Paediatric Development

Question 1

Nutrition

Answer 1

Breast vs Bottle

The world health organisation recommend exclusive breastfeeding for the first 6 months of life.

Issues with breastfeeding (e.g. poor milk supply, difficulty latching, discomfort or pain for the mother) can lead to inadequate nutrition for the baby.

Both breast and bottle feeding can lead to overfeeding, however overfeeding is more common in bottle-fed babies.

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.

It is not clear how far these benefits can be attributed to differences in socio-economic factors that contribute to a woman’s decision whether to breastfeed, and many of the claimed benefits may be due to other confounding factors.

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).

Volumes are gradually increased in the first week of life as tolerated. For example:

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

Initial Weight Loss in Babies

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. They should be back at their birth weight by day 10. If they loose more weight than this or do not regain their birth weight by two weeks, they need admission to hospital and assessment for possible causes.

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.

Question 2

Growth Charts

Answer 2

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.

Growth charts have curves that indicate the normal distribution of growth over time. Centiles (cent– meaning hundred) indicate where a child’s growth compares to the normal distribution for their age and sex. It is important to use the chart that matches the sex of the child, as growth is different between boys and girls.

To illustrate how centiles work consider these examples: If a child is on the 50th centile, she is basically exactly average height for her age. If another child is on the 1st centile, he is shorter than 99% of children his age. If another child is on the 91st centile, she is taller than 91% of children her age.

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.

Plotting Growth Charts

Plotting growth charts is a common exam question and very common task for any doctor working on paediatrics. It is important to practice this skill. To help, here are some examples (all chart images were taken from RCPCH growth charts):

Plot a 4.5 month old girl that is 6.7kg:

She is almost perfectly on the 50th centile. This means her weight is higher than 50% of girls her age, and lower than the other 50%.

Lets say you saw her again at 1 year of age and she was 8kg:

Now her weight has dropped to below the 25th centile. More than 75% of girls her age are heavier than her. If she had weighed 6kg at 4.5 months (below 25th centile) her current weight would not be concerning, but the fact that she has dropped in centiles should raise questions about why she is failing to gain weight.

Question 3

Phases of growth

Answer 3

Children go through 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

Question 4

Obesity

Answer 4

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.

Overweight is defined as a body mass index (BMI) above the 85th percentile and obese as above the 95th percentile. 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.

The biggest immediate effect of obesity in children is bullying. Obese children are at higher risk of later developing impaired glucose tolerance, type 2 diabetes, cardiovascular disease, arthritis and certain types of cancer. Unless the family engages and addresses the issue it is likely to continue into adulthood and have all the associated negative health implications of adult obesity.

Question 5

Failure to thrive

Answer 5

Failure to thrive refers to poor physical growth and development in a child. 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
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.

Question 6

Causes of failure to thrive

Answer 6

Anything that leads to inadequate energy and nutrition can lead to failure to thrive. The causes can be categorised as:

Inadequate nutritional intake
Difficulty feeding
Malabsorption
Increased energy requirements
Inability to process nutrition

Causes of Inadequate Nutritional Intake

Maternal malabsorption if breastfeeding
Iron deficiency anaemia
Family or parental problems
Neglect
Availability of food (i.e. poverty)

Causes of Difficulty Feeding

Poor suck, for example due to cerebral palsy
Cleft lip or palate
Genetic conditions with an abnormal facial structure
Pyloric stenosis

Causes of Malabsorption

Cystic fibrosis
Coeliac disease
Cows milk intolerance
Chronic diarrhoea
Inflammatory bowel disease

Causes of Increased Energy Requirements

Hyperthyroidism
Chronic disease, for example congenital heart disease and cystic fibrosis
Malignancy
Chronic infections, for example HIV or immunodeficiency

Inability to Process Nutrients Properly

Inborn errors of metabolism
Type 1 diabetes

Question 7

Assessing failure to thrive

Answer 7

The aim of assessment is to establish the cause of the failure to thrive. This involves taking a full history, examining the child and completing relevant investigations. Key areas need to be assessed:

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
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.

BMI is calculated as: (weight in kg) / (height in meters)2.

Mid parental height is calculated as: (height of mum + height of dad) / 2.

Outcomes from the 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

Question 8

Investigating failure to thrive

Answer 8

NICE guidelines from 2017 on faltering growth recommend the following initial investigations:

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.

Question 9

Managing failure to thrive

Answer 9

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.

Question 10

Short stature

Answer 10

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.

Question 11

Predicted height

Answer 11

A child’s predicted height can be calculated based on their parents’ height, measured in centimetres. The formula is different for boys and girls:

Boys: (mother height + fathers height + 14cm) / 2
Girls: (mothers height + father height – 14cm) / 2

Question 12

Causes of short stature

Answer 12

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

Question 13

Constitutional Delay In Growth and Puberty

Answer 13

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.

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.

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.

Question 14

Developmental Milestones

Answer 14

Child development is a key part of paediatrics and is commonly assessed by paediatricians. A very common exam scenario involves assessing the developmental milestones in a child to determine whether they are developing normally. Child development can be separated into four major domains:

Gross motor
Fine motor
Language
Personal and social

Question 15

Gross Motor

Answer 15

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:

4 months: This starts with being able to support their head and keep it in line with the body
6 months: They can keep their trunk supported on their pelvis (i.e. maintain a sitting position) by 6 months, however they often don’t have the balance to sit unsupported at this stage.
9 months: They should sit unsupported by 9 months. They can start crawling at this stage. They can also keep their trunk and pelvis supported on their legs (i.e. maintain a standing position) and bounce on their legs when supported.
12 months: They should stand and begin cruising (walking whilst holding onto furniture).
15 months: Walk unaided.
18 months: Squat and pick things up from the floor.
2 years: Run. Kick a ball.
3 years: Climb stairs one foot at a time. Stand on one leg for a few seconds. Ride a tricycle.
4 years: Hop. Climb and descend stairs like an adult.

Question 16

Fine Motor

Answer 16

Fine motor refers to a the child’s development of precise and skilled movements, and also encompasses their visual development and hand-eye coordination.

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 an inanimate object.
6 months: Palmar grasp of objects (wraps thumb and fingers around the object).
9 months: Scissor grasp of objects (squashes it between thumb and forefinger).
12 months: Pincer grasp (with the tip of the thumb and forefinger).
14-18 months: They can clumsily use a spoon to bring food from a bowl to their mouth.
Drawing Skills:

12 months: Holds crayon and scribbles randomly
2 years: Copies vertical line
2.5 years: Copies horizontal line
3 years: Copies circle
4 years: Copies cross and square
5 years: Copies triangle
Tower of Bricks:

14 months: Tower of 2 bricks
18 months: Tower of 4 bricks
2 years: Tower of 8 bricks
2.5 years: Tower of 12 bricks
3 years: Can build a 3 block bridge or train
4 years: Can build steps
Pencil Grasps:

Under 2 years: Palmar supinate grasp (fist grip)
2-3 years: Digital pronate grasp
3-4 years: Quadrupod grasp or static tripod grasp
5 years: Mature tripod grasp
Others:

3 years: Can thread large beads onto string. Can make cuts in the side of paper with scissors.
4 years: Can cut paper in half using scissors

Question 17

Language

Answer 17

Language refers to the child’s development of understanding and using speech and language to communicate. There are two components:

Expressive language
Receptive language
Expressive language milestones:

3 months: Cooing noises
6 months: Makes noises with consonants (starting with g, b and p)
9 months: Babbles, sounding more like talking but not saying any recognisable words
12 months: Says single words in context, e.g. “Dad-da” or “Hi”
18 months: Has around 5 – 10 words
2 years: Combines 2 words. Around 50+ words total.
2.5 years: Combines 3 – 4 words
3 years: Using basic sentences
4 years: Tells stories
Receptive language milestones:

3 months: Recognises parents and familiar voices and gets comfort from these
6 months: Responds to tone of voice
9 months: Listens to speech
12 months: Follows very simple instructions
18 months: Understands nouns, for example “show me the spoon”
2 years: Understands verbs, for example “show me what you eat with”
2.5 years: Understands propositions (plan of action), for example “put the spoon on / under the step”
3 years: Understands adjectives, for example “show me the red brick” and “which one of these is bigger?”
4 years: Follows complex instructions, for example “pick the spoon up, put it under the carpet and go to mummy”
You can also think receptive language in terms of the number of key words:

18 months: 1 key word, for example “show me the spoon”
2 years: 2 key words, for example “show me the spoon and the cup”
3 years: 3 key words, for example “put the spoon under the step”
4 years: 4 key words, for example “put the red spoon under the step”

Question 18

Personal and Social

Answer 18

Personal and social refers to the child’s development of skills in interacting, communicating, playing and building relationships:

6 weeks: Smiles
3 months: Communicates pleasure
6 months: Curious and engaged with people
9 months: They become cautious and apprehensive with strangers
12 months: Engages with others by pointing and handing objects. Waves bye bye. Claps hands.
18 months: Imitates activities such as using a phone
2 years: Extends interest to others beyond parents, such as waving to strangers. Plays next to but not necessarily with other children (parallel play). Usually dry by day.
3 years: They will seek out other children and plays with them. Bowel control.
4 years: Has best friend. Dry by night. Dresses self. Imaginative play.

Question 19

Red Flags

Answer 19

There are certain red flags for things that would suggest there is a problem:

Lost developmental milestones
Not able to hold an object at 5 months
Not sitting unsupported at 12 months
Not standing independently at 18 months
Not walking independently at 2 years
Not running at 2.5 years
No words at 18 months
No interest in others at 18 months

Question 20

Performing a Developmental Assessment

Answer 20

During the initial part of the assessment try to develop rapport with the child so they engage with you. Make it a game and fun, and give plenty of praise when the child succeeds in a task. Make sure you remember and use their name. Children generally enjoy showing what they can do. If they are shy or don’t want to engage try using the parent to encourage them and don’t be afraid simply to observe and note what they are doing. If they absolutely do not want to engage you may want to ask their parent about the milestones.

Start by making a visual estimate of the rough age of the child and observing what they are doing before asking them to do something different. Test milestones that you think the child should be able to achieve at that age and work your way up until they are unable to complete the task. For example, if they look around 2 years and you want to assess fine motor, start with a tower and see how many bricks they can build, then challenge them to build a train, then a bridge, then steps. When they fail at a task, move on to assessing their drawing ability.

TOM TIP: When talking to the child, you can encourage them in a way that lets the examiner know you have noticed certain things, such as “that is a really good pincer grip”, “you built a tower of six bricks, that is great” and “that is really good walking”.

Question 21

Global Developmental Delay

Answer 21

Global developmental delay refers to a child displaying slow development in all developmental domains. This could indicate an underlying diagnosis such as:

Down’s syndrome
Fragile X syndrome
Fetal alcohol syndrome
Rett syndrome
Metabolic disorders

Question 22

Gross Motor Delay

Answer 22

A delay that is specific to the gross motor domain may indicate underlying:

Cerebral palsy
Ataxia
Myopathy
Spina bifida
Visual impairment

Question 23

Fine Motor Delay

Answer 23

A delay that is specific to the fine motor domain may indicate underlying:

Dyspraxia
Cerebral palsy
Muscular dystrophy
Visual impairment
Congenital ataxia (rare)

Question 24

Language Delay

Answer 24

A delay that is specific to the speech and language domain may indicate underlying:

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 involves a referral to speech and language, audiology and the health visitor. Referral to safeguarding is required if neglect is a concern.

Question 25

Personal and Social Delay

Answer 25

A delay that is specific to the personal and social domain may indicate underlying:

Emotional and social neglect
Parenting issues
Autism

Question 26

Types of Learning Disability

Answer 26

Dyslexia refers to a specific difficulty in reading, writing and spelling.

Dysgraphia refers to a specific difficulty in writing.

Dyspraxia, also known as developmental co-ordination disorder, refers to a specific type of difficulty in physical co-ordination. It is more common in boys. It presents with delayed gross and fine motor skills and a child that appears clumsy.

Auditory processing disorder refers to a specific difficulty in processing auditory information.

Non-verbal learning disability refers to a specific difficulty in processing non-verbal information, such as body language and facial expressions.

Profound and multiple learning disability refers to severe difficulties across multiple areas, often requiring help with all aspects of daily life.

Question 27

Classification of learning disability

Answer 27

The severity of the learning disability is based on the IQ (intelligence quotient):

55 – 70: Mild
40 – 55: Moderate
25 – 40: Severe
Under 25: Profound

Question 28

Causes of learning disability

Answer 28

Often there is no clear cause for the learning disability. A family history of learning disability increases the risk. Environmental factors such as abuse, neglect, psychological trauma and toxins can all increase the risk.

Certain conditions are strongly associated with learning disability:

Genetic disorders such as Downs syndrome
Antenatal problems, such as fetal alcohol syndrome and maternal chickenpox
Problems at birth, such as prematurity and hypoxic ischaemic encephalopathy
Problems in early childhood, such as meningitis
Autism
Epilepsy

Question 29

Managing learning disability

Answer 29

The key to managing learning disability is with a multidisciplinary approach to support the parents and child. This involves:

Health visitors
Social workers
Schools
Educational psychologists
Paediatricians, GPs and nurses
Occupational therapists
Speech and language therapists
TOM TIP: Examiners may test you on your communication with someone that has learning disability. Remember to involve the child in any discussions where appropriate, regardless of their intellectual ability. When talking to someone with learning disability it becomes more important to make things simple to understand, give only small amounts of information at a time and always check understanding. Use tools to assist your communication, such as pictures and emojis. For example, there is a pain scale with a series of faces from happy to sad that can be used to help patients with learning disabilities communicate their level of pain.

Question 30

Capacity

Answer 30

It is important to remember that capacity is decision specific, and having learning disability does not prevent patients from being able to make decisions. They may require more time, effort and decision aids to be able to fulfil the criteria. It may take several attempts on different days or at different times of day to be able to make a decision. Capacity becomes more important as they approach adulthood, as most decisions about a child will be made by their parent or guardian.

To have capacity a patient must demonstrate the ability to:

Understand the decision that needs to be made
Retain the information long enough to make the decision
Weight up the options and the implications of choosing each option
Communicate their decision
TOM TIP: Remember the four key words for demonstrating capacity, as these are very frequently tested in exams. Remember that capacity is decision specific, meaning someone may have capacity to decide what they want for breakfast but not to decide whether to undergo complex surgery.

Question 31

Normal Puberty

Answer 31

Puberty starts age 8 – 14 in girls and 9 – 15 in boys. It takes about 4 years from start to finish. Girls have their pubertal growth spurt earlier in puberty than boys.

In girls, puberty starts with the development of breast buds, then pubic hair and finally starting menstrual periods about 2 years from the start of puberty.

In boys, puberty starts with enlargement of the testicles, then of the penis, gradual darkening of the scrotum, development of pubic hair and deepening of the voice.

Question 32

Tanner Staging

Answer 32

The tanner scale can be used to determine the pubertal stage based on examination findings of sex characteristics.

Question 33

Hypogonadism

Answer 33

Hypogonadism refers to a lack of the sex hormones, oestrogen and testosterone, that normally rise prior to and during puberty. A lack of these hormones causes a delay in puberty. This is fundamentally due to one of two reasons:

Hypogonadotrophic hypogonadism: a deficiency of LH and FSH
Hypergonadotrophic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)

Question 34

Hypogonadotropic Hypogonadism

Answer 34

Hypogonadotropic hypogonadism is where there is a deficiency of LH and FSH, leading to a deficiency of the sex hormones testosterone and oestrogen. LH and FSH are gonadotrophins. Since there are no gonadotrophins simulating the gonads, they do not respond by producing sex hormones (testosterone and oestrogen). Therefore, you get “hypogonadism” as a result of “hypogonadotropism”.

A deficiency of LH and FSH is the result of abnormal functioning of the hypothalamus or pituitary gland. This could be due to:

Previous damage to the hypothalamus or pituitary, for example by radiotherapy or surgery for previous cancer
Growth hormone deficiency
Hypothyroidism
Hyperprolactinaemia (high prolactin)
Serious chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting can delay the onset of menstruation in girls
Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
Kallman syndrome

Question 35

Hypergonadotropic Hypogonadism

Answer 35

Hypergonadotropic hypogonadism is where the gonads fail to respond to stimulation from the gonadotrophins (LH and FSH). There is no negative feedback from the sex hormones (testosterone and oestrogen), therefore the anterior pituitary produces increasing amounts of LH and FSH to try harder to stimulate the gonads. Therefore, you get high gonadotrophins (“hypergonadotrophic”) and low sex hormones (“hypogonadism”).

Hypergonadotrophic hypogonadism is the result of abnormal functioning of the gonads. This could be due to:

Previous damage to the gonads (e.g. testicular torsion, cancer or infections, such as mumps)
Congenital absence of the testes or ovaries
Kleinfelter’s Syndrome (XXY)
Turner’s Syndrome (XO)

Question 36

Kallman Syndrome

Answer 36

Kallman syndrome is a genetic condition causing hypogonadotrophic hypogonadism, resulting in failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia).

Question 37

Investigating delayed puberty

Answer 37

The threshold for initiating investigations is when there is no evidence of pubertal changes in a girl aged 13 or a boy aged 14. The first step is to take a detailed history of their general health, development, family history, diet and lifestyle. An examination to assess height, weight, stage of pubertal development and features of underlying conditions. Investigation can also be considered when there is some evidence of puberty but no progression over 2 years.

Initial investigations can be used to look for underlying medical conditions:

Full blood count and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease
Hormonal blood tests can be used to look for hormonal abnormalities:

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 is often used as a screening test for GH deficiency.
Serum prolactin
Genetic testing with a microarray test can be used to look for underlying genetic conditions:

Kleinfelter’s syndrome (XXY)
Turner’s syndrome (XO)
Imaging can be useful:

Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay
Pelvic ultrasound in girls to assess the ovaries and other pelvic organs
MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

Question 38

Managing delayed puberty

Answer 38

Management involves treating the underling condition where there is one. Patients with constitutional delay may only require reassurance and observation. Replacement sex hormones (oestrogen in girls and testosterone in boys) can be used to induce puberty under expert guidance.

Question 39

Safeguarding

Answer 39

Safeguarding involves all aspects of ensuring the welfare of a child. Child protection involves the process of protecting a child that is at risk of or suffering harm.

The legal framework for child safeguarding is the Children Act 1989. A child in need refers to a child that is likely to need supportive services to maintain their health and development, or is disabled.

Safeguarding is an essential part of the role of anyone working with children. By nature children are vulnerable to abuse and do not have the means to protect themselves or look out for themselves. It is our responsibility as healthcare professionals to take a child-centred approach and look out of the best interests of the child.

This is a summary and overview to help your basic understanding for exams and is not a substitute for safeguarding training you may require for clinical practice. If you have any safeguarding concerns always discuss these with an experienced senior colleague who can advise on the appropriate course of action.

Question 40

Types of Abuse

Answer 40

A common exam question involves identifying the types of abuse. These are:

Physical
Emotional
Sexual
Neglect
Financial
Identity

Question 41

Risk Factors For Abuse

Answer 41

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

Question 42

Possible Signs of Abuse

Answer 42

It is worth keeping safeguarding in mind when seeing any child. There are certain signs that should make you consider whether there could be safeguarding issues. This is not an exhaustive list. If in doubt always talk to a senior or someone experienced with safeguarding.

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

Question 43

Managing safeguarding concerns

Answer 43

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.

There are a number of measures that can be arranged by appropriate professionals to help support families of children with safeguarding 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

Question 44

Consent to treatment

Answer 44

Where you are concerned or unsure about the law, you can discuss with a senior or your medical defence organisation. This section is to give an overview for exams and not legal advice.

A person is recognised as an adult with full autonomy to make decisions about their health when they turn 18. 16 and 17 year olds can also make independent decisions about their health, but if they refuse treatment this can be overruled in certain situations by parents, people with parental responsibility or the court. Children under 16 can make decisions about treatment, but only if they are deemed to have Gillick competence. There is no lower limit to the age where children can make decisions about their health, however it is unusual for consent to be taken from someone under 13.

The way this is usually tested in exams relates to girls under 16 years seeking contraception from their GP. This is the scenario that established “Gillick competence” and “Frazer guidelines” in the first place.

Question 45

Gillick Competence

Answer 45

Gillick competence refers to a judgement about whether the understanding and intelligence of the child is sufficient to consent to treatment. Gillick competence needs to be assessed on a decision by decision basis, checking whether the child understands the implications of the treatment. Consent needs to be given voluntarily. When prescribing contraception to children under 16 it is important to assess for coercion or pressure, for example coercion by an older partner. This might raise safeguarding concerns.

Question 46

Frazer Guidelines

Answer 46

Frazer guidelines are specific guidelines for providing contraception to patients under 16 years without having parental input and consent. The guidelines were set down by the House of Lords in 1985. To follow the guidelines, they need to meet the following criteria:

They are mature and intelligent enough to understand the treatment
They can’t be persuaded to discuss it with their parents or let the health professional discuss it
They are likely to have intercourse regardless of treatment
Their physical or mental health is likely to suffer without treatment
Treatment is in their best interest
Children should be encouraged to inform their parents, but if they decline and meet the criteria for Gillick competence and the Frazer guidelines confidentiality can be kept.

Question 47

Safeguarding

Answer 47

It is important to explore whether there is any possibility of abuse or exploitation and if this is present confidentiality may need to be broken. Where the child is not deemed to be Gillick competent and the child is at risk of harm, this should be escalated as a safeguarding concern.

Children under 13 cannot give consent for sexual activity. All intercourse in children under 13 years should be escalated as a safeguarding concern to a senior or designated child protection doctor.