Tag Archives: child development

Down’s syndrome pathways

For General Practitioners

Down’s syndrome occurs in 1:1000 live births and is the commonest identifiable cause of learning difficulties.  There is a significant variability in appearance, personality and levels of general health and independence.  Some medical problems are over-represented in people with Down’s syndrome and, for this reason, this group of children are followed up regularly by a team usually based in the local child development centre.  In Waltham Forest the multidisciplinary Wood Street children’s specialist service team oversee the growth and development of the children with Down’s syndrome, ensuring their health needs are met and their potential for learning maximised.  Click here for their generic Specialist Children’s Services referral form.  See February 2012’s PDF for links to more resources.  I have asked the Wood Street team to add some comments and pathway information below…

January 2012 PDF ready

For Emergency Departments, For General Practitioners, , , , , ,

Do you know your valgus from your varus?  Or your myclonic epilepsy from your sleep myoclonus?  A link this month to new asthma patient information leaflets and some reminders of NICE’s “Do not do recommendations” in feverish children.  Also the BSACI egg allergy guideline.  Do leave comments on any of these topics below.

December 2011. Happy Christmas!

For Emergency Departments, For General Practitioners, , , , ,

December 2011 has snippets of information on torticollis (backed up with lots more information on the website), unconscious children, alkaline phosphatase and a link to the Map of Medicine’s recent algorithm for cough in children.  Also some pointers for your safeguarding training needs.  Download it here.

Educational psychologists in Waltham forest

For General Practitioners, , ,

Our local educational psychologists are running drop in sessions on the 3rd Wednesday of every month at their base in Leyton, E10.  The current flyer which includes contact details is here and sessions will be on-going in 2012 even if not listed here.  They tell me that they would be happy to run EP drop in sessions or parent workshops/training/support groups  at local GP surgeries and jointly with GPs or other medical colleagues  – GPs are welcome to contact them to discuss.  Their Urdu speaking colleague runs sessions in a local Mosque as well.

October’s Paediatric Pearls

For Emergency Departments, For General Practitioners, , ,

October’s edition is joint again this month on account of my right radius being fractured and its being too difficult to type and format text boxes with just my left hand…  I am obviously not quite as good at ice-skating as I thought I was.  All the topics this month should be of interest to both the ED and primary care teams anyway:  a paper on paediatric early warning scores, the start of our neurodevelopment series, an update on services for bereaved children and their families and some useful links on the subject of head-lice.

Age of walking

For General Practitioners,

It is not uncommon for us to be referred not-yet-ambulant children just past the 18 month “upper limit of normal” age of walking.  The majority of these children are using means other than crawling to get around.  I had vague recollections of having seen a table once detailing the 97th centile for walking in children who bottom shuffle, commando crawl or roll everywhere but I spent 2 or 3 fruitless hours searching the literature for it a couple of months ago.  So I was ironically excited this month to find that Archives of Disease in Childhood had reproduced it!  One of our current registrars, Dr Amy Rogers, has kindly put together an article for Paediatric Pearls with nuggets from that paper (Sharma A Developmental Examination: Birth to 5 Years. Arch Dis Child Educ Pract Ed 2011;96:162-175 doi:10.1136/adc.2009.175901) which summarises normal development and when it would be prudent to refer children for further developmental assessment:

Approach to developmental assessment – birth to 1 year: Motor1

 1)    Elicit parental/carer concerns.  Questions to ask: 

  • Do you have any concerns about the way your baby moves his arms/legs or body? Have you ever noticed any odd or unusual movements?
  • Has your baby ever been too floppy or too stiff?
  • Does your baby have a strong preference for one hand and ignore the other hand?

 2)    Gather information on social/biological risk factors:

 Risk factors for poor developmental outcomes

Biological Family and social
Prenatal: drug/alcohol use, anti-epileptics, infection Poverty, neglect, abuse, low maternal education, parental mental illness, inadequate parenting, disadvantaged neighborhood, absence of social support network
Perinatal: Prematurity, low birth weight  
Postnatal: Infection, severe hyperbilirubinaemia, injury, FTT, epilepsy  

 3)    Observe/elicit behavior and interpret findings

 Note posture and movement.  Examine tone.  Elicit primary (Moro, grasp and asymmetrical tonic neck reflex) and support reflexes (downward, sideward and forward).  Video clips of all these reflexes can be seen at http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html.

 What is not normal?

  • Fisting of hands beyond 3 months
  • Poor head control at 4 months
  • Primitive reflexes beyond 6 months
  • Flexor hypertonia in lower limbs beyond 9 months
  • Not sitting unsupported with straight spine by 10 months
  • Not walking by 18 months

 BUT preterm infants often have delayed motor milestones, early hypotonia and longer lasting asymmetrical tonic neck reflex.  Children with atypical pre-walking movement patterns (ie. non-crawlers) are late in achieving independent sitting and walking.

 Pre-walking movement pattern and motor milestones (97th percentile)2

Movement pattern Sitting (months) Crawling (months) Walking (months)
Crawling 12 13 18.5
None – stand and walk 11.5   14.5
Creeping/commando crawling 13 15 30.5
Rolling 13 14.5 24.5
Bottom Shuffling 15   27

Refer if concerned as delayed motor development may be a marker for motor disorders and may have a negative impact on a child’s performance in the cognitive and social developmental domains.  There is more information on delayed walking in a Patient Plus article written for health professionals available at http://www.patient.co.uk/doctor/Delay-In-Walking.htm.

 1         Sharma A Developmental Examination Birth to 5 Years. ADC Educ Pract Ed 2011;96:162-175

2         Robson P. Prewalking locomotor movements and their use in predicting standing and walking. Child Care Health Dev 1984;10:317-30

FONTANELLES AND HEAD CIRCUMFERENCE AT SIX WEEK CHECK

For General Practitioners, ,

with thanks to Dr Harriet Clompus.

Assessment of fontanelles is an important part of the six week check.  Large fontanelles may indicate a problem in bone ossification or hydrocephaly, while a fused anterior fontanelle can indicate craniosynostosis.  These need to be referred to paediatric outpatients.  Always remember that anterior fontanelle size is very variable (1-4.7 cm in any direction) and always needs to be assessed in context of baby’s head circumference.

A sunken fontanelle indicates dehydration, while a bulging fontanelle indicates raised intracranial pressure (but can be non-pathological – vomiting, crying, coughing – so assess when baby settled!).  These can be discussed with paediatric registrar on-call.

1)      The anterior fontanelle is diamond shaped, 1-4.7 cm in any direction at birth (black infants larger than white) and can widen in first 2 months of life.  Median age of closure is 14 months (4 – 24 months)

 2)      The posterior fontanelle is triangular and is less than 1 cm.  It closes by 6 – 12 weeks.

 

 3)      The size of the fontanelles should always be assessed in conjunction with the head circumference. 

  • Macrocephaly  – familial, hydrocephaly or skeletal disorders such as achondroplasia.
  • Microcephaly  – familial, congenital infections, fetal alcohol syndrome, trisomies

 4)      The quality of the fontanelle  should always be assessed. 

  • Soft fontanelle  – normal
  • Bulging fontanelle – raised intracranial pressure (hydrocephalus, meningitis/encephalitis) .  NB can be non-pathological in crying, coughing or vomiting infant.
  • Sunken fontanelle – dehydration

 

 1)      WIDENED FONTANELLES:  think of…

Achondroplasia

Downs

Hydrocephalus

IUGR

Prematurity

Congenital  Rubella

Neonatal Hypothyroidism (3rd fontanelle)

Osteogenesis Imperfecta

Malnutrition

Rickets/Osteomalacia

 Rickets – Think of rickets in darker skinned, breast fed babies, especially if mothers are veiled.  Infants will often have sweating on the head.  If widened sutures are found check neonatal blood spot for hypothyroidism and refer to outpatients.

 Hydrocephalus – can have widened, bulging fontanelles in conjunction with a large head.

2)      PREMATURE FUSION OF FONTANELLES AND CRANIOSYNOSTOSIS

Closure of anterior fontanelle by six weeks always pathological  (NB  by 3 months 1% of normal infants will have a closed anterior fontanelle). 

Must always assess in conjunction with head circumference – early fusion associated with microcephaly (and less commonly, macrocephaly).

Craniosyntosis is premature closure of cranial suture(s) with skull growth restriction perpendicular to fused suture and compensatory skull overgrowth in unrestricted areas.   Presents with ridging (always pathological beyond one week of life) and abnormal skull shape (usually later than six weeks).

There is a nice background overview (with useful diagrams) to craniosynostosis at http://www.cincinnatichildrens.org/health/info/neurology/diagnose/craniosynostosis.htm.

Primary craniosynostosis is due to abnormal ossification of one or more sutures.  Simple – premature fusion of one suture, complex – premature fusion of multiple sutures.  Causes include rickets, hyperparathyroidism, hyperthyroidism , idiopathic and genetic causes such as Aperts.

Secondary craniosynostosis is caused by premature closure of ALL sutures due to lack of primary brain growth. If you find a child with premature closure of fontanelles or over-riding sutures at six week check you should refer to paediatric outpatients. NB Plagiocephaly (flat occiput) is a non-pathological deformation due to ‘back to sleep’ position – no action required.  It presents with ear on flattened side presenting anteriorly.  Parallelogram shaped head (as opposed to lambdoid suture craniosynostosis trapezoid shaped)

The following articles give lots of information on fontanelles and/or sutures.  The Fuloria article is very thorough and although it focuses on neonatal examination, most of it is still relevant for the six week check.

1) The Abnormal Fontanel, J KIESLER et al Am Fam Physician. 2003 Jun 15;67(12):2547-2552.    http://www.aafp.org/afp/2003/0615/.html  (figure 2 taken from abnormal fontanel)

2)The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems, Fuloria et al, Am Fam Physician. 2002 Jan 1;65(1):61-69.   http://www.aafp.org/afp/2002/0101/p61.html

3) http://www.nice.org/CG037quickrefguide

4) http://www.patient.co.uk/doctor/Examination-of-the-Neonate.htm

5) Craniosynostosis, P Raj et al, emedicine jul 2010 Craniosynostosis : eMedicine Neurology

Neurological examination in babies

For General Practitioners, ,

I have been looking at information on primitive reflexes as I was asked by a GP whether it was significant if he could not elicit a Moro reflex at the newborn check.  Wikipedia has a nice description of the Moro reflex: “it may be observed in incomplete form in premature birth after the 28th week of gestation, and is usually present in complete form by week 34 (third trimester). It is normally present in all infants/newborns up to 4 or 5 months of age, and its absence indicates a profound disorder of the motor system.  An absent or inadequate Moro response on one side is found in infants with hemiplegia, brachial plexus palsy, or a fractured clavicle”.

You need to make sure you are eliciting it correctly first though.  I have found a great site from Utah university with little video clips of aspects of a normal and abnormal neurological examination of a 5 day old.  Take a look at http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html and watch the 2 Moro examples carefully.  Did you know the hands have to come together in the mid-line at the end?