Paediatric development Flashcards
Breast vs Bottle
Breastmilk:
Pros:
- contains ANTIBODIES
- reduced infections in neonatal period
- lower risk of necrotising enterocolitis
- Better cognitive development
- lower risk of other conditions later in life
- lower risk of sudden infant death syndrome (SIDS)
- linked to less obseity as teens
- reduced risk of breast/ovarian cancer in mum
Tho these could also be due to other socio-economic factors that also link to decision to breastfeed
Cons:
- Inadequate nutrition if difficult to do
Both breast + bottle can lead to OVERFEEDING
Feeding volumes in babies
Formula feed = 150ml/kg of body weight/day (may have to work up from less in the first week)
- may be more if preterm/underweight
Every 2-3 hour intially, then gradually increase till babies’ FEEDING ON DEMAND
Initial weight loss in babies
Up to 10% if breast fed; 5% if formula fed
- any more than this/not regained birth weight by 2 weeks -> hospital
- usually from DEHYDRATION due to under feeding
Weaning
Usually starts ~6 MONTHS
- starts with pureed foods
Progress to normal diet supplemented with milk + snacks to 1 year
Red flags in development
- Lost developmental milestones (REGRESSION)
- No response to carer interactions by 8 wks
- Not smiling by 3 months
- Not able to hold an object at 5 months
- Not sitting unsupported at 12 months (1yr)
- Not standing independently / walking at all by 18 months
- No clear words by 18 months
- No interest in others at 18 months
- Not running at 2.5 years
- Not interested in playing with peer by 3 yrs
Any sign of sidedness before 18 months
Failure to thrive
Poor physical growth + development
Faltering growth
Failure to gain adequate weight or ahieve adequate growth during infancy/early childhood (hight, weight, head circumferance in infancy)
- a significant interruption in the expected rate of growth compared with other children of similar age and sex during early childhood
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
- when urrent weight is below the 2nd centile for age, whatever the birth weight
May not be representative in neonates due to variations in growth due to antenatal factors (e.g. maternal smoking, gestational diabetes)
Causes of failure to thrive
Anything leading to inadequate energy/nutrition:
- Inadequate nutritional intake
- Difficulty feeding
- Malabsorption
- Increased energy requirements
- Inability to process nutrition
Causes of Inadequate Nutritional Intake
- Maternal malabsorption if breastfeeding
- Family or parental problems
- Neglect
- Availability of food (i.e. poverty)
- Ineffective suckling/bottle feeding
- Feeding aversion
- Physical disorders affecting feeding
Causes of Difficulty Feeding
- Poor suck (e.g. from cerebral palsy)
- Cleft lip or palate
- Genetic conditions with an abnormal facial structure
- Pyloric stenosis (the sphincter becomes thicker)
Causes of Malabsorption
- Cystic fibrosis
- Coeliac disease
- Cows milk intolerance
- Chronic diarrhoea
- Inflammatory bowel disease
- Biliary atresia
- Pancreatic cholestatic conditions
- ANAEMIA
Causes of Increased Energy Requirements
- Hyperthyroidism
- Chronic disease,
-for example congenital heart disease and cystic fibrosis, chronic lung disease of prematurity - Malignancy
- Chronic infections, for example HIV or immunodeficiency
- Inflam conditions (astma, IBD)
- Renal failure
Inability to Process Nutrients Properly
- Inborn errors of metabolism
- Type 1 diabetes
Which key areas need to be assessed when investigating failure to thrive:
- 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 would one take a feeding/eating Hx
- Ask about breast or bottle
- Feeding times + frequency
- Volume
- Difficulties feeding
Food choices + aversions. Mealtime routines + appetitee.
FOOD DIARY = helpful.
BMI claculation
(weight in kg) / (height in meters)2
Mid parental height calculation
(height of mum + height of dad) / 2.
Outcomes from failure to thrive assessment that would suggest inadequate nutrition or a growth disorder are
- Height more than 2 centile spaces below the mid-parental height centile
- BMI below the 2nd centile
Potential investigations for faltering growth
- Urine dipstick, for urinary tract infection
- Coeliac screen (anti-TTG or anti-EMA antibodies)
Further investigations usually only done if signs suggest underlying diagnosis e.g. CF or pyloric stenosis
What advice should be given to mothers struggling to breastfeed (resulting in failure to thrive)
- Encourage to feed with breastmilk prior to top-up feeds with formula
- Express when not breastfeeding to encourage lactation to continue (oftens stops otherwise)
Management options for kids experiencing inadequate nutrition
- 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
How to determine child’s growth
measure weight and hight/length and plt on UK WHO growth charts
How often does weight need to be monitored in children with suspected faltering growth
- daily if less than 1 month old
- weekly between 1–6 months old
- fortnightly between 6–12 months
- monthly from 1 year of age
When does initial neonatal weight loss usually stop
~ 3/4 days
If infants in the early days of life lose more than 10% of their birth weight
perform a clinical assessment
take a detailed history to assess feeding
consider direct observation of feeding
perform further investigations only if they are indicated based on the clinical assessment
provide feeding support (by a person with appropriate training and expertise).
If more than 2 centile spaces below the mid-parental centile
could suggest undernutrition or a primary growth disorder
Risk factors for faltering growth
Congenital anomalies (cerebral palsy, autism, trisomy 21)
Developmental delay
Gastroesophageal reflux
Low birth weight (<2.500g)
Poor oral health, dental caries
Prematurity (<37w)
Tongue-tie (controversial)
Things to consider for why baby may have faltering growth
preterm birth
neurodevelopmental concerns
maternal postnatal depression or anxiety
BMI centiles (in relation to concerns about linear growth)
- BMI< 2nd centile this may reflect either undernutrition or a small build
- BMI < 0.4th centile probable undernutrition that needs assessment and intervention
Feeding related complication in children with neurodisabiling conditions
Intesitinal failure (GI dysmotility) - can be life limiting
- can give parenteral nutrition but at what point? when can it be withdrawn?
When to consider referral for faltering growth
- symptoms or signs that may indicate an underlying disorder
- a failure to respond to interventions delivered in a primary care setting
- slow linear growth or unexplained short stature
- rapid weight loss or severe undernutrition
- features that cause safeguarding concerns
What is one reason babies may refuse to feed
Due to pain from reflux (babies have less developed LOS so reflux more easy)
When is an enteral feeding tube used for kids
- Serious concerns about weight gain
- An appropriate specialist multidisciplinary assessment for possible causes and contributory factors has been completed
- No improvement from other interventions
MUST have a SPECIFIC END GOAL and a STRATEGY FOR its WITHDRAWAL once goal reached
Next level of severeity of treatment if NG feeding isn’t working
Gastrostomy
- can reintroduce oral feeding and reverse over time
Screening for COeliac in kids
- TGA-IgA Ab and Total Serum Immunoglobulin
- while on a gluten contatining diet for 6 weeks
Can only diagnose with upper GI endoscopy + small bowel biopsy tho
Classic coeliac histology presentation
short vili + crypt hyperplasia
Milk protein allergy diff Px in kids
- iron def anaemia
- vomiting
- ECZEMA, rash
- Diarrhoea, blood in stool
- Asthma, wheeze/cough
Causes of abnormal growth control
- GH
- Thyroid
Psychosocial influence
(Rare causes of faltering growth)
Avoidant or Restrictive Food Intake Disorder (ARFID)
- significant weight loss (or failure to meet expected weight and height trajectories in children and adolescents)
- nutritional deficiencies (such as iron deficiency anemia)
- a dependence on nutritional supplements, (i.e., oral or enteral formulas), to meet energy requirements without an underlying condition necessitating this
- significant interference with day-to-day functioning due to the inability to eat appropriately.
What underlying causes should be excluded in all infants with faltering growth
- UTI
- COeliac (if eating gluten)
Only do other further investigations if indicated
Importants determinants of growth
Nature:
- Parental phenotype and genotype
- Specific system and organ integrity
- Growth promoting hormones and factors
Nurture:
- Quality and duration of pregnancy
- Nutrition
- Psycho-social environment
Newborn vs adult body proportions
Newborns: larger head, smaller mandible, short neck, chest rounded, abdomen prominent, limbs short
Adults: relative growth of limbs compared to trunk
What needs to be considered when interpreting head circumference
- Centile position
- Serial measurements
- Relation to body size
- Familial factors
Also consider the nature of sutures and fontanelles and be aware of signs on abnormal IC pressure
Which hormone has biggest effect on growth
In neonates = THYROID HORMONE
Growth hormone from around 3-4 years
Sex steroids in puberty
Neonate definition
28 days or younger
Growth and height velocity over course of fetal and childhood development
- Fastest growth rate in utero and infancy
- Gradually decreasing rate to puberty
- Pubertal growth spurt
- Growth ends with fusion of epiphyses (Oestrogen effect)
What can disproportionately short limbs potentially suggest
Achondroplasia
Most common cause of head circumference increasing up centiles in neonates/infants
Intraventricular bleeds
Can then lead to hydrocephalus
Which would you be more concerned about:
- baby with small body + normal sized head
- baby with small body + small head
Baby with small body AND small head
- the first is more likely to be due to placental insuficency as the brain should be getting most of the nutrients anyway
- the second suggests potential congenital abnormality
What would you want to do to complete a paediatric examination
HIght, weight + head circumference on growth chart
height velocity
change in height / years between measurements
Normal range for height velocity and height centile
Height velocity: 25th centile - 75th
Height: 3rd centile - 97th
Hypothalamic - pituitary axis flow
- Gonadotrophin relesing hormone
- Leutenising hormone + FSH
- Gonadal Sex hormones (testosterone, oestrogen, progesterone)
- Action in peripheral tissues
Stages of puberty in boys (Tanner staging)
- pre-pubescent
- Testicular enlargement - >3ml
- Further hair, testes + penis growth
- adult type
Stages of puberty in girls
- pre-pubescent
- Breast buds
Menarche can occur up to 4 years after initial breast bud development
girls vs boys: when does puberty occur on average
girls: 8-13 years
boys: 9-14 years
Categoristion of delay in puberty
- Hypergonadotrophic (primary - gonads don’t respond)
- Hypogonadotrophic (2nd/3rd - LH/FSH deficiency)
Causes of primary gonadal failure
Males: Kleinfelters (47XXY)
Females: Turners
Chemotherapy / Radiotherapy
Galactosemia
Trauma/surgery
Causes of secondary/teriary gonadal failure
Intracranial tumours
Chemotherapy / Radiotherapy
Congenital enzyme / receptor mutations
Prader-Willi syndrome
Sport
Eating disorders
Malnutrition
Chronic disease
Marijuana
Causes of precocious puberty / premature sexual development
True precocious = Idiopathic (90% female patients)
- from GnRH increase
Pseudopuberty = underlying ectopic
- Secreting tumours
gonads, brain, liver, retroperitoneum, mediastinum
(does not respond to usual treatment)
Commonest Tx of precosious puberty
Gonadotropin AGONIST (overstimulates - can get initial flair but then flattens of development)
True precocious vs pseudopuberty
True = Stimulated LH:FSH ratio > 1
Pseudo = Stimulated LH:FSH ratio < 1
An investigation for delayed/advanced physical development
Bone age/skeletal maturity
- Left hand X-ray
Overweight and obesity definition
Overweigth = BMI >85th centile (> 25)
Obesity = BMI >95th percentile (> 30)
Complications of childhood obesity
- Bullying
- impaired glucose tolerance,
- type 2 diabetes,
- cardiovascular disease, arthritis
- certain types of cancer
When should delayed puberty start being investigated
- If no signs of puberty by 13/14 y/o
- If signs of puberty present but don’t progess fully after 2 years
Investigations for delayed puberty
Initial for underlying causes:
- FBC/Ferritin (Anaemia)
- U+E (CKD)
- Anti-TTG, anti-EMA (Coeliac/faltering growth due to malnutrition)
Hormonal bloods:
- Early morning serum FSH and LH (the gonadotropins).
- These will be low in hypogonadotrophic hypogonadism and high in hypergonadotrophic hypogonadism. - Thyroid function tests
- Growth hormone testing.
- Insulin-like growth factor I as a screening test for GH deficiency. - Serum prolactin
Genetic testing with microarray:
- Kleinfelter’s + Turner’s
Imaging:
- Xray wrist
- Pelvic USS in girls
- MRI brain (pit pathoplogy/olfactory bulbs - ?Kallman syndrome)
Global developmental delay
Delay in 2 or more of following:
- Gross motor
- Fine motor
- Speech + language
- Social + emotional
RFx/Causes of developmental delay
- Neuro (congential e.g. spina bifida; acquired e.g. trauma, epilepsy, haemorrhage, hypoxic ischaemic encephalopathy)
- Infection
- CONGENITAL: TORCH
- Toxoplasmosis
- RUBELLA
- CMV
- Herpes/HSV
- HIV
- Mening/encephalitis - Neuromuscular disorder
- Duchenne
- Spinal muscular atrophy - Hypothyroidism
- Genetic disorders
- DOWN’S
- Pervasive developmental disorders
- ATUISM
- Metabolic disorder
- Hurle syndrome, Krabbe’s disease, Phenylketonuria
- PREMATURITY
- Idiopathic
Presentation of developmental delay
May be one specific milestone they are not meeting or a combination
Could be:
- Brought in by parents
- Referred by Health Visitor
- Cocern raised by educational setting
- SOme kids e.g. v premmies, are ROutinely followed-up for developmental delay
Developmental delay RED flags
- Social: Not SMILING by 10 WKS
-
Gross motor:
- Can’t SIT UNSUPPORTED by 12 MONTHS
- Can’t WALK by 18 MONTHS - FIne motor: Showing HAND PREFERANCE before 12 MONTHS
- Speech + Language: Not knowing 2-6 WORDS by 18 MONTHS
Refer to paediatric SPECIALIST ASSESSMENT/further investigation
First-line investigations for global developmental delay
- FBC + HAEMATENICS (anaemia)
- U + E (renal failure/hyponatraemia -> poor growth)
- CK (Duchenne - muscle breakdown)
- TFTs (congenital hypothyroid)
- LFTs (metabolic disorders)
- Vit D (motor delay if def)
- HEARING TEST (esp if isolated SALT related stuff)
Examples of 2nd line investigations for developmental delays + when would they be done
- Kareotyping / DNA analysis
- More detailed metabolic screens
- MRI
- EEG
DOne if indicated by 1st line investigations OR if still unclear after 1st set
Management of developmental delay
- Refer to community paeds -> detailed developmental assessment + holistic assessment of child + family
Mullti-disciplinary specialist therapy
- SALT
- Occupational/physio
- Portage
- Orthoptists
Tx for any underlying causes
Examples of standardised developmental assessments
- Griffiths Scales of Child Development
- Schedule of Growing Skills
Kallmann syndrome
X-LINKED RECESSIVE cause of HYPOGONADOTROPIC HYPOGONDAISM
- thought to be caused by failure of GnRH-secreting neurons to MIGRATE to HYPOTHALAMUS
Kallmann syndrome Px
- ANOSMIA
- DELAYED PUBERTY
- Hypogonadism
- Cryptorchidism
- Low sex hormone levels
- Low (or normal) LH / FSH levels
- Typically normal or above-average height
Tends to present in boys due to x-linked recessive inheritance
Kallmann syndrome Mx
- Testosterone supplementation
- Gonadotropin supplementation may stimulate sperm production if fertility is desired later in life
Define precocious puberty
Onset of 2ndry sex characteristics before age 8 (females) or 9 (males)
Investigations for precocious puberty
Usually specialist lead:
- Measure oestradiol / testosterone levels
- Measure adrenal ANDROGENS
- Brain MRI
- PELVIC US
- Intra-abdo imaging if adrenal / hepatic tumour suspected
- BONE AGE ASSESSMENT
Complications of precocious puberty
- Accelerated skeletal development + premature epiphyseal fusion -> reduced adult height
- Impact on child’s psych wellbeing
What are the types of precocious puberty
- Gonadotrophin-dependant
- Idiopathic (90%)
- BRAIN tumours
- Cranial radiotherapy
- Structural brain damage (Hydrocephalus, Infection, Trauma)
- Gonadotropin-independant
- GONADAL tumours
- ADRENAL / HEPATIC tumours
- Congenital Adrenal HYPERPLASIA
Physiology of appetite
LEPTIN - satiety
- released by ADIPOSE
- acts on stiety centres in hypothalamus
- Stimulates release of MELANOCYTE-STIMULATING hormone + CORTICOTROPHIN-RELEASING hormone
- LOW levels = release of NEUROPEPTIDE Y
GHRELIN - hunger
- produced by P/D1 cells in stomach fundus + epsilon cells in pancreas
Obesity classification
- Overweight = 25 - 30 BMI
- Obese class 1 = 30-35 BMI
- Obese class 2 = 35-40
- Obese class 3 = >40
Obesity Mx
- CONSERVATIVE: diet / exercise
- Medical (wouldn’t really use in kids):
- Orlistat (pancreatic lipase inhib -> SE = fecal incontinence/flatulence)
- Liraglutide (GLP-1 mimetic)
- Surgical
Causes of Childhood Developmental impairment
Genetic::
- Chomosomal (e.g. Downs)
- Microdeletions
- Microdeletions
- Single gene disorders (e.g. Rett syndrome, Duchenne)
- Polygenic: Autism, ADHD
Preg factors:
- Infections (CMV, HIV, Rubella)
- Drugs + alcohol
- MCA infarct (cerebral palsy)
Birth factors:
- Premmie
- Birth Asphyxia
Childhood factors:
- Infections (mening, encephalitis)
- Chronic illness
- Metabolic conditions
- Acquired brain injury
- Hearing / Visual impairment
Environmental:
- Abuse/neglect
- Low stimulation
