Growth and developmental milestones


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Growth and developmental milestones

  1. 1. Growth and Developmental Milestones • Normal Growth o Bone Age radiographs  CAN: • provide info about adult height potential of healthy children with a bone age of >7 years • if BA is advanced compared to chronologic age can offer info about length of time or severity of exposure to sex steroids • if BA is delayed can offer info about length of time of endo d/os or nutritional d/os • in children who have isolated premature pubic or axillary hair development, a bone age more than 1 year advanced increases the possibility of a serious underlying disorder (i.e. late onset CAH)  CANNOT: • Permit accurate height predictions when BA is less <7 years • Offer appropriate height predictions for kids with abnormal growth patterns due to bone or other growth d/os  Children with familial short stature usually have a normal bone age  Children with constitutional delay of growth usually have delayed bone age o Normal head circumference of full term infant  Boys = 36cm; Girls = 35cm o Growth pattern of acquired microcephaly  Primary (genetic) microcephaly is almost always present at birth  Secondary (environmental) may be present at birth or develop from a later postnatal insult • Growth and development of a brain that is potentially normal is impaired by an environmental insult • Prenatal causes include etoh exposure irradiation, IU infection (CMV, toxo, rubella) • Other causes include significant perinatal asphyxia  Microcephaly = HC more than 2 standard deviations below the mean for age and sex o Distinguish between hydrocephaly and macrocephaly  Hydrocephaly = congenital or acquired enlargement if the ventricular system  Macrocephaly = head circumference >2SD above the mean based on age and sex; causes include hydrocephalus, megalencephaly, thickened skull and space occupying lesions
  2. 2. o Normal and abnormal variations in head shape o Growth pattern of familial macrocephaly ♦ Atypical Growth o The cause of FTT is nonorganic in the majority of patients o Extensive lab eval of FTT should be deferred until outpt dietary management has been tried o Observation of feeding can elicit nonorganic causes of FTT o Poor feeding technique is a cause of FTT o Distinguish between NOFTT and organic causes of growth deficiency  NOFTT: describes the child who has grown poorly and has no identified medical condition  Organic causes of growth deficiency: infant or toddler has grown poorly and has a medical disorder known to interfere with growth, including malabsorptive diseases, genetic syndromes, endo disorders and neuro dysfunction o Distinguish between organic and nonorganic causes of FTT (above) o Formula preparation is a major factor in infant undernutrition o Inadequate intake is the most common cause of FTT o Long term consequences of FTT in infancy:  Most kids with poor growth show adequate improvement in dietary intake with intervention  Some may continue on to be picky eaters; may have anxiety disorder, few may have autism spectrum d/o  Cognitive and school outcomes of kids with h/o FTT are worse than for those who have not experienced undernutrition  They should be monitored for developmental and behavioral problems o FTT may be an expression of parental neglect/inadequacy o Differential dx for infant with FTT:  3 broad categories: FTT with microcephaly, FTT with short stature, FTT with adequate height for age and nl head circumference  FTT with microcephaly AND prominent neuro features : TORCHES, teratologic conditions, genetic syndromes, brain injury  flow chart in article for others ♦ Surveillance and Screening
  3. 3. o Understand the variations in the developmental sequence that are associated with prematurity  Preterm babies (<37 weeks) should have their developmental ages corrected for the degree of prematurity for at least the first 12 months after birth, and some may do this up to 24 months  Infants born at 32-36 weeks GA have a 1.4-fold increase in risk of intellectual disabilities  Infants born earlier than 32 weeks GA have 7-fold risk  Greater risk of neurological/behavioral problems if low birth weight (<2500g), IUGR, h/o maternal drug use; medical complications like IVH, cardiac lesions, BPD, feeding probs and ROP  Preterm infant with a grade 3 or 4 IVH has a 35-90% increased risk of neurodevelopmental disability o Understand the variations with developmental sequence that are associated with congenital visual impairment  Children with congenital or acquired blindness without associated neurological abnormalities are NOT at increased risk for motor or cognitive impairment  They are not at increased risk for language based learning disabilities or autism spectrum disorders  May begin to walk later due to different exposure to motor exploration (start walking at 18-22 months)  Typically develop language skills at same time as sighted children  Should be provided with much physical contact and comforting and encouraged to partake in self help skills and exploration of their environment o Recognize the effects of visual impairment on motor, language, and emotional development in infants and preschool children  See above o Understand the variations in hearing development that are associated with congenital hearing impairment  o Recognize the effects of deafness on motor, language, emotional and cognitive development  o Recognize the importance of regular, periodic, standardized developmental and behavioral screening for the well child population  AAP statement to • Elicit and attend the parents’ concerns about child’s development • Document and maintain a developmental hx • Conduct accurate observations of your child’s development • Identify risk and protective factors
  4. 4. • Document the process and findings from developmental surveillance  Do screenings at 9, 18 and 24/30 months visit o Know the commonly used screening tests and their limitations  Developmental surveillance: PEDS (Parents’ Evaluation of Developmental Status) or ASQ (Ages and Stages Questionnaire)  Developmental Delay in high risk population (preterm birth, economic disadvantage): ASQ or BINS (Bayley Infant Neurodevelopmental Screener; for up to age 24 months) or CAT/CLAMS (Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale; a practitioner administered instrument)  To identify specific delays: language disorders = LDS (Language Development Survey) or CLAMS; for autism = MCHAT  Limitations for all the tests include time, costs, practice management constraints, selection of screening test; for parent administered tests/surveys issues include literacy, language barriers o Know the methods of developmental and behavioral screening (See above) ♦ Developmental Milestones: Milestones for infants and young children o Recognize the normal motor developmental milestones for 2 months of age  Regards object, follows 180 degrees, lifts head and shoulders off bed in prone position o Know that lack of visual fixation by 2 months of age is abnormal o Recognize the normal cognitive/behavioral developmental milestones for 4 months of age  Laughs out loud, squeals, initiates social interaction o Know that lack of visual tracking by 4 months of age is abnormal o Know that failure to turn to sound or voice by 6 months of age is abnormal o Know socioemotional milestones at 28 weeks of age  Takes solid foods well, places feet to mouth when supine, reaches for a mirror and pats image o Know that inability to sit by 9 months is abnormal o Know that lack of babbling consonant sounds by 9 months is abnormal o Recognize the normal developmental milestones for 12 months  Pulls to a stand and cruises, takes a few independent steps, neat pincer grasp o Recognize the gross normal motor developmental milestones for 15 months of age  Plays ball with examiner, gives and takes a toy, drinks from a cup, makes a line with a crayon, makes a two cube tower, walks independently, stoops to floor and recovers to standing o Recognize the normal cognitive/behavioral developmental milestones for 15 months of age
  5. 5.  Says 3-6 specific words, follows simple commands, uses jargon, indicates some desires or needs by pointing o Recognize the normal cognitive/behavioral developmental milestones for 18 months of age  Imitates household tasks, says 7-10 words, uses words for wants or needs, identifies one or more body parts o Know that inability to walk independently by 18 months is abnormal o Know that failure to use single words by 24 months is abnormal o Know that failure to speak in 3 word sentences by 36 months is abnormal ♦ Milestones for kindergarten readiness o Know the indications of social readiness to attend school:  Ability to separate from parents for several hours at a time  Plays well with other children  Takes turns  Able to follow directions in a group activity  Able to relate to personal experiences  Tell stories