f o s e c e i p e h t p u k c i p e w d n a , m s i l a i r e t a m Most families with young children depend on child care, of varying quality. This causes \200\200 costs (only partly mitigated by government funds), long days for children, with st ress imposed by travel and exposure to infections. 778 f o s e u l a v More and more parents are devoting time once available to their children to the care of the ir own parents. They won \200\231t tell you of this in brief ward en- counters, but these f acts become clear when working in the community. 778 \201\201Pediatricians have a key role in fostering interdisciplinary collabo- ration between schools, hospitals, and other child -related institutions, and they must feel able to refer parents for physical, emotional, or social problems, or health risk behaviors that can adversely aff ect the health or emotion al or social wellbeing of their child. e s l a f e h t t i m s n a r t s e i l i m a F Developmental screening tests Developmental disorders are a group of conditions leading to impairment in at least one functional area \200\224eg cognition, motor skills (gross or \201 ne), social- emotional or communication (speech, language, hearing or vision). Around 20 \200\223 25% of children have at least one developmental delay, and as many as 50% of th ese will not be detected before starting primary school. 780 Conditions falling under the u mbrella of developmental disorders include autism spectrum dis- orders, speech-language imp airment, learning disabilities and psycho-social problems. Biological risk factors include: prematurity, low birth weight, birth asphyxia, chronic illness and hearing/vision impairme nt. Environmental risk factors include: poverty, low parental education, parental mental il lness and social isolation. 781 Developmental surveillance refers to an ongoing process of following a child over time with a view to contextualizing a child s development. It involv es discussing concerns with parents, eliciting a perinatal history, identifying risk factor s, as well as observing the child attempting diff erent skills at diff erent times and refe rring the child when appropriate to other health professionals (eg physiotherapists, speech therapists or audiometrists). Developmental sur- veillance can be incorporated into well-c hild checks, general physical examina- tion and routine immunization visits. Developmental screening refers to a brief assessment aimed at identifying those children who require furt her investigation and assessment. It is typi- cally carried out using a developmental scree ning tool. Screening should be carried out within the broader undertaking of developmental surveillance. Repeating screening at diff erent ages increases the accuracy of the test. Pa - rental concern about a child s development may in itself constitute a reliable screening test. 782 The Denver Developmental Screening Test (DDST) and its successor the Denver II ha ve largely been replaced with more sensitive tests. Screening may be based on parent report alone (parent completed tests) or through direct observation together with parent report ( directly administered tests). Some of the most commonly used tests are discussed below \200 \224all are copyrighted products: The Parents Evaluation of Developmental Status (PEDS) to ol is a parent completed test consisting of 10 questions (8 yes/no, 2 open ended). It can b e given to parents to complete prior to attending health visits and takes less than 5 minut es to complete. It has a sensitivity of 74 \200\22380% and is suitable for children up to 8 years old. 780 It identi \201 es children as low, moderate or high risk for various disab ilities and identi \201 es an optimal course of action. Available at www.pedtest.com The A ges and Stages Questionnaire (ASQ), another parent completed test, consists of 21 age speci \201 c questionnaires. It can be used to evaluate children aged 1 month to 5 years old. It has a sensitivity of 85% and takes 10 \200\22320 min- utes to complete. 780 It has a si ngle cut-off score indicating which children need further referral. Available at: agesandst ages.com The Modi \201 ed Checklist for Autism in Toddlers (M-CHAT) is a second-stage pare nt completed test that is more speci \201 c for autism spectrum disorders. It has a sensit ivity of 90%. Available free online at: www. \201 rstsigns.org. The Brigance Screens-II is a directly administered test, combining parental observation and the eliciting of skills f rom children. It covers multiple domains of development including speech-language, motor, g eneral knowledge as well as reading and math at the older age groups. Available at: www.cur riculu- massociates.com Whilst the American Association of Pediatrics recommends both devel op- mental surveillance and screening, 783 the National Screening Committee (UK) doesn t re commend developmental screening. 784 218 s c i r t a d e a P i Developmental milestones 219 Average age Milestone Red \202 ags 6 weeks smiles, \200 follow eyes past midline 4 \200\2236 months At 6 months if \200 no smile \200 no grasp \200 not rolling \200 poor head control sits with support \200 rolls \200 reaches out for objects starts babbling \200 crawls \200 sits without support \200 pulls to stand \200 give s toy on request \200 turns head to name \200 responds to bye-bye \200 gestures wit h 6 \200\2239 months At 9 months if s c i r t a i d e a P no response to words \200 lack of eye contact or facial expression no gestures \200 no passing of toys from hand to hand \200 not sitting without support or crawling babbling \200 \201 rst tooth 7 \200\22312 months At 12 months if develops pincer grasp \200 plays peek-a-boo \200 walks with a hand unable to pick up small items not crawling / bottom held shuffl ing waves goodbye not standing holding on to furniture no babbled phrases 12 \200\22315 months single words \200 listens to stories \200 drinks from cup 18 months uninterested in playing speaks 6 words \200 able to walk up steps \200 names pictures \200 walks independentl y \200 scribbles \200 builds with blocks with others \200 no clear words \200 not walking without support not able to hold crayon \200 unable to stack 2 blocks At 2 years if 1.5 \200\2232 years kicks/throws a ball \200 runs \200 2-word sentences \200 follows a 2-step has <50 words \200 diffi culty handling small objects unable to climb stairs \200 no interest in feeding command stacks 5 \200\2236 blocks \200 turns pages \200 uses a spoon \200 helps with dressing or dressing If there is regression, or loss of a previously developed skill, this should be considered a red \202 ag requiring immediate investigation. Other red \202 ags at any age include poor interaction with others, diff erence in strength between right and left sides of body, abnormal tone and strong parental concern. Pediatric reference intervals (labs vary; consult your own) 9 \200\22336 mol/L; 50 \200 \223200 g/dL <1.75 mol/L; <36 g/dL 0.6 \200\2231.0mmol/L 275 \200\223295mosmol/L 0.04 \200\2230.21mmol/L 3.5 \200\2235.5 63 \200\22381g/L; 6.3 \200\2238.1g/dL 136 \200\223145mmo l/L 2.5 \200\2234.5g/L 0.34 \200\2231.92mmol/L (=30 \200\223170mg/dL) 0.12 \200\2230.36mmol /L; 2 \200\2236mg/dL 2.5 \200\2236.6mmol/L; 15 \200\22340mg/dL <20U/L 220 Biochemistry (1mmol = 1mEq/L) AlbuminP Alk phosP IronS 36 \200\22348g/dL LeadEDTA (depends on age) Mg2+ P see below OsmolalityP 1.3 \200\2233.4g/dL PhenylalanineP \200 1-antitrypsinP AmmoniumP AmylaseP Aspartate aminotransferaseP BilirubinP Blood gasses , arterial PaCO2 PaO2 BicarbonateP Base excess CalciumP neonates: ChlorideP CholesterolP,F <80U/L Creatine kinaseP CreatinineP 25 \200\223115 mol/L; 0.3 \200\2231.3mg/dL Dehydroepia ndrosterone sulfateP: GlucoseF (lower in newborn; \202 uoride tube) IgAS 2 \200\22325 mL/L; 3 \200\22335 g/dL PotassiumP mean mmol/L 70 \200\223300u/L ProteinP <40u/L SodiumP 2 \200\22316 mol/L; 0.1 \200\2230.8mg/dL Transferrins pH 7.36 \200\2237.42 TriglycerideF,P 4.3 \200\2236.1kPa; 32 \200\22346mmHg 11.3 \200\22314.0kPa; 85 \200\223105mmHg UrateP 21 \200\22325mmol/L UreaP \200\2232 to +2mmol/L Gamma-glutamyl transferaseP 2.25 \200\2232.75mmol/L; 9 \200\22311mg/dL 1.72 \200\2232.47; 6.9 \200\2239.9mg/dL 98 \200\223105mmol/L Hormones \200\224a guide. \200\207 Consult lab \211 5.7mmol/L; 100 \200\223200mg/dL CortisolP 9am 200 \200\223700nmol/L midnight <140nmol/L, mean s c i r t a d e a P 0.8 \200\2232.8 mol/L (range) 0.1 \200\2233.6 mol/L 2.5 \200\2235.3mmol/L; 45 \200\22395mg/dL day 5 \200\22311 5 \200\22311yrs 0.8 \200\2234.5g/L (low at birth, 17 \200 -HydroxyprogesteroneP: i Rising to adult levels slowly) IgGS 5 \200\22318g/L (high at birth, falls and then 4 \200 \22315yrs days 5 \200\22311 1.6 \200\2237.5nmol/L (range) 0.4 \200\2234.2nmol/L 60 \200\223135nmol/L (not neonates) <5m U/L (higher on day 1 \200\2234) rises slowly to adult level) T4 P 0.2 \200\2232.0g/L (low at birth, rises to TSHP IgMS adult level by 1 year) <500U/mL B=boy; EDTA=edetic acid; F=fasting G=girl; P=plasma; S=serum. IgES Alk phosP U/L: 0 \200\223 \201\220yr 150 \200\223600; \201\220 \200\2232yr 250 \200 \2231000; 2 \200\2235yr 250 \200\223850; 6 \200\2237yr 250 \200\2231000; 8 \200\2239yr 250 \200\223750; 10 \200\22311yr G = 259 \200\223950, B \211 730; 12 \200\22313yr G = 200 \200\223750, B \211 785; 14 \200\22315yr G = 170 \200\223460, B = 170 \200\223970; 16 \200\22318yr G = 75 \200\223270, B = 125 \200\223720; >18yr G = 60 \200\223250, B = 50 \200 \223200. Hematology mean 1 standard deviation. Range \211\210109/L (median in bracket s) Hb g/dL MCV \202 MCHC % Retics % WCC Neutrophils Eosins Lymphs Monos Day 19.0 2 119 9 31.6 2 0.4 \200\2233.1 1 18.6 2 114 7 32.6 2 4 114 9 30.9 2 17.6 1 5 Weeks 1 \200\2232 2 \200\2233 4 \200\2235 6 \200\2237 8 \200\2239 Months \200\224all t he following Hb values are Medians/Lower limit for normal 3 6 12 Year 2 4 6 12 14B 14G 16B 16G 18B 3.2 1 1.8 1 1.2 0.2 9 \200\22330 6 \200\22326 9 \200\22340 (11) 0.02 \200\2230.8 2 \200\22311 17.3 2 112 19 32.1 3 15.6 3 111 8 33.9 2 12.7 2 101 8 34.9 2 12. 0 2 105 12 33.8 2 93 12 34.1 2 10.7 1 0.5 0.03 5 \200\22321 1.5 \200\22310 0.8 0.6 6 \200\22315 1 \200\2239.5 0.9 0.8 6 \200\22315 1.2 0.7 6 \200\22315 1.8- 1 6 \200\22315 (5) 0.07 \200\2230.1 2 \200\22317 (4) 0.07 \200\2230.1 2 \200\22317 (4) (4) (4) 0.3 \200\2232.7 0.2 \200\2232.4 (6) (6) (6) 11.5/9 11.5/9 11.5/9 88/88 77/70 78/72 6 \200\22315 6 \200\22315 6 \200\22315 (3) (3) (3) (6) (6) (5) 78/74 11.5/9 12.2/10 80/75 82/75 13/10.4 13.8/11 83/76 14.2/12 84/77 14/11.5 14.8/12 85/78 14/11.5 15/13 6 \200\22315 6 \200\22315 5 \200\22315 4 \200\22313 4 \200\22313 (3) (4) (4.2) (4.9) (5) (5) (4) (3.8) (3.1) (3) 30 \200\22336 0.8 \200\2232 12; \211 150ng/L. Note: Basophil range: 0 \200\2230.1 \211\210109/L; Bs Red cell folateEDTA 100 \200\223640ng/mL. B = boys; G = girls. Platelet counts don \200\231t va ry with age: 150 \200\223400 \211\210109/L. 4 \200\22313 2 \200\2237.5 (5) 0.04 \200\223.4 1.3 \200\2233.5 0.2 \200\223.8 221 s c i r t a i d e a P Fig 1. Mean times of eruption (in years) of the permanent teeth. Deciduous teeth Lower central incisors Upper central incisors Upper lateral incisors Lower lateral incisors A 1-year-old has 6 teeth; 1 yrs 12 teeth; 2yrs 16 teeth; 2 yrs 20. Months 5 \200\2239 8 \200\22312 10 \200\22312 12 \200\22315 Months 10 \200\22316 16 \200\22320 20 \200\22330 First molars Canines Second molars 222 UK-WHO Growth Charts: Boys 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 BOYS 0 \200\2231 year 3 4 5 6 7 8 9 10 11 Preterm 50cm 50cm 9 9 . 6 t h Age in weeks/ months 49 49 9 8 t h Birth Head Circumference 48 48 9 1 s t 47 47 7 5 t h 40 h e a d 46 46 5 0 t h 39 2 5 t h 45 45 38 9 t h 44 44 37 2 n d 43 43 0 . 4 t h 36 42 42 99.6th 98th 91st 75th 50th 25th 9th 2nd 0.4th 35 99.6th 9 8th 9 1st 7 5th 5 0th 2 5th 9th d n 2 0.4th 41 41 ) m c ( e c n e r e f m u c r i C d a e H 34 40cm 40 33 84cm 39 99.6th 32 82 38 9 9 . 6 t h 9 8 t h t 9 1 s 7 5 t h 5 0 t h 2 5 t h 9 t h 2 n d 0 . 4 t h 98th 31 80 37 91st 30 78 36 75th 76 35 29 50th l e n g t h 25th 74 34 28 9th 72 33 27 2nd 70 32 26 Gestation in weeks 0.4th 68 31cm 32 34 36 38 40 42 66 66cm Plotting preterm infants Use the low birthweight chart for infants less than 32 weeks gesta tion and any other requiring detailed assessment. Use this section for infants than 37 week s of gestation. As with term infants there may be some weight loss in the early days. From 42 weeks, plot on the 0 \200\2231 chart with year gestational correction. 64 64 62 62 9 9.6th 9 8th 9 1st 7 5th 5 0th 2 5th 9th 2 n d 0.4th 60 60 infants 58cm 58 99.6th less 56 98th 91st 54 14kg 75th 52 13.5 50th 50 13 25th 9 9 . 6 t h 9th 48 12.5 Gestational age (7 weeks preterm) 2nd 46 12 9 8 t h Actual age 0.4th 44cm 11.5 Gestational correction Plot actual age then draw a line back the number of weeks the infant was preterm and mark the spot with an arrow; this is the gestationally corrected centile. 11 11kg 9 1 s t 10.5 10.5 Some degree of weight loss is common after birth. Calculating the percentage weight loss is a useful way to identify babies who need assessment. 7 5 t h 10 10 w e i g h t 5 0 t h 9.5 9.5 9 Birth Weight 9 2 5 t h 5.5 8.5 8.5 9 t h 8 8 5 2 n d 7.5 7.5 0 . 4 t h 4.5 7 7 99.6th 98th 91st 75th 50th 25th 9th 2nd 0.4th 6.5 6.5 4 6 6 5.5 5.5 3.5 ) g k ( 5 5 99.6th 98th 91st 75th 50th 25th 9th 2nd 0.4th 99.6th t h g i e W 3 4.5 4.5 98th 91st 4 4 75th 2.5 3.5 3.5 50th 25th 3 3 2 9th 2.5 2.5 2nd 0.4th 1.5 2 2 1.5 1.5 1 Age in weeks/ months 1 1 Gestation in weeks 1 2 3 4 5 6 7 8 9 10 11 0.5kg 0.5kg 0 32 34 36 38 40 42 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 Fig 1. UK-WHO growth charts \200\224boys aged 0 \200\2231 yrs 2009 Department of Health. In 2006 the WHO introduced new growth standards which were ad opted in the UK in 2009 (2010 in Scotland) for children 0 \200\2234y (UK-WHO charts). Thes e growth standards were compiled from data from breast-fed babies (who grow slower than for mula- fed infants) \200\224from 6 diff erent nations (the US, Norway, Oman, Brazil, India a nd Ghana). The linear growth patterns were similar between nations \200\224so for this age group there aren t thought to be any ethnospeci \201 c diff erences in rate of growth. Thi s rate of growth is taken to be an optimal growth rate for children, as opposed 223 12 13 14 15 16 17 19 20 21 22 23 25 26 27 28 29 31 32 33 34 35 37 38 39 40 BOYS 1 \200\2234 years Adult Height Prediction 2 11/2 21/2 3 552cm 9 9 . 6 t h 9 8 t h 9 1 s t 7 5 t h 5 0 t h 2 5 t h 9 t h 2 n d 0 . 4 t h 124cm Age in months/ years 50 120 h e a d ft/in 6.5 cm 195 48 Measure length until age 2; measure height after age 2. A child \200\231s height is usually slightly less than their length. 116 6.4 99.6th 9 9 . 6 t h 9 8 t h 6.3 190 46 112 98th 6.2 6.1 185 91st t 9 1 s 44 108 6.0 75th 7 5 t h 5.11 180 h e i g h t 42 104 5.10 50th 5 0 t h 5.9 175 25th 2 5 t h 40cm 100 5.8 9th 5.7 170 9 t h 5.6 96 96cm 2nd 2 n d 5.5 165 0.4th 0 . 4 t h 5.4 92 92 l e n g t h 5.3 160 88 88 Plot child \200\231s height centile on the blue lines above; the black numbers show average male adult height for this centile; 80% of children will be within 6 cm of this value. 9 . 6 t h 8 t h t s 1 t 9 9 84cm 84 9 h h h 30kg 80 5 0 5 7 5 2 9 d n 2 0 . 4 t h t t 29 76 h t 28 72 27 68 26 64 25 60cm 24kg 24 h 23 23 t 9 . 6 9 22 22 h 21 21 t 8 9 20 20 t 9 1 s 19 19 18 18 7 5 t h 17 17 5 0 t h w e i g h t 16 16 15 2 5 t h 15 14 14 9 t h h t 9 . 6 9 13 13 h 2 n d t 8 9 12 12 t s 1 0 . 4 t h 9 11 11 h t 5 7 5 0 t h 10 10 2 5 t h 9 9 9 t h 2 n d 0 . 4 t h 8 8 7 7 6 6 Age in months/ years 5kg 5kg 11/2 21/2 31/2 2 3 12 13 14 15 16 17 19 20 21 22 23 25 26 27 28 29 31 32 33 34 35 37 38 39 40 41 43 44 45 46 47 48 Fig 2. UK-WHO Growth Charts \200\224boys aged 1 \200\2234 yrs. 2009 Department of Health to the previous growth charts (UK90) which described the prevailing growth pat- terns of UK children compiled from surveys done in the 1980s. As a result the UK-WHO charts have an in creased number of overweight children and fewer underweight children, when compared with th e UK90 charts. For <4yrs, the UK-WHO charts replace the UK90 charts. The UK90 charts are st ill used for children >4 (not reproduced here) \200 Separate charts exist for children wi th Down \200\231s Syndrome, Turner s and achon- droplasia 224 UK-WHO Growth Charts: Girls 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 GIRLS 0 \200\2231 year 3 4 5 6 7 8 9 10 11 Preterm 50cm 50cm Age in weeks/ months 49 49 9 9 . 6 t h Birth Head Circumference 48 48 9 8 t h 47 47 39 9 1 s t 46 46 7 5 t h 38 h e a d 45 45 5 0 t h 37 44 44 2 5 t h 36 43 43 9 t h 35 99.6th 98th 91st 75th 50th 25th 2 n d 42 42 0 . 4 t h 41 41 34 ) m c ( e c n e r e f m u c r i C d a e H 99.6th 9 8th 9 1st 7 5th 5 0th 2 5th 9th d n 2 0.4th 40cm 40 33 39 32 38 82cm 31 9 9 . 6 t h 9 8 t h t 9 1 s 7 5 t h 5 0 t h 2 5 t h 9 t h 99.6th 37 80 30 98th 36 78 91st 29 9th 2nd 0.4th 35 76 75th l e n g t h 28 50th 34 74 25th 27 33 72 9th 32 70 26 2nd Gestation in weeks 2 n d 0 . 4 t h 0.4th 31cm 68 32 34 36 38 40 42 66cm 66 Plotting preterm infants Use the low birthweight chart for infants less than 32 weeks gesta tion and any other requiring detailed assessment. Use this section for infants of than 37 w eeks term gestation. As with infants there may be some weight loss in the early days. From 42 weeks, plot on the 0 \200\2231 chart with year gestational correction. 64 64 62 62 9 9.6th 9 8th 9 1st 7 5th 5 0th 2 5th 9th 2 n d 0.4th infants 60 60 58 58cm less 56 99.6th 98th 14kg 54 91st 13.5 52 75th 50th 13 50 25th 12.5 48 9 9 . 6 t h Gestational age (7 weeks preterm) 9th 2nd 12 46 Actual age 0.4th 11.5 44cm 9 8 t h Gestational correction Plot actual age then draw a line back the number of weeks the infant was preterm and mark the spot with an arrow; this is the gestationally corrected centile. 11 11kg 10.5 10.5 Some degree of weight loss is common after birth. Calculating the percentage weight loss is a useful way to identify babies who need assessment. 9 1 s t 10 10 7 5 t h 9.5 9.5 w e i g h t 9 Birth Weight 9 5 0 t h 5.5 8.5 8.5 2 5 t h 8 8 5 9 t h 7.5 7.5 4.5 7 7 2 n d 6.5 6.5 99.6th 98th 91st 75th 5 0th 2 5th 9th 2 n d 0.4th 0 . 4 t h 4 6 6 5.5 5.5 3.5 ) g k ( 5 5 99.6th 98th 91st 75th 50th 25th 9th 2 n d 0.4th 99.6th t h g i e W 3 4.5 4.5 98th 91st 4 4 2.5 75th 3.5 3.5 50th 25th 3 3 2 9th 2.5 2.5 2nd 1.5 0.4th 2 2 1.5 1.5 1 Age in weeks/ months 1 1 Gestation in weeks 1 2 3 4 5 6 7 8 9 10 11 0.5kg 0.5kg 0 32 34 36 38 40 42 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 Fig 3. UK-WHO growth charts \200\224girls aged 0 \200\2231 yrs. 2009 Department of Health. 12 13 14 15 16 17 19 20 21 22 23 25 26 27 28 29 31 32 33 34 35 37 38 39 40 GIRLS 1 \200\2234 years Adult Height Prediction 2 11/2 21/2 3 124cm 552cm ft/in cm 9 9 . 6 t h 9 8 t h 9 1 s t 7 5 t h 5 0 t h 2 5 t h 9 t h 2 n d 0 . 4 t h Age in months/ years 5.11 180 120 50 5.10 h e a d 116 48 5.9 175 Measure length until age 2; measure height after age 2. A child \200\231s height is usually slightly less than their length. 99.6th 9 9 . 6 t h 9 8 t h 5.8 112 46 98th 5.7 170 91st t 9 1 s 108 44 5.6 75th 7 5 t h h e i g h t 5.5 104 165 42 5 0 t h 50th 5.4 100 40cm 25th 2 5 t h 5.3 160 9th 9 t h 96 5.2 96cm 2nd 2 n d 5.1 155 92 92 0 . 4 t h 0.4th 5.0 t h 88 88 150 4.11 g n Plot child \200\231s height centile on the pink lines above; the black numbers show average female adult height for this centile; 80% of children will be within 6 cm of this value. 9 . 6 t h 8 t h s t 5 t h h t 0 h 5 84cm 84 e 9 l 9 1 30kg 80 9 7 5 2 9 n 2 0 . 4 29 76 t h t 28 72 d h t 27 68 26 64 25 60cm 24 24kg 9 . 6 t h 9 23 23 22 22 8 t h 9 21 21 20 20 t s 1 9 19 19 18 18 h t 5 7 17 17 16 5 0 t h 16 w e i g h t 15 15 2 5 t h 14 14 9 . 6 t h 9 t h 9 13 13 2 n d h t 8 9 12 12 0 . 4 t h s t 1 9 11 11 h t 5 7 10 10 h t 0 5 9 9 2 5 t h 9 t h 2 n d 0 . 4 t h 8 8 7 7 6 6 Age in months/ years 5kg 5kg 11/2 21/2 31/2 2 3 12 13 14 15 16 17 19 20 21 22 23 25 26 27 28 29 31 32 33 34 35 37 38 39 40 41 43 44 45 46 47 48 Fig 4. UK-WHO growth charts \200\224girls aged 1 \200\2234 yrs. 2009 Department of Health. Risk factors for childhood obesity Changes in food availability and activity levels during the past 30 years are well known. Also: low socioeconomic status, maternal obesity, rapid i nfancy weight gain. Obesity prevention programs have some success and show that changes in school and community environ- ments can decrease childhood weight gain. In France, for exam ple, children are weighed in school regularly, and regular exercise and healthy eating (not diets) are promoted in systematic ways. Input from a family healthy-eating coach has also been found to help.785,786 Peer encouragement and feedback in the form of pedometer reading s is one way of promoting more exercise.787 For causes of obesity, see p180. For other methods of preventing adult con- sequences of childhood obesity by intervening in childhood, see p156. Z-scores for weight, height, and BMI: what do they mean? A Z score (for weight-for-age) of \200\2231 indicates that weight is 1 standard deviation (OHCM p737) below the median for t hat age/sex group. This means mildly underweight. Z \200\2232 (minus 2 standard deviations ) is moderate, and Z \200\2233 is severe. Ditto for height. In the care of children with ch ronic diseases, eg HIV, monitoring and improving the BMI Z-score is an important way of red ucing morbidity and mortality.788 A BMI Z-score of +2 to +2.5 counts as moderate obesity (severe if >2.5).789,790 BMI z-score is chief determinant of metabolic syndrome in children;791 a 1-point increase in BMI Z-sco re yields a 2-fold increase in its prevalence ( \200\200 from 27.6% to 60.7% if BMI Z-score increases from 2.3 to 3.3). BMI Z-scores also help monitoring weight-intervention programs.792 Dubowitz system for assessing gestational age 228 s c i r t a d e a P i Fig 1. Neurological criteria for Dubowitz scoring (use in conjunction with table on p230 \200\2231). Reproduced from Dubowitz, L. Assessment of gestational age: a practical scoring system Ar chives of Disease in Childhood with permission from BMJ Publishing Ltd. 229 s c i r t a i d e a P Fig 2. Assessment of gestational age: Dubowitz system. Graph for reading gestational age fr om total score. Reproduced from Dubowitz, L. Assessment of gestational age: a practical scoring system Ar chives of Disease in Childhood with permission from BMJ Publishing Ltd. 2 3 0 Pediatrics Assessment of gestational age: Dubowitz system Physical (external) criteria (for neurological criteria, see p228) Score 0 1 2 3 4 External sign Oedema Obvious oedema hands and feet: pitting over tibia No obvious oedema hands and feet: pitting over tibia No oedema Slight thickening Super \201 cial cracking and peeling, especially hands and feet Thick and parchment-like super \201 cial or deep cracking Skin texture Smooth: medium thickness Rash or super \201 cial peeling Very thin, gelatinous Thin and smooth Pale Only pink over ears, lips, palms, or soles Skin color (infant not crying) Pale pink: variable over body Dark red Uniformly pink Skin opacity (trunk) No blood vessels seen Numerous veins and venules clearly seen, especially over abdomen Veins and tributaries seen A few large vessels clearly seen over abdomen A few large vessels seen indistinctly over abdomen Lanugo (over back) At least half of back devoid of lanugo No lanugo Abundant long and thick over whole back Hair thinning especially over lower back Small amount of lanugo and bald areas Plantar creases De \201 nite deep indentations over more than anterior third No skin creases Faint red marks over anterior half of sole De \201 nite red marks over more than anterior half, indentations over less than anterior third Indentations over more than anterior third Nipple formation Nipple barely visible, no areola Nipple well de \201 ned, areola smooth and \202 at diameter <0.75cm Areola stippled, edge not raised, diameter <0.75cm Areola stippled, edge raised diameter >0.75cm Breast size No breast tissue palpable Breast tissue both sides: one or both >1cm Breast tissue on one or both sides <0.5cm diameter Breast tissue both sides, one or both 0.5 \200\2231.0cm Pediatrics 2 3 1 2 3 2 Pediatrics Assessment of gestational age: Dubowitz system (continued) Physical (external) criteria (for neurological criteria, see p228) Score External sign 0 1 2 3 4 Ear form Pinna \202 at and shapeless, little or no incurving of edge Incurving of part of edge of pinna Partial incurving whole of upper pinna Well-de \201 ned incurving whole of upper pinna Ear \201 rmness Pinna soft, easily folded, no recoil Pinna, soft, easily folded, slow recoil places, ready recoil Cartilage to edge of pinna, but soft in places, ready recoil Pinna \201 rm, cartilage to edge, instant recoil Genitalia \200 Male Neither testis in scrotum At least one testis high in scrotum At least one testis right down Female (with hips half abducted) Labia majora widely separated, labia minora protruding Labia majora almost cover labia minora Labia majora completely cover labia minora Reproduced from Dubowitz, L. Assessment of gestational age: a practical scoring system Ar chives of Disease in Childhood with permission from BMJ Publishing Ltd. 233 s c i r t a i d e a P Fig 3. Nomogram for calculating the body surface area of children. Reproduced from Dubowitz, L. Assessment of gestational age: a practical scoring system Ar chives of Disease in Childhood with permission from BMJ Publishing Ltd. Reference intervals: nutrition for preterm babies Water See p235. An intake of 180mL/kg/day (range 150 \200\223200mL/kg/day) of hu- man or formula milk meets the water needs of very low birthweight infants (VLBW; <1500g) under normal circumstances. In infants with heart fa ilure wa- ter restriction is necessary (eg 130mL/kg/day). Energy 130kcal/kg/day (range 110 \200\223165) meets the needs of the LBW infant in normal circumstances, and can be provided by formulas with similar energy density to human milk (65 \200\22370kcal/dL) in a volume o f 180 \200\223200mL/kg/day. If a higher energy density is required keep it <85kcal/dL. The problems with en- ergy densities above this are fat lactobezoars and U&E imbalance. Protein Aim for between 2.25g/100kcal (2.9g/kg/day when fed at 130kcal/ kg) and 3.1g/100kcal (4g/k g/day). Lysine should be as high as possible. Pre- cise guidelines on taurine and whey:case in ratios cannot be given. At pre- sent LBW formulas are whey-predominant. Signs of protein de \201 ciency: \200\201urea; \200\201prealbumin. Fat Aim for 4.7 \200\2239g/kg (fat de nsity 3.6 \200\2237.0g/100kcal). Longer-chain unsatu- rated fatty acids (>C12) are better a bsorbed than saturated fatty acids. Aim to have \211 4.5% of total calories as the essenti al fatty acid linoleic acid (500mg/100kcal).793 Carbohydrates Aim for 7 \200\22314g/100kcal , eg with lactose contributing 3.2 \200\22312g per 100kcal. Lactose is not essential; subst itutes are glucose (but high osmolal- ity may cause diarrhea) or sucrose ( starch hydroly sates, eg corn syrup oils). Vitamins See p123 & ESPGAN committee.794 Elements Na+: 6.5 \200 \22315mmol/L. K+: 15 \200\22325.5mmol/L. Ca2+ 1.75 \200\2233.5mmol per 100kcal. PO4 3 \200 \223 ratio: 1.4 \200\2232.0 : 1. Magnesium: 0.25 \200\2230.5mmol/ 100kcal. Iron: if breastf ed, give 2 \200\2232.5mg Fe/kg/day (recom- mended total intake). Formula-fed infants may ne ed a supplement to achieve this. Iodine: 10 \200\22345 g/100kcal. Manganese: 2.1 mol/100k cal. \200\2071cal=4.18 joules. 234 s c i r t a d e a P i 3 \200\223: 1.6 \200\2232.9mmol/100kcal. Ca2+:PO4 \200 Fluid regimens to correct dehydrationAPLS If tolerated, always use oral rehydration. Dioral yte comes in sachets which contain glucose, Na+ and K+. Show mother how to make it up (wa ter is the vital ingredient!). If breastfeeding, continue. Daily IV water, Na, and K (mmol/kg/day) MAINTENANCE needs Age (yr) <0.5 0.5 \200\2231 1 \200\2233 3 \200\2235 >5 Weight (kg) Water (mL/kg/day) Na+ <5 5 \200\22310 10 \200\22315 15 \200\22320 >20 K+ 3 2.5 2.5 2 1.5 \200\2232 150 120 100 80 45 \200\22375 3 2.5 2.5 2 1.5 \200\2232 Use 0.45% saline with 5% glucose for these needs (contains few calories, but prevents ketos is). 0.9% saline is used for many conditions at risk from hyponatraemia (see NICE guidance) . Pre-existing de \201 cits and continuing loss must also be made good. Reliable input \200\223output \202 uid balance charts are es- sential. Calculating pre-existing de \201 cit mL \211\210 % dehydration \211\210weight (kg) \211\21010; give eg as 0.45% saline ove r 24h (eg 750mL for a 10kg child who is 7.5% dehydrated). Add in K+ (20mmol/500mL) once the child has passed urine. Don \200\231t forget the maintenance \202 uids for ongoing losse s. Estimating dehydration Mild dehydration: Decreased urine output. 5% dehydration: Dry mucous membranes; decreased urine output. 10% dehydration: The above + sunken fontanelle (but if crying, pressure \200\200), pulse \200\200; hoarse cry; skin turgor \200\201. >10%: The abo ve, but worse, with: shock, drowsiness, and hypotension. If a recent weight is known, this is useful in quantifying dehydration. Fluids for the \201 rst 24h in mild dehydration Thi s is best managed at home. Encourage parents to give little and often (ie 5mL every 5min by syringe). The patient will not need treatment until they are more dehydrated. IV \202 ui ds for the \201 rst 24h in 5 \200\22310% dehydration \200 Give maintenance water requir ement (above) + the de \201 cit over 24 hours. The most physiological method is Dioralyte by NG tube, if tolerated. Some patients manage on oral \202 uids only. \200\230Rapid r ehydration \200\231 involves 4 hours of 10mL/kg/h 0.9% NaCl then maintenance after if neede d. Ensure the nurses are aware to drop the \202 uid rate after 4h, and change to 0.45%/5% glucose. 235 s c i r t a i d e a P Measure or estimate and replace ongoing losses (eg from the bowel). \200 Monitor U&E on a dmission, and at least daily. \200 IV \202 uid replacement in the \201 rst 24h in >10% dehydration NB: Fluids should be given orally if possible \200\224or by nasogastric tube, as above. Reserve IVI for those who are shocked (if IV access fails, use the intraosseous r oute, p236) or who do not tolerate NG rehydration. \200 0.9% saline 20mL/kg IVI bolus, wh ile calculations are performed. Continu- ously monitor pulse, BP, ECG. Continue with boluses until the signs of shock ease. \200 Then give the daily requirement + \202 uid de \201 cit as above, making good continu- ing loss with 0.45% or 0.9% saline depending on type of dehydration. Measure plasma and urine creatinine and osmolality (p176), and plasma bi- carbonate. Metabolic acidosis usually corrects itself. Guidelines for success: Above all be simple. Complex regimens cause errors. 1 Stay at the b edside; use clinical state + lab results to adapt IVI. 2 Beware sudden changes in Na+ ( \200\200 or \200\201); may cause seizures or central pon- tine demyelinolysis. 3 Beware hidden loss (oedema, ascites, GI pools), and shifts of \202 uid from the intravascular space to the interstitial space ( \200\230third-spacing \200\231). 4 Measure U&E and urine electrolytes often. 5 Give potassium once you know that urine is \202 owing. The ready-prepared \202 uid \200\2300.45% Saline With 5% glucose With Potass ium Chloride 20mmol/L \200\231 is usually a good choice. Be guided by serum K+.795 Hypernatraemic dehydration: (greater water loss than salt, eg from wrongly made feeds, or r arely, if breastfed.) It causes intracellular dehydration ( \201 ts, CNS thrombosis/hem orrhages on MRI).796 Treatment: rehydrate slowly with 0.45% or 0.9% saline (which is hypoto nic for a hypernatraemic patient): re- place de \201 cit over 48h, lowering Na+ by <12mmol /L/24h, and giving only 60% of maintenance volume, to avoid CNS oedema (p200). A big danger is too rapid rehydration. Hyperglycaemia is common, but self-correcting.797,798 Water bala nce in the preterm infant Water comprises 50 \200\22370% of weight gain (eg of 15g/day) in preterm babies. Insensible water loss (IWL) falls with increasing body weight, gestational age, and postnatal age; it increases with \200\200T (ambient & body) and low humidity. I n a single-walled, thermoneutral incu- bator with a humidity of 50 \200\22380% IWL \211 \210 30 \200\22360mL/kg/day (may double in infants on phototherapy under a radiant heater). Fecal water loss \211\210 5 \200\22310mL/kg/day (except during diarrhea). Urine loss: If 90mL/kg/day, there is no excessive renal stress. \200 APLS procedures \200\224intraosseus transfusion 236 \200 \200 (APLS=advanced pediatric life support.) Immediate vascular access is required in pediatric and neonatal practice in the following circumstances: cardiopulmonary arrest, severe burns, prolonged status epilepticus, hypovolaemic and septic shock. In many cases rapid intra- ve nous access is not easily obtained. Intraosseous (IO) infusion is a rapid, safe, easy, and eff ective means of obtaining vascular access, and is recommended for life-threatening pedi atric emergencies in which IV access cannot be ob- tained.799 In such an emergency attempt an IV line but if unsuccessful within 60 \200\22390s, attempt an IO line. It is safe to adm inister all intravenous medicines via the IO. Bloods can be taken and sent to the lab for c ross match, FBC, U&E.800 Inform the hematology lab they will see blasts. A blood gas can be sent (if no \202 uids given already) \200\224but it shouldn \200\231t be used on an auto analyser as it may clog the machine. Send it to the lab and inform them that it is a marrow sam- ple \200\224they may be able to test it in a cartridge analyzer.800 Contraindications Osteoporosis, osteogenesis imperfecta, and infection or fracture at the site of insertion. Technical aspects Learn from an expert. The major choice is between a manual needle or a s emi-automatic device such as an intraosseous gun or drill. The two major devices available are the Bone Injection Gun (B.I.G. ) \200\224a spring loaded device available for childr en and adults, and the EZ-IO device a reusable drill with a 15mm needle for children <39 kg, and a 25mm needle for patients >40kg. A new 45mm needle is available for those with sig ni \201 cant tis- sue/oedema overlying the site of injection. The EZ-IO may be faster than both manual needles and the B.I.G. and easier to place 1st time.801 Preparation Set trolle y: Dressing pack, povidone iodine, needles, 10mL sy- ringe, lidocaine (=lignocaine) 1% (5mL ), scalpel, intraosseous needle, paediat- ric infusion set, 10mL 0.9% saline, adhesive tape . Choosing the site of insertion The proximal tibia is the best site. Other sites are the p roximal humerus, distal femur or distal tibia. Choose a point on the \202 at anteromedial surface of the tibia, 1 \200\2232 cm medial to and 1 \200\2232cm below the tibial tuberosi ty. The child \200\231s leg should be restrained, with a small support placed behind the kn ee. Procedure \200 Sterilize the skin with antiseptic, in \201 ltrate with lidocaine as necessary. s c i r t a d e a P i (Puncturing the skin with the scalpel is not usually necessary.) Insert the intraosseous needle at an angle of 90 to the skin; advance with a boring or sc rewing motion into the marrow cavity. Correct location of the needle is signi \201 ed by a decrease in resistance on entering the marrow cavity. \200 Stabilize the needle and veri fy the position by aspirating marrow, or by the easy \202 ushing of 5 \200\22310mL of 0.9 % saline, without any in \201 ltration of surround- ing tissue. The needle should stand up right without support, but should be secured with tape. Take samples for culture, U&E, FBC, group & save! \200 Connect to IV infusion via an exte nsion: better \202 ow rates are often got by syringing in \202 uid boluses (standard bo lus is 20mL/kg of crystalloid or colloid). Complications (Infrequent) There may be extravas ation of \202 uid, or cellulitis, fractures, osteomyelitis, pain, and fat or bone microem boli. These are more common with prolonged use \200\224so intraosseous infusion should be d iscontin- ued as soon as conventional IV access is attained (should be within 24h). NB: Int raosseous delivery may also be used in adults.802 The position on the tibia in adults is 2c m medial to tibial tuberosity and 1cm above it (as opposed to below it in children). \200 Anaphylaxis (Adrenaline=epinephrine) resus.org.uk Never blame yourself for forgetting anything, except your humanity (and the dose of adrenaline). \200 Call the resuscitation/ cardiac arrest team (paramedics if in the community). \200 Ideally place patient on back w ith legs raised. If they have signi \201 cant respir- atory distress allow the patient to put themselves in a position of comfort. Do not let them stand or sit up rapidly. If comato se, use left-lateral position (to prevent caval compression). 237 \200 \200 ABCDE: Airway (any swelling, hoarseness, stridor?); breathing (rate \200\200, wheeze , fatigue, cyanosis, SpO2 <92%?); circulation (pale, clammy, BP \200\201, faints?); disabil - ity (conscious level, eg drowsy/coma?); exposure of skin (erythema/urticaria?). \200 The chief drug priority is adrenaline. Give intra-muscularly (IM). Use a suita- ble syringe fo r measuring small volumes; absolute accuracy isn \200\231t essential.803 Note strength! (1 : 1000 not 1 : 10,000.) IM dose of 3 drugs: If aged <6 months If aged 6 months \200\2236yrs 0.15mL (150 g) 0.3mL (300 g) Dose if aged 6 \200\22312yrs Adolescent/adult dose 0.5mL (5 00 g) s c i r t a i d e a P Adrenaline 1 : 1000 Chlorphenamine Hydrocortisone 0.15mL (150 g)[13] 25 g/kg 2.5mg 5mg 10 mg 25mg 50mg 100mg 200mg \200 Repeat adrenaline dose after 5min if no improvement. Also: high- \202 ow O2 ( IPPV ) & crystalloid (20mL/kg IVI). NB: weight (kg) \211\210 2 (age in yrs + 4). OK if 1 \200 \22310yrs old.