Growth + development

Question 1

What is the normal pattern of childhood growth?

Answer 1

Conception - until end of linear growth at 15-16y.
Phases:
1. Infant growth-rapid, mostly depends on nutrition, often catch up/down for their birth weight, unless there was severe IUGR or poor postnatal health in which it may be permanently reduced

2. Childhood growth-slow but steady, mid-childhood spurt around 6-8y then slows again until puberty. Main determinant is growth hormone (makes IGF-1 @ epiphyses, obv need good nutrition+health), equal in boys + girl
3. Pubertal growth-mid childhood pituitary starts releasing hormones. Height velocity increases a lot, girls enter puberty around 2y earlier but boys on average taller as they have a greater GH peak.
   Growth finished when the epiphyses fuse, they stop growing from the feet up. Most important hormone is prob oestrogen

Question 2

How is development monitored?

Answer 2

Between 0-5y are the major things. Monitored by parents, child health checks, briefly whenever a HCP sees them, progression seen at school for cognitive + abstract development.

Question 3

How would you screen development?

Answer 3

Know a few of the key milestones + their age limits - mostly children progress through this with some slight variation in actual ages

See if a lag in just one area or all fields

Overall if their developmental profile is in line with their age

Question 4

Gross motor milestones

Answer 4

Newborn: flexed limbs, symmetrical, head lag on pulling up
First few months: primitive reflexes disappear e.g. moro (sudden head extension causes arm extension then flexion). Develop postural reflexes e.g. parachute (suspended face down baby’s arms extend)

6-8w: raise head when prone [head control] (limit 4m)

6-8m: sit without support (limit 9m)

8-9m: crawling/bumshuffling

10m: stands independently, cruises around furniture (limit 12m)

12-18m: walks, unsteady, broad gait, hands apart

15m: walks steadily (limit 18m)

30m (2.5y): runs + jumps

Stairs etc - more deets depending on how many stairs

Question 5

Fine motor + vision milestones

Answer 5

6w: fixing + following (limit 3m)
4m: reaches out for toys (limit 6m)

4-6m: palmar grasp

7m: transfers toys between hands (limit 9m)
10m: mature pincer grip (limit 12m)

16-18m: makes marks with crayon

14m-4y: tower building. 3 blocks 18m, 6 blocks 2y, 8 blocks/train with 4 by 2.5y, bridge from a model 3y, steps after demonstration by 4y

2-5y: draw without seeing it done/copying 6m earlier than these. Line 2y, circle 3y, cross 3.5y, square 4y, triangle 5y

Question 6

Hearing, speech + language milestones

Answer 6

Newborn: startles to loud noises

3-4m: vocalises, coos+laughs

7m: turns to soft sounds out of sight

7-10m: indiscriminate sounds then around 10m consonant babble like mama/dada

12m: 2-3 words other than dada/mama (by 18m need to know 6 words)
18m: 6-10 words, can show two parts of body

20-24m: simple phrases with at least 2 words

2.5-3y: talks constantly in 3-4 word sentences

Question 7

Social/emotional/behavioural milestones

Answer 7

6w: smiles responsively (limit 8w)

6-8m: puts food in mouth

10m: limit for fear of strangers

10-12m: waves by bye, plays peek a boo

12m: drinks from a cup with 2 hands
18m: holds spoon + gets food to mouth

18-24m: symbolic play

2y: dry by day (potty trained), pulls off some clothing
2. 5-3y: parallel play, interactive play evolving, takes turn

Question 8

Cognitive development

Answer 8

Infants: thought processes around immediate experiences

Preschool: pre-operational thought. They are centre of world, inanimate objects are alive with feelings + motives, events have a magical element or a purpose

Middle age: operational thought. Mostly practical + orderly thought tied to immediate circumstances/specific experiences

Early-mid teens: formal operational thought. Adult style abstract thought, testing hypotheses, manipulating abstract concepts

Question 9

Hearing screening

Answer 9

Newborn: otoacoustic emission test (shortly after birth they will startle + blink at sudden noise). Tests cochlear function, often get false positives from amniotic fluid stuck in ear canal. If abnormal they are referred to audiologist for auditory brainstem response

Question 10

Vision screening

Answer 10

Newborn: low acuity, gradually increases to normal adult levels by about 5y

So vision screening is done at pre-school/school entry

Question 11

How should you assess development in a child born prematurely?

Answer 11

Up until around 2y: calculate developmental age from the EDD

After 2y: by their chronological age

Question 12

Developmental history?

Answer 12

<18m: mostly GM, vision + hearing, hand skills

18m-2.5y: mostly S+L and FM skills (GM abnormalities would be quite obvious)

2.5-4y: S+L and social/behaviour

Question 13

Developmental assessment

Answer 13

Denver Developmental Screening - more formalised screening

Specific standardised testing e.g. following up preterm infants

Cognitive function testing with IQ - but biased to cultural background etc

Question 14

How is child health surveyed?

Answer 14

Screening test
Immunisations
Developmental reviews
Health promotion
Health visitor reviews: antenatal health, new baby r/v, 6-8w check, 1y check, 2-2.5y check

Question 15

What is growth failure/weight faltering?

Answer 15

Suboptimal weight gain which can cause reduction in final height/head growth/delay development

Usually considered when child is below the 0.4th gentile, crosses down 2 centile lines or their BMI is <2nd centile

Question 16

Causes of growth failure

Answer 16

Environmental - inadequate intake e.g. breast milk supply issues, inappropriate foods offered, lack of regular meal times, infant refusing food, budget/cooking problems, psychosocial deprivation e.g. maternal depression, neglect/child abuse inc FII (deliberate underfeeding to generate low weight)

Pathological reduced intake: impaired suck/swallow e.g. cleft palate, chronic illness causing anorexia e.g. CD/CKD/CF/liver disease

Inadequate retention: vomiting, GORD

Malabsorption: coeliac disease, CF, CMPA, post-NEC, short gut syndrome

Failure to utilise nutrients: IUGR, syndromes, metabolic e.g. congenital hypothyroidism, storage disorders

Increased requirements: hyperthyroidism, CF, malignancy, CKD, chronic infection, congenital heart disease

Question 17

What is short stature?

Answer 17

Height below the 2nd centile (2 SDs below the mean) - usually constitutional but can be pathological, esp if below 0.4th centile

Question 18

Causes of short stature

Answer 18

Familial
Constitutional delay but catch up (variant of normal)
Severe IUGR/prematurity-may need GH if don’t catch up by age 4
Endocrine-hypothyroidism, GH deficiency, steroid excess, IGF-1 deficiency. Seen as weight>height centile, delayed bone age
Nutrition/long term illnesses-coeliac/CD/CF/CHD etc. Weight centileback, storage disorders back>legs

Question 19

How is genetic height estimated?

Answer 19

Mean of the mother + father height (mid parental height)

Add 7cm for a boy
Subtract 7cm for a girl

Question 20

What are the main abnormalities to screen for developmental milestones?

Answer 20

GM:

• cannot sit unsupported at 12 months
• cannot walk at 18 months
• most common causes of problems: variant of normal, cerebral palsy and neuromuscular disorders (e.g. Duchenne muscular dystrophy)

FM:
*hand preference before 12 months is abnormal and may indicate cerebral palsy

S+L:

• doesn’t smile at 10 weeks
• always check hearing
• other causes include environmental deprivation and general development delay

Question 21

Describe the primitive reflexes (present from birth, go in first few months)

Answer 21

• Stepping/walking reflex, goes around 2m
• Moro: head extension causes abduction then adduction of arms. Goes around 3-4m
• Rooting: assists in breastfeeding, goes around 4m
• Grasp: flex fingers when object placed in palm, goes around 4-5m