Postnatal and Child Development Flashcards
On what plane should the embryo be looked at to see the 4 parts of the foetal brain?
Dorsal (front) view of the embryo
At 4 weeks what are the 4 parts of the foetal brain?
Prosencephalon (future forebrain)
Mesencephalon (future midbrain)
Rhombencephalon (future hindbrain)
Future spinal cord
On what plane should the embryo be looked at to see the 3 flexures of the foetal brain?
Side view
At 4 weeks, what are the 3 flexures present in the foetal brain?
Cephalic flexures
Pontine flexures
Cervical flexures
At 5 weeks, what does the dorsal view of the foetal brain reshape to form?
Telencephalon
Diencephalon
Pons
Medulla
At 8 weeks, how has the foetal brain developed since?
Development of the ventricular system (third and fourth ventricle, and aqueduct)
Developing hemispheres
Developing cerebellum
How has the brain developed by term?
Fully developed cortex Ventricular system Aqueduct Cerebellum Pons Medulla
What are the different functions of the cerebral cortex?
Pre-frontal cortex = executive function and concentration
Primary motor cortex = supplying the nerves to the skeletal muscles
Primary somatic sensory cortex = receiving impulses from the periphery
Parietal lobe = sensory information processing
Occipital lobe = visual information processing
Temporal lobe = auditory information processing and speech
What happens if there is malfunctioning in the pre-frontal cortex?
Malfunctioning in:
Pre-frontal cortex = ADHD - attention deficit hyperactivity disorder
What 2 matters is the spinal cord made up of? Where are they found and what are they responsible for?
White matter and grey matter
White matter =
- Found on the edge of the cross section of the spine
Grey matter =
- Found in the middle of the cross section of the spine
- Grey matter in the anterior section of the cord is responsible for motor neurons
How are the nerves organised within the spinal tract and what do they supply?
Pyramidal tracts (lateral and anterior corticospinal tracts) = voluntary control
Extrapyramidal tracts = involuntary control, co-ordination of movements, regulation of posture and balance, important in primitive reflexes in small infants
What are the primitive reflexes seen when examining infants?
Moro reflex = extension of neck, abduction and then adduction of arms - develops between 28-32 weeks gestations, and should disappear between 3-6 months
Standing reflex = extension of the lower extremeties, hips slightly flexed and behind the shoulder, head free to turn - present in the newborn and at 3 months
Grasp reflex = fingers grasp tightly to objects placed into their palms
Opening of fingers due to stroking on the (pinky finger) side of their hand
Parachute reflexes = outstretched arms when tilted upside down - this protective reflex develops between 6-9 months
Side-ways parachute reflex = same as above but when child is tilted sideways rather than forwards
What is the significance of primitive reflexes?
Develops 28-30 weeks gestation
Disappear 3-6 months (Moro)
6-9 months (grasp)
Persistence of these reflexes can demonstrate impaired development
What is developement?
Global impression of a child encompassing growth in understanding, acquisition of new skills
Normal development endows a child with increasingly complex skills in order to function in society
Who knows about children’s development?
Parents
Doctors
Nursery nurses
Teachers
When is development assessed?
Opportunistically
Planned programme of reviews
What are the 4 domains of child developement?
Gross motor skills = Position Head lag Sitting Walking Running
Fine motor skills = Use of hands Grasp and fine pincer Bricks Crayon Puzzles
Speech and language = Vocalisation Words Understanding Imaginative play
Social skills = Social interaction Stranger reaction Eating skills Dressing
What do you first look at when assessing a newborn?
gross motor
See how the baby is positioned
As a newborn they will have a limited, flexed, and symmetrical posture when laying down
When they are lifted up, they have a marked lag of the head due to lack of neck muscle maturity
What is the positioning of the baby by 6-8 weeks postnatally?
(gross motor)
Better head control compared to newborn baby
Raises head to 45 degrees in prone
What is the positioning of the baby by 6-8 months postnatally?
(gross motor)
Sits without support
At 6 months: with round back, good baseline posture
At 8 months: with straight back
What can a baby do at around 3-5 months? (gross motor)
Babies begin to roll independently - from lying on their back to lying on their front
Can pull themselves up and have outstretched arms when lying on their front
What can a baby do at around 8-9 months? (gross motor)
Crawl
What can a baby do at around 10 months? (gross motor)
Cruise around furniture - pull themselves up onto furniture
Good time to counsel parents on the need of safety around the home as their child’s mobility is increasing rapidly around this stage
What can a baby do at 12 months? (gross motor)
Walk unsteadily, broad gait with hands apart
What can a baby do at 15 months? (gross motor)
Walk steadily - more steady gait
What is important to note regarding motor development?
Many variations of normal e.g. sitting to all four crawl to walk OR bottom-shuffling before walking OR commando crawling before walking
What are the gross motor milestones?
Newborn =
See how the baby is positioned
As a newborn they will have a limited, flexed, and symmetrical posture when laying down
When they are lifted up, they have a marked lag of the head due to lack of neck muscle maturity
6-8 weeks =
Better head control compared to newborn baby
Raises head to 45 degrees in prone
3-5 months =
Babies begin to roll independently - from lying on their back to lying on their front
Can pull themselves up and have outstretched arms when lying on their front
6-8 months =
Sits without support
At 6 months: with round back, good baseline posture
At 8 months: with straight back
8-9 months =
Crawl
10 months =
Cruise around furniture - pull themselves up onto furniture
Good time to counsel parents on the need of safety around the home as their child’s mobility is increasing rapidly around this stage
12 months =
Walk unsteadily, broad gait with hands apart
What are the vision and fine motor milestones?
6 weeks =
Follow moving objects or face by turning head - track for 180 degrees
4 months =
Reach out for toys
4-6 months =
Palmar grasp
Thumb and fingers grasp as one piece
‘Inferior grasp’ - use of the whole hand to grasp an object
7 months =
Transfer of objects from one hand to the other
10 months =
Hold object between thumb and index finger
‘Mature pincer grip’
16-18 months =
Make marks with a crayon – infant can copy what is being drawn by an adult (i.e. line, circle, cross, square, triangle)
14 months – 4 years =
Improve in sophisticated use of their hands and brain - tested using building blocks e.g. at 18 months, tower of 3, by 4 years, more complex towers by following steps
2-5 years =
Ability to draw without seeing how it is done
Progresses from Line –> Triangle
Can draw after seeing it done 6 months earlier
What can a baby do at 6 weeks? (vision and fine motor)
Follow moving objects or face by turning head - track for 180 degrees
What can a baby do at 4 months? (vision and fine motor)
Reach out for toys
What can a baby do at 4-6 months? (vision and fine motor)
Palmar grasp
Thumb and fingers grasp as one piece
‘Inferior grasp’ - use of the whole hand to grasp an object
What can a baby do at 7 months? (vision and fine motor)
Transfer of objects from one hand to the other
What can a baby do at 10 months? (vision and fine motor)
Hold object between thumb and index finger
‘Mature pincer grip’
What can a baby do at 16-18 months? (vision and fine motor)
Make marks with a crayon
In what does a child progressively improve at inbetween 14 months and 4 years?
(vision and fine motor)
Improve in sophisticated use of their hands and brain - tested using building blocks e.g. at 18 months, tower of 3, by 4 years, more complex towers by following steps
In what does a child progressively improve at inbetween 2-5 years? (vision and fine motor)
Ability to draw without seeing how it is done
Progresses from Line –> Triangle
Can draw after seeing it done 6 months earlier
What are the hearing, speech and language development milestones?
Newborn =
Responds to startling noises
3-4 months =
Vocalise alone or when spoken to, responds to coos and laughs
7 months =
Turns to soft sounds out sight
Sounds used indiscriminately
Hearing distraction test carried out at this age
7-10 months =
Begin to speak polysyllabic babble (sounds at different tones, qualities and volumes)
At 7 months: sounds used indiscrimately
At 10 months: sounds used discriminately to parents
- Babbles of children with hearing impairment = more monotone
12 months =
2-3 words such as ‘dada’ and ‘mama’
18 months =
6-10 words
Show parts of body e.g. where is your nose and then points
20-24 months =
Uses two or more words to make simple phrases
2.5-3 years =
Talks constantly in 3-4 word sentences
At 3 years =
- Normal development of 3 year old = few word sentences
- In a 3 year old child with autism = disordered speech and language development, no words, babble
What is apparent in a newborn? (hearing, speech and language)
Responds to startling noises
What can a baby do at 3-4 months? (hearing, speech and language)
Vocalise alone or when spoken to, responds to coos and laughs
What can a baby do at 7 months? (hearing, speech and language)
Turns to soft sounds out sight
Sounds used indiscriminately
Hearing distraction test carried out at this age
What can a baby do at 7-10 months? (hearing, speech and language)
Begin to speak at 7-10 months - pol-syllabic babble (sounds at different tones, qualities and volumes)
At 7 months: sounds used indiscrimately
At 10 months: sounds used discriminately to parents
How does babble differ between a health child and those with hearing impairments?
Babbles of children with hearing impairment = more monotone
What can a baby do at 12 months? (hearing, speech and language)
2-3 words such as ‘dada’ and ‘mama’
What can a baby do at 18 months? (hearing, speech and language)
6-10 words
Show parts of body e.g. where is your nose and then points
What can a baby do at 20-24 months? (hearing, speech and language)
Uses two or more words to make simple phrases
What can a baby do at 2.5-3 years? (hearing, speech and language)
Talks constantly in 3-4 word sentences
How can speech differ between a healthy 3 year old and a child with autism at 3 years old?
Disordered speech and language development
No words
Babble
What are the social, emotional and behavioural milestones?
• 6-8 weeks = Smiles responsively • 6-8 months = Start of self-feeding Puts food in mouth • 10-12 months = Waves bye-bye Plays peek a boo • 12 months = Drink from a cup with 2 hands Often the age at which parents are encouraged to get rid of the bottle to minimise delay in speech and language due to prolonged bottle usage - Prolonged bottle usage = dental caries, delayed speech • 18 months = Hold spoon and gets food safely to mouth, even if food gets splayed on the floor • 18-24 months = Good imaginative play • 2 years = Toilet training Dry by day Pulls off some clothing • 2.5-3 years = Parallel play Interactive play evolving Takes turns Clean and dry
Development patterns
Normal development changes as children get older
- Wide range of normal - particularly as you get older
Abnormal development patterns =
- Slow but steady
- Plateau - stopping of milestones
- Regression - reversible of milestones, early sign of serious illness e.g. neurodevelopmental regeneration
What can a baby do at 18 months? (social, emotional and behavioural)
Hold spoon and gets food safely to mouth, even if food gets splayed on the floor
What can a baby do at 18-24 months? (social, emotional and behavioural)
Good imaginative play
What can a baby do at 6-8 weeks? (social, emotional and behavioural)
Smiles responsively
What can a baby do at 6-8 months? (social, emotional and behavioural)
Start of self-feeding
Puts food in mouth
What can a baby do at 10-12 months? (social, emotional and behavioural)
Waves bye-bye
Plays peek a boo
What can a baby do at 12 months? (social, emotional and behavioural)
Drink from a cup with 2 hands
Often the age at which parents are encouraged to get rid of the bottle to minimise delay in speech and language due to prolonged bottle usage
What can prolonged bottle usage cause?
Dental caries
Delayed speech
What can a baby do at 2 years? (social, emotional and behavioural)
Toilet training
Dry by day
Pulls off some clothing
What can a baby do at 2.5-3 years? (social, emotional and behavioural)
Parallel play
Interactive play evolving
Takes turns
Clean and dry
How does normal development change as children get older?
Wide range of normal - particularly as you get older
What are patterns of abnormal developement?
Slow but steady
Plateau - stopping of milestones
Regression - reversible of milestones, early sign of serious illness e.g. neurodevelopmental regeneration
What are limit ages?
Warning for parents and health professionals of when a child has not reached particular milestones
e.g. head control by latest 4 months or sitting unsupported by latest 9 months or standing independently at 9 months or walking independently at 18 months
Give examples of abnormal motor development at 1.5-2 months that may suggest cerebral palsy?
Normally baby can push up on arms and lift their head when in the prone position (on their tummy)
BUT in abnormal motor development - Unable to lift head or push up on arms Stiff extended legs Pushing back with head Constantly fisted hand and stiff leg on one side Difficulty moving out of this position?
Give examples of abnormal motor development at 3-6 months suggestive of disinhibition of motor neurons to the lower limbs and possible early cerebral palsy?
Normally baby sits with support, with a rounded back
BUT in abnormal motor development - Unable to lift head Floppy trunk Stiff arms Extended legs Or stiff crossed legs = excess tone in the lower limbs Arms flexed and held back
Give examples of abnormal motor development 6-9 months that may suggest developmental delay or cerebral palsy?
Normally baby sits on their own, and arms are free to reach out and grasp
BUT in abnormal motor development - Poor head control Difficulty getting arms forward Arches back Pointed toes, stiff legs Will not take weight on legs Poor use of arms for play
Give examples of abnormal motor development 9-13 months that may suggest developmental delay or cerebral palsy?
Normally a baby can pull to stand
BUT in abnormal motor development - Not interested in weight bearing Difficulty in pulling to stand Stiff elgs Cannot crawl on hands an knees Uses one side of body to move
Give examples of abnormal motor development 12-18 months that may suggest developmental delay or cerebral palsy?
Normally a baby can stand and walk independently at this stage
BUT in abnormal motor development - Holds arms or both arms stiffly and bent Excessive tiptoe gait due to excess motor activity that is not inhibited by corticospinal neurons Sits with weight to one side Uses predominantly one hand for play One leg may be stiff
For vision and fine motor development, which milestones are a cause for worry?
If the baby is not:
- Fixing and following visually by 3 months
- Reaching for objects by 6 months
- Transferring objects by 9 months
- Pincer gripping by 12 months
For speech and language development development, which milestones are a cause for worry?
If the baby is not:
- Saying polysyllabic babble by 7 months
- Constant babble by 10 months
- Saying 6 words with meaning by 18 months
- Joins words by 2 years
- 3-word sentences by 2.5 years
For social, emotional and behavioural development development, which milestones are a cause for worry?
If the baby is not:
- Smiling by 8 weeks
- Scared / fearing strangers by 10 months
- Feeding self with a spoon by 18 months
- Symbolic playing by 2-2.5 years
- Interactive playing by 3-3.5 years
What is the Healthy Child Programme?
A planned programmed of review composed of 3 components:
- Screening
- General examination and immunisation
- Health education and promotion
When does screening occur?
Throughout pregnancy:
- <12 weeks = Hbopathy, rehsus. infection
- 12 weeks = USS dating and nuchal (down syndrome)
- USS detailed - heart defects, kidney defects, brain defects
- At birth = bloodspot, hearing and physical)
When does immunisation occur?
Flu jab for the mother
Soon after delivery, at 10-14 days, many vaccinations are given during the child’s first year of life
When are there child health reviews?
Birth visit 10-14 day visit 6-8 week reviews First year reviews Two year review Health review at school
When and what health promotion activity is given?
During the early years of the child's life - usually at each health review discussing things like: Relationships Breast feeding Vaccination Reading Weaning Social and emotional Injury prevention Learning Physical activity Nutrition
What health promotion activity is given during the late years?
Healthy weight
Sexual health
Encourage physical activity
What are the categories of causes of development impairment?
Prenatal
Perinatal
Postnatal
What is done when evaluating a child with abnormal development?
History
- parental concern
- birth history
- family history
PMHx
- developmental history
- current skills
Examination
- developmental assessment (general and neurological) e.g. dismorphic fet=atures, skin issues,
- further as required
Investgation
- as appropriate
What is the approach to developmental assessment?
Ask
Observe
Task
What needs to be assessed in a developmental assessment?
- Milestones proceeding age
- Expected milestones for their age
- Next important milestones - alert parent of future milestones
What factors influence developmental delay?
Ill health e.g. ear infections affecting speech
Lack of physical/physiological stimuli
Reduce inherent potential
Sensory/motor impairment
What are the types of developmental delay?
Global - delay in all 4 domains OR Specific - Langauge - Motor - Sensory - Cognitive
What are some causes of global delay?
Chromosomal abnormalities e.g. Down’s Syndrome, Fragile X
Metabolic
e.g. hypothyroidism, inborn errors of metabolism
Antenatal and perinatal factors
e.g. infections, drugs, toxins, anoxia, trauma, folate def
Environmental-social issues
Chronic illness
What are causes of motor delay?
Cerebral palsy - e.g. corticospinal injury Down's Syndrome Congenital dislocation hip Social deprivation Muscular dystrophy Neural tube e.g. spina bifida Hydrocephalus
What causes language delay?
Hearing loss
Learning disability
Autistic spectrum disorder
Lack of stimulation
Impaired comprehension of language - developmental dysphagia
Impaired speech production - stammer, dysarthria
What are some commonly used assessment tool?
Standardised tests Schedule of growing skills Griffiths developmental scale Bailey developmental scale Denver developmental screening tests
