Paediatrics Introduction 2024 PDF

Paediatrics Week 1 Welcome to the world of little (and not so little) people! CRICOS No.00213J The Queensland University of Technology (QUT) acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We...

Paediatrics Week 1 Welcome to the world of little (and not so little) people! CRICOS No.00213J The Queensland University of Technology (QUT) acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We pay respect to their Elders, lores, customs and creation spirits. We recognise that these lands have always been places of teaching, research and learning. QUT acknowledges the important role Aboriginal and Torres Strait Islander people play within the QUT community. Todays Lecture Structure Please log into gosoapbox with the code: 512-789-226 Prevalence of disease in children Part 1 – Review of the AIHW 2018 Define stages of growth in children & milestones Part 2 – Embryology Part 3 – Ontogeny Part 4 - Milestones CRICOS No.00213J Part 1 – Prevalence of disease in children Pertinent points from the Australian Institute of Health and Welfare (AIHW) Document - Australian Children in brief 2019 4.7 million children live in Australia (aged 0-14) - 51% Identify as male - 49% Identify as female = 19% of the Australian Population CRICOS No.00213J Part 1 – Prevalence of disease in children EPIDEMIOLOGY - 1 in 17 identified as Aboriginal and Torres Strait Islander (5.9%) - 1 in 5 (17%) live in the lowest socio-economic areas - 2 in 3 (70%) live in major cities - 1 in 14 (7.4%) had some level of disability (Boys 9.4%, Girls 5.4%) CRICOS No.00213J Part 1 – Prevalence of disease in children HEALTH Source: Australia's Children - in brief 2018 (AIHW – page 16) CRICOS No.00213J Part 1 – Prevalence of disease in children DIABETES - Just over 6500 Australian children had type 1 diabetes in 2017 =141 per 100,000 children - Currently, there is no reliable national estimates of type 2 diabetes among children Source: Australia's Children - in brief 2018 (AIHW – page 20) CRICOS No.00213J Part 1 – Prevalence of disease in children DISABILITY - Relates to a child's ability to participate in a range of activities, including activities of daily life - Is typically measured in terms of the level of difficulty they experience when performing the core activities of daily living Self-care Mobility Communication Schooling Source: Australia's Children - in brief 2018 (AIHW – page 16) CRICOS No.00213J Part 1 – Prevalence of disease in children DISABILITY – Most common - Intellectual (190,000 children or 4.3%) - Sensory/speech (140,000 or 3.2%) - 219,000 children had schooling restrictions (Needing special equipment to participate or attending a special school) - Estimated 177,000 children aged 0-14 had severe disability (Boys 5.2%, Girls 2.6%) - Prevalence of severe disability was highest among children 5-9 years CRICOS No.00213J Part 1 – Prevalence of disease in children https://www.aihw.gov.au/reports/children-youth/australias- children/contents/health/children-with-disability CRICOS No.00213J Part 1 – Prevalence of disease in children Mental Health Estimated 1 in 7 children aged 4-11 (almost 14%) met the criteria to be diagnosed with a mental illness Most common: Attention deficit hyperactivity disorder (ADHD): 8.2% Anxiety disorders: 6.9% CRICOS No.00213J Part 1 – Prevalence of disease in children PHYSICAL ACTIVITY - Less than 1 quarter (23%) of children aged 5-14 undertook recommended 60 mins of physical activity every day - Less than 1 third (32%) net the screen based activity guidelines - 65% (956,000) aged 5-8, 78% (740,000) aged 9-11 and 72% (652,000) aged 12-14 participated in organised physical activities outside school hours at least once per week. Source: Australia's Children - in brief 2018 (AIHW – page 31) CRICOS No.00213J End of part 1! Please go to gosoapbox! CRICOS No.00213J Part 2 – Embryological and Foetal Development The greatest developmental changes that occur in an individual's life occurs during the first four weeks following fertilisation. Lower limb buds appear between 3rd and 4th embryonic weeks Foetal period begins with the 8th embryonic week – at this stage the foot is in 90° of equinus and adducted. It is supinated and externally rotated relative to the leg Ossification of the foot begins early in the foetal period CRICOS No.00213J Part 2 – Embryological and Foetal Development EMBRYONIC PERIOD Technically begins 3rd week post-conception and ends at the end of week 8 Myriad of changes I.e. Convert Pre-lower limb buds to individual bones Embryonic cell mass divides to form: Ectoderm: Epidermis, sensory receptor and nervous tissue Mesoderm: Skeletal connective, muscle and blood tissues Endoderm: Inner layer which forms respiratory and GI tract linings CRICOS No.00213J Part 2 – Embryological and Foetal Development EMBRYONIC PERIOD – INSULTS THAT CAN CAUSE BIRTH DEFECTS Alcohol Growth retardation, craniofacial abnormalities, CNS dysfunction Fetal alcohol syndrome (FAS) ADHA, altered facial features, decreased physical growth, reduced brain growth Tobacco Increased rate of miscarriage, increased infant mortality, low birth weight, fetal hypoxia Cannabis Lower birth weight Unsure? Cocaine Very dangerous. Brain damage (4x higher). Infants are often unresponsive and irritable CRICOS No.00213J Part 2 – Embryological and Foetal Development DEVELOPMENT OF THE FOOT Derived from mesenchyme projecting through the ectoderm. 3 main stages to forming the skeleton: Mesenchymal Cartilaginous Osseous Mesenchyme differentiates to form metatarsals, phalanges and the tarsus CRICOS No.00213J  Part 2 – Embryological and Foetal Development EMBRYONIC PERIOD Week 3 The developing nervous system is evident when the endoderm thickens to form the neural plate. Week 4: the spinal cord develops. Week 3-5: Lower limb buds develop weeks (slightly after the upper limb buds). The development of the lower limb buds are fast, with discernible changes every 2 days Week 5: the femoral, tibial and common peroneal nerves branch to their respective areas of the limb bud https://www.youtube.com/watch?v=VpbdqGJ9LWk CRICOS No.00213J Part 2 – Embryological and Foetal Development EMBRYONIC PERIOD Week 6 Limbs are perpendicular to the body and laterally rotated at 90° appearing as paddles or flippers Foot is in full equinus and inverted Plantar surface of the feet face each other (‘praying’ position) Bud webbing begins to notch and regress to form digits Webbed feet or syndactyly may result from incomplete regression of limb bud webbing CRICOS No.00213J  Part 2 – Embryological and Foetal Development EMBRYONIC PERIOD Week 7 Muscles of the gastrocnemius and soleus are apparent with myogenous zones for other flexors, extensors and peroneals present but ill-defined Main nerves have branched to supply and innervate the future muscle groups Many congenital deformities of the foot occur before the 7th embryonic week, at which point the structural/skeletal component are determined. CRICOS No.00213J  Part 2 – Embryological and Foetal Development FOETAL PERIOD Period between week 8 and term (37-40 weeks) The developing foot is in marked equinus, supinated and adducted Muscles, vessels and nerves are differentiated and digits are now distinct Muscles of the gastrocnemius and soleus are apparent with myogenous zones for other flexors, extensors and peroneals present but ill-defined Main nerves have branched to supply and innervate the future muscle groups Muscles of the gastrocnemius and soleus are apparent with myogenous (Skeletal muscle development) zones for other flexors, extensors and peroneals present but ill-defined Main nerves have branched to supply and innervate the future muscle groups CRICOS No.00213J Part 2 – Embryological and Foetal Development FOETAL PERIOD Week 9 Calcaneus moves from adjacent to the talus to plantar to the talus (subtalar joint is formed) Tibia and fibular begin to form ankle mortise around the forming talar dome 1st metatarsal base articulates with the medial cuneiform, (results in the 1st met and great toe to be adducted) Distal phalanx of the great toe is the 1st bone to ossify CRICOS No.00213J  Part 2 – Embryological and Foetal Development FOETAL PERIOD Week 10-12 Foot begins to dorsiflex at the ankle Foetus is 75mm long at 12 weeks and begins to move it legs and clench its fists The inverted position of the foot continues with torsion of both the head and the neck of the talus and also at the distal calcaneus Tibia and fibula are equal length for the last time, tibial length increases. Pre-form nail tissue develops CRICOS No.00213J Part 2 – Embryological and Foetal Development FOETAL PERIOD Week 16 Feet evert due to torsional changes in the talus and calcaneus MLA develops The movement of eversion and dorsiflexion of the foot continues until birth and postnatally until the age of 6 years. Week 18 The foetus is 15cm long CRICOS No.00213J  Part 2 – Embryological and Foetal Development FOETAL PERIOD Week 21 Calcaneus ossifies (first tarsus bone to do so) Week 22 Foetus is 30cm long and has hair on its head. Nails are present CRICOS No.00213J  Part 2 – Embryological and Foetal Development FOETAL PERIOD Week 24 Ossification centre of the talus appears From Week 26: The foetal spine becomes increasingly flexed from the cervical to sacral vertebrae. At 37 Weeks: The cuboid ossifies (used as indicator for foetal maturity in conjunction with ear cartilage) CRICOS No.00213J End of Part 2! Please go to gosoapbox! CRICOS No.00213J Part 3 – Ontogeny of the Foot Ontogeny = Development of Bone 3 sections: Primary Secondary Fusion CRICOS No.00213J Part 3 – Ontogeny of the Foot PRIMARY CENTRE A primary ossification centre is the first area of a bone to start ossifying. It usually appears during prenatal development in the central part of each developing bone. In long bones the primary centres occur in the diaphysis/shaft In irregular bones the primary centres occur usually in the body of the bone. Most bones have only one primary centre (e.g. all long bones) but some irregular bones such as the os coxa (hip) and vertebrae have multiple primary centres CRICOS No.00213J Part 3 – Ontogeny of the Foot SECONDARY CENTRE A secondary ossification centre is the area of ossification that appears after the primary ossification centre has already appeared - most of which appear during the postnatal and adolescent years. Most bones have more than one secondary ossification centre. In long bones, the secondary centres appear in the epiphyses (the enlarged wide end of a long bone that articulates with other bones at joints) CRICOS No.00213J Part 3 – Ontogeny of the Foot Mackie et al 2008 Image 1 https://www.youtube.com/watch?v=vOKLFdP4pjE CRICOS No.00213J Part 3 – Ontogeny of the Foot CRICOS No.00213J Part 3 – Ontogeny of the leg Many of the paediatric foot problems presenting to the Podiatrist have their origin in ontogentic development This is generally morphological concerns of transverse & frontal plane nature CRICOS No.00213J Part 3 – Ontogeny of the leg FEMUR FRONTAL PLANE: The angle of inclination of the femur (the angle formed by the log axis of the head and neck to the long axis of the femoral shaft) Neonates the angle is approximately ~135-140 degrees Reduces in adult to ~125 degrees Zaghloul A 2018 Figure 6 CRICOS No.00213J Part 3 – Ontogeny of the leg FEMUR TRANSVERSE PLANE: Femoral neck anteversion or “medial femoral torsion.” It is thought to result from medial (internal) rotation of the limb bud in early intrauterine life. In postnatal development, The FNA angle diminishes about 1.5 degrees a year until about 15 years of age. In Adults, average femoral head and neck torsion forward of the body’s frontal plane is about 15 degrees, a little less in men (less than 15°) and a little more women (18°) https://www.youtube.com/watch?v=GTpHJumNKVM CRICOS No.00213J Part 3 – Ontogeny of the leg FEMUR TRANSVERSE PLANE: Age Newborn 5 9 16 FNA angle 31 Degrees 26 Degrees 21 degrees 15 degrees Cilbulka 2004, figure 1 CRICOS No.00213J Part 3 – Ontogeny of the leg FEMUR SAGITTAL PLANE: A mild anterior convexity may occasionally exist in the femur as the only sagittal plane influence CRICOS No.00213J Part 3 – Ontogeny of the leg TIBIA and FIBULA FRONTAL PLANE: In the newborn there is varus bowing (tibial varum) in the shaft of the tibia of about 15 – 20 degrees. The appearance of bowing in infants is accentuated by the early placement of soft tissue masses on the Apley & Soloman (1993) CRICOS No.00213J Part 3 – Ontogeny of the leg TIBIA and FIBULA SAGITTAL PLANE: Retrotorsion – not a true torsion, but a backward deflection of the tibia, most probably due to tension of the hamstring muscles ( usually biceps femoris) Retroflexion – tibia bent to be concave posteriorly (possibly due to the pull of the posterior leg muscles with attachments proximally) Retroversion - at birth the tibial plateau demonstrates a 27 degree posterior angulation – gradually raising to 5 degrees by 19 years of age CRICOS No.00213J Part 3 – Ontogeny of the leg TIBIA and FIBULA TRANSVERSE PLANE: At birth the medial and lateral malleoli are in approximately the same frontal plane – from 0 degrees to slight external rotation. 3 months after birth the malleoli begin to externally rotate – continues until age 6. CRICOS No.00213J Part 3 – Ontogeny of the leg FOOT: The average length of the foot at birth is about 7 – 10cms. It is relatively long with respect to the lower leg It is very flexible - held in approximately 15 degrees of dorsiflexion. When the newborn legs are held in a passive extended position, the feet are slightly inverted and adducted 15 degrees. There is some slight inversion/eversion present in the ankle joint in the newborn The foot can plantarflex to 50 degrees and dorsiflex to 45 degrees. CRICOS No.00213J Part 3 – Ontogeny of the leg FOOT: At birth the following bones are visible on x-ray: Talus Calcaneus Cuboid All 5 metatarsals All phalanges except intermediate and distal on the 5th toe CRICOS No.00213J Part 3 – Ontogeny of the leg FOREFOOT: The forefoot in the newborn is usually inverted 10-15 degrees on the rearfoot & fully reducible (FF supinatus) Torsion of the talar head is downward and medial about 20 – 25 degrees in the frontal plane. This increases approximately 20 degrees in a valgus direction. Forefoot adduction is approximately 20 degrees. The angle between the trochlea surface and the neck of the talus reduces from approximately 30 degrees to 20-25 degrees. Other angles which diminish with growth and contribute to correction of the adducted position of the forefoot are: The angle between the talar neck and calcaneus The angle between the talar trochlea surface and the calcaneus. CRICOS No.00213J Part 3 – Ontogeny of the leg MLA: The medial longitudinal arch is present and is easily seen in newborn and prewalking children, but in most cases the fat pad (Spitzy’s) may obscure the normal osseous arch contour. CRICOS No.00213J Part 3 – Ontogeny of the leg END OF PART 3! Please go to gosoapbox CRICOS No.00213J Part 4 – Developmental Milestones OVERVIEW Look for signs of developmental variation Expectant normative progress & timeframes There is variation in milestones following 2 years age Up to 2 years – milestone progression is usually consistent Please watch this video for an overview https://www.youtube.com/watch?v=g4HdXxz25pw CRICOS No.00213J Part 4 – Developmental Milestones OVERVIEW Progression is heavily favoured Plateau is concerning Regression is very concerning Aim to identify patterns - not just single instances of milestone aberration Identification of consistency in variance Sibling comparison affords consistency in environment CRICOS No.00213J Part 4 – Developmental Milestones I month Spontaneous motor activity generalised Lifts head when prone; poor supine head control Beginning to regard surroundings Follow objects to midline CRICOS No.00213J Part 4 – Developmental Milestones 2 Months Motor activity generalised Smiles and coos socially Follows objects past midline CRICOS No.00213J Part 4 – Developmental Milestones 3 Months Follows well with eyes May wave at toy: beginning to regard hands Good control of head when prone and looking around Head control improved when in sitting position Moro’s reflex disappearing Smiles: coos in more sustained fashion CRICOS No.00213J Part 4 – Developmental Milestones 4 Months Beginning to reach for toys symmetrically Regards toys and may pull them to mouth Removes cloth from face Control of head good when sitting Plays with hands Laughs CRICOS No.00213J Part 4 – Developmental Milestones 6 Months Reaches with either hand and begins to transfer objects Rolls over May sit briefly when placed in sitting position Laughs and interacts with examiner CRICOS No.00213J Part 4 – Developmental Milestones 8 Months Prehensile function palmer (grasping) Independent sitting Beginning to creep reciprocally Vocalises with infantile rhythms and polysyllabic vowel sounds (‘babbling’) Regards self in mirror CRICOS No.00213J Part 4 – Developmental Milestones 10 Months Crawls reciprocally Pulls up on rail Kneeled play May begin to cruise (uses support, slides feet then steps) Uses thumb and index finger in opposition May say ‘mama’ or ‘dada’ Feeds self and holds own bottle CRICOS No.00213J Part 4 – Developmental Milestones 12 Months Walks with support (double then single hand) Stands alone Places cube in cup; tries to build tower of two cubes May have two words in addition to ‘mama’ or ‘dada’ Begins to feed self with fingers CRICOS No.00213J Part 4 – Developmental Milestones 15 Months Walks alone Creeps upstairs 4 to 5 word vocabulary Drinks from a cup Beginning to feed self with a spoon Makes desires known by pointing or vocalising CRICOS No.00213J Part 4 – Developmental Milestones 18 Months Walks well Sits on a chair Throws a ball Climbs on furniture Stacks 3 – 4 cubes 10 word vocabulary Begins to identify pictures Pulls toy on string May be toilet trained during day CRICOS No.00213J Part 4 – Developmental Milestones 2 Years Runs well Undresses self partially Negotiates steps one at a time Attempts to put on socks Uses pronouns and 3 word Refers to self a ‘I’ sentences Knows full name Helps to put things away Feeds self with a spoon Refers to self by name Toilet trained during day CRICOS No.00213J Part 4 – Developmental Milestones 3 Years Alternates feet going upstairs Pedals tricycle Builds tower of cubes Names drawings Uses plurals and obeys propositional commands Feeds self well Buttons and buttons clothes and puts on shoes Negotiates stairs alternating pattern unassisted (ascension>descension) Single leg stance (eyes open) 5- 7 secs – expect marked difference SLS must preceed hopping CRICOS No.00213J Part 4 – Developmental Milestones 4 Years Runs and climbs well Walks downstairs alternating feet Hops on one foot Coordinated skipping attained Throws a ball overhead Attempts to catch a ball or kick it in the air Pedals tricycle rapidly Draws a man with head, trunk and arms or legs Counts 3 objects Names one or more colours CRICOS No.00213J Part 4 – Developmental Milestones 5 Years Skips, alternating feet Draws a man Copies a square, cross, and a circle Dresses and undresses without assistance Knows the names of 4 or more colours Counts to 10 or higher CRICOS No.00213J Part 4 – Developmental Milestones 6 Years Draws a man with hands and clothes Repeats 4 digits Knows morning and afternoon Knows left from right side Single leg stance >15 secs – minor deviation noted CRICOS No.00213J Part 4 – Developmental Milestones https://www.youtube.com/watch?v=GTpHJumNKVM CRICOS No.00213J Part 4 – Developmental Milestones Developmental Tools Griffith Developmental scales are one of the most accessible & widely used in Australian Paedatric testing More specific for gross motor developmental testing is Movement Assessment Battery for Children (Movement ABC) CRICOS No.00213J End of part 4! Please go to gosoapbox CRICOS No.00213J References AIHW: The health of Australias Children, https://www.aihw.gov.au/reports/children-youth/australias- children/contents/health/the-health-of-australias-children; updated 25/2/2022 Cibulka MT. Determination and Significance of Femoral Neck Anteversion. Physical Therapy. 2004;84(6):550- 8. Mackie EJ, Ahmed YA, Tatarczuch L, Chen KS, Mirams M. Endochondral ossification: how cartilage is converted into bone in the developing skeleton. Int J Biochem Cell Biol. 2008;40(1):46-62. Zaghloul A. Hip Joint: Embryology, Anatomy and Biomechanics. Biomedical Journal of Scientific & Technical Research. 2018;12(3). CRICOS No.00213J