Developmental milestones / failure to thrive / CAHMS Flashcards
Outline the difference between growth and development
Growth is the physical process of getting bigger
- Involves getting taller, gaining weight and increasing head circumference
Whereas development is the process of hitting developmental milestones
- Walking
- Talking
- Fine motor skills
- Smiling
State the way to roughly estimate a child’s weight
(age + 4) x 2
Or can use Broselow tape in emergencies
State some causes of short stature
Constitutionally small (familial)
Chronic diseases e.g. coeliac disease, IBD, paediatric malignancies, hypothyroidism, CKD
Genetic syndromes e.g. Prader-Willi syndrome, Turner syndrome and Noonan syndrome
Growth hormone deficiency
Malnurition
Psychological stress e.g. abuse
State some causes of tall stature
Constitutionally tall (familial)
- Precocious puberty
- Excessive growth hormone secretion
- Hyperthyroidism
- Chromosomal disorders e.g. Klinefelter Syndrome, Fragile X
- Syndromes e.g. Marfan Syndrome, Beckwith-Wiedemann Syndrome
Outline what developmental delay means and the rough categories it includes
Developmental delay = broad term referring to a delay in any of the four developmental areas
- Gross motor
- Fine motor
- Speech and language
- Social and emotional
Outline what global developmental delay means
Global developmental delay = a delay in 2 or more of the developmental areas simultaneously
I.e. 2 or more of the following
1. Gross motor
2. Fine motor
3. Speech and language
4. Social and emotional
Suggest some causes of developmental delay in the following categories:
- Global developmental delay
- Gross motor delay
- Fine motor delay
- Language delay
- Social / emotional
Idiopathic or environmental:
- Infection e.g. CMV
- Prematurity
Global developmental delay:
- Down’s syndrome
- Fragile X syndrome
- Foetal alcohol syndrome
- Metabolic disorder
Gross motor delay:
- Cerebral palsy
- Visual impairment
- Muscular dystrophy
- Spina bifida
Fine motor delay:
- Cerebral palsy / dyspraxia
- Visual impairment
- Muscular dystrophy
Language delay:
- Cerebral palsy
- Autism / learning disability
- Hearing impairment
- Neglect
- Social factors e.g. talkative siblings
Social / emotional:
- Autism
- Parenting issues/ neglect
Suggest a red flag sign for the following developmental signs
1. Gross motor
2. Fine motor
3. Speech and language
4. Social and emotional
- Gross motor:
- Not sitting unsupported by 12 months
- Not walking by 18 months - Fine motor
- Showing hand preference BEFORE 12 months of age - Speech and Language
- Not knowing 2-6 words by 18 months - Social and emotional
- Not smiling by 10 weeks
Suggest some first line investigations to consider for global developmental delay
FBC and haematinics = iron / folate deficiency
U&Es = renal failure or hyponatraemia
Creatinine kinase = Duchenne Muscular Dystrophy
Thyroid function tests = congenital hypothyroidism
Liver function tests = metabolic disorders (particularly if dysmorphic features)
Vitamin D = linked to motor delay
Hearing test = if isolated speech and language delay
Briefly suggest how to manage a child with developmental delay
- Referral to a community paediatrician (detailed developmental assessment)
- Can use standardised developmental assessment e.g. Griffiths Scales of Child Development
Management is mainly MDT e.g. SALT or occupational therapists
Briefly outline Down’s syndrome
Genetic condition by which there are 3 copies of trisomy 21 (extra copy)
- This gives characteristic dysmorphic features
- Extent to which individuals are affected varies
State the frequency of Down’s syndrome and the average life expectancy
1:1000 live births
Most common chromosomal abnormality in the UK
Average life expectancy: 60 years
State a risk factor for Down’s syndrome
Increased maternal age
State some dysmorphic features of Down’s syndrome
- Epicanthic folds
- Single palmar crease
- Upward sloping palpable fissures
- Flattened face and nasal bridge
- Low set, folded ears
- Brachycephaly
- Short neck
- Short stature
- Hypotonia
State some complications of Down’s syndrome (general and ENT)
General:
- Learning disability
- Cardiac defects: ASD, VSD, patent ductus arteriosus, TOF
- Hypothyroidism
- Leukaemia
- Dementia
ENT:
- Recurrent otitis media
- Hearing impairment
- Visual impairment
Outline the combined test for Down’s syndrome and when it occurs
Combined test:
1. Maternal blood test
- Beta-HCG
- PAPPA
2. Ultrasound for nuchal translucency
Occurs between 11-14 weeks
Provides a risk score to then suggest whether to do either amniocentesis or chorionic villus sampling
State some regular follow up investigations that are needed in children diagnosed with Down’s syndrome
- Audiometry
- Visual tests
- Thyroid checks
State some reasons for failure to thrive to do with inadequate nutritional intake
- Unable to access food (poverty)
- Maternal malabsorption issues (breastfeeding)
- Neglect
State some reasons for failure to thrive to do with difficultly feeding
- Cleft lip or palate
- Abnormal facial structure e.g. genetic conditions
- Poor suck e.g. cerebral palsy
- Pyloric stenosis
State some reasons for failure to thrive to do with malabsorption
- Coeliac disease
- IBD
- Cystic fibrosis
- Cows milk intolerance
- Chronic diarrhoea
State some reasons for failure to thrive to do with increased energy requirements
- Hyperthyroidism
- Chronic diseases e.g. congenital heart disease and cystic fibrosis
- Chronic infections e.g. HIV or immunodeficiency
- Malignancy
State some reasons for failure to thrive to do with process nutrients properly
- Type 1 diabetes
- Inborn errors of metabolism
At what age should a child achieve the following gross motor milestones:
- Limbs flexed in symmetrical pattern and head lag on pulling up
- Lifts head
- Sits without support
- Crawling
- Stand independently / cruise around furniture
- Walks unsteadily with a broad gait
- Walks steadily
- Run and jump
Limbs flexed, symmetrical pattern and head lag on pulling up = newborn
Lifts head = 6 – 8 weeks
Sits without support = 6 – 8 months
Crawling = 8 – 9 months
Stand independently / cruise around furniture = 10 months
Walks unsteadily with a broad gait = 12 months
Walks steadily = 15 months
Runs and jumps = 2.5 years
At what age should a child achieve the following vision / fine motor milestones:
- Follows moving object / face by turning head (fixing and following)
- Reaches for toys
- Palmar grasp
- Transfers toys from one hand to another
- Mature pincer grip
- Makes marks with crayons
- Tower of 3
- Tower of 6
Follows moving object / face by turning head (fixing and following) = 6 weeks
Reaches for toys = 4 months
Palmar grasp = 4-6 months
Transfers toys from one hand to another = 7 months
Mature pincer grip = 10 months
Makes marks with crayons = 16-18 months
Tower of 3 = 18 months
Tower of 6 = 2 years
At what age should a child achieve the following pencil skills (drawing without seeing how it’s done)
- Line
- Circle
- Cross
- Square
- Triangle
Can copy 6 months earlier!
Line – 2 years
Circle – 3 years
Cross – 3.5 years
Square – 4 years
Triangle – 5 years
At what age should a child achieve the following hearing, speech and language milestones:
- Startles to loud noises
- Vocalises alone or when spoken to, coos and laughs “aa, aa”
- Turns to soft sounds out of sight / polysyllabic babble (“babababa, lalalalala”)
- Sounds use indiscriminately then discriminately to parents
- ‘Dada’ or ‘Mama’ plus 2-3 other words
- 6-10 words / able to point to 2 things when asked parts of the body
- Joins two or more words to make simple phrases e.g. “Give me teddy”
- Talks constantly in 3 – 4-word sentences / 2 joined commands
Startles to loud noises = Newborn
Vocalises alone or when spoken to, coos and laughs “aa, aa” = 3-4 months
Turns to soft sounds out of sight / polysyllabic babble (“babababa, lalalalala”) = 7 months
Sounds used indiscriminately at 7 months, progressing to used discriminately to parents at 10 months “Dada, Mama” = 7-10 months
‘Dada’ or ‘Mama’ plus 2-3 other words = 12 months
6-10 words / able to point to 2 things when asked parts of the body = 18 months
Joins two or more words to make simple phrases e.g. “Give me teddy” = 20-24 months
Talks constantly in 3 – 4-word sentences / 2 joined commands = 2.5 – 3 years
At what age should a child achieve the following social, emotional and behavioural milestones:
- Smiles responsively
- Puts food in their mouth
- Waves bye-bye, plays peek-a-boo
- Drinks from a cup with two hands
- Holds spoon and gets food safely to mouth
- Imaginative play
- Toilet training (dry by day) / pulls off some clothing
- Parallel play / interactive play evolving / takes turns
Smiles responsively = 6 weeks
Puts food in their mouth = 6-8 months
Waves bye-bye, plays peek-a-boo = 10-12 months
Drinks from a cup with two hands = 12 months
Holds spoon and gets food safely to mouth = 18 months
Imaginative play = 18 – 24 months
Toilet training (dry by day) / pulls off some clothing = 2 years
Parallel play / interactive play evolving / takes turns = 2.5 – 3 years
State some things a 6-8 weeks old should be able to do in terms of developmental milestones (in terms of gross motor, vision / fine motor and social / behavioural)
Gross motor: lift their head
Vision / fine motor: follows moving object / face by turning head (fixing and following)
Social / behavioural: smiles responsively
State some things a 12 month old should be able to do in terms of developmental milestones (in terms of gross motor, vision / fine motor / hearing, speech and language and social / behavioural)
Gross motor: Walks unsteadily with a broad gait
Vision / fine motor: Mature pincer grip
Hearing, speech and language: ‘Dada’ or ‘Mama’ plus 2-3 other words
Social / behavioural: Drinks from a cup with two hands
State some things a 18 month old should be able to do in terms of developmental milestones (in terms of gross motor, vision / fine motor / hearing, speech and language and social / behavioural)
Gross motor: Walk steadily
Vision / fine motor: Tower of 3
Hearing, speech and language: 6-10 words / able to point to 2 things when asked parts of the body
Social / behavioural: Hold spoon, able to get food to mouth safely
State some things a 24 month old should be able to do in terms of developmental milestones (in terms of gross motor, vision / fine motor / hearing, speech and language and social / behavioural)
Gross motor: Walk steadily / close to running
Vision / fine motor: Tower of 6
Hearing, speech and language: Joins two or more words to make simple phrases e.g. “Give me teddy”
Social / behavioural: Toilet training (dry by day) / pulls off some clothing
State the normal developmental age limit for sitting without support
State the red flag age if not achieved by this age
6 – 8 months
Red flag age: 9 months
State the normal developmental age limit for walking unsteadily with a broad gait
State the red flag age if not achieved by this age
12 months
Red flag age: 18 months
State the normal developmental age limit for fixing and following (vision)
State the red flag age if not achieved by this age
6-8 weeks
Red flag age: 3 months
State the normal developmental age limit for reaching out for toys
State the red flag age if not achieved by this age
4 months
Red flag age: 6 months
State the normal developmental age limit for transfering toys from one hand to another
State the red flag age if not achieved by this age
7 months
Red flag age: 9 months
State the normal developmental age limit for a mature pincer grip
State the red flag age if not achieved by this age
10 months
Red flag age: 12 months
State the normal developmental age limit for smiling responsively
State the red flag age if not achieved by this age
6 weeks
Red flag age: 8 weeks
State the normal developmental age limit for imaginative play
State the red flag age if not achieved by this age
18-24 months
Red flag age: 2-2.5 years
At what age should a child have reached the following developmental gross motor milestone: lift head
6 – 8 weeks
At what age should a child have reached the following developmental gross motor milestone: sit without support
6 – 8 months
At what age should a child have reached the following developmental gross motor milestone: crawl
8 – 9 months
At what age should a child have reached the following developmental gross motor milestone: stand independently / cruise around furniture
10 months
At what age should a child have reached the following developmental gross motor milestone: walk (unsteady broad gait)
12 months
At what age should a child have reached the following developmental gross motor milestone: walk steadily
15 months
At what age should a child have reached the following developmental gross motor milestone: run and jump
2.5 years
At what age should a child have reached the following developmental vision / fine motor milestone: follows moving object / face by turning head (fixing and following)
6 weeks
At what age should a child have reached the following developmental vision / fine motor milestone: reaches for toys
4 months
At what age should a child have reached the following developmental vision / fine motor milestone: palmar grasp
4-6 months
At what age should a child have reached the following developmental vision / fine motor milestone: transfers toys from one hand to another
7 months
At what age should a child have reached the following developmental vision / fine motor milestone: mature pincer grip
10 months
At what age should a child have reached the following developmental vision / fine motor milestone: makes marks with crayons
16-18 months
At what age should a child have reached the following developmental vision / fine motor milestone: tower of 3
18 months
At what age should a child have reached the following developmental vision / fine motor milestone: tower of 6
2 years
State the triad of features for autism
- Difficulties with social interaction
- Difficulties with social communication
- Repetitive behaviours / sensory issues
State the triad of features for ADHD
- Inattention
- Hyperactivity
- Impulsivity
State the triad of features for ADHD
- Inattention
- Hyperactivity
- Impulsivity
State 3 medications that can be used in the treatment of ADHD
- Methylphenidate (Ritalin)
- Dexamphetamine
- Atomoxetine
State how many simple infections a child can have in a year without being concerned (excluding other concerning features)
Normal for a child to have 4-8 infections in a year, especially at nursery / school / winter months
State some features of recurrent infections that might warrant further investigation
- Failure to thrive
- More than 8 infections per year
- Severe infections
- Atypical infections e.g. candida
- Chronic diarrhoea since infancy
State some investigations to consider for a child presenting with recurrent infections
Bloods:
- FBC
- Immunoglobulins
- Previous antibody response to vaccinations
- HIV test
- Complement proteins
Others:
- Chest x-ray (repeated scarring)
- Sweat test (cystic fibrosis)
- CT chest (bronchiectasis)
State some differentials to consider in children with delayed speech and language
- Pregnancy related
- Hearing related
- Developmental issues
Pregnancy related:
- TORCH (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex)
- HIE / hypoxia during birth
Hearing related:
- Cerebral palsy
- Congenital deafness
- Ototoxic drugs
- Infections affecting hearing e.g. meningitis, head trauma
Developmental:
- Autism
- Chromosomal conditions / global developmental delay / learning disability
- Abuse / home difficulties / talkative siblings / multilingual
