I was a bit overloaded in December and couldn’t manage to get a newsletter out. The nurses in my own ED noticed but I don’t think anyone else was particularly bothered! Hope the Christmas break went well for everyone. January 2013 brings some more on speech development, a reminder of the BTS 2008 guideline on cough, another plug for vitamin supplementation and part 2 of Jess Spedding’s minor injuries series. Do leave comments below.
Tag Archives: child development
Talipes equinovarus
Talipes (Neonatal Clubfoot) with thanks to Dr Mujahid Hasan and the paediatric physiotherapy department at Barts Health
Newborn babies can present with one of two types of Talipes:
- Congenital Talipes Equinovarus (CTEV or fixed/structural Talipes)
- Positional foot problems
Click here for the Whipps Cross physiotherapists and Muj’s complete, illustrated article.
October 2012 ready to go!
Coins, magnets and batteries on the menu this month as well as some more cows milk protein allergy resources. A reminder about child developmental milestones courtesy of one of our medical students and NICE on headaches. Do leave comments!
August 2012 PDF digest
August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog. A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter. Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures. Do leave comments…
Stammering, stuttering and dysfluency services
Dr Harriet Clompus who is currently training as a community paediatrician and Louise Parker, the interim lead for speech and language services at Wood Street Health Centre have put together this article on stammering (the terms in the title are all synonymous). Do leave comments or questions.
“I think that the worst part of being a stutterer is giving the impression that I’m unable to converse, that what I say doesn’t really make sense anyway… The person I’m talking to starts fidgeting, and as I pray internally – ‘No, don’t look away’ – a familiar feeling of despair arises” …. Guardian Weekend 7th July 2012, What I’m really thinking – The Stutterer
5 out of every 100 children will stammer (or stutter – the terms are synonymous) as they learn to talk. Stammer affects all social classes and language groups. It is four times more common in boys than girls, and often occurs in families. It is thought that there may be a genetic basis for stammer.
Usually children who stammer have had apparently normal speech development until the age of 3 or 4. As their speech becomes more complex, they begin to have problems with fluency, and are said to have a stammer or stutter.
What is stammering?
– Tense, jerky, effortful speech
– Difficulty in getting a sentence started
– Stretching sounds
– Repeating words
– Stopping speaking half way through a sentence
Stammer is affected by stress – the more stressful the speaking situation the more likely an existing stammer is to occur. This can create a vicious cycle, inhibiting speech and social interaction. However, emotional stress does not lead to stammer and there is no evidence that particular styles of parenting ‘cause’ stammer.
1 in 5 children who stammer will have a persistent stammer into adulthood. It is difficult to predict which child will have a natural recovery, or how long that recovery will take. However, early referral (within one year of onset of stammer) to sources of help reduces the persistence of stammer and can transform a child’s life.
Waltham Forest Community Speech and Language Services (based at Wood Street) run Specialist Dysfluency service for adults and children, led by Dysfluency Specialist Louise Parker (tel 0208 430 7970). Parent, Health visitor, SENCO and GP can all refer. If a professional is referring they should use the Wood Street Children’s Community Services referral form and a pre-CAF form. Waiting time for first appointment is 18 weeks or less.
Louise Parker and her team including Jo Quinlan, SLT, use a range of therapeutic interventions including Lidcombe therapy for pre-schoolers. Lidcombe therapy was designed in Australia and puts parents at the centre of their child’s therapy with a series of exercises which the therapist oversees. In 2005, a randomised controlled trial showed that Lidcombe was an effective method of treating stammer. Jones et al, Randomised Control Trial of Early Intervention with Lidcombe Method BMJ 2005
With the North East London Foundation Trust (NELFT) now including Waltham Forest, Barking & Dagenham, Havering & Redbridge Speech and Language Therapy Services (SLT), the SLTs working in the area of dysfluency will have an even stronger network.
GPs who are unable to access Wood Street or other SLT services, can refer to The Michael Palin Centre for Stammering Children in Islington, which runs intensive courses in school holidays for older children. Tel 02033168100 www.stammeringcentre.org (the centre will charge commissioning groups for the service).
The British Stammering Assosciation (http://www.stammering.org/) has a wealth of information, in many languages, for professionals, parents and children on its website. It also has a phone helpline staffed by people who stammer. Tel 0845 603 2001/0208 8806590
The Fluency Trust (http://www.thefluencytrust.org.uk) provides residential courses in activity centres for children older than 10 years.
City University, London provides intensive week long courses in school holidays for those over 8 years. Contact Bethan Lewis, tel 0207 040 8288 www.city.ac.uk/lcs/compass/stammering/Intensive.html
Feeding disorders
Fussy eating is one of the most common things that parents present with to both primary and secondary care. My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject. I hope you find the structure as sensible, helpful and reassuring as we did.
FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica). We have not covered here eating disorders such as anorexia or bulimia.
Common presentations include:
- Dysphagia
- Food refusal
- Self feeding inadequacy
- Excessive meal duration
- Choking, gagging, vomiting
- Inappropriate mealtime behaviours
- Food selectivity by type and texture
Normal feeding development is as follows:
- Up to 6 mths – breast/bottle fed milk
- 6-12 mths – solids introduced and increased in variety & volume. Milk intake begins to decrease.
- At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
- 15 mths – hold spoon, messy feeding, use feeding cup
The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how. Some parents struggle to adapt to this:
- Messy
- Feeding cues can be missed
- Parental fear that insufficient food will be taken, child will lose weight
- Parents own food preferences
- Rejection of a food and assumption that child will never like it
- Time pressures
The health professional must look for an organic cause of food refusal:
| Organ system | GI disorder | Mechanism |
| Mouth | Carious teeth Structural with oral dysphagia |
Pain Reluctance to swallow |
| Pharynx | Tonsils Aspiration |
Pain, obstruction Choke, gag |
| Oesophagus | Reflux oesophagitis Cows milk allergy |
Pain, burning |
| Stomach | Motility disorder | Reduced appetite, discomfort |
| Colon | Constipation | Pain, discomfort, reduced appetite |
Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.
There are 5 key elements to the assessment:
- How is the problem manifested?
- Is the child suffering from any disease?
- Have child’s growth & development been affected?
- What is the emotional climate like during mealtimes?
- Are there any great stress factors in the family?
Red flags to look out for include:
- Swallowing difficulty with cough, choke or gag
- Vomiting/abdominal pain/arching/grimacing/eye watering
- Recurrent chest infections
- Stridor on feeding
- Snoring with sleep apnoeas
- Constipation
The history is, as always in medicine, of paramount importance and needs to be fairly detailed:
- Birth History
- Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
- Developmental progress
- Chronology of feeding problem
– Diet since birth - – Changes of milk formulae
– Introduction of solids - Current diet (typical day)
- What happens at meal times?
- Family & Social history
Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age. Refer children with red flags or significant faltering growth to secondary services.
- Management of the well child in primary care:
- Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
- Encourage family foods
- Meal time management (see NHS Lothian’s dietetic advice)
- Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship
The multidisciplinary approach:
- Health Visitor – can assess child within home situation
- Dietician
- – Nutritional assessment and feeding advice
- – Calorie enrichment
- – Calorie supplementation
- – Enteral feeds (very occasionally)
- Speech & Language therapist
- – Direct assessment of feeding & advice in home situation
- – Parent-child interaction
- – Is swallow safe?
- – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)
Summary points:
- Feeding disorders in children are common
- Occur in healthy children but assessment should be made for organic causes
- – GI tract problems
- – Developmental delay
- – Autistic spectrum disorder
- Watch out for obligate milk drinkers
- Meal time management is crucial
- Involve Health Visitor
Further resources:
Weaning your premature baby. Free download from Leicestershire Dietetic Service 2011
Help! My child won’t eat and My child still won’t eat. British Dietetic Association. Available to buy in packs from http://www.ndr-uk.org/
My Child Won’t Eat by C Gonzalez – these are both books and the links are to www.amazon.co.uk
New Toddler Taming by C Green
The Perinatal Parent Infant Mental Health Service (PPIMHS)
The PPIMHS teams are made up of perinatal psychiatrists, community mental health practitioners and psychotherapists/psychologists and they accept referrals from Health Visitors, GPs, midwives, Children’s Centres workers or other health professionals and self-referrals. Click here for their referral form. They may signpost elsewhere after the initial consultation if appropriate or they will offer the parent/carer and infant/child 9-12 sessions to work on the parent-infant relationship and/or psychiatric support as required.
Groups particularly at risk of having problems with bonding include families with ex-premature babies who have spent a significant amount of time on the Special Care Baby Unit, those where the baby has feeding issues or is difficult to soothe, those where breastfeeding failed to establish and those where there was a traumatic birth or difficult conception and/or pregnancy. Many of the parents on their case load have a personal history of disturbed attachments and are keen not to let history repeat itself. A recent audit showed that 41% of their mothers had some sort of mental health diagnosis which means that 59% did not. Click here for an information leaflet about their service that you might like to give to your patients.
Mums with postnatal depression or post-partum psychosis should be referred directly to PPIMHS. Parents struggling with a crying baby or fussy toddler but with no bonding issues should be referred to their health visitor. The PPIMHS team is a tier 3 (specialised) service concentrating primarily on the parent-infant relationship and perinatal mental health.
Symptoms in the baby that might suggest a bonding problem:
extreme clingy behaviours, fussy, difficult to soothe, abnormal self-soothing behaviours (eg. head-banging, hair-pulling, scratching), excessive sleep problems, extreme feeding problems, lack of verbal and non-verbal communication, stiff or floppy posture, extreme fearfulness or watchfulness, lack of interest in the world, no comfort sought from parents, avoids eye contact with parents, smiles very little.
Symptoms in the parent:
high anxiety and panic about the baby, excessive A and E or GP presentations, feeling frightened of harming the baby, lack of separation between parent and baby, baby never put down, excessive sterilising of bottles and toys, detached feelings about the baby, no pride in their development, anger about baby as if baby intends to upset the parent, feelings of failure as a parent, inability to cope.
There is some evidence around this issue and around maternal stress during pregnancy and the effect of high maternal cortisol levels on the foetus’ developing brain. I have asked the Waltham Forest PPIMHS psychologists to write a bit about that and correct anything I have written about their service!
Stages of normal speech development
With thanks to Fionnuala O’Driscoll, Speech and Language Therapist at Wood Street Specialist Children’s Services for the table below:
| Age (years) | 0-1 | 1-2 | 2-3 | 3-4 | 4-5 | 5-6 | 6-7 |
| Attention and Listening | Distractible | Single channelled | Single channelled but flexible | Shared attention | Shared and integrated attention | Able to focus for longer periods of time | Can spend hours on chosen activity |
| Play and Social Interaction | Exploratory, relational or constructive.Eye contact and turn taking from birth. | Symbolic or pretend play.Turn taking in play from 18 months. | Pretend and imaginary play.Plays with others in small groups. | Role play.Cooperative play develops.May like simple jokes. | Chooses own friends.Learn to turn take in conversation.Can discuss emotions. | Able to play games by rules.Plans sequences of pretend events in play. | Group play with less pretend play.Can play alone happily. |
| Understanding of Language | Understands a few simple words (bye bye) | Understands familiar words and phrases in context | Follows simple instructions and later short stories | Follows short stories and longer instructions | Understands stories, longer instructions and conversations | Understands 13,000 words.Beginning to reason and understand abstract concepts | Understanding of vocabulary doubles in size.Understands abstract concepts. Can reason, predict, and infer. |
| Use of Language | Cooing, babble, simple words | First words and later 2 word phrases | 2-3 word phrases – longer phrases | Longer 4-5 word sentences usually well formed (4 yr) | Well formed sentences combining up to 8 words.Tells simple sequence of events. | Longer sentences with mostly appropriate grammar.Tells simple stories. | Uses language for a range of purposes e.g. persuade, question, negotiate, discuss.Tells more complex stories. |
| Speech | p, b, m, w and vowels | n, t, dSpoken words not always recognizable. | k, g, ng, h | f, s, l, y | sh, z, v, ch, th, r, clusters May have difficulty with multisyllabic words (hospital) | Generalising speech sounds to connected speech | Generally mature by 7 years old |
Disordered puberty neatly explained
With thanks to Dr Amy Rogers for unravelling endocrinology for the better understanding of all non-endocrinologists. All girls under 8 and boys under 9 with signs of puberty should be referred to a paediatrician and you could leave it at that. But for those who want to know a bit more about it (or check up on what we do about it…) read on!
The British Society of Paediatric Endocrinology and Diabetes (BPSED) is recognised by the Royal College of Paediatrics and Child Health (RCPCH) as the society responsible for this field of paediatric medicine. It is currently chaired by Professor Dattani of Great Ormond Street Hospital and represents the only U.K. society responsible for governing the training of doctors in paediatric endocrinology and diabetes and actively supporting the ongoing training and education of allied healthcare professionals in this specialist area. Lots of resources available at www.bsped.org.uk
The hormones of puberty: Hypothalamic-Pituitary-Gonadal Axis:
(http://www.ohioshaolindo.com/China%27s%20Arts/image016.jpg)
Start of puberty in girls = palpable breast bud (B2)
Start of puberty in boys = testicular vol >3.5ml
Androgens promote other secondary sexual characteristics: smelly feet, acne, body odour and mood swings!
Timing of puberty is dependent on socioeconomic status, nutritional and genetic factors.
In the UK early puberty = <8years girls, <9 years boys. Interpret in conjunction with family history (age of maternal puberty), ethnicity (Afro-Caribbean or mixed race = commoner to have early menarche), BMI (overweight = associated with early puberty), social factors (adoption and lower SEC = early puberty) and past medical events. Approx 10% girls achieve menarche whilst still in primary school.
RED FLAG: ARRESTED PUBERTY = SERIOUS PATHOLOGY
Pubertal development may be:
1) Concordant (following the normal pattern), i.e. breast buds, pubic hair then menses/increased testicular vol, pubic hair then penile enlargement).
OR
2) Discordant, e.g. progressive breast enlargement with no pubic hair, or penile enlargement with small testicles. Suggests over activity of sex hormone (oestrogen/testosterone) production in the periphery, i.e. adrenals, gonads (ovaries/testes) or tumours.
Causes of precocious puberty
Central precocious puberty (gonadotrophin dependent)
- Idiopathic = Most common cause in girls (10 times more common than boys). Slowly progressing (breast and pubic hair growth, modest growth spurt, bone age advanced <1yr, few changes on pelvic USS) or more aggressive (height velocity greater, bone age advanced >1 yr). Ovarian and uterine enlargement (>2ml) on USS. Pubertal response to stimulation test. Boys: testicular enlargement, virilisation, pubertal response to stimulation test.
- Tumour = Second most common cause in both sexes (at least half of all boys presenting with central precocious puberty), typically a hypothalamic hamartoma
- Optic glioma (NF)
- Longstanding/severe peripheral secretion
- Abnormal brain (hydrocephalus, septo-optic dysplasia)
- CNS damage (infection/trauma/ low dose irradiation)
- Adoption
- HCG production (CNS or peripheral tumours)
- Hypothyroidism
Peripheral precocious puberty (gonadotrophin independent): peripheral oestrogen
Thelarche
Ovary tumour or cyst (including McCune-Albright syndrome and massive ovarian oedema)
Drug/dietary sources
Testicle/liver tumour
Peripheral precocious puberty (gonadotrophin independent): peripheral androgen
Adrenarche
Atypical congenital adrenal hyperplasia (CAH)
Adrenal tumour (including Cushing’s)
Testicular tumour
Testotoxicosis (male limited family history) and McCune-Albright syndrome (irregular café-au-lait patches, bony changes on xray and ovarian cysts (that may be huge).
Investigation
Examination alone is often enough to determine if this is “true” puberty or just early thelarche (breast development) or pubarche (body hair), especially if combined with bone age.
- X-ray right wrist (bone age)
- Pelvic and abdominal USS (looking for tumours, cysts, size and position of gonads/internal genitalia)
Definitive test for central precocious puberty = GnRH stimulation test:
1) Measure LH, FSH, oestrogen/testosterone at base-line.
2) Give GnRH and monitor serial response of LH and FSH (20mins and 60mins)
Interpretation:
| 20mins | 60mins | ||
| LH/FSH | ↑ | ↓ | Central precocious puberty |
| LH/FSH | ↓ | ↓ | Peripheral precocious puberty |
MRI hypothalamus, pituitary and brain in aggressive forms of early puberty, in girls less than 6 years of age, any child with neurological signs, and all boys.
Other tests to consider:
- TFTs (elevated TSH in hypothyroidism can mimic FSH, inducing early testicular and ovarian enlargement)
- Tumour markers (HCG can be produced from pineal, hepatic and testicular tumours) and alpha fetoprotein will be raised but LH/FSH will be low and non-stimulatable.
- Testosterone, oestrogen, morning LH/FSH
Treatment
1) Early thelarche or pubarche: None. However, if pubarche associated with being overweight in girls, important to control weight, otherwise at increased risk of polycystic ovary syndrome (PCOS) and Type 2 diabetes later in life.
2) Supportive, let nature take its course: coping with periods, behavioural and cosmetic changes. School need to be aware.
3) Triptorelin or Goserelin injection = long acting GnRH analogues (given every 4-12 weeks depending on preparation used and body’s response to it). Will slow down or stop development. Continued until child’s peers are entering puberty, typically aged 10-11years. GH in addition, may result in improved final height, in girls.
Additional notes on discordant sexual development:
Thelarche: commonly present from infancy, non-progressive, may be unilateral. No treatment required.
Ovarian (and adrenal, testicle or liver) tumours secreting oestrogen are rare and often present with a palpable mass and prominent breast development with no other signs of puberty.
Thelarche-like symptoms are produced from oestrogen containing medications.
Adrenal androgens are the commonest cause of early virilisation leading to sexual hair growth, body odour, acne, greasy hair and mood swings.
Adrenarche = normal maturation of the adrenal glands leading to enhanced secretion of the androgen DHEA. Usually co-existent with the onset of normal puberty and contributes most of the androgenic component of puberty in young females. Premature adrenarche may be familial, spontaneous, or with an ill-understood association with hydrocephalus. No treatment required. A proportion of girls affected will proceed to PCOS, especially if they gain excessive weight.
Atypical CAH (mild, non-salt wasting type) mimics adrenarche and can be easily differentiated by a urinary steroid profile or a short Synacthen test and measurement of 17 alpha hydroxyprogesterone. A pubertal response to stimulation testing will require treatment with both hydrocortisone and GnRH agonists to achieve a reasonable final height.
Non-iatrogenic Cushing’s syndrome tends to be accompanied by excess adrenal androgen secretion and hirsuitism.
Isolated premature menarche is relatively common disorder of unknown aetiology. USS demonstrates prepubertal uterus with no endometrial lining between bleeds. Differential diagnosis includes rare local lesions, e.g. sarcoma, abuse and vaginal foreign body.
Mild, transient breast enlargement occurs in approx 50% boys in early puberty, but severe persistent gynaecomastia is increasingly common, possibly secondary to nutritional excess or environmental chemicals. Usually accompanies early puberty but can be pre-pubertal. Investigations for ectopic oestrogen secretion, karyotype, liver and thyroid function are usually normal. If present for >18m, may require surgical removal. If diagnosed early, treatment with anti-oestrogen medication such as anastrozole may have some benefit.
Paediatric Pearls for February 2012
Click here for this month’s PDF digest! It ‘s quite hard providing a balance of information for GPs and ED juniors now that I am only doing the one newsletter. I think we’ve succeeded this month with neurodevelopmental milestones in Down’s syndrome and essential tremor aimed mainly at GPs and pulled elbow, anaphylaxis and the FEAST study aimed more towards the emergency medicine practitioners. Many thanks to my colleagues who have contributed this month. The FEAST video makes fascinating and inspiring watching for any health professional, regardless of specialty. Do leave comments, questions, suggestions!