alone

Question 10

What might you expect a child to be able to do at 4-5 years?

Answer 10

GM - Hop, skip and use a climbing frame
FM+V - 4 = copies cross, 5 = copies square and triangle
H+S - Asks ‘why’, ‘when’ and ‘how’ questions
S - Knife and fork, dress independently (not laces and buttons) and plays with other children

Question 11

What are some red flags to development?

Answer 11

Not sitting without support by age 9 months
Not walking by age 18 months
REGRESSION - should never LOSE SKILLS
Hand preference before 18m (Cerebral palsy)
Persisting primitive reflexes beyond 6m

Question 12

What is GLOBAL DEVELOPMENTAL DELAY?

Answer 12

This is if you are behind for your age in 2 of the 4 domains

Question 13

What are some causes of delayed walking?

Answer 13

Parents started walking late - always ask 
DDH 
Cerebral palsy 
Chromosomal abnormalities 
Spina bifida
Genu varum
DMD

Question 14

What are some clinical signs of DMD?

Answer 14

CENTRAL WEAKNESS - ask the child to lie on the floor and then ask them to get up - if they walk up on their hands and feet suggests DMD

It is X-linked recessive

Question 15

What are some causes of speech delay and what should you ask in hx?

Answer 15

Hearing impairment - all newborns should have hearing assessment so always check for this in red book
Multiple languages spoken at home - not pathological
Structural - tongue tie, cleft palate

Question 16

What are some general causes of global developmental delay?

Answer 16

• Hypothyroidism
• Chromosomal abnormalities
• Fetal alcohol syndrome
• Neurometabolic conditions
• Neuroasphyxia
• PVL (peri-ventricular leukomalacia)
• IVH - Intra-ventricular haematoma
• Head trauma
• Neglect

Question 17

When should parents start weaning their child?

Answer 17

6 months old

Question 18

What things should be initially given to the weaning child and what things can only be given after a certain age?

Answer 18

Start with pureed fruit, root vegetables and rice, gradually increase amount and variety
AVOID eggs, wheat and fish before 6/12
AVOID cow’s milk until 12 months
AVOID honey until 12 months - has bacteria in that can cause botulinism
AVOID sugary snacks, salty foods, soft cheeses, unpasteurised products and shellfish

Question 19

What are some important investigations to do in a child who you suspect might be malnourished?

Answer 19

ANTHROPOMETRY

• skin fold thickness over triceps muscle
• Upper arm circumference (if <115mm - severe malnutrition)
• Weight for height - if more than 3 SDs away from the mean then severe malnutrition

Question 20

How should we manage malnourished children?

Answer 20

Always try enteral feeding first which can be done either nasogastrically or via gastrostomy

If this isn’t sufficient or there are concerns about absorption then we should consider parenteral feeding

Question 21

What is marasmus and what causes it?

Answer 21

This is when the child appears very thin, they are wasted, can see bones.
it is caused when there is deficiency in all energy types (incl protein)

Question 22

What is Kwashiorkor and what causes it?

Answer 22

This is when there is severe protein deficiency

Child is ascitic, has dry, unusually pigmented skin, swollen ankles, thin, dry hair and moon phase

Question 23

How should we manage severe malnutrition?

Answer 23

• Correct hypoglycaemia and electrolyte abnormalities
• Wrap up warm
• Rehydrate but conservatively (fluid overload can lead to heart failure)
• Vitamin A really important

Start foods that are low in proteins (high protein won’t be tolerated initially)
Formula 75 then Formula 100

Question 24

Why is the vision of the newborn so poor?

Answer 24

Unmyelinated optic nerve and immature fovea

Question 25

When are adult levels of eye sight reached?

Answer 25

6/6 vision reached at approx 3-4 years

Question 26

What is a squint and when should we consider resolving them?

Answer 26

Misalignment of the visual axis - consider re-aligning at 12 weeks if they have not self-resolved

Question 27

What categories of squint are there?

Answer 27

CONCOMITANT - most common. Non-refractive error, corrected with glasses, squinting eye is usually convergent
PARALYTIC - Paralysis of motor nerves, varies with gaze direction, ?SOL
MANIFEST OR LATENT - is it there all the time or does it only come on with specific movement

Question 28

In what ways can you assess for squint?

Answer 28

1. CORNEAL LIGHT REFLEX - shine light and see whether it is reflected in the same place on both corneas. Can also assess for red reflex at this point as well
2. COVER TEST. Get patient to focus on something in distance. Cover fixing eye then see if squinting eye adjusts
   - Normal eye should have no movement
   - Then repeat this with child looking at near object

Question 29

What are some causes of visual impairment/blindness in the child?

Answer 29

Genetic: T21, CHARGE syndrome
Congenital: Cataracts, albinism, retinal dystrophy, retinoblastoma, congenital infection (CMV or RUBELLA)
Antenatal/perinatal: Retinopathy of prematurity, oxygen supply in newborn can lead to this - retinal vessel proliferation, HIE, Cerebral damage, optic nerve hypoplasia
Post-natal: Trauma, infection , JIA/optic neuritis

Question 30

How great does hearing loss have to be to affect developing of speech and language?

Answer 30

At least 60dB

Question 31

What are some causes of sensorineural hearing loss?

Answer 31

INHERITED - Connexin 26, Usher’s syndrome, Waardenberg syndrome, Pendred syndrome, Jervell-Lange-Nielson syndrome
ACQUIRED - Birth asphyxia, hyperbilirubinaemia, CMV, RUBELLA, SYPHILIS
Post-natal - drugs (aminoglycosides), meningitis, head injury, labrynthitis, acoustic neuroma

Question 32

What are some causes of conductive hearing loss?

Answer 32

External ear abnormalities (ear canal atresia / stenosis), middle ear abnormalities, acute otitis media, chronic otitis media, secretory otitis media

Question 33

Who does fragile X syndrome occur in and what are some features?

Answer 33

BOYS - X-linked recessive. CCG repeat in FMR1 gene (>200 is full mutation)

FEATURES: learning difficulties, macrocephaly, macro-orchidism, large everted ears, prominent mandible, broad forehead, mitral valve prolapse, joint laxity, scoliosis, autism, hyperactivity