Paediatrics Development Flashcards
How long is breast feeding recommended for?
First 6 months (from WHO)
What are the benefits of breast feeding?
Free
Overfeeding is less common (than in bottle fed)
Breast milk contains antibodies which protect neonate from infection
Linked to reduced infections in neonatal period, better cognitive development, reduced risk of SIDS, less obesity in later life
Evidence that breastfeeding reduces breast cancer and ovarian cancer risk in mother
Some benefits may be linked to confounding factors
What are the disadvantages of breastfeeding?
Poor milk supply
Difficulty latching
Discomfort or pain for the mother
= inadequate nutrition for the baby
How much should a baby be fed?
150ml of milk per kg of body weight (preterm/underweight may require larger) evenually they transition to feeding on demand (when they are hungry)
How are feeding volumes in increased in the first week of life?
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
How much weight can a baby lose by day 5 of life?
Breast fed = 10%
Formula = 5%
Back at birth weight by day 10
What if a baby loses more weight than expected?
Admission to hospital and assessment
What is the most common cause of excessive weight loss?
Dehydration due to underfeeding even when don’t look clinically dehydrated
When does weaning usually start?
Around 6 months - starts with pureed foods which are easy to palate, swallow and digest e.g. pureed fruit and “baby rice” over the next 6 months
What are growth charts?
Used to plot a childs weight, height and head circumference for age and gender
What are the 3 phases of growth?
First 2 years = rapid growth driven by nutrition
From 2 years to puberty = steady slow growth
During puberty = rapid growth spurt driven by sex hormones
Why is there an increase in obesity in children?
Readily available, affordarble, hyper-palatable, high calorie food = overconsumption
Physical activites replaced by sedentary activities
What is overweight and obese?
Overweight = BMI above 85th percentile
Obese = above 95th percentile
What are the features of obese patients?
Tall for their age and come from overweight families
If short and obese then consider endocrine investigations (e.g. for hypothyroidism)
What is the effect of obesity in childhood?
Bullying
Impaired glucose tolerance
Type 2 diabetes
CVD
Arthritis
Cancer
What is the definition of faltering growth?
Fall in weight across:
One or more centile spaces
What are the causes of failure to thrive?
Inadequate nutritional intake
Difficulty feeding
Malabsorption
Increased energy requirements
Inability to process nutrition
What are some causes of inadequate nutritional intake?
Maternal malabsorption if breastfeeding
Iron deficiency anaemia
Family or parental problems
Neglect
Availability of food (i.e. poverty)
What are some causes of difficulty feeding?
Poor suck e.g. cerebral palsy
Cleft lip or palate
Genetic conditions with abnormal facial structure
Pyloric stenosis
What are some causes of malabsorption?
Cystic fibrosis
Coeliacs disease
Cows milk intolerance
Chronic diarrhoea
IBD
What are some causes of increased energy requirements?
Hyperthyroidism
Chronic disease e.g. congenital heart disease and cystic fibrosis
Malignancy
Chronic infections e.g. HIV or immunodeficiency
What may cause an inability to process nutrients properly?
Inborn errors of metabolism
Type 1 diabetes
What are the aspects to the assessment for failure to thrive?
Pregnancy, birth, developmental and social history
Feeding history (breast / bottle fed, times, volume, frequency)
Eating history (food choices, aversions, meal time routines, appetitie in children)
Ask for food diary
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
What outcome from assessment would suggest growth disorder?
Height more than 2 centile spaces below the mid-parental height centile
BMI below the 2nd centile
What are the initial investigations for faltering growth?
Urine dip for UTI
Coeliac screen (anti-TTG or anti-EMA)
Further investigations where additional signs/symptoms suggest diagnosis e.g. CF or pyloric stenosis
What is the management of faltering growth due to breast feeding problems?
Multidisciplinary team with regular reviews
Breast feeding problems = help from midwives, health visitors, peer groups and “lactation consultants)
Supplement with formula milk to improve growth (often results with breastfeeding stopping)
What is the management of faltering growth when inadequate nutrition is the cause?
- Encourage regular structured mealtimes and snacks
- Reduce milk consumption to improve appetite for other foods
- Review by dietician
- Additional energy dense foods to boost calories
- Nutritional supplement drinks
- Consider enteral tube feeding: has to have defined end point
What is a childs predicted height?
Boys = (M+D + 14)/2
Girls = (M+D-14cm)/2
What are the causes of short stature?
Familial short stature
Constitutional delay in growth and development
Malnutrition
Chronic diseases e.g. coeliac disease, IBD or congenital heart disease
Endocrine disorders e.g. hypothyroidism
Genetic conditions e.g. Down syndrome
Skeletal dysplasias e.g. achondroplasia
What is constitutional delay in growth and puberty?
Variation on normal development - causes short stature in childhood when compared to peers but normal height in adulthood
Puberty is delayed and growth spurt is then longer
What is a key feature of CDGP?
Delayed bones age - age of child estimated with x-ray images of wrist and hand ans assessing the size and shapre of bones and growth plates - these children have a delayed bones age
How is the diagnosis of CDGP made?
Suggestive history and examination
X-ray of hand and wrist to assess bone age
What is the management of CDGP?
Exclude other causes
Reassure parents
Monitor growth over time
What are the 4 domains of child development?
Gross motor
Fine motor
Language
Personal and social
What are the gross motor milestones?
Head downwards:
4 months: Support their head and keep it in line with the body
6 months: Maintain sitting position by 6 months, however they often don’t have the balance to sit
9 months: They should sit unsupported by 9 months. They can start crawling at this stage. Maintain a standing position
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.
What are the early milestones for fine motor skills?
8 weeks: Fix their eyes on an object 30 centimetres in front of them attempt to follow it. 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.
How do drawing skills in an child develop?
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
How do tower of bricks skills develop in a child?
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
How do pencil grasps develop over time?
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
What other fine motor skills develop over time?
3 years - thread large beads onto string
4 years - cut paper in half
What are the 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
What are the receptive language milestones?
3 months: Recognises parents and familiar voices
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 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”
What are the social developmental milestones?
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.
What red flags suggest that there is a problem?
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
How to perform a developmental assessment?
Use their name
Use parents to encourage
Visually estimate how old
Test milestones and work up
Say things to let examiner know“really good pincer grip” “you build a tower of 6 bricks” “thats really good walking”
What is:
Dyslexia
Dysgraphia
Dyspraxia
Auditory processing disorder
Non-verbal learning disability
Profound and multiple learning difficulty
Dyslexia - difficulty in reading, writing and spelling
Dysgraphia - difficulty in writing
Dyspraxia (aka developmental co-ordination disorder) - specific type of difficulty in physical co-ordination - delayed gross and fine motor skills
Auditory processing disorderb - difficulty processing auditory information
Non-verbal learning disability - difficulty in processing non-verbal information e.g. body language and facial expressions
Profound and multiple learning disability - difficulties across multiple areas - often requiring help with all aspects of daily life
How is the severity of learning disability measured?
55-70 = mild
40-55 = moderate
25-40 = severe
Under 25 = profound
What are the causes of learning difficulties?
Often no clear cause
FH increases risk
Environmental factors e.g. abuse, neglect, phychological trauma and toxins all increase risk
Which genetic conditions are associated with learning difficulty?
Down’s syndrome
Antenatal problems e.g. Fetal alcohol syndrome and maternal chickenpox
Problems at birth e.g. prematurity and hypoxic ischaemic encephalopathy
Meningitis
Autism
Epilepsy
Who is in the multidisciplinary team for learning difficulties?
Health visitors
Social workers
Schools
Educational psychologists
Paediatricians, GPs and nurses
Occupational therapists
Speech and language therapists
How does capacity vary with learning difficulties?
Decision specific - may take several attempts on different days to make a decision
How is capacity demonstrated?
Understand decision to be made
Retain information long enough to make decision
Weight up options
Communicate decision
When does puberty happen in girls and boys respectively?
Girls = 8-14
Boys = 9-15
Taking 4 years from start to finish
How does puberty progress in girls?
Breast buds
Pubic hair
Menstrual periods about 2 years from start of puberty
How does puberty progress in boys?
Enlargement of testicles
Enlargement of penis
Darkening of scrotum
Development of pubic hair
Deeping of voice
What scale is used for puberty?
Tanner scale
What is hypogonadism?
Lack of the sex hormones, oestrogen and testosterone which normally rise prior to and during puberty
What are the 2 causes of hypogonadism?
Hypogonadotrophic hypogonadism: deficiency of LH and FSH
Hypergonadotrophic hypogonadism: lack of response to LH and FSH by the gonads (testes and ovaries)
What could cause hypogonadotropic hypogonadism?
Abnormal functioning of the hypothalamus or pituitary gland
- Previous damage to the hypothalamus or pituitary e.g. by radiotherapy or surgery for previouc cancer
- Growth hormone deficiency
- Hypothyroidism
- Hyperprolactinaemia (high prolactin)
- Serious chronic conditions e.g. CF or IBD
- Excessive exercise or dieting can delay onset of menstuation
- Constituational delay in growth or development - temp delay in grwoth and puberty without underlying physical pathology
- Kallman syndrome
What are the causes of hypergonadotrophic hypogonadism?
Abnormal functioning of the gonads, due to:
Previous damage to gonads (e.g. testicular torsion, cancer, infections e.g. mumps
Congenital absence of testes
Kleinfelter’s syndrome (XXY)
Turner’s syndrome (XO)
What is Kallman syndrome?
Genetic condition causing hypogonadotrophic hypogonadism resulting in failure to start puberty associated with anosmia
When to start investigating for delayed puberty?
No evidence of pubertal changes in girl aged 13 or a boy aged 14
How to assess a patient with delayed puberty?
Take detailed history of general health, development, FH, diet and lifestyle
Examination to assess height, weight, stage of pubertal development and features of underlying conditions
What are the inital investigations for pubertal delay?
FBC and ferritin for anaemia
U&Es for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease
What hormonal blood tests for delayed puberty?
Early morning serum FSH and LH
TFTs
Growth hormone testing (insulin-like growth factor I is used as a screening test for GH deficiency)
Serum prolactin
What genetic testing is there for pubertal delay?
Genetic testing with a microassay
- Kleinfelter’s syndrome (XXY)
- Turner’s syndrome (XO)
What imaging can be used for pubertal delay?
X-ray of the wrist for bone age and to inform a diagnosis of constitutional delay
Pelvic ultrasound in girls to assess ovaries and other pelvic organs
MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome
What is the management of pubertal delay?
Treat underlying condition
Constitutional delay = reassurance and observation
Oestrogen in girls and testosterone in boys (replacement sex hormones) can be used to induce puberty under expert guidance
What is safeguarding and child protection?
Safeguarding = all aspects of ensuring welfare of child
Child protection = process of protecting a child that is at risk of / suffering harm
What is the legal framework for child safeguarding?
Children Act 1989
What are the different types of abuse?
Physical
Emotional
Sexual
Neglect
Financial
Identity
What are the risk factors for abuse?
Domestic violence
Previously abused parents
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
What are some possible signs of abuse?
Who to raise safeguarding concerns to?
Safeguarding team - person who identifies concern should escalate it to someone who can action it
Who does the safeguarding team refer cases to?
Children’s services (social services)
What the the management of safeguarding concerns?
What health decisions can 16 and 17 year olds make?
Can children under 16 make decisions about treatment?
Yes but only if they are
What is Gilick competence?
What are Frazer guidelines?
At what age can a child give consent to sexual activity?
Over 13 years old
How is child palliative care different from adult?
- Number of children who die is small
- Many of the conditions are rare and diverse / genetic
- Needed for few days, weeks or months
What are the four fundamental principles?
Autonomy - right to self-determination
Non-maleficence - need to avoid harm
Beneficence - ability to do good
Justice
