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Child Development Hospital )of Dr Priscilla Julies, Consultant Paediatrician, Royal Free Dr Katarina Harris , Consultant Paediatrician , Whittington Hospital Learning Objectives • SESSION 1- 04/04/2022 • Know normal developmental milestones • Summarise and present relevant findings • Identify risk factors and red flags for abnormal motor development • SESSION 2 – 11/04/2022 • Know how to perform a general signs and neurocutaneous syndromese facial • Know how to perform an examination of gross motor development and neurology in an infant Session 1: Learning Objectives •Know normal developmental milestones •flags for abnormal motord red developmentWhat is child development? The process of increasing physical, intellectual, emotional and social abilities influenced by genetic and environmental factors continuously altering each otherNormal Development: Principles ➢a continuous process in 4 areas: gross motor, fine motor and vision language and hearing and social Interaction The sequence is the same, the rate varies from child to child Primitive reflexes should be lost before the voluntary movement develops Top to Toe, Flexion to Extension, Back to Front, Small to big,Vertically or horizontally? Vertically all the milestones in order from birth to and of childhood within a particular domainVertically or horizontally? Horizontally: the milestones across all domains that a typical child of a certain age should have achievedWhy is developmental assessmentimportant? •Screening •Identify those at risk •Reassure •Diagnosis Early identificationProcess for identification of developmental impairment • Surveillances : universal for all children – to promote good care and parenting , identify risk factors , early identification of developmental difficulties •developmentalfunction and risk of impairment and arrangerise assessment /investigations • Developmental assessment for established concerns : to provide description of child’s developmental strength and weakness for planning management • Diagnostic or functional assessment - planning of management Normal gross motor development • Birth - observe posture • 6 weeks – good head control (raises head to 45 degrees when in a prone position and stabilises head when in a sitting position) • 6 months- sits without support , rounded back • 9 months – stands, holding on, sits with straight back • 12 months – walks ( 9-18 months ) • 18 month - walks alone ( red flag if not walking) 2y - runs, jumpsNormal gross motor development: Quick Aide Memoire 3 months 6 months 12 months Chest up Sit Stand Open Hands Reaching and Pick up phone swiping (PINCER) Coos and Point 1 finger Gurgles Babbles Talk (1WORD) Watches Recognise Imitate Daddy Parents Parents Face Future Goals 2y 3y (3/t) 4y (4 f ) GM Run Stand (3 limbs) hops Jump tricycle 2 feet per step FM 2X3 block tower 3X3 block tower 4X3 block tower 360 degrees (circle) Cross + x Line (2 ends) Speech and 2 words together 3 words phrases 4 words sentences Language Social/Cogniti II play Play together Fun, friends on Sharing Spoon and Fork Fork and Knife Fine Motor and Vision •6 weeks-Fixing and following to 90° with head movement, 3-4 month – watches own hand ( hand regard ) •6 months- improved visual perception leads to hand with index finger 8- 9 monthpalmar grasp, exploration •10-12 months-Pincer grasp as maturing grasp leads to thumb finger apposition, casting, object permanence,Fine Motor and Vision • Bricks-15 months- tower of 2 -18 months-tower of 3 bricks -2 years-tower of 6 bricks -3 years- tower of 9 bricks and copies a bridge -4 years-builds stepsFine Motor Milestone 18months 2 years 3 years 4 years 5 yearsLanguage and hearing • Birth-Startles to noises • 12 months- knows name, • 15 months- 2 words • 18 months- 6-20 words • 2 years-2 words sentences, >20 words • 3 years- knows sex, first and last name and colours • 5 years- asks “how” and “when”HearingT ests • Neonate Oto acoustic emissions Auditory brain evoked potentials • 6-18 months Distraction testing • 24-30 months Performance test • 2-4 years Speech discrimination test • Over 4 years Pure tone audiometrySocial Interaction • 6 weeks- smiles responsively • 3 months- laughs • 9 months-stranger anxiety, develops conventional gestures • -understands no and “bye-bye” -plays peek- a – boo • 12 months –drinks from a cup, waves “bye-bye” • 18 months-points to named body parts -simple symbolic play • 3 years-brushes teeth -make-believe play • 5 years-able to put on clothes • -uses knife and forkDevelopmental Assessment in Clinical Practice • Explore Parental concerns • History : Pregnancy and risk factors around delivery, decreased foetal movements, infections, prematurity , resuscitation , feeding difficulties • Developmental milestones, Family history/medication/ allergies • Examination Weig?Dysmorphic, Alertnessnelle Eyes, Mouth ?cleft palate Examination of all systems + Genitalia + Hips, neurological examination incl: primitive reflexes (?symmetrical) HearingMaking sense of the findings • Developmental findings change over time for a specific child • Large variation of normal within population needs to be acknowledged and discussed with parents • Interpretation of findings requires combination of examination findings together with information about biological (birth/physical/hearing/vision) an social risks (family/ environment) and psychological attributes (behaviour/ affect/ anxiety /attention) in real life • Careful conclusion needed to avoid diagnosing developmental delay while a sensory impairment might have impacted on child’s functioning in testing environmentMaking sense of the findings • Planning investigation is a clinical decision , positive yield for global developmental delay is approx. 50% if associated with other findings or dysmorphism • investigate e.g seizures – Landau kleffner, low threshold for referral to • Term developmental delay implies expected catch up , which might be misleading • Early diagnosis is associated with better outcome • Offer reassurance / advice how to promote child’s development and function to prevent e.g unwanted behaviours or other complications • Refer early to physio/ OT/SLT / paediatrics/ neurology/ geneticsDevelopmental Patterns• Any questions ? • Thank youRISK Factors History Risks Age, Sex Prematurity-correct until age 2y Family History consanguinity unexplained severe childhood illness or death; Hearing, Neurological, Muscular, learning problems Antenatal + Birth Decreased fetal movements drugs Infections Prematurity Need for resuscitation Brain haemorrhage seizures Symptoms Early feeding difficultiesRED FLAGS History RED FLAGS Sensory Deficits Vision or Hearing loss Symptoms Normal intervals with intermittent/progressive/unexplained symptoms Developmental Pattern late milestones slowing loss of previouslyacquired skills (regression) Milestones Not Sitting unsupportedby9 mo -GM not walking by 18 mo Difficulty stairs2 y Only tiptoeing -FM Not holdingobjects placed in hand5mo Not reaching 6mo Not pointingto share interest 2y -Lang No words by 18mo - No 2-3 word sentences 3y Speech unintelligible 4y Social and Play No smiling by 8 weeks No eye contact No pointing by 2 yearsHearingT ests • Neonate Auditory response cradle Auditory brain evoked potentials • 6-18 months Distraction testing • 18-30 months Cooperative testing • 24-30 months Performance test • 2-4 years Speech discrimination test • Over 4 years Pure tone audiometry • Any age Oto acoustic emissions Tympanometry