Normal Child Development and Developmental Problems, ENT

Question 1

Define child development.

Answer 1

The biological, psychological and emotional changes that occur between birth and adolescence as the individual progresses from dependency to increasing autonomy. It is a continuous process with a predictable sequence however each child’s development is unique.

Question 2

Give 5 influences on a child’s development.

Answer 2

1. Genetic factors.
2. Stimulating environment.
3. Pregnancy factors e.g. premature? Mum’s health?
4. Healthy attachment.
5. Medical conditions.
6. Abuse/neglect/domestic violence.
7. Healthy peer relationships.
8. Education.
9. Nutrition.
10. Parenting style.

Question 3

What are the 4 domains of child development?

Answer 3

1. Gross motor.
2. Fine motor and vision.
3. Speech, language and hearing.
4. Social interaction and self care skills.

Question 4

What are the developmental milestones for gross motor function?

Answer 4

• 3m: lifts head on tummy.
• 6m: chest up with arm support, can sit unsupported.
• 8m: crawling.
• 9m: pulls to stand.
• 12m: walking.
• 2 years: walking up stairs.
• 3 years: jumping.
• 4 years: hopping.
• 5 years: rides a bike.

Question 5

With regards to gross motor development, at what age would you expect a child to do the following:

a) walking.
b) jumping.
c) crawling.
d) walking up stairs.

Answer 5

a) Walking - 12 months.
b) Jumping - 3 years.
c) Crawling - 8 months.
d) Walking up stairs - 2 years.

Question 6

What are the developmental milestones for fine motor and visual function?

Answer 6

• 4m: grabs an object using both hands.
• 8m: takes objects in each hand.
• 12m: scribbles with crayons e.g. circle, cross, square.
• 18m: builds a tower of 2 cubes.
• 3 years: builds a tower of 8 cubes.

Question 7

With regards to fine motor and visual development, at what age would you expect a child to do the following:

a) drawing with crayons.
b) building a tower of 8 cubes.
c) takes an object in each hand.
d) builds a tower of 2 cubes.

Answer 7

a) Drawing with crayons - 12m.
b) Building a tower of 8 cubes - 3 years.
c) Takes an object in each hand - 8m.
d) Builds a tower of 2 cubes - 18m.

Question 8

What are the developmental milestones for speech, language and hearing?

Answer 8

• 3m: laughs and squeals
• 9m: can make sounds such as ‘dada’ and ‘mama’.
• 12m: can say one word.
• 2 years: can form short sentences and name body parts.
• 3 years: speech is mainly understandable.
• 4 years: knows colours and can count.
• 5 years: knows the meaning of words.

Question 9

With regards to speech, language and hearing, at what age would you expect a child to do the following:

a) form short sentences and name body parts.
b) knows colours and can count.
c) laughs and squeals.
d) has mainly understandable speech.

Answer 9

a) Forms short sentences and name body parts - 2 years.
b) Knows colours and can count - 4 years.
c) Laughs and squeals - 3 months.
d) Has mainly understandable speech - 3 years.

Question 10

What are the developmental milestones for social interaction and self-care skills?

Answer 10

• 6 weeks: smiles.
• 6 months: finger feeds.
• 9m: waves bye-bye.
• 12m: uses cutlery.
• 2 years: undresses, feeds toys.
• 3 years: plays with others, names a friend.
• 4 years: dresses with no help, plays a board game.

Question 11

What does ‘The healthy child programme’ encourage?

Answer 11

1. Encourages care to keep children healthy and safe.
2. Promotes healthy eating and activity.
3. Identifies problems in children’s development.
4. Identifies ‘at risk’ families for more support.
5. Ensures children are prepared for school.

Question 12

Give two examples of concerning child development with regards to gross motor function.

Answer 12

1. Not sitting by 12 months.

2. Not walking by 18 months.

Question 13

Give an example of concerning child development with regards to fine motor function.

Answer 13

Hand preference before 18 months.

Question 14

Give two speech and language examples that may suggest concerning child development.

Answer 14

1. Not smiling by 3 months - blindness? ASD?

2. No clear words by 18 months - ASD? Language problems?

Question 15

Give two examples of concerning child development with regards to social development.

Answer 15

1. No response to carers interactions by 8 weeks.

2. No interest in playing by 3 years.

Question 16

Give 5 red flags in child development.

Answer 16

1. Regression.
2. Poor health/growth.
3. Significant family history.
4. Abnormal findings on examination e.g. microcephaly.
5. Safeguarding indicators.

Question 17

Causes of developmental delay: give examples of genetic causes.

Answer 17

1. Chromosomal disorders e.g. Down’s syndrome.
2. Micro-deletions or micro-duplications.
3. Single gene disorders e.g. Duchenne.
4. Polygenic e.g. ASD, ADHD.

Question 18

Causes of developmental delay: give examples of pregnancy related causes.

Answer 18

1. Congenital infections e.g. CMV, HIV.
2. Exposure to drugs/alcohol.
3. MCA infarct.

Question 19

Causes of developmental delay: give examples of birth related causes.

Answer 19

1. Prematurity.

2. Birth asphyxia (due to hypoxia).

Question 20

Causes of developmental delay: give examples of childhood related causes.

Answer 20

1. Infections e.g. meningitis.
2. Chronic ill health.
3. Acquired brain injury.
4. Hearing or visual impairment.

Question 21

How might you investigate someone’s child development if you suspected that there was something wrong?

Answer 21

Thorough history and examination. Tailor any investigations to the child e.g.

• Boys not walking by 18m check creatinine kinase for Duchenne.
• Focal neurological signs -> MRI brain.
• Genetic testing.
• Unwell, failure to thrive -> metabolic investigations.

There is no ‘developmental screen’, investigations need to be tailored towards to the child.

Question 22

Define childhood disability.

Answer 22

Someone who has a physical or mental impairment that results in a marked, pervasive limitation on activity. For example, Down’s syndrome and Cerebral Palsy.

Question 23

Give 3 clinical features of down’s syndrome.

Answer 23

1. face: upslanting palpebral fissures, epicanthic folds, Brushfield spots in iris, protruding tongue, small low-set ears, round/flat face, flat occiput
2. single palmar crease, pronounced ‘sandal gap’ between big and first toe
3. hypotonia
4. congenital heart defects (40-50%, see below)
5. duodenal atresia
6. Hirschsprung’s disease

Question 24

What is cerebral palsy?

Answer 24

A disorder of movement and posture due to a non-progressive lesion of the motor pathways in the developing brain

Question 25

Give 3 causes of cerebral palsy.

Answer 25

80% antenatal - hypoxia, infection, haemorrhage, ischaemia. 10% peri-natal - hypoxia, infection, haemorrhage. 10% postnatal - hypoxia, infection e.g. meningitis, haemorrhage, trauma, hypoxic ischaemic encephalopathy

Question 26

Describe the support that is offered to someone with cerebral palsy.

Answer 26

1. Physiotherapists for mobility and hand function. 2. SALT for communication. 3. Feeding support. 4. Sleeping support.

Question 27

Give 3 potential consequences of hearing loss.

Answer 27

1. Speech and language delay. 2. Social problems e.g. behavioural issues. 3. Academic underachievement.

Question 28

How does hearing loss in children often present?

Answer 28

1. Parental concern. 2. Speech, behavioural or educational problems. 3. Incidentally on screening.

Question 29

What are the 3 types of hearing loss?

Answer 29

1. Conductive hearing loss- ear canal/middle ear 2. Sensori-neural hearing loss- cochlea/auditory nerve 3. Mixed.

Question 30

Give 3 causes of conductive hearing loss.

Answer 30

1. Glue ear. 2. Ear wax. 3. Otitis media. 4. Perforated ear drum.

Question 31

Describe the management of conductive hearing loss.

Answer 31

Conductive hearing loss is usually ENT managed: - Wait and wait - most will resolve on their own. - Grommet insertion. - Temporary hearing aid.

Question 32

Give 3 risk factors for sensori-neural hearing loss.

Answer 32

1. Family history. 2. Special care baby unit (SCBU). 3. Consanguinity.

Question 33

Describe the management of sensori-neural hearing loss.

Answer 33

Sensori-neural hearing loss is often managed by a paediatrician. Treatments involve hearing aids or cochlea implants.

Question 34

How would you manage mixed hearing loss?

Answer 34

You would address the conductive problem first and then offer a hearing aid.

Question 35

When is hearing tested in children?

Answer 35

1. New-born hearing screen. 2. School entry hearing test. 3. Long term monitoring is done in high risk groups.

Question 36

Is the new-born hearing screen an objective or subjective test?

Answer 36

It is an objective test - response or no response. If there are concerns, the patient is followed up with evoked response audiometry.

Question 37

What are the 3 aims of hearing testing in children?

Answer 37

1. Measure hearing threshold (dB). 2. To be frequency specific (Hz). 3. Obtain single ear information if possible.

Question 38

Name 4 types of subjective hearing testing.

Answer 38

1. Behavioural observational audiometry. 2. Distraction testing. 3. Visual reinforcement audiometry. 4. Performance testing and play audiometry.

Question 39

Name 2 organisms that can cause acute otitis media.

Answer 39

S.pneumoniae. | H.influenzae.

Question 40

Give 3 symptoms of acute otitis media.

Answer 40

1. Pain. 2. Fever. 3. Generally unwell 4. Otorrhoea.

Question 41

Give 2 potential complications of acute otitis media.

Answer 41

1. Extra-cranial: mastoiditis, tympanic membrane perforation. 2. Intra-cranial: meningitis, abscess.

Question 42

Describe the treatment for acute otitis media.

Answer 42

Watch and wait. Analgesia. If recurrent, offer antibiotics and consider a grommet.

Question 43

What is the function of a grommet?

Answer 43

A grommet keeps the middle ear aerated and prevents the accumulation of fluid in the middle ear.

Question 44

When might a grommet be indicated?

Answer 44

1. Recurrent acute otitis media. 2. Chronic otitis media + effusion. 3. Ear and throat dysfunction.

Question 45

What is the common name for otitis media + effusion?

Answer 45

Glue ear.

Question 46

What causes glue ear?

Answer 46

Infection! 45% follow AOM.

Question 47

Give 5 risk factors for glue ear.

Answer 47

1. Older sibling. 2. Male. 3. Nursery attendance. 4. Parental smoking. 5. Allergies.

Question 48

What are the criteria for considering a tonsillectomy?

Answer 48

1. >7 episodes of acute tonsilitis in a year. | 2. OSA or sleep-deprived breathing.

Question 49

Give a cause of retinopathy of prematurity.

Answer 49

Hyperoxic insult. Retinopathy of prematurity can lead to blindness.

Question 50

Breast feeding has many benefits. Give 4 benefits for the infant.

Answer 50

1. Reduces the risk of infection. 2. Reduces the risk of allergic disease. 3. Reduces the risk of GORD. 4. Reduces risk of necrotising encephalitis in preterm infants.

Question 51

Breast feeding has many benefits. Give 3 benefits for the mother.

Answer 51

1. Reduces the risk of breast cancer. 2. Reduces the risk of PPH and post-natal depression. 3. Optimum child spacing. 4. Less food/medical expense.

Question 52

Give 5 medical problems that preterm infants may suffer from.

Answer 52

1. Respiratory distress syndrome 2. Apnoea and bradycardia. 3. Patent ductus arteriosus. 4. Infection. 5. Jaundice. 6. Intraventricular haemorrhage. 7. Cystic periventricular leukomalacia. 8. Necrotising enterocolitis. 9. Retinopathy of prematurity. 10. Hypothermia.

Question 53

Describe the aetiology of strabismus.

Answer 53

Multifactorial - hereditary and refractive errors. There is also a higher incidence in infants with cerebral palsy. Febrile illness can be a trigger.

Question 54

Define ambylopia.

Answer 54

Defective acuity that persists after correction of refractive error and removal of any pathology.

Question 55

Describe the treatment for ambylopia.

Answer 55

1. Refractive adaptation - wear appropriate glasses for 16w. 2. Occlusion of better seeing eye. 3. Atropine drops in better eye.

Question 56

What is the Moro reflex?

Answer 56

The Moro (startle) reflex is a primitive reflex that is a response due to a sudden loss of support. Sudden extension of the head causes symmetrical extension then flexion of the arms.

Question 57

Why should primitive reflexes disappear?

Answer 57

Primitive reflexes should gradually disappear as postural reflexes, that are essential for motor development, develop.

Question 58

Why is it concerning if primitive reflexes persist?

Answer 58

There may be a sign of CNS dysfunction.

Question 59

Name 3 primitive reflexes.

Answer 59

1. Grasp. 2. Rooting. 3. Moro. 4. Asymmetrical tonic neck reflex. 5. Stepping response

Question 60

How does cerebral palsy often present?

Answer 60

Abnormal limb/trunk posture and tone in infancy and delayed milestones. Feeding difficulties. Abnormal gait once walking is achieved. Asymmetric hand function before 12 months. Primitive reflexes may persist.

Question 61

Cerebral palsy is characterised according to neurological features. What are the categories?

Answer 61

1. Spastic - hemiplegic, quadriplegic, diplegic. 2. Dyskinetic- chorea, athetosis, dystonia 3. Ataxic.

Question 62

How might you investigate a child who is presenting with signs of cerebral palsy?

Answer 62

1. Cytogenetic tests. 2. Metabolic tests. 3. Imaging e.g. MRI brain. 4. Neurophysiological tests.

Question 63

Why might the clinical signs of cerebral palsy change over time?

Answer 63

The clinical signs may change over time as the brain matures but the underlying aetiology is not progressive.

Question 64

What drug can be used to treat spasticity in children with cerebral palsy?

Answer 64

1. oral diazepam 2. oral and intrathecal baclofen 3. botulinum toxin type A 4. orthopaedic surgery 5. selective dorsal rhizotomy

Question 65

Which is more concerning: a paralytic or a non-paralytic squint?

Answer 65

Paralytic squints are more concerning.

Question 66

What type of squint may require neuro-imaging?

Answer 66

Paralytic squints. These may be due to a space occupying lesion e.g. brain tumour.

Question 67

Causes of delayed puberty

Answer 67

Delayed puberty with short stature: Turner's syndrome Prader-Willi syndrome Noonan's syndrome ``` Delayed puberty with normal stature: polycystic ovarian syndrome androgen insensitivity Kallman's syndrome Klinefelter's syndrome ```

Question 68

When should antibiotics be considered in otitis media?

Answer 68

Symptoms lasting more than 4 days or not improving Systemically unwell but not requiring admission Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease Younger than 2 years with bilateral otitis media Otitis media with perforation and/or discharge in the canal

Question 69

Define enuresis.

Answer 69

Involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract'

Question 70

Describe the mx of nocturnal enuresis.

Answer 70

1. Look for possible underlying causes/triggers (e.g. Constipation, diabetes mellitus, UTI if recent onset) 2. Advise on fluid intake, diet and toileting behaviour 3. Reward systems (e.g. Star charts) 4. An enuresis alarm is first-line for children under the age of 7 years 5. Desmopressin may be used first-line for children over the age 7 years, particularly if short-term control is needed or an enuresis alarm has been ineffective/is not acceptable to the family

Question 71

What are the causes of precocious puberty in boys?

Answer 71

bilateral enlargement = gonadotrophin release from intracranial lesion unilateral enlargement = gonadal tumour small testes = adrenal cause (tumour or adrenal hyperplasia)

Question 72

Name 4 postural reflexes.

Answer 72

1. Labyrinthine righting 2. Postural support 3. Lateral propping 4. Parachute