GROWTH AND DEVELOPMENT

1. Percentile - Data is arranged in ascending order from 0 to 100 to show which percentage of the distribution is above and below the item

2. The Standard Deviation is a measure of how far away a particular value is from the normal. Its symbol is σ (the Greek letter sigma). It is the square root of the Variance.

3. A z score is the number of standard deviations above or below the mean a particular score For instance, if a person scored a 70 on a test with a mean of 50 and a standard deviation of 10, then they scored 2 standard deviations above the mean. Converting the test scores to z scores, an X of 70 would be:

i.e

Definitions of growth and development:

1. Growth:a. It is physical maturation. It is the increase in size of the body – in height, weight and

other measurable areas. b. Rates vary during different stages of growth ; The growth rate is rapid during

the prenatal,neonatal, infancy and adolescent stages and slows during childhood2. Development:

a. Development is physiological and psychological maturation.b. It is the gaining of behaviour and skills in all aspects of the child’s life.

3. Developmental milestones:Developmental milestones are a set of functional skills or age-specific tasks that most children can do at a certain age range.

4. Domains of development:1. Gross motor: using large groups of muscles to sit, stand, walk, run, etc., keeping

balance, and changing positions.

2. Fine motor: using hands to be able to eat, draw, dress, play, write, and do many other things.

3. Language: speaking, using body language and gestures, communicating, and understanding what others say.

4. Cognitive: Thinking skills: including learning, understanding, problem-solving, reasoning, and remembering.

5. Social: Interacting with others, having relationships with family, friends, and teachers, cooperating, and responding to the feelings of others.

FACTORS AFFECTING GROWTH AND DEVELOPMENT:

1. Major factors are: a. Nature (intrinsic forces) Eg genetic makeup; sex etc.b. Nurture (extrinsic forces) Eg. Nutrition, loving care etc.

2. Pre-natal environmenta. 1-Factors related to mothers during pregnancy:

i. Nutritional deficienciesii. Diabetic mother

iii. Exposure to radiationiv. Infection with German measlesv. Smoking

vi. Use of drugsb. Factors related to fetus:

i. Mal-position in uterusii. Faulty placental implantation

3. Genetic control: a. Examples of genetically controlled aspects are:

i. Dental and skeletal maturation ii. The timing of ossification of bones

iii. The body size: eg. familial obesity iv. The stunted growth in achondroplasia is inherited as a simple dominant gene. v. Chromosomal abnormalities like trisomy 18 and 21 are associated with growth

retardation.vi. Genetic short stature : Rubinstein Taybe

vii. Genetic origin of mental retardation : Rett syndromeviii. The difference between male and female patterns of growth.

4. Race: there is racial difference in growth as seen in pigmies who are shorter5. Environment:

a. Seasonal variation in growth has also been observed b. Races of mankind vary in stature according to the climates in which they live.c. Lack of sunlight can lead to Vit.D deficiency rickets and short stature

6. Endocrine:a. Growth hormone controls the rate of growth upto the time of adolescent spurt.b. Thyroid hormone plays a vital role throughout the whole of growth; short staure and

mental deficiency are features of hypothyroidism.

c. Gonadotrophins are responsible for the growth of the ovaries and testis, and later on the secretion of the amounts of estrogens and testosterone. They are responsible for the growth and development of secondary sex characters

d. Testosterone, produced by the testicle, is important in stimulating growth and it is responsible for the greater growth of muscle

7. Nutritional: a. Essential amino acids have been claimed to be essential for growth b. Deficiency of zinc causes stunting, interference with sexual development and falling

out of hairc. Iodine is needed for the manufacture of the thyroid hormonesd. Bone growth depnds on adequate supply of calcium and phosphorus e. Iron is required for the production of haemoglobin.Chronic anemia affects growth and

mental development. f. In vitamin C deficiency the intercellular substance of bone is inadequately formed. g. Vitamin D deficiency is the cause of rickets.h. Nutrition: Macro nutrition affects growth: e.g. Marasmus, nutritional dwarfism etci. Nutritional dwarfism is produced by chronic malnutrition.

8. Cultural:a. Vetgetraian and non vegetarian diet may have implications on growthb. Cultural food and cultural practices also may affect growth; eg. Vagan and food

faddism; 9. Prenatal exposure to teratogens:

i. Mercury poisoning, ii. Foetal alcohol syndrome

10. Postnatal: i. Meningitis,

ii. Brain injuryiii. Chronic illness: iv. CHD, v. diabetes,

vi. Cystic fibrosis, vii. Bronchial asthma etc

11. Physical and neurologic maturation: e.g. i. Child is able to walk after 2 years only;

ii. physiological decrease in growth, appetite, and sleep at 2 years 12. Temperament: child’s intrinsic qualities Eg:

i. the easy, highly adaptable child, ii. the difficult child, who withdraws from new stimuli and is easily frustrated;

iii. the slow-to-warm-up child13. Socioeconomic:

a. Children from different socioeconomic levels differ in average body sizeb. Size of family exerts an indirect influence on the rate of growth

14. Psychologic influences:a. Attachment: child’s dependence on parents

i. Tender loving care promotes good physical and psychological development;

ii. Parental deprivation leads to growth retardation and developmental delay.b. Contingency: this refers to the attention given by adult care givers (parents, grant

parents etc) which nurtures the social and psychological development of the child. Better the care normal will be the development.

15. Secular trend:a. Overall economic conditions of world have improved in last 100 years and there is

found tendency for children to become progressively larger ay all ages.a. There has been rather a fast reduction in the age of menarche

PATTERNS OF G&D

a. There are definite and predictable pattern of growth and development that are continuous, orderly and progressive.

i. Crawl à Creep à Walkii. Babbles à Words à Sentences

iii. Scribble à Writingb. Directional Pattern:

iv. Cephalocaudal Pattern ( Head to Tail)v. Proximal to Distal (Midline to peripheral)

vi. Mass to specific (Differentiation)c. Sequential Pattern:

i. Involves a predictable sequence of Growth and Development ii. Child starts crawling before walking

iii. First child plays alone, then with others.

GROWTH AND DEVELOPMENT - 0 to 3 years

1. 0-2 months:1. Physical:

i. Weight:1. Wt loss by 10% of birth weight in first week; regains it in 2 week2. Gains 30 gm /day in first month (fastest growth in life)

ii. Active Moro response; tonic neck postureiii. Visual preference to human face

2. Cognitive:i. Recognizes facial expression like smile

3. Emotional:i. Crying in response to wet diaper

ii. Cries while hungry and relief after feeding2. 2-6 months:

1. physical:i. weight is doubled at the end of 4 months

ii. Disappearance of asymmetric tonic neck reflex iii. Grasp reflex disappear to hold and release objects voluntarilyiv. intentional rolling overv. Holds heads with bopping 3 mo, steadily at 4-5 mo

2. Cognitive:

i. Starts shifting attention from breast feeding mother to other things 3. Emotional development and communication:

i. Says inga - 3 moii. Loughs aloud - 4 mo

iii. Excited at sight of food- 4 moiv. sadness when parents are unavailable

3. 6-12 months:1. Physical:

i. At 1 year the birth weight triples; length increase by 50%; HC increases by 10 cmii. Sits supported 6-7 mo; without support 10 mo; pivots while sitting 9-10 mo;

iii. Crawl and pulling to stand 8 moiv. pincer grasp by 12 mo;v. Walks by 1 yr

vi. Mandibular central incisors erupt2. Cognitive:

i. At 9 mo, search for objects if hidden- object permanenceii. Plays peek-a-boo; pat-a-cake and waves bye bye -10 mo

3. Emotional:i. stranger anxiety

4. Communication:i. Utter syllables like ma, da, pa – babbling 8-10 mo

ii. Responds to nameiii. Says mama, dada-12 mo

4. The second year: 12-18 mo1. Physical:

i. Growth rate slows and appetite declinesii. exaggerated lumbar lordosis and protruding abdomen

iii. increase in head circumference by 2 cm2. Cognitive:

i. Stacks blocks: Makes tower of 3 cubes by 15 mo; 4 cubes by 18 moii. Symbolic play: pretends to drink from an empty cup

iii. Imitates parent or older children3. Emotional:

i. Orbit around parents ii. Exhibit temper tantrums

4. Linguistic:i. words like no, bye-bye, give-me etc -12 mo

ii. Names body parts 5. Second year: 18-24 mo:

1. Physical:i. 90% head circumference achieved in 2 yr

2. Cognitive:i. Symbolic play: Feeds a toy from empty plate

3. Emotional:i. Shows separation anxiety when parents are missing

ii. Uses a toy or blanket (transitional object) while sleeping to represent absent parent

4. Linguistic:i. 15-20 words at 18 mo and 50-100 words at 2 years

ii. Combine two wordsiii. Understands 2 –step commands like give the ball and take the shoes

6. Age 3 years: (Preschool)1. Weight: average gain of about 2 kg per year2. Height: average growth of about 7 cm per year3. Gross motor:

1. Walks up stairs unassisted2. Rides a tricycle3. Stacks 10 blocks

4. Fine motor:1. draws straight lines and circle2. Uses spoon well and feeds self3. Dresses and undresses self except for buttons and laces4. Holds a pencil in writing position5. Develop handedness

6. Adaptive:1. Has all 20 primary ("baby") teeth2. Bladder and bowel control are established; 3. Understands size differences (i.e., big and little)4. Counts up to four objects by 4 years old

7. Speech:1. Speaks in three word sentences 2. Can remember simple rhymes or lyrics3. Uses "please" and "thank you"5. Names colors

8. Social:1. play with other children2. Understands concept of "mine" and "his/hers" Definition and introduction:

Gross Motor Fine Motor Language Social/Adaptive

1 mo Lifts head when prone Visually fixes to midline Vocalizes Regards faces, social smile at 6 wks

2 mos Can lift head 45° and extend arms forward when prone

Can follow across midline, grabs clothes

Coos Social smile

4 mos Can raise head and chest when prone, no head lag, rolls front to back

Hands together, objects to mouth

Responds to voice, squeals

Regards own hands

6 mos Sits up unsupported Reaches for toys, ulnar grasp

Babbles, responds to name, imitates

Stranger anxiety

sounds

8 mos Can stand if held Transfers across midline Mama/dada (non-specific)

Waves bye-bye at 8.5 mos

9 mos Crawls, pulls to a stand

Finger-thumb grasp Jabbers Plays patty-cake, separation anxiety

10 mos Cruises at 11 mos Pincer grasp Mama/dada (specific)

Plays peek-a-boo

12 mos Walks alone or with support

Throws Few words plus mama/dada

Drinks from a cup

15 mos Walks well, walks backwards

Scribbles, can make tower of 2-3 cubes

Points, follows simple commands

Hugs parents, uses spoon/fork, removes clothes

18 mos Runs, walks up stairs, kicks ball

Tower of 3-4 cubes 10 words Feeds self, helps brush teeth, pts to body parts

2 yrs Walks up and down stairs, throws a ball overhead, jumps

Initiates pencil stroke, tower of 6 cubes

2-3 word phrases, 25% of speech understandable

Listens to stories, parallel play

2.5 yrs Walks on toes Tower of 8 cubes Knows name, 50% of speech understandable

Dry at night, toilet trained between 2-3 yrs

3 yrs Goes up stairs with alternating feet, stands on one foot, rides tricycle

Copies a circle and a cross, hand preference

3 word phrases, knows age and gender, 75% of speech understandable

Plays with others, shares toys, partially dresses self

4 yrs Hops on one foot Copies a square, uses scissors

Tells a story, asks questions, knows full name, 90% of speech understandable

Interactive play, role play, goes to toilet alone, dresses self completely, brushes teeth on own

5 yrs Skips, rides a bike with training wheels

Copies a triangle, ties shoes, prints name, draws a person (6 parts)

Names 4 colours, fluent speech, can say alphabet

Plays competitive games with rules

DEVELOPMENTAL THORIES

1. Major Child Development Theories:a) Freud's psychosexual stage theory b) Erikson's psychosocial stage theory c) Kohlberg's moral understanding stage theory d) Piaget's cognitive development stage theory e) Bronfenbrenner's ecological systems theory

2. Sigmund Freud:

1. Children's development is determined by basic sexual and aggressive drives, the basic instincts by which animal live.

2. Phases of development: Children are going through multiple stages of sexual development,: Oral, Anal, Phallic, Latency, and Genital. In the oral phase, children are focused on the pleasures that they receive from sucking and biting with their mouth. In the Anal phase, this focus shifts to the anus as they begin toilet training and attempt to control their bowels. In the Phallic stage, the focus moves to genital stimulation and the sexual identification that comes with having or not having a penis.

3. Oedipus complex: During this phase, Freud thought that children turn their interest and love toward their parent of the opposite sex and begin to strongly resent the parent of the same sex. He called this idea the Oedipus complex as it closely mirrored the events of an ancient Greek tragic play in which a king named Oedipus manages to marry his mother and kill his father.

4. Id-ego-superego: Freud thought that all babies are initially dominated by selfish urges for immediate gratification which he labeled the Id. As babies attempt and fail to get all their whims met, they develop a more realistic appreciation of what is realistic and possible, which Freud called the "Ego". Over time, babies also learn about and come to internalize and represent their parents' values and rules. These internalized rules, which he called the "Super-Ego", are the basis for the the developing child's conscience that struggles with the concepts of right and wrong and works with the Ego to control the immediate gratification urges of the Id.

3. Erik Erikson 1. Erik Erikson (1902-1994): Erikson's theory combines how people develop beliefs

psychologically and mentally with how they learn to exist within a larger community of people, and it’s called a 'psychosocial' theory.

2. Erikson’s stages: trust versus mistrust; autonomy versus shame and doubt; initiative versus guilt; industry versus inferiority; identity versus identity confusion; intimacy versus isolation; generativity versus stagnation; and integrity versus despair.

3. For example, the first psychosocial stage is trust versus mistrust, and it spans from birth to about age one year. During this phase, if children are consistently provided all their basic needs such as food, clean diapers, warmth, and loving affection and soothing from caregivers, they will learn that they can trust other people in their environment to love them and to take care of them, and they will believe the world is good. If infants are neglected and not given these things consistently or if they are taken care of roughly and unpredictably, they will learn to question their caretakers and to believe that others will not always be there to support them when it’s needed. Learning to trust others is the first necessary step to learning how to have loving, supportive relationships with others and to have a positive self-image.

4. The second stage, autonomy versus shame and doubt, spans ages one to three years. When children are autonomous, they feel confident that they can make their own choices and decisions and that they will be positive experiences. Young children become autonomous when caregivers are supportive and give children the safe space to make their own decisions and to experiment with their bodies and problem-solving skills without shaming or ridiculing the child.

5. The third stage, initiative versus guilt, spans ages three to six years. When children develop initiative, they continue to develop their self-concept and gain a desire to try new things and

to learn new things while being responsible for their actions to some extent. If caregivers continue to give children a safe space to experiment and appropriate stimuli to learn, the children will continue to find their purpose. However, if caregivers try to create too many strict boundaries around what children can do and to force too much responsibility on kids, children will feel extreme guilt for their inability to complete tasks perfectly.

4. Lawrence Kohlberg 1. Lawrence Kohlberg (1927-1987) described three stages of moral development which

described the process through which people learn to discriminate right from wrong and to develop increasingly sophisticated appreciations of morality.

2. He believed that his stages were cumulative; each built off understanding and abilities gained in prior stages. According to Kohlberg, moral development is a lifelong task, and many people fail to develop the more advanced stages of moral understanding.

4. Jean Piaget 1. Swiss psychologist Jean Piaget (1896-1990), created a cognitive-developmental stage theory

that described how children's ways of thinking developed as they interacted with the world around them. Infants and young children understand the world much differently than adults do, and as they play and explore, their mind learns how to think in ways that better fit with reality.

2. Piaget's theory has four stages: sensorimotor, preoperational, concrete operational and formal operational.

3. During the sensorimotor stage, which often lasts from birth to age two, children are just beginning to learn how to learn. They learn by experiencing everything with their five senses, hence "sensory," and by learning to crawl and then walk, point and then grasp, hence, "motor."

4. During the preoperational stage, which often lasts from ages two though seven, children start to use mental symbols to understand and to interact with the world, and they begin to learn language and to engage in pretend play.

5. In the concrete operational stage that follows, lasting from ages seven through eleven, children gain the ability to think logically to solve problems and to organize information they learn.

6. Finally, during the formal operational stage, which often lasts from age eleven on, adolescents learn how to think more abstractly to solve problems and to think symbolically, e.g., about things that aren't really there concretely in front of them.

5. Urie Bronfenbrenner:

1. (1917-2005) developed the ecological systems theory to explain how everything in a child and the child's environment affects how a child grows and develops.

2. He labeled different aspects or levels of the environment that influence children's development, including the microsystem, the mesosystem, the exosystem, and the macrosystem.

3. The microsystem is the small, immediate environment the child lives in such as their immediate family or caregivers and their school or daycare. How a child acts or reacts to these people in the microsystem will affect how they treat her in return.

4. Bronfenbrenner's next level, the mesosystem, describes how the different parts of a child's microsystem work together for the sake of the child. For example, if a child's caregivers

take an active role in a child's school, such as going to parent-teacher conferences and watching their child's soccer games, this will help ensure the child's overall growth

5. The exosystem level includes the other people and places that the child herself may not interact with often herself but that still have a large affect on her, such as parents' workplaces, extended family members, the neighborhood, etc. For example, if a child's parent gets laid off from work, that may have negative affects on the child if her parents are unable to pay rent or to buy groceries; however, if her parent receives a promotion and a raise at work, this may have a positive affect on the child because her parents will be better able to give her her physical needs.

6. Bronfenbrenner's final level is the macrosystem includes things such as the relative freedoms permitted by the national government, cultural values, the economy, wars, etc. These things can also affect a child either positively or negatively.

ANTHROPOMETRY

Formulas for Approximate Average Height and Weight of Normal Infants and Children:Weight gain:

1. In NB:Wt loss by 10% of birth weight in first week; regains it in 2 week; Gains 30 gm /day in first month (fastest growth in life)

2. Birtweight doubles at 5 mo; triples at 1 year; quadruples at 2 years3. Formula for weight gain:

WEIGHT KILOGRAMS

At birth 3.25

3–12 mo Age(mo) x 92

1–6 yr Age (yr) × 2 + 8

7–12 yr Age(yrs)x7-52

Height gain:At birth: 50 cm1year: +25 cm= 75 cm2 year: + 12.5 cm= 87.5 cm3 year: + 6 cm= 93.5 cm4 year:+6 cm= 100cm8 year: 125 cm12 year: 150 cmAdult : ht at 2 years x 2= 175 cm

Formulae for height:

HEIGHT CENTIMETERS (INCHES)

At birth 50 (20)

At 1 yr 75 (30)

2–12 yr age (yr) × 6 + 77 (age [yr] × 2½ + 30)

Primary Dentition: no third molars; age of shedding 7-13 years.

Mandibular Maxillary

Central incisors 5–7 mo 6–8 mo

Lateral incisors 7–10 mo 8–11 mo

Cuspids (canines) 16–20 mo 16–20 mo

First molars 10–16 mo 10–16 mo

Second molars 20–30 mo 20–30 mo

BODY PROPORTIONS:1. The lower body segment is defined as the length from the symphysis pubis to the floor, and

the upper body segment is the height minus the lower body segment.2. The ratio of upper body segment divided by lower body segment (U/L ratio) equals

approximately:a. 1.7 at birth,b. 1.3 at 3 yr of age, andc. 1.0 after 7 yr of age.

3. Higher U/L ratios are characteristic of short-limb dwarfism or bone disorders, such as ricketsHEAD CIRCUMFERENCE (HC) -

Measurement of HC -By the crossed tape technique- the occipitofrontal diameter is measured.Importance of HC -When the HC is less than the third percentile for that age & sex, it is called `microcephaly' When the HC is more than 97th percentile, it is called `macrocephaly'

At Birth 34 cmFirst 3 months: 2 cm increase per month= 40 cm at 3 moNext 3 months: 1 cm increase per month= 43 cm at 6 moNext 6 months: 0.5 cm increase per month= 46 cm at 12 mo2nd year : + 2 cm= 48 cm3rd year: + 1 cm= 49 cmAdolescent 50.5 cmAdult 56 cm

CHEST CIRCUMFERENCE (CC)Measurement of CC :Crossed tape technique at the level of nipples anteriorly & inferior angle of scapula posteriorly.At birth the HC is > the CC by about 2 cms. At 9-12 months, the measurements become equal & CC exceeds the HC after that. This transition is delayed in malnutrition.

MID ARM CIRCUMFERENCE (MAC) -Measurement of MAC -It is taken at the midpoint (between tip of the acromian process & olecranon process of ulna) while the arm is hanging by the side.Importance of MAC -It is used as an age independent criterion for detecting malnutrition as it remains almost

constant between 16- 17 cm for about 5 yrs (from l yr to 6 yrs). It is because of gradual replacement of the fat of infancy by muscle mass. When less than 13.5 cms it indicates malnutrition & when less than 12.5 cms it indicates severe malnutrition.

Anthropometric measures used in the diagnosis of malnutrition and age independent criteria

Nutritional anthropometry:This is a valuable index of assessment of nutritional status. 2/3 of children with PEM does not present with clinical signs but are diagnosed by anthropometry.1. Weight for age:

Most sensitive method when recorded serially. A decrease in weight gain / loss in weight can be seen within 1 month.

2. Height for age: Compares the child's height with the expected height for the age.

3. Weight for height: This compares a child's weight with the expected weight of the same height. It is useful for differentiating between acute and chronic malnutrition.Acute malnutrition: Child is wasted i.e. weight for age and height is low but height for age is normal.Chronic malnutrition: Child is stunted i.e. weight for age is low and height for age is low.

4. Mid upper arm circumference (MUAC): Normal MUAC for a child between 1-5 years of age is greater than 13.5 cm. If the MUAC is 12.5-13.5, the child has mild to moderate malnutrition and if it is less than 12.5 cm it is suggestive of severe malnutrition. This is useful for screening a large number of children but less useful in long term growth monitoring.

5. Chest/ Head circumference Chest circumference = Head circumference at one year of age.

Chest circumference > Head circumference after 2 years of age. In PEM, chest circumference is less than Head circumference even after 2 years of age.

6. Skin fold thickness: It is an indication of the availability of caloric stores in the form of subcutaneous fat. Sites for measurement are triceps and subscapular region.

7. Body mass index: BMI is calculated as weight in Kg/height in M²; E.g. a 6 year old girl with BMI of 21 is overweight whereas 16 year old girl with BMI 21 is just above the 50th percentile

8. The most important measurement for malnutrition is the growth curve: weight for age is plotted as percentiles curves and growth is monitored over a period of time; it is also called road to health chart

Age Independent Criteria1. Weight for Height2. MID ARM CIRCUMFERENCE (MAC) -

1. Measurement of MAC -2. It is taken at the midpoint (between tip of the acromian process & olecranon

process of ulna) while the arm is hanging by the side.3. Importance of MAC -4. It is used as an age independent criterion for detecting malnutrition as it

remains almost constant between 16- 17 cm for about 5 yrs (from lyr to 6 yrs),It is because of gradual replacement of the fat of infancy by muscle mass. When less than 13.8 cms it indicates malnutrition & when less than 12.5 cms it indicates severe malnutrition.

3. Quac stick -1. It is a rod with 2 sets of markings. One indicates the height & the other shows

the expected MAC of a normal child for the corresponding height. The MAC of the child being examined is obtained & the stick is placed behind the standing child. If the height of the child is more than the height expected for the measured MAC, the child is considered to be malnourished.

4. Shakir's tape for MAC -1. It is a plastic tape with coloured zones -2. Green (>13.5 cms), corresponding to the MAC for normal Yellow (12.5 to 13.5

cms) borderline3. Red (<12.5 cms) wasted arms.

5. Bangle test -1. A bangle with an inner diameter of 4 cms is slipped up the arm of the child. If

it crosses the elbow, the child is considered malnourished. It is a less sensitive method as the width of the arm also depends on the thickness of the bones besides the muscle mass.

6. SKIN FOLD THICKNESS (SFT) -1. Measurement of SFT -2. Over triceps muscle or the subscapular region by using Herpenden's calipers.3. Importance -4. The SFT varies according to age & nutritional status of the patient. Normally it

is 10 mm or more. SFT < 6 mm indicates severe malnutrition.

Sexual development

1. Adolescence is a period of rapid physical, emotional, cognitive, and social development. Generally, adolescence begins at age 11–12 years and ends between ages 18 and 21. Most teenagers complete puberty by age 16–18 years;

2. Most girls enter puberty at age 9 or 10 years, reach menarche on average at 12 1/2, and achieve full fertility by age 15 or 16. Boys begin pubertal development somewhat later than girls, at age 11 or 12 years, produce sperm (spermarche) and have their first ejaculation on average at age 13 or 14, and achieve full fertility at approximately age 16.

3. Puberty consists of a series of predictable events, and the sequence of changes in secondary sexual characteristics has been categorized by several groups. The staging system utilized most frequently is that published by Marshall and Tanner and the sequence of changes, commonly referred to as "Tanner stages".

4. Sexual maturity rating (SMR) includes age ranges of normal development and specific descriptions for each stage of pubic hair growth, penis and testis development in boys, and breast maturation in girls.

CLASSIFICATION OF SEX MATURITY STATES IN BOYS SMR STAGE PUBIC HAIR PENIS TESTES1 None Preadolescent Preadolescent2 Scanty, long, slightly pigmented Minimal change/

enlargementEnlarged scrotum,pink, texture altered

3 Darker, starting to curl, small amount

Lengthens Larger

4 Resembles adult type, but less quantity; coarse, curly

Larger; glans andbreadth increase in size

Larger, scrotum Dark

5 Adult distribution, spread to medial surface of thighs

Adult size Adult size

CLASSIFICATION OF SEXUAL MATURITY STATES IN GIRLSSMR STAGE PUBIC HAIR BREASTS

1 Preadolescent Preadolescent2 Sparse, lightly pigmented, straight, medial

border of labiaBreast and papilla elevated as small mound; diameter of areola increased

3 Darker, beginning to curl, increased amount Breast and areola enlarged, nocontour separation

4 Coarse, curly, abundant, but less than in adult Areola and papilla form secondary mound

5 Adult feminine triangle, spread to medial surface of thighs

Mature, nipple projects, areola part of general breast contour

FAILURE TO THRIVE

Definition and introduction:1. FTT is defined as either a weight for age that falls below the 5th percentile

Classification:

Organic (medical) and nonorganic (psychosocial or environmental).Etiology:

The causes of organic FTT:1. Gastrointestinal:

1. Gastroesophageal reflux, 2. Pyloric stenosis, 3. Cleft palate/cleft lip,4. Lactose intolerance,5. Malabsorption:

a. Celiac diseaseb. Cystic fibrosisc. Cow's milk protein allergyd. Biliary atresia or liver disease

2. Renal:i. Urinary tract infection,

ii. Chronic renal insufficiency3. cardiopulmonary

i. Cardiac diseases leading to congestive heart failure,ii. Asthma,

iii. Cystic fibrosis,4. Endocrine:

i. Diabetes mellitus,ii. Adrenal insufficiency or excess,

5. Neurologic:i. Mental retardation,

ii. Degenerative disorders 6. Infectious:

i. Parasitic or bacterial infections of the gastrointestinal tract,ii. Tuberculosis,

iii. Human immunodeficiency virus disease 7. Metabolic:

i. Inborn errors of metabolism8. Congenital:

1. Chromosomal abnormalities,2. Perinatal infections3. Miscellaneous

a. Lead poisoning,b. Malignancy,

Causes of Non organic failure to thrive:1. FTT occurs when a child, usually an infant, is not fed adequate

calories.2. Maternal factors: ignorance, negligence; child abuse3. Emotional: or maternal deprivation ; Father: absence or

alcoholism2. Clinical Manifestations:

a. Failure to meet expected height and weight. b. Alopecia, loss of subcutaneous fat, reduced muscle mass, dermatitis, recurrent

infections, marasmus, and kwashiorkor. c. Anthropometry:

i. Body mass index for age less than the 5th percentile

ii. Length for age less than the 5th percentile

iii. Weight for age less than the 5th percentile

iv. Weight less than 75 percent of median weight for age

v. Weight less than 75 percent of median weight for length

vi. Weight velocity less than the 5th percentile

3. Red Flag Signs and Symptoms Suggesting Medical Causes of Failure to Thrive

1. Cardiac findings suggesting congenital heart disease or heart failure (e.g., murmur, edema, jugular

venous distention)

2. Developmental delay

3. Dysmorphic features

4. Failure to gain weight despite adequate caloric intake

5. Organomegaly or lymphadenopathy

6. Recurrent or severe respiratory, mucocutaneous, or urinary infection

7. Recurrent vomiting, diarrhea, or dehydration

8. The laboratory evaluation:i. Complete blood count,

ii. Lead level, iii. Urinalysis iv. Bone age is often helpful in distinguishing family short stature (bone age

equivalent to chronological age) from endocrine or nutritional abnormalities (bone age is less than chronological age).

v. Other tests:1. Thyroid function studies, 2. Tests for gastroesophageal reflux and malabsorption, 3. Organic and amino acids, 4. Sweat test

9. Diagnosis:

History/Physical Examination Diagnostic ConsiderationSpitting, vomiting, food refusal Gastroesophageal reflux, chronic, tonsillitis, food

allergiesDiarrhea, fatty stools Maabsorption, intestinal

parasites, milk protein intoleranceRecurrent wheezing Primary TB, Asthma, aspiration, cystic fibrosisRecurrent infections HIV

10. Treatment:

1. Organic FTT:a. The underlying medical condition should be treated. b. Nutritional management

2. For older infants and young children with psychosocial FTT:a. Age-appropriate nutritional counseling should be provided to parents. b. For parents of breastfed infants, recommending breastfeeding more often, ensuring

lactation support, or discussing formula supplementation until catch-up growth is achieved may be helpful.

c. Parents of formula-fed infants may be instructed on how to make energy-dense formula by concentrating the ratio of formula to water during periods of catch-up growth

d. For toddlers, mealtimes should be approximately 20-30 min, e. Solid foods should be offered before liquids, f. Children should eat with other people and not be force fed. g. High-calorie foods, such as peanut butter, whole milk, cheese, and dried fruits, should

be emphasized. 3. Severe malnutrition:

a. It is an indications for hospitalization, further diagnostic and laboratory evaluation, lack of catch-up growth, and evaluation of the parent-child feeding interaction.

b. Caloric intake should be monitored, and the parent-child feeding interaction should be observed.

7. Prognosis:a. FTT in the 1st yr of life, regardless of cause, is particularly ominous. Maximal postnatal

brain growth occurs during the first 6 mo of life. The brain grows as much during the 1st yr of life as during the rest of a child's life.

b. Approximately one third of children with psychosocial FTT is developmentally delayed and has social and emotional problems.

DEVELOPMENTAL DELAY

1. Definition: Attainment of developmental milestones < 2 standard deviation from the norm; the term usually is reserved for children younger than five years.

2. Types of developmental delay: a. Gross/fine motor

b. Speech/language,

c. Cognition

d. Social

e. Adaptive (activities of daily living)a. Global developmental delay: delay in two or more domains.

3. Prevalence: 1% to 3% of children younger than 5 years of age 4. Causes of developmental delay:

a. Antenatal: 1. Gnetic:

1. Trisomy 212. Fragile X syndrome (Male)3. Rett syndrome(Female)

2. Endocrine: Cretinism3. Infection: TORCHS 4. Toxic: Fetal alcohol syndrome5. IUGR 6. Prematurity 7. Post natal:

1. Hypoxic ischemic encephalopathy2. Kernicterus3. Infection: Meningitis Encephalitis4. Malnutrition5. Child neglect6. Head trauma

5. Cl. Features and evaluation:a. Language delay :

i. no mama/dada/babbling by 12 months, no 2-word phrases by age 2, b. Fine motor/adaptive delay

i. Significant delays in activities such as self-feeding, toileting, and dressing

ii. Prolonged, messy finger feeding and drooling c. Gross motor:

i. Clumsinessd. Cognitive delay:

i. Difficulties with memory, problem-solving and logical reasoning.

ii. Difficulty following directions (particularly multipart directions). e. Social delays:

i. Lack of peer play and imaginative play 6. EARLY DETECTION:

a. parents’ concerns about their child’s development, b. observation of developmental pattern c. Family history: H/O family members with mental retardation, developmental delaysd. Dysmorphologic Examination: mental retardation and physical anomalies

7. Evaluation of milestones:

AGE (MO) GROSS MOTOR FINE MOTOR SOCIAL SKILLS LANGUAGE

3 Supports weight on forearms

Opens hands spontaneously

Smiles appropriately Coos, laughs

6 Sits momentarily Transfers objects Shows likes and dislikes Babbles

9 Pulls to stand Pincer grasp Plays pat-a-cake, peek-a-boo Imitates sounds

12 Walks with one hand held

Releases an object on command

Comes when called 1–2 meaningful words

18 Walks upstairs with assistance

Feeds from a spoon Mimics actions of others At least 6 words

24 Runs Builds a tower of 6 blocks

Plays with others 2–3 word sentences

A child who does not attain the milestones for the appropriate age may be considered to have developmental delay.

8. Screening Tests: i. Parents’ Evaluation of Developmental Status (PEDS) is a parent interview

ii. Ages and Stages Questionnaires (ASQ) is a parent completed questionnaire iii. Bayley Infant Neurodevelopmental Screener Test iv. Denver Developmental Screening Test II: most well-known and frequently used

screening tests v. Indian Tools:

a) The Developmental Assessment Tool for Anganwadis (DATA) is a screening test designed for identifying toddlers aged 1.6 to 3 years attending Anganwadis (government sponsored preschool centers in India) and administered by Anganwadi workers.

b) The Trivandrum Developmental Screening Chart (TDSC) was developed from the Bayley Scales (using Baroda Norms). It is a 17 item screening tool for children up to 24 months of age.

c) The Disability Screening Schedule (DSS) is a broadbased screen for the identification of major disabilities in children under 6 years of age.

9. Medical evaluation:i. Head circumference for micro/macrocephaly

ii. Weight and height for growth deficiencyiii. Dysmorphology (minor and major congenital abnormalities) iv. Eye exam for poor tracking, strabismus, etcv. Ear exam for recurrent/chronic OM; hearing

vi. Visionvii. Abdomen for Hepato Spelno Megaly (metabolic disease)

viii. Skin for neurocutaneous lesions ix. Neurologic exam for reflexes, tone, symmetry, strength

10. Lab Tests:i. Cytogenic Studies: Karyotying

ii. Fluorescence in situ hybridization for the subtelomeric regions of each chromosome iii. Molecular Genetic Diagnostic Testing iv. FRAGILE X SYNDROME: Fragile X syndrome is the most common genetic cause v. Metabolic Studies

a. Thyroid function testingb. CPK/Aldolase if abnormal muscle tone (Muscular dystrophy)

vi. Magnetic Resonance Imaging for brain anomaliesvii. EEG if suspected seizure activity/encephalopathy

11. TREATMENTa. Speech and language therapyb. Occupational therapyc. Physical therapyd. Sensory integratione. medical or surgical treatments

12. Prevention:1. Prevention of Alcohol abuse in mother2. Prevention of Teen pregnancy

3. Prevention of Head trauma4. Safe sex to prevent STD and HIV5. Immunization to prevent CNS infections: e.g Hib vaccine6. New born screening for metabolic disorders- PKU; hypothyroidism 7. Antenatal screening for trisomy and counselling

MENTAL RETARDATION (Intellectual disability)

1. Definitions:

a. Intellectual disability (formerly called mental retardation) refers to a group of disorders that have in common deficits of adaptive and intellectual function and an age of onset before maturity is reached.

b. Three criteria must be met to establish the diagnosis of intellectual disability: i. Significantly subaverage intellectual function- Intelligence quotient of less

than 70ii. Significant impairments in adaptive function- cognitive and adaptive skills less

than 2 SD below the mean.iii. Onset before 18 years of age.

2. Two broad groups:a. Mild (IQ >50-70), which is more associated with environmental influences, and b. Severe (IQ < 50), which is more frequently linked to biologic causes.

3. Etiology of MR:a. Mild intellectual disability:

i. Genetic or chromosomal syndromes with multiple, major, or minor congenital anomalies (velocardiofacial syndrome, williams syndrome, noonan’s syndrome),

ii. Intrauterine growth restriction, iii. Prematurity, iv. Perinatal insults, intrauterine exposure to drugs of abuse (including alcohol),

and v. Sex chromosomal abnormalities.

b. Severe intellectual disability: i. Chromosomal (e.g., down syndrome wolf-hirschhorn syndrome, deletion 1p36

syndrome) and other genetic and epigenetic disorders (e.g., fragile x syndrome, rett syndrome, angelman and prader-willi syndromes),

ii. Abnormalities of brain development (e.g., lissencephaly), and iii. Inborn errors of metabolism or neurodegenerative disorders

(mucopolysaccharidoses)

S.NO Cause Examples % of case1 Chromosomal

abnormalities:1. Trisomy;2. Klinefelter etc

22

2 Genetic syndromes 1. Fragile X syndrome;2. Prader – Willi3. Rubinstein-Taybi syndrome4. Rett syndrome

21

3 Brain abnormality 1. Hydrocephalus;2. meningomyelocoel;3. lissencephaly

9

4 Inborn errors: 1. PKU;2. Tay-Sachs

8

5 Congenital infections: 1. HIV;2. TORCHS

4

6 Familial 1. Environment;2. genetic

6

7 Perinatal: 1. HIE; meningitis;2. IVH;3. PVL;4. fetal alcohol syndrome

4

8 Post natal: 1. Trauma;2. meningitis;3. hydrocephalus

5

9 Unknown 1. Cerebral palsy 21

5. Incidence: a. 2.5% of the population have intellectual disability, and 85% of these individuals fall into

the mild range.b. Children with intellectual disability also may be incorporated into another diagnosis (e.g.,

autism, cerebral palsy).c. Intellectual disability occurs more in boys than in girls: 2 : 1 in mild intellectual disability

and 1.5 : 1 in severe intellectual disability.6. Clinical Manifestations:

1. Most children with intellectual disability do not keep up with their peers and fail to meet age-expected norms. In early infancy,

2. Intellectual disability is usually identifiable by age 3 yr. 3. There are no specific physical characteristics of intellectual disability, but dysmorphisms

may be the earliest signs that bring children to the attention of the pediatrician.4. Seizure disorders, cerebral palsy, hypotonia, and autism are seen more commonly in

conjunction with intellectual disability than in the general population.5. Symptoms include:

1. Learning and developing more slowly than other children of the same age2. Difficulty communicating or socializing with others3. Lower than average scores on IQ tests4. Trouble learning in school5. Inability to do everyday things like getting dressed or using the bathroom without

help6. Difficulty hearing, seeing, walking, or talking7. Inability to think logically

6. Classification:1. Mild

1. IQ 50-702. Slower than normal in all areas3. No unusual physical signs

4. Can learn practical skills5. Reading and math skills up to grades 3-66. Can conform socially7. Can learn daily task skills8. Functions in society

2. Moderate 1. IQ 35-492. Noticeable delays, particularly speech3. Can learn simple communication4. Can learn elementary health and safety skills5. Can participate in simple activities and self-care6. Can perform supervised tasks7. Can travel alone to familiar places

3. Severe 1. IQ 20-342. Significant delays in some areas; may walk late3. Little or no communication skills, but some understanding of speech with

some response4. Can be taught daily routines and repetitive activities5. May be trained in simple self-care6. Needs direction and supervision socially

4. Profound 1. IQ <202. Significant delays in all areas3. Congenital abnormalities present4. Needs close supervision5. Requires attendant care6. May respond to regular physical and social activity7. Not capable of self-care

6. Developmental assessment1. Parents' Evaluation of Developmental Status (PEDS), 2. Ages and Stages Questionnaires (ASQ) and Child Development Inventories (CDI).3. The most common psychological tests for children include:

1. Wechsler’s scale2. The Bayley Scales of Infant Development-III,3. The Stanford-Binet Intelligence Scale4. Vineland adaptive behaviour scale

4. Indian Tools:a) The Developmental Assessment Tool for Anganwadis (DATA) is a screening test

designed for identifying toddlers aged 1.6 to 3 years attending Anganwadis (government sponsored preschool centers in India) and administered by Anganwadi workers.

b) The Trivandrum Developmental Screening Chart (TDSC) was developed from the Bayley Scales (using Baroda Norms). It is a 17 item screening tool for children up to 24 months of age.

c) The Disability Screening Schedule (DSS) is a broadbased screen for the identification of major disabilities in children under 6 years of age.

7. Clinical Evaluation:i. Family history: indicates heritable disorder: eg. Inborn errors ii. Dysmorphologic Examination: indicate a specific genetic disorder: eg Down syndrome

iii. Neurologic Examination:a. Microcephalyb. Macrocephalyc. Spastic child etc

8. Lab Tests:a. Cytogenic Studies

1. Karyotype: a. Chromosomal abnormalities: trisomy 21 b. Sex chromosome aneuploidy : Turner

2. DNA analysis: Fragile X syndrome 3. FISH probes:

a. Prader-Willi/Angelman syndromeb. Cri du chat syndrome

9. Metabolic Studies: a. Plasma amino acids (aminoacidopathies)b. Urinary organic acids (organic acidopathies)c. Urinary mucopolysaccharides and oligosaccharides (mucopolysaccharidoses)d. Plasma 7-DHC (Smith-Lemli-Opitz syndrome)e. Thyroid function testsf. Very-long-chain fatty acids (peroxisomal disorders)g. Creatine kinase (in the assessment of profound central hypotonia versus

myopathy)11. EEG if suspected seizure activity/encephalopathy (Landau-Kleffner)12. Imaging:

1. Brain MRI & Head CT scan1. calcifications with TORCH infections 2. Tuberous sclerosis 3. Craniosynostosis

2. Skeletal films: assessment of growth. 13. D.D of developmental delay:

1. Autism2. Borderline intellectual functioning3. Child Abuse & Neglect, 4. Dyslexia5. Rett's Syndrome

14. Complications:1. Respiratory disease is the most prevalent cause of death 2. Schizophrenia may have a prevalence of 3% in individuals with MR/ID 3. Sexually transmitted diseases (STDs), hepatitis B, and Helicobacter pylori infection,

are increased significantly among individuals with MR/ID.

4. As many as 20% of individuals with MR/ID have seizures.5. GU complications include urinary incontinence and poor menstrual hygiene.

15. Prevention:1. Prevention of maternal:

1. Alcohol abuse 2. Teen pregnancy3. Reproductive tract infection by safe sex

2. Prevention of Head trauma and child abuse3. Immunization to prevent CNS infections4. New born screening for metabolic disorders- PKU; hypothyroidism5. Antenatal screening for trisomy

16. Treatment:1. MR is not treatable2. Involves multiple disciplines, including special educators, language therapists,

behavioral therapists, occupational therapists, 3. Attention to Sexuality/abuse4. Medications, when prescribed, are targeted to specific comorbid psychiatric disease

or behavioral disturbances. Eg: Stimulants, antidepressants etc17. Prognosis:

1. Mild retardation: Near normal life in adulthood2. Life expectancy is not adversely affected3. Severe forms may be able to lead life with medical and social support

PREVENTABLE CAUSES OF MENTAL RETARDATION

Category Type Examples Detection/Prevention

Prenatal

Chromosomal disordersSingle gene disorders

Downs syndrome Antenatal triple testInborn errors of metabolism, such as galactosemiaphenylketonuriaHypothyroidism

Newborn screening

myelo-meningocele Prenatal ultrasound

Adverse material / environmental influences

Deficiencies, such as iodine deficiency and folic acid deficiency

Iodized saltFolic acid supplementation

Using substances such as alcohol (maternal alcohol syndrome), nicotine, and cocaine during early pregnancy:

Prevention of alcohol, cocain abuse and smoking

Severe malnutrition in pregnancy:Nutrition supplementation

Syphilis: Antenatal testing for syphilis and treatment

HIV MTCTexcessive exposure to radiation Avoiding radiation

Perinatal Rh incompatibility In utero and exchange transfusions

Con RubellaRubella vaccination

Third trimester Complications of pregnancyDiseases in mother such as heart and kidney disease and diabetes

Antenatal check up and high risk management

Placental dysfunction

LabourDifficult and/or complicated delivery; Birth trauma Obstetric care

Neonatal Septicemia, severe jaundicehypoglycemia

Essential newborn

PostnatalInfancy and childhood

Brain infectionsTuberculosis, BCGJapanese encephalitis JE vaccine; Mosquito controlbacterial meningitis HIB vaccination

Trauma Head injury Helmets, guards and railingsToxins Chronic lead exposure Screening for lead in bloodNutrition Severe and prolonged malnutrition Nutrition supportG&D Gross understimulation Tender loving care

EVALUATION AND MANAGEMENT OF THE CHILD WITH SPEECH DELAY

1. Speech is verbal expression, while language is the knowledge of a symbol system 2. Speech delay: a child is considered to have speech delay if the child's speech development is

significantly below the norm for children of the same age.3. Normal Speech Development:

Normal speech progresses through stages of cooing, babbling, echolalia, jargon, words and word combinations, and sentence formation.

Age Normal Pattern of Speech Development

1 to 6 months: Coos in response to voice

6 to 9 months: Babbling

10 to 11 months Imitation of sounds; says "mama/dada" without meaning

12 months Says "mama/dada" with meaning; often imitates two- and three-syllable words

13 to 15 months Vocabulary of four to seven words in addition to jargon; <20% of speech understood by strangers

16 to 18 months Vocabulary of 10 words; some echolalia and extensive jargon; 20% to 25% of speech understood by strangers

19 to 21 months Vocabulary of 20 words; 50% of speech understood by strangers

22 to 24 months Vocabulary >50 words; two-word phrases; dropping out of jargon; 60% to 70% of speech understood by strangers

2 to 2 1/2 years Vocabulary of 400 words, including names; two- to three-word phrases; use of pronouns; diminishing echolalia; 75% of speech understood by strangers

2 1/2 to 3 years Use of plurals and past tense; knows age and sex; counts three objects correctly; three to five words per sentence; 80% to 90% of speech understood by strangers

3 to 4 years Three to six words per sentence; asks questions, converses, relates experiences, tells stories; almost all speech understood by strangers

4 to 5 years Six to eight words per sentence; names four colors; counts 10 pennies correctly

4. Epidemiology1. Affects 3 to 10 percent of children.

2. Three to four times more common in boys than in girls.5. Etiology:

1. Mental retardation2. Hearing loss3. Maturation delay (developmental language delay)4. Expressive language disorder (developmental expressive aphasia)5. Bilingualism6. Psychosocial deprivation7. Autism8. Elective mutism9. Receptive aphasia10. Cerebral palsy

6. Mental Retardation 1. Accounts for more than 50 percent of cases.2. Known causes of mental retardation include genetic defects, intrauterine infection,

placental insufficiency, maternal medication, trauma to the central nervous system, hypoxia, kernicterus, hypothyroidism, poisoning, meningitis or encephalitis, and metabolic disorders.

7. Hearing Loss 1. Hearing loss at an early stage of development may lead to profound speech delay.2. Hearing loss may be conductive or sensorineural. 3. Conductive loss:

i. Otitis media with effusion. ii. Atresia of the external auditory canal.

4. Sensorineural hearing loss:i. It may result from intrauterine infection, kernicterus, ototoxic drugs, bacterial

meningitis, hypoxia, intracranial hemorrhage, ii. certain syndromes:

1. Pendred syndrome, 2. Waardenburg syndrome, 3. Usher syndrome)

iii. chromosomal abnormalities:1. Trisomy syndromes

8. Maturation Delay 1. A delay occurs in the maturation of the central neurologic process required to produce

speech. 2. More common in boys; family history of "late bloomers" is often present.3. The prognosis is excellent; normal speech development by the age of school entry.

9. Receptive Aphasia 1. comprehension of spoken language is the primary problem 2. The speech is sparse, agrammatic and indistinct in articulation.3. Most children with receptive aphasia gradually acquire a language of their own,

understood only by those who are familiar with them.10. Expressive aphasia:

1. Inability to translate ideas into speech.

2. Comprehension is normal; children may use gestures to supplement their limited verbal expression.

11. Bilingualism 1. A two language speaking home environment may cause a temporary delay in the

onset of both languages. 12. Psychosocial Deprivation

1. Physical deprivation:e.g., poverty, poor housing, malnutrition2. Social deprivation e.g., child neglect3. Abused children

13. Autism 1. Onset occurs before the child reaches the age of 36 months. 2. Characterized by delayed language development, fail to make eye contact, smile

socially, failure to relate to others and stereotyped repetitive motor activity. 3. Echolalia is common 4. More common in boys than in girls.

14. Elective Mutism 1. Typically, children with elective mutism will speak when they are on their own, with

their friends and sometimes with their parents, but they do not speak in school, in public situations or with strangers.

2. more in girls than in boys.3. The basis is family psychopathology. Electively mute children usually manifest other

symptoms of poor adjustment, such as poor peer relationships or overdependence on their parents.

15. Cerebral Palsy 1. Delay in speech is common in children with cerebral palsy. 2. More in athetoid type of cerebral palsy. 3. The following factors may account for the speech delay: hearing loss, incoordination

or spasticity of the muscles of the tongue, coexisting mental retardation 16. Clinical Evaluation

1. Developmental History: A thorough history, with special attention to language milestones, is extremely important in making the diagnosis. The physician should be concerned if:

i. The child is not babbling by the age of 12 to 15 months, ii. Not comprehending simple commands by the age of 18 months,

iii. Not talking by two years of age, iv. Not making sentences by three years of age, v. Is having difficulty telling a simple story by four to five years of age.

vi. If the child's speech is largely unintelligible after three years of age vii. Generalized delay in all aspects of developmental milestones suggests mental

retardation as the cause of a child's speech delay.2. The medical history should include:

i. Any maternal illnesses during the pregnancy, ii. Perinatal trauma,

iii. Infections iv. Asphyxia,

v. Pre term gestational age at birth, vi. Low birth weight,

vii. Use of ototoxic drugs, viii. Psychosocial history,

ix. Language(s) spoken to the child, and x. Family history of significant illness or speech delay.

3. Physical Examination and Screening Tests i. A precise measurement of the child's height, weight and head circumference

ii. Any dysmorphic features or abnormal physical findings iii. A complete neurologic examination including vision and hearing evaluations.

4. Screening tests:i. The Peabody Picture Vocabulary Test (Revised) is a useful screening

instrument for word comprehension. ii. The Denver Developmental Screening Test

iii. For assessing the intellectual and adaptive functioning: 1. The Stanford-Binet Intelligence Scale, 2. The Bayley Scales of Infant Development, 3. The Wechsler Intelligence Scale for ChildrenRevised (WISCR), and 4. The Wechsler Preschool and Primary Scale of Intelligence (WPPSI).

17. Diagnostic Evaluation 1. Audiometry, 2. Tympanometer to identify conductive component (e.g., middle ear effusion) 3. An auditory brain-stem response 4. Karyotype – eg. Fragile X syndrome. 5. An electroencephalogram for subclinical seizure activities in the temporal lobe.

18. Managementa. Multidisciplinary team includes the physician, a speech-language pathologist, an

audiologist, a psychologist, an occupational therapist and a social worker. b. Hearing loss: hearing aids, lip-reading instruction and myringotomy,ossicular

reconstruction and cochlear implantation c. Psychotherapy for the child with elective mutism. d. Parents need to adjust their speech to the level of the particular child. e. Teachers should use of small group instruction for children with speech delay.

DEVELOPMENTAL DISORDERS

PICA i. Definition: Repeated or chronic ingestion of non-nutritive substances such as plaster, charcoal,

clay, ashes, paint and earth.ii. Causes:

1. Mental retardation2. Lack of parental nurturing: Maternal deprivation, parental separation, parental

neglect, child abuse3. Nutritional: Deficiencies in iron, calcium, zinc, 4. Autism

5. Kleine-Levin syndrome: ? autoimmune hypothalamic dysfunction; Adolescent boys; Self limiting; Hypersomnalence, hyperphagia, hypersexuality

6. Pregnancyiii. Risk of pica:

1. Lead poisoning2. Parasitic infestation: ascariasis, soil-borne toxoplasmosis and toxocariasis3. Hyperkalemia following cautopyreiophagia (ingestion of burnt match heads).4. Ocular larva migrans can result in retinal lesions and loss of vision.5. Malnutrition 6. Tooth abrasion, abfraction, and surface tooth loss

iv. Tests:1. screening of blood:

lead concentrations Anemia

2. Abdominal radiography for ingested materials3. Upper GI endoscopy to diagnosis bezoar formation

v. Treatment:1. Address any identified nutritional deficiencies; 2. Associating the pica behavior with bad consequences or punishment (mild aversion

therapy) followed by positive reinforcement for eating the right foods.3. Medications for mental retardation.

ENURESIS

Definition:Discharge of urine twice a week for 3 consecutive months into clothes beyond 5 years.

Prevalence: 5-7% male; 3% in femalesEtiology:

1. Familial- Gene in chr 222. Reduced Argenine vasopressin secretion; 3. Enuresis can be divided into primary enuresis (PE) and secondary enuresis (SE) which

develops after 6-month period of continence 4. Factors that cause nocturnal polyuria in children with enuresis include the following:

i. Fluid ingestion before bedtimeii. Low nocturnal secretion of ADH

iii. Excess intake of caffeine5. Other causes:

a. Small functional bladder capacity b. Cystitis

6. Constipation 7. cerebral palsy 8. myelomeningocele 9. Seizure disorder.10. Diabetes mellitus 11. Diabetes insipidus

Laboratory Studies

1. Urinalysis: wbcs, glucose and sp.gravity and culture2. bladder ultrasonography to assess residual urine volume 3. MRI of the spine

Treatment:1. The child should be encouraged to void before bed. 2. not to drink to excess fluid after the evening 3. Alarm therapy: attached at bedtime to the underwear or pajamas in a position chosen to

promptly sense wetness4. Desmopressin acetate: 0.2 mg, administered 1 hour before bedtime; hyponatremic-related

seizures associated with the use of desmopressin5. Anticholinergic therapy: oxybutynin is 2.5-5 mg administered at bedtime6. Imipramine: 25 mg 1-2 hours before bedtime

INFANTILE COLIC

1. Definition: a. Severe paroxysmal crying in late afternoon of infants in the first few months of life; b. Colic is often defined by the “rule of three”: crying for more than three hours per day, for

more than three days per week, and for longer than three weeks in an infant who is well-fed and otherwise healthy. (Wessel criteria)

2. Etiology:a. It may be a result of hyperperistalsis. Motilin is thought to cause hyperperistalsisb. Maternal (or paternal) personality or anxiety may cause colicc. Most infants outgrow colic by four months of age lends support to a neurodevelopmental

cause d. Some responds to elimination of cow milk from mother of infant diete. Exposure to cigarette smoke and its metabolites may be related to colic. Maternal smoking

during pregnancy may be associated with colicf. Lower counts of intestinal lactobacilli were observed in infants with colic

3. Diagnosis:a. Colic remains a diagnosis of exclusion Rule out :

o Corneal abrasiono Hair wrapped around toes and fingerso Strangulated herniao Torsion of testis or appendix of the testiso Lactose intolerance o Milk protein allergyo Traumao UTIo GE refluxo Bronchiolitis

4. Treatment:1. Breastfeeding should be encouraged to continue; therapeutic benefit from eliminating

milk products, eggs, wheat, and nuts from the diet of breastfeeding mothers have been observed.

2. Dicyclomine hydrochloride has adverse effects (eg, apnea) ands not recommended.3. Simethicone is a nonabsorbable medication that changes the surface tension of gas

bubbles; Experimental evidence does not support its use in colic. 4. Sedatives, such as phenobarbital, chloral hydrate, and alcohol (gripe water) should never

be used, however tempting. 5. Herbal remedies have been used in many cultures. Evidence of their safety and efficacy

are needed.THUMB SUCKING:

1. Thumb sucking is a behavior found in humans, chimpanzees2. Sucking is one of a baby’s natural reflexes and completely typical for babies and young

children. 3. Most thumb-suckers stop gradually by the time they are five years old.4. If it goes on beyond 6 to 8 years, it may affect the shape of the oral cavity or dentition.

Management:1. Praise when he or she doesn't suck his or her thumb.2. Find another way to comfort the child (example: a stuffed toy or special blanket).3. put a bandage on the thumb, or apply an over-the-counter bitter liquid, such as Mavala Stop

or Thum).4. Reward for not sucking thumb

BREATH HOLDING SPELL

1. Incidence 0.1 to 5%2. Age 6 mo to 6 years3. Reflexive holding of breath in expiration following a period of provoked cry4. Becomes silent, apneic, turns pale (pallid) or blue (cyanotic)5. Loss of consciousness and opisthotonus, body jerks, urination and frank convulsions may occur6. Resolves spontaneously 7. DD: Seizures, CNS tumors, familial dysautonomia etc8. Management:

i. Reassure parentsii. Ignore spells and monitor for any complications

iii. Support the child but do not become submissiveiv. Unconsciousness:v. Place the child on his side

vi. Maintain airwayvii. Atropine .01 mg / kg SC for bradycardia or asystole

TEMPER TANTRUMS

1. 1-4 years; once a week in 50-80% of this age group2. Clinical:

i. Child throws himself down, kick and scream; holds his breathii. A manifestation achieving autonomy and mastery over the environment

iii. Annoying at home, embarrassing in public3. Cause: not mature enough to cope with difficulties4. Management

i. Prevention:

a. Minimize the need to say "no" by "child-proofing" the environment b. Use distraction when frustration increases; direct the child to other, less

frustrating activities; and reward the positive response.c. Present options within the child's capabilities so that he or she can achieve

mastery and autonomy.d. Fight only those battles that need to be won, and avoid those that arouse

unnecessary conflict.ii. During the attack:

a. Do not abandon the preschool child when a tantrum occurs. Stay nearby during the episode without intruding.

b. Do not use negative terms when the tantrum is occurring. Instead, point out that the child is out of control and give praise when he or she regains control.

c. Never let a child hurt him- or herself or others.d. Time out: Take your child away from the problem and give her time alone to

calm down. A good rule of thumb for a time-out is 1 minute of time-out for every year of your child’s age. For example, a 4-year-old would get a 4-minute time-out. After the time-out is over, talk with your child and make sure she understands why she got a time-out and how to deal with it next time.

iii. After an attack a. Do not hold a grudge after the eventb. Psychiatry in resistant cases

ATTENTION DEFICIT / HYPER ACTIVE DISORDER (ADHD)

1. Neuro deveolpmental disorder; 2-10% of school children2. Triad:

i. Impulsivity: act without thinking first, not learning from past mistakesii. Inattention:

iii. Hyperactivity 3. Impulsivity

i. Act without thinking first, ii. Not learning from past mistakes

iii. Speak When they're supposed to be quietiv. Cut in linev. Can't wait their turn in line or in a game

vi. Cognitively impulsive ADHD kids will make a multiple number of guesses in a short period of time.

4. Inattention i. No attention to details

ii. Short attention spaniii. Easy distractibility iv. Forgetfulnessv. Failure to listen when spoken to

vi. Failure to engage in tasks 5. Hyperactivity

i. Fidgetiness

ii. Difficulty in remaining seated in class iii. Excessive running and climbingiv. Not awaiting turnsv. Excessive talking : Answer before question is complete

6. Etiology a. Genetic : multifactorialb. Associated with :

i. Fragile X syndromeii. Williams syndrome

iii. Angel man syndromeiv. Klinefelterv. Turner

vi. Fetal alcohol syndromec. Perinatal:

i. CNS trauma/ infections/ toxinsii. Prematurity/ asphyxia

iii. Hyperthyroidism 7. Management

a. Disorder diminish between 10-25 years b. Medicationsc. Behavioural intervention strategiesd. Parent traininge. ADHD and school

II. Medications a. Stimulants:

i. Stimulant: Methyl phenindate; amphetamineii. Non stimulant: Atomoxetine ; Clonidine

b. School-Based Interventions: i. Help teachers meet children’s educational needs by teaching them skills to

manage the children’s ADHD behaviours in the classroom

DYSLEXIA

1. Definition: Difficulty to read, while intelligence is normal2. Etiology:

Genetic Familial

3. Epidemiolgy: 5-10% school children4. Pathogenesis:

a. Defect in left temporo - parieto-occipital brain regions which does not function properly while reading

b. Clinical i. Difficulty in text reading – slow readers

ii. Under achiever in schooliii. Difficulty in comprehending

iv. Difficulty in writing v. Inability to memorize

vi. Difficulty in spelling vii. Difficulty in doing simple mathematical problems

viii. Difficulty Learning any new language5. Diagnosis

i. It is a clinical diagnosisii. Family history

iii. Teacher observationiv. Oral reading to measure reading accuracy and fluency using set of graded readers

under timed conditionsv. Compare with peers

6. Celebrity Dyslexics i. Alexander Graham Bell – Inventor

ii. Agatha Christie – Writeriii. Leonardo da Vinci – Artistiv. Thomas Edison – Inventorv. Albert Einstein - Scientist

vi. Bill Gates - Microsoft Chairmanvii. Michael Faraday - Chemist and Physicist

7. Treatment i. Special school and teachers

ii. Help groupiii. Phonic instructions: sound for lettersiv. Guided repeated oral readingv. Accommodation rather than remediation

8. Prognosis:Schooling and early intervention may help near normal achievements

AUTISM SPECTRUM DISORDER

i. ASDs are pervasive Neurologic disorder that are highly heritable; involve multiple genes and demonstrate great phenotypic variation and hence a spectrum disorder.

ii. Etiology:a. Advanced paternal age and maternal age have been shown to be an associationb. Syndromes associated with autism:

i. Fragile X syndrome ii. Tuberous sclerosis

iii. Phenylketonuriaiv. Fetal alcohol syndrome

v. Angelman syndromevi. Rett syndrome

vii. Smith-Lemli-Opitz syndromec. Expossure to terotogenic factors in AN periodd. Measles-mumps-rubella (MMR) vaccine?

iii. Incidence: 6 per 1000 children; male female ratio is 6:1iv. Pathology:

a. Structural changes in cingulate gyrusb. Early accelerated brain growth and followed by slow growth c. Macrocephaly in 20-30%

v. Clinical features:

a. The disorder is often recognized between the ages of 15 and 24 monthsb. Restricted, repetitive, and stereotyped patterns of behavior, interests, and

activities c. Significant language delays d. Teachers notice difficulties with peer interactions. e. They are content being alone, ignore their parents' bids for attention, and seldom

make eye contact or bid for others' attention with gesturesf. In general there is a with qualitative impairment of:

i. Social interactionii. Communication

iii. Reciprocityiv. Imagination and play

g. Abnormal eye contacth. Failure to orient to namei. Failure to use gesture to point or showj. Failure to smilek. Lack of sharingl. Lack of peer playm. Absence of imaginary play

vi. DD I. Fragile X syndrome

II. Tuberous sclerosisIII. Angel man syndrome

vii. Diagnosis:I. Screening using checklist

II. 20% have microcephalyviii. Treatment

I. Behavior therapyII. Special schooling

III. Drugs:1. Clomipramine (tricyclic antidepressant)2. Clonidine 3. Stimulants: amphetamine; methylphenidate

ix. Prognosis:I. May be able to live self-sufficient, employed and live in community

II. Schizophrenia is a complication