Development

Question 1

What is plotted in a growth chart and what is it plotted against?

Answer 1

Plot a child’s weight, height and head circumference against the normal distribution for their age and gender.

The child’s measurements are plotted on a graph using a dot.

Question 2

What is plotted on the x-axis and y-axis of a growth chart?

Answer 2

x-axis: age

y-axis: weight, height, head circumference

Question 3

What do the curves indicate on a growth chart?

Answer 3

The normal distribution of growth over time.

Question 4

What do the centiles indicate on a growth chart?

Answer 4

Centiles indicate where a child’s growth compares to the normal distribution for their age and sex.

Use chart that matches sex of child as growth is different between boys and girls.

Question 5

If a child is on the 50th centile and a child is on the 1st centile for height, what does this mean?

Answer 5

50th centile - child is exactly average height for their age

1st centile - child is shorter than 99% of children their age

Question 6

If a child is not gaining weight or height, what is important to establish with the growth chart?

Answer 6

Establish whether the child is maintaining their centile. If a child is on the 9th centile but has always been on the 9th centile then it is much less concerning than a child that was on the 91st centile and is now on the 9th.

Question 7

What are the 3 phases of growth in children?

Answer 7

1) First 2 years - rapid growth driven by nutritional factors
2) From 2 years to puberty - steady slow growth
3) During puberty - rapid growth spurt driven by sex hormones

Question 8

Why is obesity occurring in children?

Answer 8

• consuming more calories than are expended through activity and growth
• readily available, affordable, hyper-palatable, high calorie foods
• shift from physical activities and outdoor play to sedentary activities e.g. video games and screens

Question 9

What is overweight defined as in terms of BMI and centiles?

Answer 9

BMI >85th percentile

Question 10

What is obese defined as in terms of BMI and centiles?

Answer 10

BMI >95th percentile

Question 11

What are the effects of obesity in children?

Answer 11

• bullying
• developing impaired glucose tolerance
• T2DM
• CVD
• arthritis
• cancers
• likely to continue into adulthood unless family engages and addresses the issue

Question 12

How is failure to thrive defined?

Answer 12

Poor physical growth and development in a child.

Question 13

What is faltering growth?

Answer 13

Fall in weight across:

• one or more centile spaces if birthweight was below 9th centile
• two or more centile spaces if birthweight was between 9th and 91st centile
• three or more centile spaces if their birthweight was above 91st centile

Question 14

What are broad causes of failure to thrive?

Answer 14

• inadequate nutritional intake
• difficulty feeding
• malabsorption
• increased energy requirements
• inability to process nutrition

Question 15

What are causes of inadequate nutritional intake leading to failure to thrive?

Answer 15

• maternal malabsorption if breastfeeding
• iron deficiency anaemia
• family or parental problems
• neglect
• availability of food (ie. poverty)

Question 16

What are causes of difficulty of feeding that lead to failure to thrive?

Answer 16

• poor suck e.g. due to cerebral palsy
• cleft lip or palate
• genetic conditions with abnormal facial structure
• pyloric stenosis

Question 17

What are causes of malabsorption that lead to failure to thrive?

Answer 17

• cystic fibrosis
• coeliac disease
• cow’s milk intolerance
• chronic diarrhoea
• IBD

Question 18

What are causes of increased energy requirements that lead to failure to thrive?

Answer 18

• hyperthyroidism
• chronic disease e.g. congenital heart disease, CF
• malignancy
• chronic infections e.g. HIV, immunodeficiency

Question 19

What are causes of inability to process nutrients properly leading to failure to thrive?

Answer 19

• inborn errors of metabolism

- T1DM

Question 20

What must be involved in a history and examination for failure to thrive?

Answer 20

• pregnancy, birth, developmental, social history
• feeding or eating history
• observe feeding
• mum’s physical and mental health
• parent-child interactions
• height, weight, BMI (if >2 years) and plot on growth chart
• calculate mid-parental height centile

Question 21

What is involved in a feeding history?

Answer 21

• breast or bottle feeding
• feeding times
• volume and frequency
• any difficulties with feeding

Question 22

What is involved in an eating history?

Answer 22

• food choices
• food aversion
• meal time routines
• appetite
• consider a food diary

Question 23

How is BMI calculated?

Answer 23

BMI = weight (kg)/height^2 (m2)

Question 24

How is the mid parental height calculated?

Answer 24

(height of mum + height of dad) / 2

Question 25

What outcomes from assessment would suggest inadequate nutrition or a growth disorder?

Answer 25

- height more than 2 centile spaces below mid-parental height centile - BMI below the 2nd centile

Question 26

What key investigations should be done for faltering growth?

Answer 26

- urine dipstick (r/o UTI) | - coeliac screen (anti-TTG, anti-EMA antibodies)

Question 27

What is the management for failure to thrive?

Answer 27

Management depends on the cause and may involve MDT input. Regular reviews to monitor weight gain.

Question 28

How can difficulty with breastfeeding be managed?

Answer 28

- supplement with formula milk (successful but often results in breastfeeding stopping - encourage to feed with breastmilk prior to top-up feeds and express when not breastfeeding to encourage lactation to continue)

Question 29

How can inadequate nutrition be managed?

Answer 29

- encouraging regular structured mealtimes and snacks - reduce milk consumption to improve appetite for other foods - review by dietician - additional energy dense foods to boost calories - nutritional supplement drinks

Question 30

If other measures fail and serious concerns for failure to thrive, what may the MDT consider?

Answer 30

Enteral tube feeding. Must have clear goals and a defined end point.

Question 31

How is short stature defined?

Answer 31

- height more than 2 standard deviations below the average for their age and sex - below the 2nd centile

Question 32

How can a child's predicted height be calculated?

Answer 32

Boys: (mother height + father height + 14cm) / 2 Girls: (mother height + father height - 14cm) / 2

Question 33

What are the causes of a short stature?

Answer 33

- familial short stature - constitutional delay in growth and development - malnutrition - chronic diseases e.g. coeliac disease, IBD, congenital heart disease - endocrine disorders e.g. hypothyroidism - genetic conditions e.g. Down syndrome - skeletal dysplasias e.g. achondroplasia

Question 34

What is constitutional delay in growth and puberty?

Answer 34

A variation on normal development leading to short stature in childhood when compared with peers but normal height in adulthood. Puberty is delayed and growth spurt during puberty lasts longer. Ultimately reach predicted adult height.

Question 35

What is a key feature of constitutional delay in growth and puberty?

Answer 35

Delayed bone age compared with the reference for their age and sex.

Question 36

How is bone age estimated?

Answer 36

Images of wrist and hand x-ray to assess size and shape of the bones and growth plates.

Question 37

How is constitutional delay in growth and puberty diagnosed?

Answer 37

History, examination, xray of hand and wrist to assess bone age

Question 38

What is the management for constitutional delay in growth and puberty?

Answer 38

- exclude other causes of a short stature and delayed puberty - reassure parents and child - monitor growth over time

Question 39

What are the differentials for ADHD?

Answer 39

- general developmental delay - medication side effects e.g. salbutamol, anti-histamines - ill-disciplined - over-tired - severe emotional abuse and neglect

Question 40

What are the core symptoms of autism?

Answer 40

Impairment in: - social interaction - communication - limited range of activities/repetitive behaviours

Question 41

What are the core symptoms of ADHD?

Answer 41

- hyperactivity - impulsivity - inattention

Question 42

What are differentials for autism?

Answer 42

- CNS development abnormalities - Fragile X syndrome - tuberous sclerosis - expressive and receptive language disorders - Rett syndrome (females, developmental regression, microcephaly, hand-wringing)

Question 43

What age are medications used in ADHD from?

Answer 43

Over 6 years old

Question 44

What are educational psychologists?

Answer 44

Go into school environment and assess child alongside peers, their processing and any signs of learning difficulties.