Paediatrics involves the assessment, diagnosis and management of infants, children and young people with disturbances of health, growth, behaviour and/or development. It also addresses the health status of this group through population assessments, intervention, education and research.
What does a paediatrician do?
A paediatrician is a child’s physician who provides not only medical care for children who are acutely or chronically ill but also preventive health services for healthy children. A paediatrician manages physical, mental and emotional well-being of the children under their care at every stage of development in both sickness and health.
Aims of paediatrics
The aims of the study of paediatrics is to reduce infant and child rate of deaths, control the spread of infectious disease, promote healthy lifestyles for a long disease-free life and help ease the problems of children and adolescents with chronic conditions.
Paediatricians diagnose and treat several conditions among children including
· Injuries, infections, genetic and congenital conditions, cancers, organ diseases and dysfunctions
Paediatrics is concerned not only about immediate management of the ill child but also long term effects on quality of life, disability and survival. Paediatricians are involved with the prevention, early detection, and management of problems including:-developmental delays and disorders, behavioural problems, functional disabilities, social stresses, mental disorders including depression and anxiety disorders.
DEVELOPMENTAL MILESTONES IN CHILDREN – a parent’s guide
Dr Warwick Smith – General and Development Paediatrician
Introduction:
Most babies and children reach important milestones within the expected timeframes. But in some cases developmental delays can occur. It is important to recognise when a child may not be developing at an average pace. This article will help to explain normal developmental progress for adults and children, when to seek help, and what tests and investigations are necessary to establish any problem areas.
Benefits of early identification for at risk children:
Early developmental intervention and education helps to influence a young, malleable and responsive brain.
It helps to maximise a child’s developmental potential; their functional abilities such as social communication, mobility and adaptive skills. It also helps to limit maladaptive functioning.
Parents can learn how their child is developing in relation to other children, tailor their expectations to what the child can achieve, and provide stimulation, and toys to match the child’s readiness for the different milestones. This allows family members to think that they are doing all their can to assist the child, and to bolster the child’s sense of being appreciated for who he or she is – an important preventative measure against further emotional disability.
Early intervention will provide preventive strategies for environmentally, and possibly biologically, at-risk children.
In some cases early diagnosis of a genetic disorder, metabolic or infectious disease can prevent further damage, or another child being born with the same disability.
Identification rates of developmental disabilities:
DISABILITY PREVALENCE (per 1000) DOCTOR FIRST TO MAKE DIAGNOSIS (% of time) MEAN MONTH OF AGE AT IDENTIFICATION
Mental retardation 25 76 39
Learning disability 75 12 69
ADHD 150 44 59
Cerebral palsy 2-3 99 10
Visual impairment 0.3-0.6 87 55
Hearing impairment 0.8-2 64 39
 
More severe developmental delays come to parents and doctors attention earlier – this includes mental retardation, cerebral palsy and vision problems. These disabilities are usually diagnosed before a child starts school. However, less severe problems like learning difficulties and attention deficit hyperactivity disorder (ADHD), are usually identified in school age children.
Signs and symptoms of developmental delay:
• The child may not be able to feed, sit, crawl, walk, talk, or be toilet trained.
• The child may show a lack of responsiveness and fail to reach normal milestones within the expected timeframe.
• Children who are blind or who have vision difficulties are likely to have delayed exploration skills and take longer to walk (18 to 24 months). Their first smile may be delayed. Language skills may be normal but there could be a delayed understanding of “I” and “you”. They find it difficult to understand the properties of objects and shapes.
• Deaf children are likely to have delayed language milestones.
• There may be behavioural problems such as sleeping difficulties, poor social interactions, unusual dietary habits, self stimulation, and self mutilation.
• “Dysmorphic”(unusual shape or appearance) features are often equated with mental retardation.
Diagnosis:
Doctors will look at the following factors when investigating concerns about developmental delays:
• Biological risk – genetic risk factors or neonatal risk factors for intellectual handicap.
• Environmental risk – maternal and family care, health care, nutrition, and limited opportunities for stimulation of normal development leading to delays in development.
• Established risk – a diagnosed medical disorder either present at birth or arising afterwards which has a high risk of resulting in developmental delays.
• Evaluation of the effects of possible emotional neglect or physical or sexual abuse.
• Recognised neurological disorders – seizures, movement disorder, spasticity etc.
• Effect of a chronic illness/organ dysfunction.
Warning signs of developmental delay:
• “Good” baby
• Late smiling
• Delayed visual alertness
• Late chewing/gagging
• Persistent reciprocal kicking
• Primitive reflexes
• Persistent hand regard/mouthing/slobbering
• Altered vocalisations (repeated and constant stimulus to elicit cry)
• Voice quality guttural, piercing, shriek-like, high pitched, weak or thin
• Delayed babble repertoire
• Lack of interest and concentration
• Aimless overactivity
• Neuromuscular weakness
• Blind or deaf
• Drug effects
• Emotional deprivation
The best predictors of development are skills relating to brain functioning, rather than reaching specific movement milestones within the expected timeframe.
Motor milestones are excellent indicators of movement skills, but correlate poorly with intellectual functioning.
Language and problem solving milestones in infancy provide the best insights into intellectual potential, and their evolution is independent of motor skills which may be obscured by physical disability.
Psychosocial abilities are critical to understand the whole child and in making a meaningful assessment about behaviour, but they do little in assessing motor and intellectual skills.
What is a delay?
A developmental delay is defined as absence of age specific developmental behaviours.
The following is a guideline by age and months of delay:
AGE DELAY
6 months 1.5 months
12 months 3 months
18 months 4 months
24 months 6 months
30 months 7 months
 
A delay in learning increases the risk for diagnosis of a specific mental disability or medical condition. These may include:
• Mental Retardation
• Cerebral Palsy
• Pervasive Developmental Disorder/Autism
• Blind or Deaf
• Specific Developmental Disorder (language/speech disorder)
• Attention Deficit Hyperactivity Disorder
A developmental delay becomes Mental Retardation after the age 3 years due to ability to provide more accurate tests; however, a diagnosis may be made earlier where there is a significant degree of impairment. (Moderate mental retardation suspected at 12 months, established by 2 years; mild mental retardation suspected at 2 years, established at 3 years). However, parents need to maintain hope, therefore continue to use delay, where there is potential for catch up.
Complicating factors:
• Normal developmental spurts and lags.
• Gender differences (girls earlier than boys and more rapid rate of development, except with some motor skills – onset of walking, and visuospatial skills i.e. jigsaw puzzles. Girls earlier with some social and communication skills. “Peak” spurt of speech and language around 18 to 24 months; for boys between 2 to 3 years).
• Correction for prematurity – more relevant for motor development than language skills (correct up to approx. 18-24 months).
Risk factors
Prenatal maternal factors:
• Previous miscarriage or stillbirth
• Acute or chronic illness (e.g. HIV)
• Poor nutrition
• Hyperthermia
• Use of drugs or alcohol
• Toxaemia
• Fetal movements
Perinatal factors:
• Obstetric complications
• Prematurity (less than 33 weeks)
• Low birth weight (less than 1500g)
• Multiple birth
Neonatal factors:
• Neurological events (e.g. seizures)
• Sepsis or meningitis
• Severe jaundice
• Hypoxia due to breathing difficulties
• Neonatal intensive care unit admission of more than 5 days
Postnatal factors:
• Seizures
• Sepsis or meningitis
• Recurrent ear infections
• Poor feeding
• Poor growth
• Exposure to lead or other toxins
Factors in the family history:
• Consanguinity
• Developmental delay (difficulty walking, talking, learning)
• Neurological disease (muscle weakness, seizures, migraines)
• Deafness/Blindness
• Cardiomyopathy
• Known chromosomal abnormalities
Factors in the social history:
• History of abuse or neglect
• Limited financial or social support
• Lack of food, clothing or shelter
• Teenage parent
• Single parent
• Mentally retarded parent
• Stressful life events (e.g. divorce, death, or unemployment of parent)
• Substance abuse in the home
• Parental chronic illness limiting caregiving ability
Physical characteristics of mental retardation:
Intellectually handicapped children may show some unusual physical signs indicative of mental retardation, these may include a small or large head circumference, a short stature, obesity (Prader-Willi Syndrome), excessive height, limb deformities, unusually shaped ears or placement, and skeletal abnormalities.
Developmental evaluation
Various screening techniques are used to assess the level of intellectual functioning for babies and children. Some of these include:
Cubes:
4 months Tries to reach cube, but overshoots and misses
5 months Able to grasp voluntarily. Uses both hands
6 months More mature grasp. Drops one cube when another is given
7 months Holds cube in one hand. Bangs cube on table. Transfers, and retains one when another is given
8 months Reaches persistently for cube out of reach
9 months Matches cubes
10 months Release beginning. Holds cube to examiner but will not release it
11 months Begins to put cubes in and out of container
12 months Beginning to cast objects onto the floor
15 months Tower of two. Holds two cubes in one hand
18 months Tower of three or four
Common objects (penny, shoe, pencil, ball):
18 months Names one
2 years Names two to five
2.6 years Names five
Colours:
3 years Names one
4 years Names two or three
5 years Names four
Drawing:
15 months Imitates scribble or scribbles spontaneously.
18 months Makes stroke imitatively.
2 years Imitates vertical and circular stroke.
2.6 years Two or more strokes for cross. Imitates horizontal stroke.
3 years Copies circle. Imitates cross. Draws a man.
4 years Copies cross
4.6 years Copies square
5 years Copies triangle
6 years Copies diamond
Risk factors for developmental delay identified on developmental assessment:
Motor skills
AGE FINDINGS
4.5 months Does not pull up to sit
5 months Does not roll over
7-8 months Does not sit without support
9-10 months Does not stand while holding on
15 months Not walking
2 years Not climbing up or down stairs
2.5 years Not jumping with both feet
3 years Unable to stand on one foot momentarily
4 years Not hopping
5 years Unable to walk a straight line back and forth or balance on one foot
Language
5-6 months Not babbling
8-9 months Not saying “da” or “ba”
10-11 months Not saying “dada” or “baba”
18 months Has less than three words with meaning
2 years No two word phrases or repetition of phrases
2.6 years Not using at least one personal pronoun
3.6 years Speech only half understandable
4 years Does not understand prepositions
5 years Not using proper syntax in short sentences
Mental skills
2-3 months Not alert to mother
6-7 months Not searching for dropped object
8-9 months No interest in peek-a-boo
12 months Does not search for hidden object
15-18 months No interest in cause and effect games
2 years Does not categorise similarities (e.g. animals vs. vehicles)
3 years Does not know own full name
4 years Cannot pick shorter or longer of two lines
4.6 years Cannot count sequentially
5 years Does not know colours or any letters
5.6 years Does not know own birthday or address
Psychosocial
3 months Not smiling socially
6-8 months Not laughing in playful situations
1 year Hard to console, stiffens when approached
2 years Kicks, bites, screams easily without provocation. Rocks back and forth in crib. No eye contact or engagement with other children or adults
3-5 years In constant motion, resists discipline, does not play with other children
Obstacles to identifying at risk children
Clinical evaluation by doctors only identifies about half the children in need due to some of the following factors:
• The natural wide variation among children makes it easy to ignore a subtle finding.
• The potential to overlook one area of development. All streams of development need to be assessed.
• Parents and doctors may find it difficult to discuss their fears and be unwilling to confront the painful reality that the child may have a developmental problem. Doctors need to use the phrase: “The child will grow out of it” with caution.
Early intervention and treatment
What works?
• Multidisciplinary teams to work with the parents and child
• Whole development of the child
• Home-based programmes for preschool children
• Parental involvement
• Increasing skills for parents
• Early intervention
Protective factors for children with developmental delay
There are several recognised factors which may help limit problems linked to slow development. These include:
• The child displays physical robustness and vigour, an easy temperament, and intelligence.
• There are affectionate ties and socialisation practises within the family that encourage trust, autonomy, and initiative.
• External support systems which reinforce competence and provide children with a positive set of values.
• A sense of self esteem and confidence.
• A belief in one’s own self-sufficiency and ability to deal with change
• A range of social problem solving approaches
Dr Warwick Smith
General and Development Paediatrician
Auckland
New Zealand
http://www.familydoctor.co.nz/conditions.asp?A=32727&category_name=&
Article taken from Family Doctor site.