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Chapter: Medicine Study Notes : Paediatrics

Child Development

Represents the interaction of heredity and the environment: o Heredity: potential of the child o Environment: extent to which potential is achieved.

Growth and Development


Child Development


·        Represents the interaction of heredity and the environment:

o   Heredity: potential of the child

o   Environment: extent to which potential is achieved.  Requires:

·        Physical needs: warmth, clothing, shelter, food, health, activity with rest

§  Psychological needs: security, personal identity, self-respect, independence, opportunity to learn, play, affection and care

·        Areas of child development:

o  Gross motor

o  Find motor

o  Language (expressive, receptive, non-verbal)

o  Social (interaction, play, self-care)

o  Cognitive: all of the above

·        Requirements for development (need all of them):

o  Hardware (neurons, muscles, etc)

o  Motivation (often driven by frustration – a child can‟t do what it wants to)

o  Nurturing environment

·        Types of assessment:

o  Developmental screening: point in time snapshot

o  Developmental surveillance: following over time

o  A formal assessment will yield a Developmental Quotient.  < 100 Þ delay.  100 Þ advanced.


Developmental assessment


·        Indirect assessment of the acquisition of life skills 

·        Establish rapport: use names a lot, „thanks for coming‟, etc ® more valid assessment

·        History:

o  Current development and time course of development

o  Order of questions should be: 

§  When asking about milestones, start with things he is likely to be able to do and work up. Get better rapport than starting at the upper limit and working down

§  Hearing: What things can he hear?

·        Have you been concerned about his hearing?

·        What makes you confident of that?

§  Vision: What small things does he see?

·        Have you been concerned?

·        What makes you confident of that? 

§  Gross motor: roll, sit, crawl, pull to stand, walk, run, scoot, pedal (progression: head ® trunk ® limbs) 

§  Fine motor: pincer, feeding self, spoon, drawing, blocks 

§  Expressive language: coo, babble, words with meaning, combinations (most common area of delay – usually focal not global) 

§  Receptive language: Responds to familiar voice, to own name, one or two step instruction, knows name, gender, address, prepositions, pronouns

§  Social: smile responsively, laugh, stranger aware, play with peers, name friend

§  Self care: manage cup, spoon, undress, toilet, dress, laces

o  Get history of influences on development:

§  Miscarriages, still births

§  Pregnancy: toxins, alcohol, infections

§  Birth: APGAR (usually means brain was vulnerable before birth), gestation, birthweight

§  Neonatal congential abnormalities, feeding, jaundice, infections

§  Early milestones (smiling, sitting, walking, first words)

§  Illness (eg CF, heart/renal disease, epilepsy)

§  Hearing (®speech delay), vision (® good verbal, poor motor)

§  Nutrition, constipation (especially if mobility problems)

§  Current development, especially social, self-care

§  Behaviour problems (sleep, tantrums)

§  Family stress

§  Family history, especially of development

o  History from other sources (eg kindy teacher)

o  Review previous rate of development: may get slowing before loss

o  Past Medical History: ABFWIMPS

·        Observation: Look systematically across each of the 6 areas.  Use toys as tools.

·        Examination:

o   On lap first (stranger shyness from 8 months)

o   Dysmorphism: eyes, head shape, body proportions

o   Height, weight, head circumference – plot them

o   Vision (do first, affects motor): following, hundreds and thousands

o   Localise to noise (do before language): if concerned then formal testing 

o   For each of gross motor, fine motor, expressive and receptive language, social and self care on the table below: 

§  Ask open-ended questions to establish the floor (eg I notice he‟s walking, what other clever things is he doing)

§  Then use closed questions to establish a ceiling (eg can he walk backwards, throw over arm) 

§  Then summarise: So he can ….. but is not yet …. Have I got that right?… Therefore he is at age X for that domain

o   Summary: age for each domain is X, Y, X.  Therefore, overall, he‟s developmentally around age

o   [Average for X, Y, Z]

o   Other:

§  Skin pigmentation (eg tuberous sclerosis – seen under Woods lamp)

§  Ears, eyes, heart, abdomen, puberty

§  Neurologic exam

§  Relationship with parents

·        Plan: for areas of weakness

o   If significant delay then early intervention 

o   If some delay then anticipatory guidance – „what could you do to help‟ – use Knowledge, attitudes/fears, practices, barriers framework

o   Always pitch safety advice at the level of gross motor skills


Development Chart: normal development from 0-60 months


·        Ref: Dr Russell Wills

·        Red flags:

o   Not smiling by 2 months

o   No eye contact by 3 months

o   Not reaching for objects by 5 months

o   Not sitting unaided by 9 months

o   Not walking unaided by 18 months

o   Not using words by 18 months

o   No 2 – 3 word sentences by 30/12 months


·        Older kids:

o   Gross motor: bike (can ride without trainer wheels at 5), sport (running, kicking), clumsiness

o   Fine motor: computer, play station 

o   Cognitive: don‟t ask if does OK at school – everyone does OK these days! Instead, does he do age appropriate work, need extra tuition, etc


Cognitive Development


·        Overall process: 

o   Autonomy: dependent on parents ® peers ® independent

o   Abstract thinking (what if?): concrete ® mature

o   Future consequences of present actions 

o   Gratification: immediate ® delayed

o   Satisfaction with body image 

o   Black and white ® comfort with shades of grey

·        Infancy (birth – 2 years): Developmental issues:

o   Later develop goal directed activity

o   Learn to distinguish between self and surroundings

o   Develop object permanence

o   Need secure attachment relationship with parents

o   Separation, individuation in toddler years 

o   At 2: trial and error problem solving, planned and purposeful play but limited content, egocentric, parallel play 

·        Preoperational (3 – 5 years):

o   Egocentric world view (I made it happen, so it‟s my fault) 

o   Use of magical thinking, difficulty distinguishing real from symbolic (if I wish it, it will come true)

o   Trial and error problem solving only

o   One aspect of a problem at a time

o   Cannot order a series of events 

o   Cause and effect thinking: I did X, then Y happened, therefore X ® Y

o   Imaginative play

o   Gradually move from parallel play to interactive play with peers

o   Separation and autonomy 

o   At 5: symbolic thought (imagination), classify by colour/shape, curiosity, magical thinking, social values, rules internalised but fixed, turn-taking, cooperative plan, other‟s perspective, increasing independence 

·        Concrete Operational (6 - 10 years):

o   Black and white thinking, right and wrong

o   Capable of simple logic and problem solving

o   Can order things in a chronological sequence

o   May have difficulties with multiple perspectives

o   Peer relationships increasingly important

o   Sharing games, competition

o   Analogy, metaphor, figures of speech being 

o   Able to concentrate for longer, delay gratification, predict personal and social consequences of actions, plan ahead

·        Formal Operations (10 – 13 years):

o   Better memory, concentration, forward planning

o   Social skills refined

o   Still concrete and literal (black/white, good/bad, right/wrong)

o   Limited abstraction: eg what if I didn‟t do this? (Contrary-to-fact abstraction) 

o   Dramatic changes to body ® constant comparisons and normal anxieties

o   Need to conform with peer norms

o   Difficult to take others perspective‟s

o   Difficult to understand complexity

o   Difficult to apply rules to own situation

o   Lack future orientation/forward thinking

o   Clear consequences

·        Middle Adolescence (14 – 16 years):

o  Developing abstract and complex thought

o  Beginning to see other‟s perspectives, starting to cope with shades of grey

o  Increased self consciousness

o  Easily swayed – not certain of own view

o  Still difficult to integrate conflicting ideas

o  Narcissistic (feels good/what I want ® therefore its right ® impulsiveness)

o  Less need to conform to peer norms, try alternative beliefs and philosophies

o  Need limits to be secure, limit testing

·        Late adolescence

o  Adult memory and concentration

o  Mature abstractions, problem-solving, self reflection and long range planning

o  Weigh up multiple information

o  See multiple meanings, complex relationships, different points of view, tolerant of shades of grey

o  Able to think hypothetically and plan for possible events

o  Remains more difficult to use new abilities in challenging situations

o  Autonomous: able to leave home and return for counsel, rely on own opinion


Developmental Delay


·        Constant slow development leads to widening gap 

·        Investigations: hearing, vision, chromosomes, DNA screen (eg Fragile X, Angelman, Prader-Willi), thyroid, metabolic, mucopolysaccharide screen, CK (Duchenne‟s), brain imaging, EEG

·        Type of Diagnosis:

o  Functional Diagnosis:

§  Mobility, communication, learning, self-care, socialising, etc

§  What does the child need to achieve age-appropriate function

o  Pattern diagnosis:

§  Autism

§  Cerebral palsy

§  Other syndromes

o  Biological diagnoses: DNA disorders, brain injury

·        IQ scores:

o  < 20 profound intellectual disability

o  20 – 35 severe

o  35 – 50 moderate

o  50 – 70 mild

o  70 – 85 borderline

o  Definite or highly probable cause in majority < 50.  Cause in about half < 70

·        Management:

o  Objectives:

§  Maximising function

§  Preventing and treating secondary problems

§  Supporting carers 

o   Referral: paediatrician, geneticist, psychologist (eg cognitive testing), SLT (speech, swallowing, play), physiotherapist (gross motor problems), OT (fine motor, self care, aids and equipment), early intervention groups, VNDT (Visiting Neurodevelopmental therapist), support groups

o  Medical assessment of a diagnosed, disabled child

§  Always consider new illnesses

§  Look for syndrome specific health problems

§  Feeding difficulties, nutrition

§  Constipation

§  Medication

§  Carer Stress

§  Access to services and allowances


Tamariki Ora (Well Child) National Schedule


·        Covers:

o  Health education and promotion

o  Health protection and clinical assessment

o   Family/whanau care and support

·        Health education/promotion topics to cover at appropriate stages

·        Prevention:

o   Types: 

§  Primary: shifting the whole population curve ® improves the overall standard

§  Secondary: identifying risk factors ® early or targeted intervention

§  Tertiary: minimising impact of established disease 

o   Benefits of prevention: ¯adult sequalae: injury, child abuse, delinquency and arrest rates

·        PPV of parental concerns about delay is about 80 –90%. Must act or refer on parental concern


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