Reproduction 5 - Child Growth & Development Flashcards
1
Q
What do centile charts measure?
A
- Height
- Weight
- Head circumference (measures brain development)
- BMI
2
Q
How are centile charts used?
A
- Plot the age against height
- 50% of children shorter than 50th centile, and 25% shorter than 25th centile
- Different for boys and girls
3
Q
How are children measured accurately?
A
- Equipment should be accurate and maintained properly
- Position the child properly
- Make sure you take shoes off and hair out of the way
- Calculate age and plot correctly
- Measured lying down before the child is old enough to stand
4
Q
How is child height monitored?
A
- Centile charts look at cumulative height
- Height velocity is how fast a child is growing in cm per year (height now-height last visit / age now-age last visit)
- Consider growth of parents and siblings
5
Q
List influences of normal child growth
A
- Events before birth- poor fetal growth, low birth weight, prematurity
- Medical issues in childhood- malnutrition, chronic disease, endocrine problems including growth hormone deficiency
- Genetic factors- the height of the family and any inherited disorders of growth.
- Randomness. (Not every child of the same parents will be the same adult height, and tall parents can occasionally have a short child. There are multiple genes which determine adult height, and these are randomly distributed at conception.)
6
Q
How do children grow?
A
- Fastest phase in the first 2 years (first year 23-25cm)
- Most children move to a centile position at this age and then stick with it
- Movement up or down centiles is then unusual (pattern is the most important thing)
- Phase of fast growth at puberty - pubertal growth spurt
- Timing of this depends on the age at which the child enters puberty
- Skeleton matures as the child grows. At the end of puberty, the epiphyses fuse and growth stops
- Late puberty can result in falling behind in height
- In childhood nutrition has less impact
7
Q
Describe the hormonal control of growth and growth hormone secretion
A
- GH is the more important hormonal factor
- Controlled by GNRH from the hypothalamus, and somatostatin which suppresses it
- Released as pulses mostly overnight
- GH has growth effect itself and also stimulates release of IGF1 (insulin like growth factor 1)
- IGF1 stimulates growth in all tissues of the body, and exerts negative feedback
- Influenced by nutrition, sleep, exercise and stress
8
Q
List causes of short stature
A
- Pubertal and growth delay
- IUGR/SGA
- Chronic disease (causing inflammation)
- Endocrine causes - GH deficiency, thyroid hormone deficiency, steroid excess
- Genetic disorders (achondroplasia, turner, downs syndrome)
- Psychological distress and neglect
- If a normal pattern, there may not be a medical problem - eg. short parents)
9
Q
List causes of tall stature
A
- Marfan or Soto sydrome
- Tall parents
- GH excess from a pituitary tumour (rare)
- Children with precocious puberty will be tall children, but short adults as growth stops early
10
Q
How are short children treated?
A
- If confirmed GH deficiency they will receive treatment
- Treatment for other bone growth disorders
- However, short normal children receive no treatment as it is not worth the time and expense
11
Q
How is obesity defined?
A
- For adults BMI of over 25 kg/m2 is overweight and over 30 kg/m2 is obese.
- Children have lower BMI than adults and this changes with age so these figures do not apply, therefore obesity is assessed on the BMI centile position.
12
Q
Describe incidence of obesity worldwide
A
- Rates of obesity and overweight have increased but may not continue to go up at the same rate for the future
- There are some nations who have a much higher rate of obesity than others. In some areas of the world obesity is a feature of poverty and in others associated with affluence.
- Some ethnic groups have less “tolerance” of obesity and are more likely to get complications like type 2 diabetes at a lower BMI
- 2/3 adults, 1/4 2-10 year olds, 1/3 11-15 year olds
13
Q
What are the complications of obesity?
A
- Barker hypothesis (risk of death higher in very underweight or very overweight individuals)
- Type 2 diabetes
- PCOS
- Cardiovascular disease (high cholesterol, high blood pressure)
- Breathing difficulties
- Bone and joint problems
- Some cancers
- Orpthopaedic problems
- Emotional and behavioural (stigmatism, bullying, low self-esteem)
14
Q
Why does obesity happen?
A
- Balance of food versus energy expenditure
- Hunger is regulated by the hypothalamus (eg. leptin, POMC, PC-1, MC4R). Small number of people have gene mutations affecting these hormones/ receptors.
- Some gene variants (eg. FTO gene) affect eating behaviour and appetite, and can make an individual eat in a way more likely to gain weight)
15
Q
Describe history taken in children
A
- Antenatal – illnesses/infections; medications; drugs; environmental exposures
- Birth – Prematurity, Prolonged/complicated labour
- Postnatal – illnesses/infections; Trauma
- Consanguinity – increases chances of chromosomal or autosomal recessive conditions
- Developmental milestones from parent
16
Q
Describe examinations taken to monitor child development
A
- Growth parameters (height, weight and head circumference)
- Dysmorphic features
- Neurological examination and skin
- Systems examination to identify associations, syndromes
- Standardised developmental assessment – Schedule of growing skills II, bailey developmental scale, denver
17
Q
How are abnormalities in child development monitored?
A
Depends on suspected cause but may include
- Cytogenetic studies
- Metabolic screen (thyroid, renal, liver and bone profiles)
- Blood ammonia and lactate
- Urine and blood organic and amino acids
- Creatine kinase
- Imaging – CT, MRI
- EEG
- Nerve and muscle biopsy
- Referral to other members of the MDT
18
Q
What is cerebral palsy?
A
- Disorder of movement and posture arising from a non-progressive lesion of the brain acquired before the age of 2 years.
- Affecting corticospinal pathways - flexor contraction overcomes extensor movement
- Incidence 1-2 per 1000 live births
- Most causes (~80%) are antenatal
- Presentation may evolve and vary with age
19
Q
List associated problems with cerebral palsy
A
- Learning difficulties
- Epilepsy
- Visual impairment
- Hearing loss
- Feeding difficulties
- Poor growth
- Respiratory problems.
20
Q
How are children with cerebral palsy managed?
A
- Minimise spasticity and manage associated problems
- Dietitian
- Specialist health visitor (advice for parents, advocate)
- Paediatritian (Assessment, diagnosis, medial management
- Psychologist (monitor cognitive function, behavioural testing, educational advice)
- Speech and language therapist (feeding, language and speech development)
- Physiotherapist (balance and mobillity)
- Occupational therapist (hand eye coordination, housing adaptations)
21
Q
What is autism spectrum disorder?
A
- Prevalence is 3-6 per 1000 live births
- Boys>girls
- Usually presents between 2 – 4 years of age
- Features include impaired social interaction; speech and language disorder; and imposition of routines with ritualistic and repetitive behaviour.
22
Q
What are the comorbidities of autism?
A
- Learning and attention difficulties
- Epilepsy
23
Q
How is autism managed?
A
Intensive support for the child and family
24
Q
List diagnositc criteria for attention deficit hyperactivity disorder
A
- Inattention
- Hyperactivity
- Impulsivity
- Lasting > 6 months
- Commencing < 7 years and inconsistent with the child’s developmental level
- These features should be present in more than one setting, and cause significant social or school impairment.
25
What are children with ADHD at risk of?
- Conduct disorder
- Anxiety disorder
- Aggression (increased incidence of criminal behaviour)
- Increased risk of substance abuse
- Antisocial personality
26
List risk factors for ADHD
- Boys > girls 4:1
- Learning difficultires and developmental delay (prefrontal cortex - dopamine)
- Neurological disorder (epilepsy, cerebral palsy, first degree relative with ADHD, family member with depression, learning disability)
27
How is ADHD managed?
- Psychotherapy – Behavioural therapies
- Family therapy
- Drugs – If behavioural therapy alone insufficient; stimulants, e.g. methylphenidate (Ritalin), amphetamines (dexamphetamine)
- Diet – Some children benefit noticeably from exclusion of certain foods from their diet, e.g. red food colouring
28
What is the prevalence of learning difficulty?
- Prevalence of moderate learning difficulty is 30 per 1000 children
- 20% of children have special educational needs, 2% severe disability
- Prevalence of severe learning difficulty is 4 per 1000 children
(Mild, moderate, severe or profound)
29
List causes of learning disability
- 25% of children with severe learning disability have no identifiable cause
- Chromosome disorders (30%)
- Other identifiable syndromes (20%)
- Postnatal cerebral insults (20%)
- Metabolic or degenerative diseases (1%)
30
How does learning disability present?
- Reduced intellectual funcitoning
- Delay in early milestones
- Dysmorphic features
- Associated problems (epilepsy, sensory impairment, ADHD)
31
How are learning disabilities managed?
Involves establishing a diagnosis and input from the multidisciplinary team with long term follow up
32
Define normal development
The global impression of a child which encompasses growth, increase in understanding, acquisition of new skills and more sophisticated responses and behaviour. It serves to endow the child with increasingly complex skills in order to function in society.
33
What are the four domains of development?
- Gross motor and posture (the way we move)
- Fine motor and vision (use of hands)
- Language and hearing
- Social, emotional and behaviour (social interaction, eating skills, dressing)
34
What are limit ages in development?
The age by which developmental processes should have been achieved, 2SDs from the mean age
35
What is abnormal development?
- Slow acquisition of skills (slow but steady, plateau or regression)
- Large normal range of developmental stages
- May occur in more than one domain
- Biological factors such as folate deficiency impact
36
How do children present with developmental concerns?
- Identification of antenatal or postnatal risk factors
- Developmental screening
- Concerns raised by parents or other healthcare professonals
- Present at any age
37
Why is growth measured?
- Poor growth in infancy is associated with high childhood morbidity and mortality.
- Growth is best indicator of health
- Demonstration of normality of growth by age and stage of puberty
- Identify disorders of growth
- Assess obesity
38
What can be learnt from head circumference?
- Brain growth
| - Hydrocephalus
39
When is the fastest phase of growth?
- Antenatally
| - Maternal health and placenta are important factors
40
What is bone age?
- Stage of bone development
- Cartilagenous, growth plates ossify
- Look at the maturation of the growth plates
41
When is growth stopped?
- Bones mature and epiphyses fuse at the end of puberty
| - Final part of growth occurs in the spine, final epiphyses to fuse are in the pelvis
42
What is done if a child has a single short measurement of height?
Identify
- Birth history and weight
- Parental heights (mid parental centile, shift curve down)
- Medical history
- Previous measurements
43
What tests are performed if a child is short and falling from a centile?
- Full blood count
- CRP
- Serum iron
- Liver and kidney function
- Thyroid function
- Coeliac screen
- IGF1
- Bone age
- Pituitary function/ MRI
44
List causes of abnormal growth despite normal hormones
- Turner syndrome
- Down syndrome
- Skeletal dysplasia (measure full and sitting height to find leg length)
- Significant illnesses can interefere (inflammation, poor nutrition and drugs eg. steroids)
45
List chronic paediatric diseases that can affect growth
- Asthma
- Sickle cell
- Juvenile chronic arthritis
- Inflammatory bowel disease (crohns disease, coeliac disease)
- Cystic fibrosis
- Renal failure
- Congenital heart disease
46
List common problems in children
- Delayed walker
- Clumsy
- Delayed speech and language (Wernickes and Brochas)
- Odd social interaction - ASD/Aspergers
- Sleep onset/ frequent night walking, eating and toileting
- Hyperactivity
47
List the factors influencing developmental delay
- Lack of physical/ psychological stimuli
- Ill health
- Sensory/motor impairment
- Reduced inherent potential
48
List types of developmental delay
- Global
| - Specific (language, motor, sensory or cognitive)
49
List causes of global developmental delay
- Chromosomal abnormalities (e.g. Down’s syndrome, Fragile X)
- Metabolic (e.g. hypothyroidism, inborn errors of metabolism)
- Antenatal and perinatal factors (Infections, drugs, toxins, anoxia, trauma, folate deficiency)
- Environmental-social issues
- Chronic illness
50
List causes of motor delay
- Cerebral palsy
- Global delay eg Down’s syndrome
- Congenital dislocation of the hip
- Social deprivation
- Muscular dystrophy- Duchenne’s
- Neural tube defects: spina bifida
- Hydrocephalus
51
List causes of language delay
```
Hearing loss
Learning disability
- Autistic spectrum disorder
- Lack of stimulation
- Impaired comprehension of language
- Developmental dysphasia
- Impaired speech production (stammer, dysarthria)
```
52
What are the objectives of management?
- Maximise mobility
- Minimise discomfort
- Promote speech and language
- Promote social and emotional health
53
List members in child development services and describe their role
- Specialist health visitor (helps coordinate multidisciplinary and multi-agency care, advice on development of play or local authority schemes E.g. portage)
- Paediatrician (Assessment, investigation and diagnosis, continuing medical management, coordination of input from therapists and other agencies – health, social services, education)
- Occupational therapist (eye-hand coordination, ADL (activities of daily living) – feeding, washing, toileting, dressing, writing, seating, house adaptations)
- Physiotherapist (balance and mobility, postural maintenance, prevention of joint contractures, spinal deformity, mobility aids, orthoses)
- SALT (feeding, language and speech development, augmentive and alternative communication aids Eg. Makaton)
- Dietician (feeding and nutrition advice)
- Social worker/ social services (advice on benefits, disability, motility, housing, day nursery placements, advocate for child and family)
54
List antenatal causes of damage to brain development
- Infectious agents (toxoplasmosis, syphilis HIV or HepC, Rubella, Cytomegalovirus and Herpes)
- Hormones (androgenic agents, DES, maternal diabetes, maternal obesity)
- Drugs (valproic acid and alcohol)
55
List postnatal causes of damage to brain development
- Infections
- Metabolic disorders
- Toxins
- Trauma
- Domestic violence
- Malnutrition
- Maternal mental health disorders
56
Define median age
The age at which half of the standard population achieve each milestone
57
List the developmental milestones in gross motor performance
- New-born – limbs flexed in symmetrical posture, head lag on pulling up.
- 6-8 weeks – raises head to 45degrees in prone.
- 6-8 months – sits without support.
- 8-9 months – crawling.
- 10 months – cruising around furniture.
- 12 months – walks unsteadily.
- 15 months – walks steadily.
58
What are primitive reflexes?
- Protective and promote support balance and orientation
- Should disappear by 4-6 months
- Stepping, moro, grasp, asymmetric tonic reflex and rooting
59
List the developmental milestones in fine motor and vision
- Object permanence is attained at 9 months of age – the idea that when out if sight, not out of mind.
- 6 weeks – turns head to follow object.
- 4 months – reaches out to toys.
- 4-6 months – palmar grasp.
- 7 months – transfers between hands.
- 10 months – mature pincer grip.
- 16-18 months – marks with crayons.
- 14 months-4 years – towering.
- 2-5 years – ability to draw without seeing how it’s done (after seeing it can be done 6m earlier
60
List the developmental milestones in language and hearing
- New born – startles.
- 3-4 months – vocalises alone or when spoken to.
- 7 months – turns to soft sounds out of sight.
- 7-10 months – uses sound indiscriminately or discriminately.
- 12 months – two to three words other than dada or mama.
- 18 months – six to ten words.
- 20-24 months – makes simple phrases.
- 1.5-3 years – talk constantly in 3-4 word sentences
61
List developmental milestones in social, behaviour and play
- 6 weeks – smile responsively.
- 6-8 months – puts food in mouth.
- 10-12 months – wave bye, play peek-a-boo.
- 12 months – drink from cut with two hands.
- 18 months – can eat by themselves.
- 18-24 months – symbolic play.
- 2 years – potty trained.
- 2.5-3 years – parallel play.
62
List the limit ages
- Walking independently 18 months.
- Fixes and follows visually 3 months.
- Joins words 2 years.
- Symbolic play (the ability of children to use objects, actions or ideas to represent other objects, actions, or ideas as play. A child may push a block around the floor as a car or put it to his ear as a cell phone) 2-2.5 years.
63
Describe presentation of cerebral palsy
- Abnormal limb tone and delayed milestones.
- Feeding difficulties.
- Abnormal gait once walking achieved.
- Asymmetric hand function before 12 months.
- Primitive reflexes persist.
