Tag Archives: parenting

Stages of normal speech development

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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

November’s Paediatric Pearls available now!

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This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month!  NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below).  Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.

Educational psychologists in Waltham forest

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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.

Common breastfeeding problems

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My ED consultant colleagues requested that we run a series on “feeding issues” in Paediatric Pearls as it forms a part of the ED trainees curriculum and is a common subject to come up in conversation with parents in the ED.  It seems appropriate to begin the series with an article on breastfeeding problems put together by our breastfeeding counsellor, Jo Naylor, and one of the current paediatric trainees, Dr Sarah Prentice.  Their full article is downloadable here and I have reproduced some nuggets in this month’s Paediatric Pearls newsletter and below.

Breastfeeding adequately? Inadequate milk intake?
 feeding every 2 – 5 hours for 20 – 40 minutes  infrequent feeds
 3-4 wet nappies and changing stool by day 3  continued urates and/or meconium after day 3
 pain free breastfeeding  painful feeds, ineffective sucking
 weight loss < 10%  weight loss > 10%
 baby settled between feeds  fretful, hungry baby

 

Reminder: handout of local breastfeeding drop-in groups available here.

I intend to cover the following topics over the next few months (some of which have actually already been touched on in previous months):  vitamin supplementation, formula milk, gastro-oesophageal reflux, starting solids, allergy, fussy eating, food refusal, dentition and use of bottles, healthy eating, obesity, eating disorders.    Please do leave requests for other topics below.

Vitamin D guidance at last!

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Take a look at this not-definitive-but-nevertheless-sensible guideline on Vitamin D deficiency in both adults and children which Barts and the London published in January 2011:  http://www.icms.qmul.ac.uk/chs/Docs/42772.pdf.  Please note that it is NOT a national guideline and the authors acknowledge that more research is needed in this area and that variations in practice are common, even across London.

The Paediatric Pearls newsletters are checked every month by my consultant colleagues.  We have been keen to put something together for GPs on vitamin D for a few months now but are struggling with the lack of evidence and consensus in this area.  Some of the comments I have received back from my colleagues concerning this guideline include:

  • A cut off of 80nmol/l is too high as the lower limit of normal.  Most hospitals (including Whipps) use 50nmol/l because symptoms do not tend to be evident until that level.
  • The paediatric clinical guideline currently in use at the Royal London Hospital is not quite the same as their Clinical Effectiveness Guideline in that it advocates lower doses of vitamin D therapy (than the BNFc) for a longer period of time.  The advantage of this is that no monitoring of calcium levels is required.
  • Liquid ergo or colecalciferol are difficult to get hold of nationally and some patients find it hard to find a community pharmacist who will supply it.  There is a shortage of it at the moment and it is expensive.  It would make practical sense therefore to just treat the deficient ones (<25nmol/l) rather than the asymptomatic insufficient patients (25 to 50nmol/l).  This is in practice what the majority of us do, ensuring that the insufficient (and even sometimes the asymptomatic deficient group) ones get vitamin supplementation (400IU/day).
  • “Symptomatic” includes general aches and pains and does not just refer to hypocalcaemic tetany or rickets. 
  • Healthy Start vitamins are available again now and are a better long term option than Abidec or Dalivit as they are free to young mothers and their children and to people on benefits, see http://www.healthystart.nhs.uk/.  They should be available at all health centres at low cost (if the family does not qualify for healthy start vouchers) to all breastfeeding babies and then for the over ones when they have moved on to cows’ milk.
  • We all agree that children with rickets and bone deformities secondary to vitamin D deficiency should be seen in secondary care as they require a greater degree of monitoring, especially their calcium levels, when first started on high doses of colecalciferol.  There is also a risk of cardiomyopathy in this group.
  • The Clinical Effectiveness Guideline from the Barts and the London group states that 90% of South Asian people in their region (mainly Tower Hamlets in east London) are vitamin D deficient.  We don’t yet seem to have found an answer as to why there are not even more cases of rickets or hypocalcaemic tetany in that region then. 

I suspect, as usual, the answer to the vitamin D conundrum is not quite as straight forward as this guideline makes out.  Do leave comments below.

This is the 2011 Barts Health Vitamin D guidance, with thanks to pharmacist Nanna Christiansen for allowing me to upload it to this site.  Please note that the doses here are not the same as the BNFc.  There is a wide range of doses which you can prescribe for Vitamin D deficiency and insufficiency and no national agreement on what constitutes either deficiency or insufficiency.

GP’s July 2011

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This month I have reproduced some immunisation myths and truths from Dr Ravindran’s excellent summary published in full somewhere on this blog (use the search function if you can’t find it below). NICE’s UTI guideline has just been reviewed; did you know there was a section called “Do not do recommendations”? Worth a look as we are all guilty of doing some of what we are not supposed to. Our new list of local breastfeeding drop-in groups is out, reduced unfortunately since the cutting back of Childrens centres’ funding. The GMC have clarified parental responsibility nicely and, as a step-parent myself, I was quite pleased to see the sensible point on the end too. Lastly, it is a bit depressing to be told that it takes 3 times longer in the UK for a child with a brain tumour to be diagnosed than in the US. Do leave comments below.

July 2011 ready for ED health professionals

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Less text boxes this month because of the importance of the parental responsibility issues in the ED, highlighted in the featured GMC 0-18 document.  Also a brief look at the recently reapproved UTI NICE guideline.  Did you know they did a section called “Do not do recommendations”?  We have done a quick round up of relevant academic papers for you this month and pointed you to a site aimed at improving our woeful pick up rate of childhood brain tumours.  Do leave comments here.

Umbilical issues

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This month we have covered umbilical granulomas and hernias as part of the feature on 6-8 week baby checks. Our surgeon with an interest in paediatrics is happy to see children from around 3 years of age if their umbilical hernia has not spontaneously resolved by then.  This topic is covered succintly, including a list of differential diagnoses, in an on-line Australian handbook of neonatal care. Inguinal hernias are a different matter altogether (they carry a far greater risk of becoming incarcerated) and one of the junior paediatricians is working on a “Pearl” about them for the May or June PP edition. 

There is not much evidence published on what to do with umbilical granulomas.   They occur when the inflammatory process at the umbilicus leads to excess granulation tissue preventing the raw area from developing new epithelial tissue.  One theory is that infection has a part to play.  I do nothing when asked about them in the Emergency Department but then I don’t follow up those patients so some GPs may feel that masterly inactivity is not enough!  They tend to take a few weeks to months to clear up.  There are references in the literature to fusidic acid, cool boiled water, salt, silver nitrate and reassurance.  Salt seems to be “in” at the moment.  All comments welcome!

Attention Deficit Hyperactivity Disorder

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I featured the 2008 NICE guideline on ADHD in the February 2011 GP version of the Paediatric Pearls newsletter.  All parents of children who are being assessed for possible ADHD should be given information about local parent training/education programmes, not to insinuate that they are poor parents but in recognition of the fact that parenting skills need to be fully optimised to meet the above average parenting needs for this group of children.  Try http://www.walthamforestclass.gov.uk/familylearning/fm.aspx#parenting  for information on lots of free parenting classes provided by Waltham Forest.

Locally, ADHD is dealt with by the Child and Family Consultation Service and all referrals should go to the child psychiatrists and psychologists there please.