Growth, Development and Health

Question 1

What are the recognised phases of childhood?

Answer 1

Neonate - < 4 weeks 
Infant - < 12 months/1 year
Toddler - around 1-2 years
Pre-school - around 2-5 years
School age
Teenager/adolescent

Question 2

Main childhood objectives

Answer 2

To grow
To develop and achieve their potential 
To attain optimal health 
To develop independence
To be safe 
To be cared for 
To be involved

Question 3

Features of development

Answer 3

Gaining functional skills throughout childhood
Gradual but rapid process
Typically from birth to 5 years (but brain develops in utero)
Fairly consistent pattern but rate will vary
Cell growth, migration, connection, pruning and myelination
Sequence of events in each domain
School - cognitive and though development, early skills become more refined

Question 4

Key developmental fields

Answer 4

Gross motor
Fine motor
Social and self-help 
Speech and language 
Hearing and vision

Question 5

Key milestones

Answer 5

Achievement of key development skills

Social smile, sitting, walking, first words

Question 6

When do you refer a child for concerns about milestones?

Answer 6

If not achieved by age limit - 2 standard deviations from the mean

Question 7

For how long do you correct for prematurity?

Answer 7

Until 2 years

Question 8

What is the median age for walking?

Answer 8

12 months - 50% by this age

Question 9

When do you refer a child who is not walking?

Answer 9

If not walking by 18 months

Question 10

Why is development important?

Answer 10

Learning functional skills for later life
Hone skills in a safe environment
Allow brain’s genetic potential to be fully realised
Equip us with tools needed to function as older children and adults
Many are completely automatic

Question 11

Influencing factors of development

Answer 11

Genetics

• family
• race
• gender

Environment
- use of technology very early on tends to have adverse effect on development

Positive early childhood experience

Developing brain vulnerable to insults

• antenatal
• postnatal
• abuse and neglect

Question 12

Adverse environmental factors

Answer 12

Antenatal

• infections e.g. CMV, rubella, VZV
• toxins e.g. maternal smoking/drinking/drugs

Postnatal

• infection e.g. meningitis, encephalitis
• toxins e.g. solvents, mercury
• trauma e.g. head injuries
• malnutrition e.g. iron, folate, vitamin D
• metabolic e.g. hypoglycaemia, hyper/hyponatraemia
• maltreatment/under-stimulation/domestic violence
• maternal mental health issues

Question 13

Why do you assess development?

Answer 13

Reassurance and showing progress
Early diagnosis and intervention
Discuss positive stimulation/parenting strategies
Provision of information
Improving outcomes (pre-school years critical)
Genetic counselling
Co-existent health issues

Question 14

Who assesses development?

Answer 14

Patients

• Child surveillance vs developmental screening vs developmental assessment
• Specific groups e.g. premature, syndromes, events

Assessors

• Parents and wider family
• Health visitors, nursery, teachers
• GPs, A&E, FYs, STs, students
• Paediatricians and community paediatricians

Question 15

What are the features/components of assessing development?

Answer 15

Health Child Programme (HCP) UK
Screening may not always be sensitive/specific
Listen to parental concerns/videos on phone
Opportunistic questions - target the right area
Review the red book
Good observation of play and activity
Medical history and examination
Most common mistake is not thinking about it

Question 16

How do we assess development?

Answer 16

Building blocks - grasping, moving, building
Crayons - just holding, holding and moving, deliberately drawing
Balls - central core stability then throwing then kicking
Tea sets - imaginary play
Colouring books - identify colours, language assessment

Question 17

How do you decide what is normal in development?

Answer 17

Not always easy
Think about each developmental field - deficiency may predominantly affect one area
What sequence/pattern has come before?
What skills have been achieved?
What has not yet been achieved?
Is one field falling behind the other e.g. global delay vs specific developmental delay
Are the skills gained age-appropriate?

Question 18

What do you need to consider to recognise normal variation?

Answer 18

Early developers
Late normal 
Bottom shufflers - walking delay 
Bilingual families - apparent language delay 
Familial traits

Question 19

What are the red flags for development?

Answer 19

Loss of developmental skills or plateau of development
Parental/professional concern re vision - simultaneous referral to paediatric ophthalmology
Hearing loss - simultaneous referral for audiology/ENT
Persistent low muscle tone/floppiness
No speech by 18 months, especially if no other communication - simultaneous referral for urgent hearing test
Asymmetry of movements/increased muscle tone
Not walking by 18 months/persistent toe walking
OFC > 99.6th or < 0.4th/crossed two centiles/disproportional to parental OFC
Clinical uncertainty/think development may be disordered

Question 20

What does child health screening provide an overview of?

Answer 20

Health and development

Question 21

What are the child health screening programmes?

Answer 21

UK Healthy Child Programme

Child Health Programme (Scotland) based on HAL4

Question 22

Where is child health screening based?

Answer 22

Primary care - GP, health visitor, midwife

Question 23

What are the main components of child health screening?

Answer 23

Health promotion
Developmental screening (including hearing)
Immunisation

Parental/carer observations and concerns are crucial
Record, advise and refer as appropriate

Question 24

Where is the progress of development recorded?

Answer 24

In red book

Question 25

What does the child health programme include screening for?

Answer 25

``` PKU Congenital hypothyroidism CF Medium chain acyl-CoA dehydrogenase deficiency Sickle cell disorder ```

Question 26

Components of child health programme

Answer 26

``` Newborn exam and blood spot screening Newborn hearing screening (by day 28) Health visitor in first week 6-8 week review (max 12 weeks) 27-30 month review (max 32 months) Orthoptist vision screening (4-5 years) If needed - unscheduled review, recall review ```

Question 27

Components of 6-8 week review (GP and health visitor)

Answer 27

Identification data - name, address, GP Feeding - breast/bottle/both Parental concerns - appearance, hearing, eyes, sleeping, movement, illness, crying, weight Development - gross motor, hearing and communication, vision and social awareness Measurements - weight, OFC, length Examination - heart, hips, testes, genitalia, femoral pulses and eyes (red reflex) Sleeping position - supine, prone, side

Question 28

Components of 27-30 month review (GP and health visitor)

Answer 28

``` Identification data (name, address, GP) Development - Social, behavioural, attention and emotional - Communication, speech and language - Gross and fine motor - Vision, hearing Physical measurements (height and weight) Diagnoses/other issues ```

Question 29

Components of healthy child programme

Answer 29

Antenatal Birth-1 week - feeding, hearing, examination, vitamin K, immunisations, blood spot 2 weeks - feeding, maternal mental health, jaundice, SIDS 6-8 weeks - examination, immunisations, measurements, maternal mental health 1 year - growth, health promotion, questions 2-2.5 years - development, concerns, language 5 years - immunisations, dental, support, hearing, vision, development

Question 30

Components of health promotion

Answer 30

``` Smoking Alcohol/drugs Nutrition Hazards and safety Dental health Support services Additional input during immunisations/as issues are identified ```

Question 31

Why and who do we immunise?

Answer 31

Highly effective public health measure Reduction and eradication of diseases All children (additional if "at risk") Chronological age i.e. don't correct premature No live vaccines e.g. MMR if child is immunocompromised (except HIV) Egg allergy is not a contraindication to MMR Postponed if unwell - fever, systemic symptoms

Question 32

Components of history taking of immunisations

Answer 32

Frequently updated Different schedules in different countries Older children may not have been immunised against the current list Check with the parents and red book (but they may just say they're up-to-date) Mild temperature, discomfort, swelling - common Anaphylaxis - rare No link with autism

Question 33

What are the 3 key parameters of physical measurements?

Answer 33

Weight - grams and kg Length (cm) or height if > 2 years Head circumference in cm

Question 34

Physical measurements that are not routine but may be done

Answer 34

``` Weight for age Length (or height) for age BMI in kg/m^2 Weight for length Rate of weight gain in g/kg/day - infants only ```

Question 35

What is the average weight, length and OFC at birth?

Answer 35

3.3kg 50cm OFC 35cm

Question 36

What is the average weight and length at 4 months?

Answer 36

6.6kg | 60cm

Question 37

What is the average weight, length and OFC at 12 months?

Answer 37

10kg 75cm OFC 45cm

Question 38

What is the average weight and length at 3 years?

Answer 38

15kg | 95cm

Question 39

What is a centile?

Answer 39

% divisions of population sampled

Question 40

What is failure to thrive?

Answer 40

Child growing too slowly in form and usually function at the expected rate for his or her age Significantly low rate of weight gain - crossing centile spaces Not a diagnosis but description of pattern Means supply of energy/nutrients < demand for energy/nurients

Question 41

Causes of failure to thrive in early life due to deficient intake

Answer 41

Maternal - poor lactation - incorrectly prepared feeds - unusual milk or other feeds - inadequate care Infant - prematurity - small for dates - oro-palatal abnormalities - neuromuscular disease - genetic disorders

Question 42

Causes of FTT due to increased metabolic demands

Answer 42

``` Congenital lung disease Heart disease Liver disease Renal disease Infection Anaemia Inborn errors of metabolism Cystic fibrosis Thyroid disease Crohn's/IBD Malignancy ```

Question 43

Causes of FTT due to excessive nutrient loss

Answer 43

Gastro-oesophageal reflux Pyloric stenosis Gastroeneteritis (post-infectious phase) Malabsorption - Food allergy - Persistent diarrhoea - Coeliac disease - Pancreatic insufficiency - Short bowel syndrome

Question 44

Non-organic causes of FTT

Answer 44

Poverty/socio-economic status Dysfunctional family interactions (especially maternal depression or drug use) Difficult parent-child interactions Lack of parental support e.g. no friends, no extended family Lack of preparation for parenting/education Child neglect Emotional deprivation syndrome Poor feeding or feeding skills disorder Feeding disorders e.g. anorexia, bulimia in later years