Pediatric book-4-33.pdf

Chapter 1 Growth and Development Chapter 1 Growth and Development Learning Objectives: By the end of this chapter, students should be able to: 1. Define infant growth and iden...

Chapter 1 Growth and Development Chapter 1 Growth and Development Learning Objectives: By the end of this chapter, students should be able to: 1. Define infant growth and identify the stages of growth. 2. Know factors affecting growth and development. 3. Demonstrate steps in evaluation of growth. 4. Explain information related to developmental milestones. 5. Define failure to thrive (FTT), discuss its multiple causes, recognize the typical clinical features, and know how to manage an infant or a child presented with it. Contents: 1. Factors influencing growth and development. 2. Stages of human growth and development. 3. Assessment of growth. 4. Assessment of development. 5. Failure to thrive. -2-  Chapter 1 Growth and Development Growth and Development Case 1 Osama is a 9-month-old male infant, is seen by his family doctor because of concern that he is not growing fast enough. He is only on the 10th centile for height and below the 5 th centile for weight. What is the greatest influence on his growth rate at his age? At his age nutrition has the greatest influence on his growth rate. Along with good health, happiness and thyroid hormones, infant growth (from birth to 12 months of age) is most dependent on good nutrition. Growth in the 1st year of life contributes about 15% to final adult height What about the other factors; the genes and growth hormone? Genes are important but without adequate nutrition a child’s growth potential will not be achieved. Genetic influences begin to affect growth mostly after the 1st year of life. 1. Growth hormone is particularly important in determining growth after infancy and continues to exert an effect until growth ceases -3-  Chapter 1 Growth and Development What are the points you should look for in your evaluation? The followings should be looked for in details: 2. History: medical history, past history, developmental history, dietetic history and family history. 3. Complete examination: General examination including Anthropometry & systemic examination for detection any signs of vitamins or minerals deficiency or any organic cause. Growth: is the natural increase of size of the body as a whole and of its separate parts. It results from multiplication and increase in the size of cells. It is the fundamental physiologic process that characterizes childhood, so; Nutrition for infants, children, and adolescents should support normal growth and development and, Growth should be closely monitored as it is a sensitive indicator of a child nutritional status. Growth during infancy is: Rapid, Critical for neurocognitive development, Has the highest energy and nutrient requirements relative to body size than any other period of growth? Factors influencing Growth and Development: 1- Genetic factors 2- Environmental factors and socio-economic status 3- Maternal factors: Nutritional deficiencies Diabetic mother Exposure to radiation Infection Smoking Use of drugs 4- Endocrinal factors: Thyroid and growth hormones. 5- Nutritional factors: child nutrition. 6- Chronic infections: (e.g., tuberculosis) and chronic debilitating diseases (e.g., congenital heart disease (CHD), chronic kidney disease (CKD) -4- Chapter 1 Growth and Development 7- Physical activity: bed-ridden children do not grow normally. Stages of Human Growth & Development: Growth during early life can be divided into periods: 1. Intrauterine stage: (from the time of fertilization to the time of birth) 1. Embryonic stage: (first 8 weeks of gestation) - It is the period of organogenesis. 2. Fetal stage: (9-40 weeks of gestation) - It is a period of rapid growth and development. a. Early fetal period (9-24 weeks of gestation). b. Late fetal period (25-40 weeks of gestation). 3. Perinatal: (from 28th week of fetal life to 7th day after delivery) 2. Extrauterine stage: (postnatal) 1. Neonatal period: (First 28 days after birth). 2. Infancy: (first 2 years of life) - It is the period of most rapid physical growth & mental development. - It is the period of weaning. - The curious child is exploring what around him. a. Early infancy (1-12 months) b. Late infancy (12-24 months) 3. Toddlerhood: (from 1-3 years) 4. Early childhood: (preschool age 3-6 years) - It is the period of exploring the outside world and starts learning. 5. Late Childhood: (School age 6-12 years) - The school child starts studying and having exams. 6. Adolescence: (12-20 years) - It is the period of passage from childhood to puberty and adulthood - The timing of start and the velocity of pubertal changes are highly variable from person to person. a. Early adolescence: 12-14 years old. b. Middle adolescence: 15-16 years old. c. Late adolescence: 17-20 years old. -5- Chapter 1 Growth and Development Assessment of Growth: Physical Growth in pediatrics can be assessed through: 1. Anthropometry 2. Dental age 3. Bone age. 1. Anthropometry How can you assess anthropometric measures? ▪ Get an accurate body measurement e.g., weight, height, head circumference, etc. by special scales. ▪ Compare this measurement with growth standards obtained from normal individuals of same age, sex, and community by plotting this measurement on percentile growth charts. ▪ The growth chart is the best tool to determine patterns of growth, with separate charts for boys and girls (review the clinical book). ▪ The charts measure weight for age, height for age, head circumference for age, weight for height, and body mass index (BMI). ▪ Each chart has multiple curves (either 5–95% or 3–97%). a. Weight: Average weight at birth is 3 - 3.5 kg. There is an initial weight loss of 5-10 % during the first 3 to 4 days of life. The loss is usually regained by the 7th –10th day of life. During infancy, weight increases as follows: - 750 g (3/4 kg) / month for the first 4 months (wt = 6 kg at 4 month) - 500 g (1/2 kg) / month for the second 4 months (wt = 8 kg at 8 month) - 250 g (1/4 kg) / month for the third 4 months (wt = 9 kg at 12 month) During early childhood (from 2-6 years): – Weight in kg = (Age in years x 2) + 8 During late childhood (from 7-12 years): – Weight in kg = (Age in years x 7) – 5 2 -6- Chapter 1 Growth and Development b. Length / Height: Length: (recumbent supine length) is taken from infants and children less than 2 years old. Height: (standing) is measured from children more than 2 years old. – Birth length: 50 cm. – First 3 months: increases 3 cm / month (length at 3 months = 59 cm). – Second 3 months: increases 2 cm / month (length at 6 months = 65 cm). – From 7-12 months: increases 1.5 cm / month (length at 12 months = 75cm). – From 1-2 years: increases 0.5-1 cm / month (length at 2 years = 87cm). -7- Chapter 1 Growth and Development c. Body Proportions: Upper / lower Age segment ratio ‫ ــ‬Upper segment / lower segment ratio (U/L ratio) or (U / L) crown to symphysis / symphysis to heel, reflects Birth 1.7: 1 maturation of linear growth. ‫ ــ‬In cretinism, children are short and have an infantile 3 years 1.33: 1 U / L segment ratio. 5 years 1.25: 1 d. Head Circumference: Puberty 1: 1 ‫ ــ‬The size of the skull depends on the growth of the brain. ‫ ــ‬If the brain does not grow adequately, the skull will be small (microcephaly). - To measure the skull the tape is applied firmly over the glabella and supraorbital ridges anteriorly and posteriorly to the posterior occipital protuberance (passing through the widest possible circumference. -8- Chapter 1 Growth and Development ‫ ــ‬Rate of growth of head: During 1st year (average): Head Age Circumference – First 3 months: 2 cm / month – Next 9 months: 0.5 cm / month Birth 35 cm From the end of 1st year to adulthood 3 months 41 cm – Head circumference increases only 10 cm. ‫ ــ‬Anterior fontanel: 6 months 43 cm At birth 2.5 X 2.5 cm, closes between 6 and 18 months. 9 months 44 cm ‫ ــ‬Posterior fontanel: 1 year 45 cm At Birth posterior fontanel is nearly closed. It may close during the 1st 3 months after birth 5 years 50 cm 12 years 53 cm e. Mid-arm Circumference: ‫ ــ‬Measured in the non-dominant arm, midway Adults 55 cm between the acromial and olecranon processes. Normal Mid-arm Circumference: It is between 13.5 and 14.5 cm in children 1-5 years old. Overtly malnourished those below 12.5 cm. Border line malnutrition those between 12.5 and 13.5 cm. f. Body Mass Index (BMI): - BMI = Weight (kg) / Height2 (meter) - The result should be plotted against standard percentile charts for BMI in different ages (see latter). Weight Status Category Percentile Range of BMI for age Underweight < 5th percentile Normal or Healthy Weight 5th percentile to < 85th percentile Overweight 85th to < 95th percentile Obese 95th percentile or greater -9- Chapter 1 Growth and Development 2. Teething – Eruption of teeth follows a special pattern, and its retardation may indicate retardation in osseous development. a. Deciduous teeth (milk) (20 teeth) Lower central incisors 5-7 months (2 teeth) at 6m Upper central incisors 6-8 months (4 teeth) at 7m Upper lateral incisors 7-10months (6 teeth) at 8m Lower lateral incisors 8-11 months (8 teeth) at 9m First molars (4 new teeth) 12 months (12 teeth at 1 year) Canines (4 new teeth) 18 months (16 teeth at 1.5 years) Second molars (4 new teeth) 24 months (20 teeth at 2 year) b. Permanent teeth (28-32 teeth) First molar (4 new teeth) 6-7 years Central incisors (changed 4 teeth) 7-8 years Lateral incisors (changed 4 teeth) 8-9 years Canines (changed 4 teeth) 9-10 years First premolars (changed 4 teeth) 10-11 years Second premolars (changed 4 teeth) 11-12 years Second molars (4 new teeth) 12-13 years Third molars (4 new teeth) 17-25 years (32 teeth at adulthood) - 10 - Chapter 1 Growth and Development 3. Skeletal (osseous) maturation – Bone age, determined radiographically, is the best index for assessment of general growth as bone age equals to the chronological age of normal individuals. – The following data are usually assessed: 1. Number and size of epiphyseal centers. 2. Size, shape, density, and sharpness of outline of the ends of bones. 3. Distance separating epiphysis and metaphysis or the degree of fusion between these two elements. – Time of ossific centers appearance in the X-ray: 1. At birth: The ossific centers at the lower ends of femur and the upper end of tibia are usually present at birth 2. At age of 3 weeks: The ossific center appears in the head of humerus. 3. At the age of 2 mo-6 yr: The ossific centers of the carpal bones in the wrist appear successively, approximately one center per year. (Roughly between 2-6 years bone age = number of carpal centers ‫ــ‬1) e.g; two carpal centers are present at one year of age. – This can be determined by comparing the radiograph of the child bones with standard atlas of bone maturation radiographs of different ages. – Clinical application (discrepancy between the chronological age and bone age) 1. Retardation of bone age: the bone age is lower than the chronological age in the following conditions: prematurity, undernutrition, rickets, endocrinal hypofunction like hypothyroidism. 2. Advanced bone age: the bone age exceeds the chronological age in the cases of precocious puberty. - 11 - Chapter 1 Growth and Development Assessment of Development Case 2 Omar has just had his first birthday party. During his party he commando crawled with great speed, although he cannot walk. He managed to pick off all the round chocolate sweets from his birthday cake. He can say two words with meaning. After his birthday party, he impressed his guests by waving goodbye. Which area of Omar’s development is delayed? None – his development is within normal limits. He has achieved normal milestones for 12-month- old. Explain what are the gross motor, fine motor, social and language developmental milestones does Omar have? Gross: Omar commando crawls, so is expected to walk later than the median age of 12 months. Fine: He is able to perform a pincer grip to be able to pick small chocolates off his birthday cake Social, emotional, and behavioral development: He can wave goodbye. Speech and hearing: He is able to say two words with meaning. Case 3 Female infant demonstrates rolling from front to back. When prone she lifted her torso off the couch on her hands. When pulled to a sitting position she has a straight back and good head control. She sits briefly unsupported and bears weight on her legs. She is not crawling and does not attempt to pull to stand. As regard to her gross motor development what is her developmental age? 6 months old. Regarding the fine motor development what do you expect her to do? Reaches to objects & brings them to mouth, Transfers objects between hands. If this infant coos and only shows social smile but does not recognize her mother yet, what is the expected age as regards to her social development? She has 4 months old only as regard to her social and language development. What is the next step in her plan management? Regular follow up of neurological and developmental milestones. - 12 - Chapter 1 Growth and Development If there is a language delay, hearing loss must be excluded firstly. If there is a lack of development or regression of language skills with impaired social interaction, restricted activities and stereotypic behaviors, autistic spectrum disorder to be considered. Many factors may affect development as genetic factors, maternal factors, nutritional factors or any chronic disease. So, complete history taking and full clinical examination including (neurologic examination), development testing and anthropometric measurements must be done. Development: means maturation of organs and systems, acquisition of new skills and functions as well as ability of adaptation and assuming responsibilities. – It is a continuous process from conception to maturity. – The sequence of development is similar in all children, but its rate varies from child to child. – The direction of development is cephalo-caudal, i.e., the infant controls his head before he can sit, and crawls before he can walk. – The developmental process reflects the maturation of the brain and nervous system. – The newborn cannot do any voluntary activities; all his behavior is reflex in nature. – As maturation proceeds, this reflex activity is replaced by specific individual responses. Development is assessed in 4 major fields: 1. Gross motor: e.g., head control, sitting, standing, etc. 2. Fine motor: e.g., coordination of hands and eyes, using fingers, etc. 3. Social: i.e., social reaction of child with his surroundings and relatives. 4. Language: all visible and audible forms of communications. Assessment is based on acquisition of milestones occurring sequentially and at a specific rate: each skill area has a spectrum of normal and abnormal. Abnormal development in one area increases likelihood of abnormality in another area, so careful assessment of all skills is needed. Developmental diagnosis is a functional description/classification and does not specify an etiology. Developmental delay is performance significantly below average, i.e., developmental quotient (developmental age / chronologic age X 100) of 95 per cent accurate in diagnosing coeliac disease (it is important to simultaneously measure immunoglobulin A (Ig), as anti-TTG is an IgA antibody and IgA deficiency would invalidate the test). The definitive diagnosis is usually based on an endoscopy with a jejunal biopsy. Note that Crohn’s disease is very rare in this agegroup so, Rami’s father illness is coincidental. - 17 -  Chapter 1 Growth and Development What is the appropriate treatment for this condition? Treatment is with a gluten-free diet. Failure to Thrive (FTT): - Definition: a term used to describe children who are not growing as expected. Weight is consistently or progressively decreasing below the 3 rd to 5th percentile for age and sex, or there is decrease in the percentile rank of 2 major growth parameters in a short period. - Etiology: the cause may be an identified medical condition or may be related to environmental factors. Most cases of FTT are multi-factorial. The physiologic basis for FTT of any etiology is inadequate nutrition and is divided into: 1. Organic FTT 2. Non-Organic FTT 3. Mixed. 1. Organic FTT: Growth failure is due to an acute or chronic disorder that interferes with nutrient intake, absorption, metabolism, or excretion or that increases energy requirements. Some Causes of Organic Failure to Thrive Mechanism Disorder CNS disorder (cerebral palsy) Decreased nutrient intake Cleft lip or palate Celiac disease Cystic fibrosis Malabsorption Disaccharidase deficiency (lactase deficiency) Inflammatory bowel disease Short gut Gastroesophageal reflux disease Excessive loss of Pyloric stenosis nutrients Protein-losing enteropathy Proteinuria Chromosomal abnormality (Down syndrome) Impaired metabolism Classic galactosemia Inborn errors of metabolism - 18 - Chapter 1 Growth and Development Bronchopulmonary dysplasia Cystic fibrosis Increased energy requirements Heart failure Hyperthyroidism Infection 2. Non-organic FTT: Up to 80% of children with growth failure do not have an apparent organic disorder. Growth failure occurs because of environmental neglect (e.g., lack of food), stimulus deprivation, or both. 1. Lack of food may be due to: Poverty. Poor understanding of feeding techniques. Improperly prepared formula (e.g., over-diluting formula to stretch it because of financial difficulties). Inadequate supply of breast milk (e.g., the mother is under stress, exhausted, or poorly nourished). 2. Stimulus deprivation: Nonorganic FTT is often due to disordered interaction between a child and caregiver. In some cases, the infant or the child becomes depressed, apathetic, and ultimately anorexic due to stimulus deprivation. 3. Mixed FTT In mixed FTT, organic and nonorganic causes can overlap; children with organic disorders also have disturbed environments or dysfunctional parental interactions. Likewise, children with severe undernutrition caused by nonorganic FTT can develop organic medical problems. - Clinical manifestations: Children with organic FTT may present at any age depending on the underlying disorder. Most children with nonorganic FTT manifest growth failure before age 1 year and many by age 6 months. Age should be plotted against weight, height, and head size on growth standards and growth charts Weight is the most sensitive indicator of nutritional status. When FTT is due to inadequate caloric intake, weight falls from the baseline percentile before length does. Reduced linear growth usually indicates severe, prolonged undernutrition. Simultaneous fall of length and weight suggests a primary disorder of growth or a - 19 - Chapter 1 Growth and Development prolonged inflammatory state. Reduced growth in head circumference occurs late and indicates very severe or long- standing undernutrition. FTT is associated with physical and social delays, and if occurring in older children, delayed puberty. A child who does not gain weight satisfactorily despite outpatient intervention usually is admitted to the hospital so that all necessary observations and diagnostic tests can be made. During hospitalization, the child’s interaction with people in the environment is closely observed. Some children with nonorganic FTT have been described as wary of close contact with people, preferring interactions with inanimate objects if they interact at all. Hospitalized children who begin gaining weight well with proper feeding techniques, and number of calories are more likely to have nonorganic FTT. - Diagnosis: it can be reached by: - Frequent monitoring of the anthropometric measures especially the weight. - Thorough medical, family, and social history. - Diet history. - Laboratory testing. - Testing: if a thorough history or physical examination does not indicate a particular cause, the following screening tests are recommended: Complete blood count including differential leucocytic count. ESR. BUN and serum creatinine and electrolytes levels. Urinalysis (including ability to concentrate and acidify) and culture. Stool for pH, reducing substances, odor, color, consistency, and fat content. Other tests that are sometimes appropriate include: – Thyroxine level if growth in height is more severely affected than growth in weight – Growth hormone deficiency should be suspected when height and weight fall off simultaneously – A sweat test should be done if the child has a history of recurrent upper or lower respiratory tract disease, a ravenous appetite, foul-smelling bulky stools, hepatomegaly, or a family history of cystic fibrosis. - 20 - Chapter 1 Growth and Development – Newborn screening results should be reviewed for other genetic diseases. – Investigation for infectious diseases for children with evidence of infection. – Radiologic investigation if there is anatomic or functional pathology (e.g., pyloric stenosis, gastroesophageal reflux). - Prognosis: Prognosis with organic FTT depends on the cause. With nonorganic FTT, most of the children ages > 1 year achieve a stable weight above the 3rd percentile. Children who develop FTT before 1 year are at high risk of cognitive delay, especially verbal and math skills. If diagnosed before 6 months, where the rate of post-natal brain growth is maximal, are at highest risk. General behavioral problems occur in about 50% of children. - Treatment: can be summarized in the following points: Sufficient nutrition: a nutritious diet containing adequate calories for catch-up growth (about 150% of normal caloric requirement) and individualized medical and social supports are usually necessary. Treatment of underlying disorder. Long-term social support providing sufficient health and environmental resources to promote satisfactory growth. - 21 - Chapter 1 Growth and Development Practice Questions (Choose one correct answer) 1- During infancy, body weight increases during the first 4 months as follows: a) 500 gm/ month. b) 400 gm/ month. c) 750 gm/ month. d) 600 gm/ month. 2- The average head circumference of an infant at 1 year of age is: a) 50 cm. b) 35 cm. c) 45 cm. d) 40 cm. 3- The healthy infant shows social smile at the age of: a) 1st month. b) 2-3rd month. c) 3-6th moth. d) 4-5th month. 4- At one year of age, the number of the carpal ossific centers in the healthy infant is: a) One center. b) Two centers. c) Three centers. d) Four centers. 5- The normal infant can wave bye-bye by the age of : a) 6th month. b) 9th month. c) 12th month. d) 15th month. 6- In healthy infants, the active palmar grasp appears at the age of : a) 1st month. b) 3rd month. c) 6th month. d) 4-8th month - 22 - Chapter 2 Behavioral Pediatrics Chapter 2 Behavioral Pediatrics Learning Objectives: By the end of this chapter, students should be able to: 1. Describe normal social and behavioral development at different age groups 2. Describe factors affecting normal development 3. Describe the different types, causes and management of common behavioral and developmental disorders. Contents: 1. Factors Affecting development and behavior 2. Some common developmental and behavioral disorders. 23 Chapter 2 Behavioral Pediatrics Case 1 A healthy 7-year-old boy presents to your office for concerns of difficulty in school. He was born at full term by a repeat cesarean section after an uneventful pregnancy. He met all developmental milestones on time. He is now repeating the first grade. Teachers complain that he frequently does not turn in his homework assignments and when he does it is full of careless mistakes. He often gets out of his chair during class and disrupts his classmates. Even when he raises his hand to answer a question, he usually ends up speaking out of turn. His family has to help him with his homework at night and he requires constant redirecting. His parents are currently separated, and his grandmother provides much of his care as his mother works full-time. His father never finished high school but no one in the family has been diagnosed with a learning disability. General Examination: The child is a no dysmorphic 7-yearold boy. He cooperates with the examination but is very fidgety and distractible. Neurologic Examination: Mental Status: He is alert and cooperative. Language: He has fluent speech without dysarthria. Cranial Nerves: His pupils are equal, round, and reactive to light. His extra ocular muscles are intact and there are no visual field cuts. His face is symmetric. The tongue is midline. Motor: He has normal bulk and tone with 5/5 strength throughout. Coordination: Finger- to-nose is intact bilaterally. Sensory: Normal light-touch, temperature, and vibration. Gait: He has a normal heel, toe, flat, and tandem gait. Reflexes: 2+ throughout with bilateral plantar flexor responses. What is the most probable diagnosis? Attention deficit hyperactivity disorder. How is this condition diagnosed? – There are no specific laboratory tests for the work-up of ADHD – This child requires a formal assessment of achievement, intellectual abilities, and education. – Testing is most often performed through the school system or by an independent psychologist. – This should confirm or exclude the diagnosis of ADHD and/or a learning disability, – As well as screen him for other psychiatric disorders. – If there is a concern for a concomitant psychiatric condition, the child – Should be referred to a psychiatrist for further management. – Complex cases may require referral to developmental or behavioral specialists What is the appropriate treatment for this condition? – Teamwork is essential! It is not one-man show!! Collaboration by parents, general educators, 24 Chapter 2 Behavioral Pediatrics special educators, counselor, psychologist, and the physician will bring the greatest results. – Medication: Ritalin or other. – Dietary changes: 1- More fish & tuna and sea foods 2- No more sugars and sweets, chocolate 3- No more junk and fast foods. – Behavior management. – Structured teaching Factors affecting development and behavior 1. Genetic and Pre-natal: as in ADHD, and Autism. 2. Peri-natal: ADHD. 3. Post-natal and Environmental may induce and or exaggerate the behavioral problems e.g. infectious agents, irradiations, food additives, junk and fast foods (bakeries are exceptional) and heavy metal exposure. 4. Mass media effects. 5. Death or Traveling of one of parents or both, grandparents and beloved person. 6. Stressor and multiple or sustained psychical traumas as wars, disasters, exams, excessive competitions, child abuse and trafficking. 7. Care-givers influences as in schools& nurseries 8. Drugs specially abused ones, mercury of vaccines. 9. Developmental or maturational defects. 10. Lack or complete absence of family or /and society support. 11. New baby in the family. 12. Idiopathic. Some common developmental and behavioral disorders A. Breathe Holding Spells (infantile syncope). Criteria: – Involuntary. – Initiated by a noxious stimulus – Associated with crying – Consciousness and posture may be lost 25 Chapter 2 Behavioral Pediatrics – Occurs from infancy through age of 5 – Two types: pallid or cyanotic – May be associated with convulsive movements Etiology: It is due to immaturity or developmental delay of the respiratory center causing it to stop working and hence stoppage of breathing with prolonged and or repetitive expirations during crying. With arrest of breathing, severe hypoxia and/or hypercarbia reach to the high levels needed for the respiratory center to regain work, so a vicious circle commences Management: EAT the guardians: Explanation, Assurance and Training of the guardians as parents and grand- parents, relatives, neighbors (if needed) as the attacks will stop by age of 5 years. Some cases may need some investigations as Echocardiography or even CT or MRI to assure the family. B. Enuresis and Encopresis Definitions: Enuresis: Uncontrolled micturition by the age of 5 years. Types of enuresis: - Primary or secondary, - Nocturnal, diurnal or mixed Encopresis: uncontrolled defecation beyond the age of 4 years. Types of encopresis: - Retentive with overflow, or non-retentive. - Primary or secondary. Etiology: - Maturation or developmental defect. - Sleep disorders. - Genetic. - Psychogenic stressors. - Organic: as spina bifida, UTI, Constipation…. etc - Hormonal as in ADH deficiency (diabetes insipidus), diabetes mellitus. - Lack of parental toilet training. 26 Chapter 2 Behavioral Pediatrics - Severe pelvic trauma - Child abuse. - Compulsive water drinking. - Physical Stressors and illnesses. - Bad sanitary conditions Management: - Full history taking and thorough physical examination especially abdomen, pelvis, spine, rectum, blood pressure, and urine analysis should be performed. - Parents must avoid corporal punishment which causes psychic insult and aggravates the problem (with regards to organic causes), instead try encouragement. - Use least possible drugs, tools as Enuresis Alarm Devices (EADs) and instructions. C. Attention-deficit/hyperactivity disorders (ADHD) Triad of ADHD: - Inattention - Hyperactivity - Impulsivity 2nd Triad of ADHD: each of above is: - Pervasive - Progressive - Persistent for more than 6 months and occurs in the first decade of life. According to DSM-MD IV-TR (Diagnostic and Statistical Manual of Mental Disorders-fourth edition –Text Revision) is characterized by: I) INATTENTION DOMAIN OR SIGNS: - Do not complete assignments. - Disruptive. - Often “off task”. - Impulsive behavior. - Over curious without satisfaction! - Finally, it is a “complete mental chaos”!! 27 Chapter 2 Behavioral Pediatrics II) HYPERACTIVITY DOMAIN or SIGNS: - Hyperactive (and Destructive) - Fidgety (enemy of the chairs) - Runs around the room (like a bee) - Overexcited (for nothing) - Blurts out answers (bizarre) - Interferes with other’s activities - Struggle with school and rejection by their peers (colleagues). Intervention strategy for ADHD: Teamwork is essential! It is not one-man show!! Collaboration by Parents, general educators, special educators, counselor, psychologist, and the physician will bring the greatest results. Medication: Ritalin or other Dietary changes: a) More fish & tuna and sea foods, b) No more sugars, sweets, chocolate, junk or fast foods. Behavioral management. Structured teaching. - Academic assignments must be clear and manageable. - Make sure that the student understands what to do. - Smaller, less complex tasks may be required followed by reinforcement. - Place students near teacher or in front row, maintain eye contact. - Provide work area without distractions for individual work. - Provide verbal and visual directions. - Warn about and explain transitions between activities or places. - Have a few simple rules and review these rules - Reward appropriate behavior, withhold or reinforcement for inappropriate behavior, rank your child higher than expected. - Use charts, points, stickers, etc, to make reinforcement visible. Finally, programs of intervention should be affordable for the child and his family. 28 Chapter 2 Behavioral Pediatrics D. Autistic Spectrum Disorders (ASD) (Childhood Autism) Autism is more common in males than females occurs in about 4-5 out of 10,000 live births (1/2000). Autism is explained by altered brain neuro-chemistry resulting in disturbed information processing and weak retrieval memory. May resemble a computer infected by a virus deleting most new data and preventing saving them! May be exaggerated by deficiency of trace elements specially zinc and selenium. Children who are diagnosed as autistic show problems in three main areas: – Social interaction – Communication – Stereotyped behavior problem. Manifestations of Children with Autism Often show a severe lack of language development. Most communicate in a limited, usually showing various abnormal speech and language characteristics. A minority (severe cases) may not communicate at all. Usually show atypical characteristics in the production, form, and content of their speech. Speech sounds may have inappropriate volume, pitch, rate, rhythm, or tone, be monotonous, have a melody like quality, or be high pitched Body language is atypical They may not make or sustain eye contact, vary their facial features, or change their body posture when conversing. They show little or no emotions. Exclude much of the rest of the social world. Lack of social reciprocity. Do not interact with others with typical emotionalism. Some display stereotyped movements or behaviors such as hand flicking, spinning, or complex body movements, produced for escape or self- mutilation. These behaviors are enhanced by excitement, anxiety, boredom and social demands. 29 Chapter 2 Behavioral Pediatrics Investigations 1. EEG 2. Hearing acuity. 3. MRI 4. I.Q. 5. Early diagnosis using some tests as Childhood Autism Rating Scale (CARS) Treatment NO COMPLETE CURE!! But doctors, therapists, teachers and parents can help. Behavioral and educational therapy programs like: Treatment and Education of Autistic Children (TEACH) are very helpful. Doctors must be frank and optimistic using simple language and must not leaving the family desperate behind them. Neuroleptic agents as Haloperidol, Risperidone and some Antidepressants may help with regards to their side effects. Hyper-baric Oxygen. E. Other Behavioral disorders: 1. Sleep Disorders (BEARS): B > Bedtime Problems. E > Excessive Daytime Sleepiness. A > Awakening During the Night. R > Regularity and Duration of Sleep. S > Snoring 2. Anxiety disorders. 3. Mood disorders as major depression. 4. Childhood psychosis as childhood schizophrenia and Asperger’s syndrome. 5. Habit disorders as tics, thumb sucking and teeth grinding. 6. Gender identity disorder (GIDs). 7. Disruptive disorders as aggression and conduct disorders. 8. School phobias (the great imitators!!). 30 Chapter 2 Behavioral Pediatrics Practice Questions (Choose one correct answer) 1. Triad of ADHD (Attention-deficit /hyperactivity disorder) is: a) Inattention, hyperactivity and anxiety b) Inattention, irritability and anorexia c) Hyperactivity, impulsivity and inattention d) Confusion, insomnia and inattention 2. Autistic-spectrum disorders (ASD) are caused by interaction of: a) Genetic and environmental factors b) Infectious and developmental factors c) Idiopathic d) All of the above. 3. Nocturnal enuresis is caused by: a) Developmental and organic factors b) Behavioral disturbances c) Nightmares and terrors d) All of the above. 4. Breath holding attacks are treated by: a) Analeptic drugs and brain stimulants. b) Bronchodilators and sedative drugs. c) Explanation, assurance and training of the family. d) Tonics and calcium supplementation. 5. Children with ADHD could be improved by: a) Sweetened and junk foods. b) Fishes, tuna and sea foods. c) Hypnotic and sedative drugs. d) Anticonvulsant drugs 6. Causes of behavioural disturbances in children are a) Genetic and familial factors. b) Environmental pollution and junk foods. c) Mass media and school effects. d) All of the above. 31