A child’s development represents the interaction of hereditary and environmental factors. Hereditary factors determine the potential of the child, and the environment influences whether or not that potential is achieved. For optimal development the environment has to meet and provide for the child’s intellectual and psychological needs. Such needs will naturally vary with the age of the child and the chronological state of development:
- An infant will be physically dependent on parents and requires a limited number of carers to meet its psychological needs
- A primary school child can usually meet some of its own physical needs as well as coping with social relationships
- A teenager is able to meet most of their physical needs but requires increasingly complex emotional needs.
Any child whose development is delayed or has not reached standard ‘milestones’ needs assessment to determine the cause and work out how best the child and their family can be helped. Development can be disrupted by a direct medical disorder, e.g. cerebral palsy; indirectly through chronic ill-health, e.g. severe congenital cardiac disease; physical or psychological needs not being met (environmental factors); or reduced inherited potential.
Development is most rapid in the first 4 years of life, which can conveniently be split into five periods as shown in Table 17.1.
There is considerable individual variation in the age at which a child passes through one period to another.
Specific areas of development
Development can be divided into eight functional skills. These can provide a framework for detailed assessment and surveillance in developmental paediatrics:
- Gross motor skills
- Fine motor skills
- Language comprehension
- Expressive language
- Social skills
- Behaviour and emotional development.
It is possible for a child to have a deficiency in one skill area which can impact on other areas, e.g. hearing impairment can result in poor language development and social skills.
Range of normality and individual variation
Rate of development
Although there is a variation in the rate at which children attain milestones, all may come within normal.
Pattern of development
Development is not straightforward and uniform. Motor milestones can be attained in different ways by different children. There is even more variation in the areas of social skills and behaviour.
Eventual level of attainment
This depends on heredity and environment.
|8 weeks||Responsive smiling|
|3 months||Good eye contact|
|5 months||Reaches for objects|
|10 months||Sits unsupported|
|18 months||Walks unsupported|
|18 months||Says single words with meaning|
|30 months||Speaks in phrases|
Further assessment is indicated if these skills have not been acquired by this age.
In assessing milestones, it is important to appreciate that both attainment and quality are important. Table 17.2 contains some developmental ‘age limits’.
In the UK, child health surveillance examinations occur at regular intervals, which correspond to the stages outlined in Table 17.1.
At each of these reviews, the individual areas of developmental skills are considered. Equally important is the child’s overall development. How well are individual skills intregrated and what is the quality of development? At these reviews, the child’s health and growth are also checked. One other important part of health that is also addressed in the first 5 years of life is immunisation. The standard UK immunisation schedule is shown in Table 17.3.
Language and speech
Language and speech are different entities. In a language disorder the speech sounds are perfect but a child is unable to communicate because of language difficulty. Alternatively they can use the underlying rules for speech but cannot communicate because no one can understand what they say.
Language can be further subdivided into language comprehension and expressive language, and a deficit may occur in either. Both of these elements go through a developmental progression.
|Birth||BCG/hepatitis B (if at risk)|
|8 weeks||DTP, Hib, Polio|
|3 months||DTP, Hib, Polio|
|4 months||DTP, Hib, Polio|
|4 years||DT, Polio|
BCG = Bacille Calmette–Guérin (TB); DTP = diphtheria, tetanus, pertussis; Hib = Haemophilus influenzae type b; MMR = measles, mumps, rubella.
Language problems are recognised first by parents and health professionals. Diagnosis and treatment are specialist areas and require speech and language therapists or paediatricians.
Language and speech delay
Common causes include: hearing loss, environmental deprivation or general developmental delay. Once a cause is identified and hearing checked, a therapy programme may be initiated for the parents under the therapist’s direction.
Language and speech disorders
These are more serious and require specialist diagnosis and treatment, e.g. stammering, incomprehensible speech (dysarthria), receptive aphasia (inability to comprehend language) and expressive aphasia (inability to speak). Related conditions with speech and language problems are autism and Asperger’s syndrome.
The early detection of deafness is very important because, if untreated, the child will have impaired speech, language and learning, and behavioural problems as a result of communication difficulty.
This can be divided into sensorineural and conductive (see Chapter 9).
Sensorineural loss is uncommon (1 in 1000 of all births). It is usually present at birth or develops in the first few months of life. It is caused by damage to the cochlea or central neural pathways. Screening occurs at birth (otoacoustic emission), 6–9 months (distraction test), 15 months to 4 years (threshold audiometry), and 4 years and above at school entry if hearing loss is suspected (threshold audiometry).
Sensorineural loss is irreversible. Early amplification with hearing aids is necessary for optimal speech and language development. Cochlear implants may be required where aids give insufficient amplification. Intensive peripatetic specialist teaching support is required.
Children with hearing impairment can be educated either in mainstream schools or in specialist hearing units attached to mainstream schools. If the need is unmet with these measures, then schools for children with severe hearing impairment can perform a vital role.
Conductive hearing loss from middle ear disease can be up to 60 dB but is usually less. It is more common than sensorineural hearing loss. It is often acquired in the early years of life and may be recurrent. In most children, there are no risk factors, but children with cleft palate, Down syndrome and atopy are prone.
Any child with delayed or poor speech or language must have their hearing checked. Detection is generally by the same methods as detailed for sensorineural loss, with the exception of electrical stimulation tests, which are not useful. Impedence audiometry tests whether the middle ear is functioning normally. If a decongestant and a long course of antibiotics do not improve the condition, then surgery with the insertion of tympanoplasty tubes (grommets) with or without adenoid removal may be considered. The role of surgery is controversial.
Intervention should be based on functional disability rather than absolute hearing loss.
Most newborns can fix and move their eyes horizontally. There is a preference for looking at faces. Initially there may be an apparent squint when looking at near objects due to overconvergence. By 6 weeks the eyes should move together with no squint. Babies slowly develop the ability to focus at distances, and visual acuity improves until adult level is achieved at 3 years.
Visual impairment may present in infancy with:
- lack of following and fixation
- random eye movements
- not smiling responsively by 6 weeks post-term
- delayed development and visual inattention
- loss of red reflex from a cataract
- a white reflex in the pupil: retinoblastoma; cataract; retinopathy of immaturity.
Upper respiratory tract infections (URTIs) account for almost half of children’s visits to their GPs. Up to 15% of children in the UK have asthma, and this figure is rising.
Upper respiratory tract infections
Most are viral, but it may be hard to distinguish viral from bacterial infections.
Otitis media (OM)
Otitis media is an acute infection of the middle ear. In bacterial infections, the tympanic membrane may be bulging. In viral infections, there is an appearance of dilation of blood vessels around the circumference of the drum and over the handle of the malleus. Viral OM is usually bilateral and associated with viral pharyngitis. Rarely bacterial infection may spread to mastioditis and meningitis. The most frequent complication is a persistent middle ear effusion (glue ear) with loss of hearing and a potential detrimental effect on language development.
White exudate on the tonsil does not distinguish viral from bacterial infection. Viral tonsillitis (often adenovirus) is more common in pre-school children. Bacterial infection with Streptococcus is more common in schoolage children. EBV (glandular fever) causes a florid tonsillitis, and petechial haemorrhages may be seen on the palate. All children should have a throat swab for culture and blood for screening for glandular fever (monospot test) where appropriate.
A β-haemolytic streptococcal infection may be complicated by glomerulonephritis or rheumatic fever, although this is more common in developing countries.
Rarely a peritonsillar abscess (quinsy) may require surgical treatment. All children should have symptomatic treatment with paracetamol, and antibiotics given when the throat swab results are available.
Acute lower respiratory tract infection
Worldwide this is the most common cause of death in children under 5 years. Mortality is low in the UK and is largely confined to children with pre-existing cardiac and respiratory disease.
Worldwide, Streptococcus pneumoniae and Haemophilus influenzae are common causes. In the UK, atypical organisms such as Mycoplasma pneumoniae are responsible for a large number of cases. It is important to identify the organism responsible, and a nasopharyngeal aspirate should be collected if possible for bacterial culture and viral immunofluorescence, together with samples for blood culture and serology. Antibiotics and follow-up chest radiographs to ensure effective treatment are required.
This is uncommon now in the UK since immunisation, but it is still a common cause of death in the developing world. Measles may be followed by croup, OM or bronchopneumonia.
Laryngotracheobronchitis is commonly caused by the parainfluenza virus in spring or autumn. A cough with no respiratory distress or stridor requi/>