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CHAPTER 15
Child health surveillance Surveillance of the child under 5 Dr Helen Bantock, MRCP Dr Michael Modell, FRCP, FRCGP
SUMMARY 1. General health checks should be made at the following times as outlined in these guidelines: * Initial neonatal assessment * 7-10 day check * 6-week check * 7-9 months: general examination with particular attention to hearing and vision * 18-24 months: check with special attention to gait, speech and understanding * 36-42 months: general examination and developmental assessment. 2. Parental concern over a child's special senses should be carefully followed up and investigated. 3. Immunization schedules are as follows: 0-2 months: Neonatal BCG (variable depending upon local public health policy and countries of origin of local residents) 2 months: 1st diphtheria, tetanus, pertussis (DTP) and polio, Hib 3 months: 2nd DTP and polio, Hib 4 months: 3rd DTP and polio, Hib 12-18 months: MMR 4 years: Preschool DT and polio There are very few contra-indications. 4. Failure to thrive may be caused by infection, a metabolic problem or emotionalfactors. It is most commonly revealed by: * poor weight gain over a period of time * rapid weight loss. These quidelines are in two parts. The first part outlines a programme of surveillance which we hope all general practitioners will find helpful. The second part is more applicable to practices which organize their own child health clinics.
PART I: GENERAL GUIDELINES Introduction Child health surveillance implies that the health and development of children is monitored over a period of time. Although selected times are chosen for formal review, children with suspected problems will be seen by the doctor and health visitor more often.
Children under 5 are seen by their family doctor on average eight times a year (OPCS, 1991). Many more unreported psychosocial problems are likely to be suspected during ordinary consultations than at formal child surveillance sessions. For example a rise in the frequency of consultations for minor upper respiratory tract infections may be a pointer to increasing family distress. Recently there has been a change in emphasis in child surveillince with less reliance on ritualistic assessment procedures and more on parental involvement in making an evaluation of children's progress. A major review of child health surveillance (Hall, 1991) demonstrated that a number of screening tests were of limited sensitivity and reliability and have lead to a rationalization of paediatric surveillance. Experience with the normal range of development makes it more likely that general practitioners will be alerted to developmental delay and immature behaviour in children brought in for other reasons. Five per cent of young children will have hearing defects and 10% visual problems, often not noticed unless specifically looked for. These can slow a child's acquisition of language and progress at school. By monitoring a child's overall progress and giving advice and support about child rearing and health promotion, some cases of child abuse may be prevented and others detected early. There is a need to look for evidence of neglect so that help may be given to a family and its children protected. Signs that alert health professionals to the possibility of child abuse are listed in Appendix 1. These guidelines do not cover the acutely ill child in any detail. Babies are most vulnerable in the first month or two of life and symptoms which may indicate major illness are listed in Appendix 1.
Guide to average development progress 6 weeks Smiles responsively, watches the face of mother when she talks. Follows a bright or light object to about 90°. 8 months Sits stably with no head lag. Uses both hands equally readily to pick up small objects. Transfers from one hand to the other. Turns to nearby sounds. Vocalizes with single syllables. Looks for fallen objects. 24 months Should be walking steadily. Although many children will not be speaking clearly they should understand what is being said to them. Most will have a vocabulary of 50 words or more, many joining 2 words together. Imitates domestic chores.
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Most children are speaking 3 or 4-word sentences with subject, verb and object. Speech therapist assessment is needed if the child is not joining 3 words together or speech is not intelligible even to the parents. A list of equipment is given in Appendix 2.
3 years
Neonatal screening Screening for phenylketonuria and hypothyroidism is carried out at 7 days by the midwife, whether the baby is at home or in hospital. Infants of African and Afro-Caribbean extraction are at risk for sickle cell disease. Neonatal screening (by analysis of the haemoglobin) is carried out on all newborns because early prophylactic penicillin prevents an overwhelming pneumococcal infection. The health visitor should visit in the second week to explain the services available to assess parent-child interaction and to discuss the immunization schedule (Appendix 3).
The infant who fails to thrive Children who fail to thrive may do so over a prolonged period or have an acute loss of weight. (a) Poor weight gain over a prolonged period This is a sensitive indication of a feeding or psychosocial problem (a urinary tract infection may cause this picture so urine culture is an important investigation). If poor weight gain is diagnosed by plotting sequential weights on a growth chart and a fall across centile lines is observed, then full assessment involving close liaison with the health visitor is essential. (b) Rapid weight loss In a small infant the commonest cause is dehydration due to acute diarrhoea and/or vomiting. However, any acute illness such as urinary tract infection may be associated with weight loss, especially if the child is ill for more than a few days. Head circumference Most babies with a big head are merely reflecting their inheritance; however be concerned if the head circumference is crossing the centiles. Signs of hydrocephalus include abnormal separation of the sutures, tense fontanelle, prominent flattened veins and downward deviation of the eyes.
Hearing checks About one child per 1000 has severe bilateral sensorineural hearing loss but chronic secretory otitis media (CSOM or 'glue' ear) occurs commonly throughout the first 5 or 6 years of life. Parents who have been given the check list about children's hearing (Appendix 4) may notice abnormal responses if their child cannot hear. Hearing is usually tested by health visitors when the child is about 7 months of age. Children should be referred for audiological assessment if there is any doubt about their hearing or quality of vocalizations.
A recent major review by the Medical Research Council on screening children's hearing concludes that while screening in the second half of the first year and just after school entry are virtually standard, health authorities without intermediate screening programmes should not at present introduce them. The review also recommends that those authorities with more than one intermediate screen should immediately disband all but one (Haggard and Hughes, 1991). The editors therefore feel that one of the intermediate hearing checks can be justified on current evidence. Since the evidence is still unclear on this point, we feel that individual practitioners should make up their own minds and be prepared to modify their opinions in the light of future evidence.
Vision Children's vision develops from 3/60 at birth to 6/6 at 3 years. If they have severe long sight (hypermetropia) or unequal visual acuity, children will develop a squint. Persisting squint leads to poor vision (amblyopia) in the squinting eye. Children are often brought with a possible squint. Diagnosis can be difficult. Check the eyes with the child looking straight at you. Note prominent epicanthic folds (an unequal epicanthus gives rise to an apparent squint). The reflection on the cornea of a light held a few feet away will be symmetrical unless there is a squint. The cover test is difficult to perform, but try to note whether the eyes are stationary as they are alternatively covered and uncovered. Refer to an ophthalmologist: 1. If there is a constant squint 2. If there is a history of intermittent squint and the child does not have unequal epicanthic folds.
Nutrition Dietary advice may be important in certain ethnic groups; 5-10% of children have a haemoglobin concentration of less than 11 g/dl between 6 months and 6 years. Lack of sufficient iron may cause increased likelihood of infections and behavioural problems. Rickets and iron deficiency are sometimes seen in babies of South Asian parentage because of late weaning. Growth Most children remain on a stable growth trajectory (centile). In order to detect those children with growth failure (which may be due to emotional neglect, chronic physical disease, lack of growth hormone or metabolic factors) it is helpful to note the length of children at 6 weeks and 8 months and their standing height at 3 years (and at 2 if there is any query regarding growth) on the height centile charts. Any child who crosses the centiles downwards or whose length is well below the 3rd centile needs careful assessment. Parent-held records Some districts are using parent-held child health records. The use of parent-held records should: * clearly document immunization status * promote parental involvement * promote communication between professionals.
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Proposed child health surveillance programme The following outline has been produced by Camden and Islington Family Health Services Authority and Bloomsbury and Islington, and Hampstead Health Authorities. Initial neonatal assessment Enquire about any parental concerns. Review family history, pregnancy and birth. Full examination should include testes, heart, hips, red reflex (for congenital cataracts), weight, head circumference, length, phenylketonuria and thyroid (Guthrie) test at 5-10 days. Give encouragement to breast feeding.
Discharge/10 days Enquire about parental concerns, check hips and heart, and arrange for electrophysiological tests for infants at high risk for hearing loss. 6-week check Check history. Enquire about parental concerns especially concerning vision and hearing (and whether baby in high risk category). Provide check list for hearing loss. Carry out general physical examination, including hips, eyes, weight, length, head circumference. Arrange diagnostic hearing or vision tests if parents are concerned. The possibility of postnatal depression in the mother should also be considered and the relationship between mother and baby should be observed. Breast feeding should be enquired about. 8 months (7-9) Enquire about parental concems regarding health and development. Ask specifically about hearing and vision. Carry out general physical. Check testes, and hips. Observe visual behaviour, look for squint. Check weight, length, head circumference. Carry out distraction hearing test.
21 months (18-24) Enquire about concerns particularly regarding behaviour, vision and hearing. Confirm normal gait, assess speech (words) and verbal understanding. No 'routine' test of vision or hearing - refer for diagnostic assessment if any concern or doubt.
the focus will be on nutrition, passive smoking, sleeping position, immunization, and prevention of accidents, particularly scalds and fires; at 6 weeks this information can be reinforced; at 6-9 months increasing mobility must be taken into account and discussion of gates and safety guards is appropriate as well as car safety. The desirability of preventing sunburn should be mentioned. Developmental needs should be dealt with; at 18-24 months the danger of falls from heights could be discussed, as well as the importance of a safe environment in the kitchen and the danger of accidental poisoning. Play and language stimulation are important. At 3 years road safety precautions are a suitable topic as well as nutrition, dental care and preparation for school (Hall, 1991).
Audit points 1. Proportion of registered children in the target age groups fully immunized (either by the practice or elsewhere). 2. Number of children with delayed diagnosis of a significant medical problem, for example undescended testicle discovered late, or undiagnosed sensorineural deafness becoming apparent at 2 years, or congenital dislocation of hip presenting in the second year. 3. The proportion of women who intended to breast feed who are still doing so at six weeks.
PART II: CHILD HEALTH SURVEILLANCE The following guidelines are for family doctors carrying out child health surveillance in the practice. Please read in conjunction with Part 1. Somewhat different schedules may be in use in different parts of the country and in many cases local training courses are available.
Organization of a surveillance programme As a rule, one half-day child health clinic is required each week for a practice with three principals. Ideally the clinic will need to be organized so that the general practitioner and health visitor can work together when carrying out developmental assessments. Any mothers who bring babies for physical problems, weight checks, simple advice on feeding problems, or immunization can be seen separately by the relevant person. I week
39 mionths (36-42) Enquire about concerns especially regarding development, vision, squint and behaviour. Discuss any possible special educational problems or needs and refer if appropriate. Carry out general physical examination, including testes, developmental assessment including speech and behaviour, height, weight; test vision if squint, family history of visual impairment or parental concern (Sonksen-Silver test recommended). Check hearing (Stycar or matched toy test). Each assessment provides an opportunity for health education. The topics will vary somewhat according to age. For instance, at the first asessment after discharge from hospital
Many mothers are discharged from hospital within a day or two of the birth of their baby. By 6 weeks the infant has passed its most vulnerable stage.
PhYsical examination: Has the initial weight loss now stopped? Are the baby's colour, tone and responsiveness normal'? Are all four limbs moving as they should? Do the heart and lungs appear to be working properly? Does the baby have a normal urinary stream'? Are the external genitalia normal and both testes in the scrotum? Are there any abnormal masses in the abdomen or malformations that have been missed? Are the hips normal? (Appendix 5). Note the head circumference.
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Within first month The health visitor makes a new birth visit to explain the services available and identify babies who are eligible for neonatal BCG (Appendix 3). 6-week check GENERAL HISTORY
* Does the mother appear to have a warm relationship with the child? * Is the baby contented and feeding and sleeping well? (Look out for possibility of postnatal depression.) * Indications of major organic disease are listed in Appendix 1. * Is weight gain satisfactory? * (Inco-ordination of sucking and swallowing may be associated with cerebral palsy.) * If breastfeeding has been initiated, is it continuing? DEVELOPMENTAL HISTORY
Allowance must be made for pre-term birth. Risk factors for hearing loss include: * neonatal intensive care for meningitis, perinatal infection or severe asphyxia * craniofacial abnormalities, eg cleft palate * family history of sensorineural loss If any of these factors are present the baby should be referred to the community paediatrician for further investigation. Ask whether the buiby is responding to household noises (give Hints for Parents if not already given by health visitors, Appendix 4). EXAMINATION
Before examining the baby ask whether the infant coos or vocalizes in response to the parent. Does the baby smile when the carer talks to him or her? Does she or he watch when being fed or spoken to? It is particularly important to assess nutrition at this age. Note the weight and length. 1. Awareness: Notice the baby's alertness. Can you elicit a smile in response to your own? 2. Head size: Measure the head circumference and note any abnormalities of shape, fontanelles or sutures. 3. Dysmorphic features (structural defects that develop before birth): Affected children may also have sensory defects or learning difficulties. Infants with more than one significant malformation will need a genetic assessment. 4. Skin: 50% of infants have temporary pink areas around the head or neck (salmon patches). Strawberry naevi (raised, red, compressible cavemous haemangiomas) appear in the first couple of months. 'Toxic erythema' is a harmless blotchy rash, sometimes with central pustules, which comes and goes in different areas, unlike staphylococcal skin lesions which may spread and do not resolve spontaneously. African and Asian babies may have 'blue spots', which can be confused with fading bruises. Their presence should always be noted. 5. Motor: Does the baby move all limbs actively and equally? Note any asymmetry or abnormal tone.
(a) In prone position, the 6-week baby reverts to the fetal position when asleep, with knees drawn up under his abdomen. When awake, hips are partly extended. (b) When pulled to sit, there is considerable head lag, but the head is briefly raised. (c) In ventral suspension, a normal 6-week-old baby can momentarily hold up his head in the same plane as the rest of his body.
6. Spine: Check for abnormalities such as sacral pits; some perhaps with overlying tuft of hair may be associated with a spina bifida occulta. This may rarely be associated with a spinal cord or nerve root lesion. 7. Hips: Congenital dislocation of the hip (CDH), commoner in females, is present in 2 per 1000 babies, although up to ten times this number may show instability in the first week of life. Late dislocations can also be associated with acetabular dysplasia. For this reason, the hips should be examined each time a child is seen for preschool developmental checks. A family history of CDH, breech delivery, postural deformities, oligohydramnios and fetal growth retardation all lead to an increased risk of CDH. Examination for CDH in the first three months of life is by the Ortoloni/Barlow manoeuvres (Appendix 5). 8. Cardiovascular system: The incidence of congenital heart disease (CHD) is 6 per 1000. Check the peripheral pulses, especially the femoral pulses (absent or weak pulses may be associated with coarctation of the aorta). Persistent breathlessness, which is worse on feeding, with sweating and inability to suck, is a significant sign of heart failure and may be accompanied by an enlarged liver. However, healthy infants have a very variable respiratory rate. Up to 50% of children may have benign, soft, systolic murmurs heard separated from normal heart sounds. These often vary with position and may disappear altogether. Soft systolic murmurs can be re-evaluated later in the first year. In addition to the presence of a murmur, fixed splitting of the second sound or its absence are important signs of a congenital heart disease such as an atrial septal defect. Many serious cases of congenital heart disease are not associated with a murmur. Central cyanosis is always significant. 9. Testes: Check that both are present. At birth 6% of males have one or both testes undescended and the rate is five times higher in low birth weight babies. Only 1.6% remain undescended at 3 months and after this time further natural descent is unlikely. Therefore, undescended testes should be checked again and referred for a surgical opinion if still undescended by 8 months of age. An early operation may improve fertility. 10. Eyes: Red reflex can be checked with the ophthalmoscope on plus 1 to plus 3: look at the eye from a distance of 16-30 cm. Opacities show clearly against the red reflex from the retina. Roving nystagmus is an important sign of ocular pathology. Minor differences in pupil size are common but usually insignificant. Vision is best tested in the supine position. The baby should follow a dangling ring or ball, held 20-30 cm from the face, from side to side. Indications for early reassessment or referral are: 1. Any major anxiety of the mother or doctor.
2. Suspected congenital heart disease. 3. Dysmorphic features (chromosomal studies may be needed). The child might also be deaf. 4. Be concerned if the head circumference is crossing the centile lines (using measurements that do not include the measurement at birth, as this may be affected by moulding). Most babies with a big head have inherited it. 5. Head lag or any abnormality or asymmetry of tone. 6. Visual abnormalities - cataract, nystagmus, inability to fix and follow. 7. Any major physical abnormality. 7-month hearing check Hearing during the first year of life is assessed by the distraction test. This requires two people working in collaboration and is usually carried out at 7 months of age often by health visitors in separate sessions devoted to hearing checks. A quiet environment is essential. (See Appendix 6 for details.) By about 7 months an infant can sit securely and turn to localize sounds at ear level. If this level of developmental maturity has not been reached, then the test cannot be used. By the age of 10 months a baby has developed object permanence, so that when a distractor's toy is hidden, the baby wants to get down and find it. In such circumstances the test is very difficult to perform. It is therefore essential to check hearing well before this age. Although in the remainder of these guidelines testing at four further ages is discussed, routine developmental testing on several occasions is not justified. Health visitors and general practitioners should concentrate their attentions on those children with social, physical or developmental factors causing concern.
8-month check This is a good age to make an assessment of the child's general development. At 8 months a child should: 1. Sit stably with no head lag using both arms to prop. 2. Use both hands equally readily to pick up small objects. Accept a cube and transfer it to the other hand. 3. If the child is not using both hands equally, especially if the underused hand is kept closed and the child does not prop with this hand, hemiplegia is a possibility. 4. The child will usually be able to point at and pick up a small object (eg a Smartie or raisin) with a pincer grip. 5. Look for fallen objects. EXAMINATION
1. Ask about the baby's general progress and social skills. He/she should be eating lumpy food, finger feeding and enjoying little games. 2. Check immunization status, measure weight, length, head circumference. 3. Carry out physical examination with particular reference to the cardiovascular system and abdomen, hips and position of testes in boys.
4. Motor screening: Different ethnic groups develop at slightly different rates (Afro-Caribbean children are normally more advanced than other groups). Look for asymmetry and hyper or hypotonia - does the baby seem to slip through your fingers when lifted? 5. Hearing: Assess this by parental history and distraction tests, if not done at 7 months or if that examination was failed. 6. Language: Double syllable, consonant babble - da da, good intonation patterns. 7. Vision: Does the child see across the street and pick up small crumbs from the floor? Is there a family history of squint or refractive error? EXAMINATION FOR SQUINT
For examination for squint, see Part I (page 80). REASONS FOR REFERRAL
Severe parental anxiety Squint Failure of hearing test Marked developmental delay, especially if baby sits like a pudding and shows only a fleeting interest in any toy 5. Developmental regression - loss of skills previously acquired 6. Suspected neurological abnormality such as hemiplegia 7. Persistent failure to thrive. Note: As the 7-month hearing test is a screening test for sensorineural loss (although many babies with moderate hearing loss due to CSOM will be identified), it is essential that 100% of babies are examined. If a child has missed the 7- and 8-month test, a health visitor or general practitioner should visit the parents and go over the age-appropriate questions in Hints for Parents. If there is any concern over the child's hearing, a referral should be made.
1. 2. 3. 4.
13-15 months 1. Measles, mumps, rubella vaccination (MMR). 2. Check testes if not examined at 8 months. 3. Ask about squint. 4. Is the baby walking; if so, are there any problems? 5. Check hips again. 6. Discuss with parents methods of avoiding accidents and the importance of simple play materials. 18-24 months This assessment may be done at home by the health visitor and is concerned particularly with parental guidance and education. 1. Immunization: Check all immunizations have been given. 2. Motor development: The child should be walking steadily.
3. Language development: Many children will have a vocabulary of between 50-200 words. They will be making simple 2-word utterances. The speech of 70% of children is intelligible most of the time, at least to the parents. However, many children will not be speaking. If they have normal comprehension then parents can be reassured that speech will follow. To test comprehension show the child 5 or 6 large toys (eg cup, spoon, brush, ball and car). Hand one at a time initially and see what he/she does with it. When all the toys have been shown, place them all in front of the child and request them one at a time. By 18 months a child should hand them all (but not name them) so at 2 years if a child cannot do this, language delay is present. If a child will co-operate with you, you can use miniature toys to see if she/he can understand commands that associate comprehension of two information-carrying words, eg put the baby to bed. Note whether the child spontaneously gives a doll a drink, brushes her hair, and so on. Refer to a speech therapist for full assessment at 24 months if: The child has few recognizable words . The child does not ask for things by gesture or pointing The child cannot hand the large toys on request. Children with language delay should be referred to the audiology clinic for hearing testing, which in this group is difficult to do satisfactorily in the practice clinic. 4. Hearing: Loss of hearing due to secretory otitis media is common at this age. If there is parental concern about the child's hearing and he or she is able to identify the common objects, then a simple speech discrimination test can be carried out using large pictures (eg spoon, shoe, cup, duck) or the five large toys. An alternative test of hearing is to ask children to point to parts of the body which are softly spoken 2 or 3 metres away. As with the toy test, children must be shown what to do first. 5. Growth and gait: If there are any concerns the height and weight must be plotted on the centile chart. Confirm that the child is walking with a normal gait.
3-year check (36-42 months) This is an ideal time to look at the child's progress before entry to nursery school. Check that all the necessary immunizations have been given. Have the parents any concerns about their child's vision, hearing, behaviour or development? Observe the relationship between the child and the parents and siblings if present. It is not too early to consider referral if the problems seem severe. LANGUAGE
By 3 years a child should use sentences with subject, verb and object, for example "we drive car", "dolly sit chair". Refer for a speech therapy assessment if: * unintelligible to those who know the child * not joining 3 words together * not understanding action words or prepositions * not handing 2 objects on request. The Egan Bus Puzzle is a quick standardized language screen that is useful between 2 and 4 years of age.
HEARING
The seven-paired toy test is very useful (see Appendix 7). Refer for audiology if a child fails several items or needs raised voice levels. If the mistakes are corrected on the second request and the child does not mouth breathe or snore, retest in 6-8 weeks' time. VISION
1. First check for squint. 2. Enquire about family history of refractive error and visual impairment; if either are present this suggests the need for testing. 3. Acuity. Plastic letters are easier than key cards at this age. At 3 years, 80-90% of children can use the single plastic letters and chart. Uni-ocular testing must be done if at all possible. The Sonksen Silver Screening test is based on Snellen equivalents and can be carried out at 3 metres (see Appendix 8). A less satisfactory alternative is to use single letters held up by the examiner. (This will not detect
astigmatism.) MOTOR
If there is parental concern about motor development observe gait and either kicking or throwing a ball. Between 3 and 4 years children begin to go first upstairs one foot/step and later downstairs one foot/step. Cognitive and fine motor development can be tested by asking the child to copy a train or bridge built from 1" bricks. Is the child also able to copy a circle and maybe a cross? Most children will complete a simple puzzle and be obviously right or left handed. PHYSICAL EXAMINATION
Measure height and weight and plot on centile chart. Check testes (if not checked since 8 months). Check cardiovascular system. If a child is deaf, language delayed, poorly co-ordinated, falling off growth centiles, has deficient cognitive skills or is delayed in all areas of development, refer to the local under 5s service.
The school examination If a child was seen at age 3 for a full assessment, routine examination at 4 is not necessary. However, parents should be asked if they have any concerns about their child's progress. All children will need the preschool booster of diphtheria, tetanus and polio. All will have a hearing and vision test by the school nurse when they begin school, but not until their second term. EXAMINATION
If a child was not seen at age 3 or is giving rise to concern, the following examination may be helpful: * Ask if there are any parental anxieties over hearing, speech, behaviour or physical problems.
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* Measure height and weight; plot on centile chart. * Check for squint and check visual acuity and note whether there is a family history of visual problems. * Check hearing by toy test if there are any concerns or the child snores or mouth breathes. If there are concerns about motor development and coordination the following assessment can be undertaken: Gross motor: Ask child to stand on one foot and then the other. Ask the child to hop. About half will be able to do it alone, but most will make a good attempt if their hand is held. Fine motor co-ordination: Ask the child to copy a circle (by 3), a cross (by 4) and a square (by 5 years). The child should have a mature grasp of the pencil. Alternatively most children can draw a picture of their mother which includes a head, body, facial features and limbs (although not always emerging from the anatomically correct positions).
APPENDIX 2 EQUIPMENT General
Auroscope Ophthalmoscope Baby scales Height and length measuring equipment Tape measure Stethoscope
Hearing tests:
7 paired toys (14 items) Cup, spoon Manchester rattle
Vision tests:
Sonksen Silver screening test Plastic letters Red ball (2" diameter on string)
Miscellaneous: I " bricks, formboard Large and small toys
Stationery:
References Haggard M and Hughes E (1991) Screening Children's Hearing. London, HMSO. Hall DMB (ed) (1991) Health for All Children. 2nd ed. Oxford, OUP. Office of Population Censuses and Surveys, Social Survey Division (1991) General Household Survey 1989. London, HMSO.
Tanner-Whitehouse centile charts Head circumference charts Hints for Parents (hearing) Referral forms to Under 5s, Child Development Team, Special Needs Register and Audiology Spare parent-held records
APPENDIX 3 IMMUNIZATION Contra-indications to immunization are listed in Immunization Against Infectious Disease (DoH et al., 1992).
Recommended schedule
APPENDIX 1
Neonatal BCG - selected population, see below 2 months First diphtheria, tetanus, pertussis (DTP), oral polio, Haemophilus influenzae type B (Hib) 3 months Second DTP, oral polio, Hib 4 months Third DTP, oral polio, Hib 12-18 months Measles, mumps, rubella vaccine (MMR) 4 years Preschool booster diphtheria, tetanus (DT), polio Practice fridges should be checked at regular intervals to ensure that the interior temperature is maintained at about 4°C. BCG: Babies from the Indian Subcontinent and sub-Saharan Africa should receive this before 2 months of age. Note: Special training is usually needed for doctors wishing to give neonatal BCG. 0-2 months
CHILD ABUSE AND MAJOR ILLNESS Child abuse Indicators of possible child abuse are as follows: * Bruises and injuries which are either not adequately explained or where the story is inconsistent with the physical findings * Withdrawn behaviour - 'frozen awareness' * General appearance of neglect - unwashed, dirty clothes, failure to thrive * Poor bonding between parents and children * Onset of wetting, nightmares, etc. * Soreness of genitalia, inappropriate sexual behaviour.
HIV infection
Major illness in the first 3 months Possible indicators of major illness in the first 3 months are as follows: * Loss of interest in feeding, sucking and surroundings * Vomiting which is profuse or associated with other symptoms * Bile or bloodstained vomit * Loss of eye-to-eye contact with mother * Abnormal irritability * Loss of colour and tone * Abdominal distension * Dehydration * Persistent tachycardia * Associated fever or drowsiness.
All HIV positive babies should follow the normal protocol for immunization unless they develop signs of AIDS-related complex (ARC) or evidence of immune deficiency (AIDS). If an asymptomatic HIV + baby is in contact with measles, he/she should be given immunoglobulin even if he/she has received MMR. (Discuss with community paediatrician.) In households where there are adults with AIDS, oral polio vaccine may be given to babies, but caregivers should wash their hands carefully after changing nappies for 3-6 weeks.
Reference Department of Health, Scottish Home and Health Department, and Welsh Office (1992) Immunization Against Infectious Disease. London, HMSO.
86 APPENDIX 4 HINTS FOR PARENTS - TO DETECT DEAFNESS
Can your baby hear you? Here is a checklist of some of the general signs you can look for in your baby's first year:
Shortly after birth Your baby should be startled by a sudden loud noise such as a hand clap or a door slamming and should blink or open his/her eyes widely to such sounds.
By I month He/she should be beginning to notice sudden prolonged sounds like the noise of the vacuum cleaner and should pause and listen to them when they begin.
By 4 months He/she should quieten or smile to the sound of your voice even when he cannot see you. He may also turn his head or eyes towards you if you come up from behind and speak to him from the side.
By 7 months He/she should turn immediately to your voice across the room or to very quiet noises made on each side if he is not too occupied with other things.
* Leg posture - The thigh on the affected side is held in partial lateral rotation, flexion and abduction. * Limb shortening - There is above knee shortening and asymmetry of the skin creases. This is detected by measuring the distance from the anterior superior iliac spine to the medial malleolus.
APPENDIX 6 NOTES ON THE HEARING TEST FOR 7-MONTH BABIES The object of the test is to detect babies with hearing impairment due either to congenital sensorineural loss (2/1000) or to glue ear (5-10/100). The baby must be able to sit securely on his mother's lap and turn to localize sounds. Seven months is the optimum age for the test to be performed. Prior to testing, the parent should be questioned about the baby's hearing responses (Hints for Parents) and asked about any family history of deafness.
The room As quiet a room as possible should be used, preferably carpeted without any noisy clocks, lights or radiators. There should be no obvious shadows or flapping curtains. A suggested layout is given in Figure 1.
The lay-out
By 9 months He/she should listen attentively to familiar everyday sounds and search for very quiet sounds made out of sight. He should also show pleasure in babbling loudly and tunefully.
STIMULUS '.
By 12 months He/she should show some response to his/her own name and to other familiar words. He may also respond when you say 'no' and 'bye bye' even when he cannot see any accompanying gesture. A routine hearing screening test should be performed on your baby between 7 and 9 months of age and your health visitor or general practitioner will be able to help and advise you at any time before or after this test if you are concerned about your baby and his hearing or development.
APPENDIX 5 SCREENING FOR CONGENITAL DISLOCATION OF THE HIP
Method The pelvis is held still with one hand while the other grasps the thigh with the middle finger placed over the greater trochanter and the thumb pressing on the inner aspect of the thigh. The knee and hips are flexed and the hip abducted to about 45 degrees. Stability of the hip is tested by trying to move the femur in and dislocate it out of the acetabulum by applying forward and backward pressure with the finger and thumb. If the head of the femur is felt to move, with or without an audible clunk, then dislocation is present. Ligamentous clicks without movement of the head are common and do not indicate congenital dislocation of the hip (CDH). The classical signs of CDH are more obvious from about six weeks and easy to see in unilateral cases. These are: * Limitation of abduction - This is the most important sign of CDH. With the infant supine and hips flexed to 90 degrees the thighs will normally abduct to 75 degrees.
LOW TABLE W|. _
PARENT
|,'CHILD
.'
DISTRACTOR
STIMULUS . Figure I Suggested layout for the room.
It is good policy to chalk around the feet of the parent's chair so that it remains in the same position. Measure the distance of three feet from the approximate position of the child's ears on each side and draw a line. Ensure that the parent's chair is placed in such a position that there are no posters on the wall to divert the child's attention. Make sure that the tester and distractor are not wearing clothes that rustle, brightly coloured clothes, chunky, noisy jewellery or glasses that distract the child. Do not wear perfume or perfumed lacquer. Explain to the parent the purpose of the test and give a brief explanation of the procedure.
87 Make sure the baby is well, and is not tired or irritable. Do not attempt to test the baby if he has a heavy cold or a rattling, wheezy chest or cough that can drown the test sounds. Make sure the baby is not wearing restrictive, bulky clothes and is not too hot. The parent and distractor should face each other across a low table. The parent should sit upright with knees together. The baby should be held firmly but gently, sitting on the parent's knees, not resting against the parent's body, hands on the baby's waist on either side (Figure 2).
Figure 2
Correct position of mother and baby for hearing test.
In speech, the carrying power is given by the vowels, oo, ah, etc., which are low frequency. However, the intelligibility is given by the consonants, for example f, th, sh, and these sounds are always softer than the vowel sounds. Thus, loss at high frequencies has a profound effect on an individual's ability to understand spoken words. The tester should then take the cup and spoon. Allow the distractor to attract the child's attention onto the table. It is often helpful to use small toys and 'phase out' the baby's attention by covering them with the hands. The distractor should not look directly at the baby. Rub the spoon gently along the inside rim of the cup. If the child turns say 'Good', and repeat on the other side. If the child does not respond to the quiet sound, make it louder until the child turns and then say 'Good'. (Make the test sounds for 4 seconds and then stop for 2 seconds and repeat.) Then try the Manchester rattle. Hold the rattle by the handle, keeping it in a horizontal position and gently rotate it 45 degrees (a quarter of a turn) enough to make the beads move. Rotate it gently backwards and forwards for 4 seconds and then stop for 2 seconds and repeat. As soon as the child turns, stop the stimulus. Do not make the sounds any louder, or for too long, or the child will get bored. Try the other side. It does not matter in which order you present the remaining stimuli. Remember to praise the child. Regular monitoring of test sounds with a sound level meter is essential. Levels should be between 35 and 40 dB.
Pass/fail criteria The distractor should stand behind and to the side of the parent, ready to make the test sounds in the correct position, that is three feet away from the baby's ear, 6 inches behind (so out of the baby's line of vision) and on a level with the auditory meatus (Figure 3).
From above
3 FOOT
Figure 3 Correct position for distractor in relation to the baby's ear. Have a form and pen ready in a position on a table behind the tester so that each response can be recorded.
Refer to the audiology clinic if: 1. The baby responds to the cup and spoon and hum but not to the high frequency 'ss' and rattle on both sides 2. The baby does not respond to any sounds (either on one or both sides). If the baby responds to all sounds on one side but fails to respond to the high frequency sounds in the other ear he may be retested either by the health visitor or at the 8-month check, provided his parents have no anxieties over his hearing responses (see hints for hearing), and he is babbling normally. Any baby should be referred to the audiology clinic if there is either parental or health visitor concern about hearing. Note: A deaf child may be continually looking round and several dummy runs should be done to check that turns are in response to the sound stimuli. The distractor will use many different techniques according to the response of the child. Sometimes it is useful for the distractor just to make a quiet sound and then let the tester take over. On other occasions he might just bounce a ball and then hide it.
Nature of the sound stimuli
Cup and spoon The sounds generated cover a wide range of frequencies. Being familiar noise, young babies usually respond immediately. Hum This covers 1000 Hertz, ie low frequencies.
Manchester rattle 6000 Hertz - a specific high frequency.
'ss'- voiced sound High frequencies but less specific than the rattle.
APPENDIX 7 a
7-PAIRED TOY TEST The aim of routine screening is to separate the suspect from the normal through positive evidence of normality, not to decide whether or to what degree a loss exists. The Barry McCormick toy test (modified Kendall) can be carried out on children of 3 years and over. Acoustic conditions should be as quiet as possible. External sounds are not necessarily disturbing from the point of view of the child's field of interest. The test should be administered using minimally voiced speech at a distance of three feet. Two adults are needed, one to sit with the child and reassure him
88 (and to monitor the level of the voiced speech of the tester), the other to administer the test. The child should be seated comfortably at a table with the adult helper close by him. The toys should be placed in front of the child so that they are in direct view and can easily be touched by the child. The tester should then make sure the child identifies each toy correctly and knows the exact name the tester will be calling the toy, for example plane not aeroplane, lamb not sheep. Because of the difficulty of providing suitable toys, two items such as a saucer and sheep may have been supplied instead of plate and lamb - if so, say to the child who names the saucer "yes, but today we will call it a plate" and similarly lamb for sheep. The tester then kneels across the table from the child and asks him to point out a few toys, especially the three different animals. Once the child has got the idea of the test the tester then retreats to three feet and asks the child to show another toy. The tester covers his mouth so that the child cannot lip read. Remember when voicing the words that it is not enough to hear some parts of the word, the child must be able to hear every part of the word to distinguish them with certainty - use a very quiet conversational voice, not a whisper, and practise with a sound level meter to achieve 40 db. The toys may be asked in any order and from experience it is better to have the list of toys by you so you can tick off the toys as they are identified. It is crucially important to the test that the child succeeds on the paired items, for example: plane/plate man/lamb horse/fork house/cow tree/key duck/cup
shoe/spoon If no sound level meter is available, voice levels can be monitored by the helper, who should just fail to hear one or two words at a distance of 10 feet.
Note: Both testers should have normal hearing. Paired toys should not be next to one another.
Pass/fail criteria 1. Most normally hearing children of 3+ will be very fast and accurate. If developmentally delayed, they may fidget with the toys or fail to recognize some items (especially the animals). 2. If a child fails one or two items consistently, allow him/her to lip read (without raised voice levels). If this enables the correct choice to be made, review in 6-8 weeks. 3. If several items are failed, or raised voice levels are needed, then refer at once for a fuller assessment in the audiology clinic. 4. If there is any doubt about their hearing, children should be referred at once for assessment.
APPENDIX 8
VISION SCREENING The Sonksen Silver Acuity System (Keeler) can be used to test acuity in children from 3 years upwards. It comes in a compact plastic folder with full instructions. It is the best system available because: 1. It uses 3 metres as the test distance. 2. It incorporates a row of test letters and astigmatism is detected (the crowding phenomena). 3. It meets the Snellen standard specifications. If children will not allow each eye to be tested separately, they should be reviewed in 6 months' time. Near vision testing is not essential. Refer children with visual acuities of 3/6 or worse in either or both eyes. Retest in 3 months and then annually - children with only one line difference between the eyes and with acuities of 3/4.5 in the worst eye.
CHAPTER 15
Child health surveillance Surveillance of the child under 5 Dr Helen Bantock, MRCP Dr Michael Modell, FRCP, FRCGP
SUMMARY 1. General health checks should be made at the following times as outlined in these guidelines: * Initial neonatal assessment * 7-10 day check * 6-week check * 7-9 months: general examination with particular attention to hearing and vision * 18-24 months: check with special attention to gait, speech and understanding * 36-42 months: general examination and developmental assessment. 2. Parental concern over a child's special senses should be carefully followed up and investigated. 3. Immunization schedules are as follows: 0-2 months: Neonatal BCG (variable depending upon local public health policy and countries of origin of local residents) 2 months: 1st diphtheria, tetanus, pertussis (DTP) and polio, Hib 3 months: 2nd DTP and polio, Hib 4 months: 3rd DTP and polio, Hib 12-18 months: MMR 4 years: Preschool DT and polio There are very few contra-indications. 4. Failure to thrive may be caused by infection, a metabolic problem or emotionalfactors. It is most commonly revealed by: * poor weight gain over a period of time * rapid weight loss. These quidelines are in two parts. The first part outlines a programme of surveillance which we hope all general practitioners will find helpful. The second part is more applicable to practices which organize their own child health clinics.
PART I: GENERAL GUIDELINES Introduction Child health surveillance implies that the health and development of children is monitored over a period of time. Although selected times are chosen for formal review, children with suspected problems will be seen by the doctor and health visitor more often.
Children under 5 are seen by their family doctor on average eight times a year (OPCS, 1991). Many more unreported psychosocial problems are likely to be suspected during ordinary consultations than at formal child surveillance sessions. For example a rise in the frequency of consultations for minor upper respiratory tract infections may be a pointer to increasing family distress. Recently there has been a change in emphasis in child surveillince with less reliance on ritualistic assessment procedures and more on parental involvement in making an evaluation of children's progress. A major review of child health surveillance (Hall, 1991) demonstrated that a number of screening tests were of limited sensitivity and reliability and have lead to a rationalization of paediatric surveillance. Experience with the normal range of development makes it more likely that general practitioners will be alerted to developmental delay and immature behaviour in children brought in for other reasons. Five per cent of young children will have hearing defects and 10% visual problems, often not noticed unless specifically looked for. These can slow a child's acquisition of language and progress at school. By monitoring a child's overall progress and giving advice and support about child rearing and health promotion, some cases of child abuse may be prevented and others detected early. There is a need to look for evidence of neglect so that help may be given to a family and its children protected. Signs that alert health professionals to the possibility of child abuse are listed in Appendix 1. These guidelines do not cover the acutely ill child in any detail. Babies are most vulnerable in the first month or two of life and symptoms which may indicate major illness are listed in Appendix 1.
Guide to average development progress 6 weeks Smiles responsively, watches the face of mother when she talks. Follows a bright or light object to about 90°. 8 months Sits stably with no head lag. Uses both hands equally readily to pick up small objects. Transfers from one hand to the other. Turns to nearby sounds. Vocalizes with single syllables. Looks for fallen objects. 24 months Should be walking steadily. Although many children will not be speaking clearly they should understand what is being said to them. Most will have a vocabulary of 50 words or more, many joining 2 words together. Imitates domestic chores.
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Most children are speaking 3 or 4-word sentences with subject, verb and object. Speech therapist assessment is needed if the child is not joining 3 words together or speech is not intelligible even to the parents. A list of equipment is given in Appendix 2.
3 years
Neonatal screening Screening for phenylketonuria and hypothyroidism is carried out at 7 days by the midwife, whether the baby is at home or in hospital. Infants of African and Afro-Caribbean extraction are at risk for sickle cell disease. Neonatal screening (by analysis of the haemoglobin) is carried out on all newborns because early prophylactic penicillin prevents an overwhelming pneumococcal infection. The health visitor should visit in the second week to explain the services available to assess parent-child interaction and to discuss the immunization schedule (Appendix 3).
The infant who fails to thrive Children who fail to thrive may do so over a prolonged period or have an acute loss of weight. (a) Poor weight gain over a prolonged period This is a sensitive indication of a feeding or psychosocial problem (a urinary tract infection may cause this picture so urine culture is an important investigation). If poor weight gain is diagnosed by plotting sequential weights on a growth chart and a fall across centile lines is observed, then full assessment involving close liaison with the health visitor is essential. (b) Rapid weight loss In a small infant the commonest cause is dehydration due to acute diarrhoea and/or vomiting. However, any acute illness such as urinary tract infection may be associated with weight loss, especially if the child is ill for more than a few days. Head circumference Most babies with a big head are merely reflecting their inheritance; however be concerned if the head circumference is crossing the centiles. Signs of hydrocephalus include abnormal separation of the sutures, tense fontanelle, prominent flattened veins and downward deviation of the eyes.
Hearing checks About one child per 1000 has severe bilateral sensorineural hearing loss but chronic secretory otitis media (CSOM or 'glue' ear) occurs commonly throughout the first 5 or 6 years of life. Parents who have been given the check list about children's hearing (Appendix 4) may notice abnormal responses if their child cannot hear. Hearing is usually tested by health visitors when the child is about 7 months of age. Children should be referred for audiological assessment if there is any doubt about their hearing or quality of vocalizations.
A recent major review by the Medical Research Council on screening children's hearing concludes that while screening in the second half of the first year and just after school entry are virtually standard, health authorities without intermediate screening programmes should not at present introduce them. The review also recommends that those authorities with more than one intermediate screen should immediately disband all but one (Haggard and Hughes, 1991). The editors therefore feel that one of the intermediate hearing checks can be justified on current evidence. Since the evidence is still unclear on this point, we feel that individual practitioners should make up their own minds and be prepared to modify their opinions in the light of future evidence.
Vision Children's vision develops from 3/60 at birth to 6/6 at 3 years. If they have severe long sight (hypermetropia) or unequal visual acuity, children will develop a squint. Persisting squint leads to poor vision (amblyopia) in the squinting eye. Children are often brought with a possible squint. Diagnosis can be difficult. Check the eyes with the child looking straight at you. Note prominent epicanthic folds (an unequal epicanthus gives rise to an apparent squint). The reflection on the cornea of a light held a few feet away will be symmetrical unless there is a squint. The cover test is difficult to perform, but try to note whether the eyes are stationary as they are alternatively covered and uncovered. Refer to an ophthalmologist: 1. If there is a constant squint 2. If there is a history of intermittent squint and the child does not have unequal epicanthic folds.
Nutrition Dietary advice may be important in certain ethnic groups; 5-10% of children have a haemoglobin concentration of less than 11 g/dl between 6 months and 6 years. Lack of sufficient iron may cause increased likelihood of infections and behavioural problems. Rickets and iron deficiency are sometimes seen in babies of South Asian parentage because of late weaning. Growth Most children remain on a stable growth trajectory (centile). In order to detect those children with growth failure (which may be due to emotional neglect, chronic physical disease, lack of growth hormone or metabolic factors) it is helpful to note the length of children at 6 weeks and 8 months and their standing height at 3 years (and at 2 if there is any query regarding growth) on the height centile charts. Any child who crosses the centiles downwards or whose length is well below the 3rd centile needs careful assessment. Parent-held records Some districts are using parent-held child health records. The use of parent-held records should: * clearly document immunization status * promote parental involvement * promote communication between professionals.
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Proposed child health surveillance programme The following outline has been produced by Camden and Islington Family Health Services Authority and Bloomsbury and Islington, and Hampstead Health Authorities. Initial neonatal assessment Enquire about any parental concerns. Review family history, pregnancy and birth. Full examination should include testes, heart, hips, red reflex (for congenital cataracts), weight, head circumference, length, phenylketonuria and thyroid (Guthrie) test at 5-10 days. Give encouragement to breast feeding.
Discharge/10 days Enquire about parental concerns, check hips and heart, and arrange for electrophysiological tests for infants at high risk for hearing loss. 6-week check Check history. Enquire about parental concerns especially concerning vision and hearing (and whether baby in high risk category). Provide check list for hearing loss. Carry out general physical examination, including hips, eyes, weight, length, head circumference. Arrange diagnostic hearing or vision tests if parents are concerned. The possibility of postnatal depression in the mother should also be considered and the relationship between mother and baby should be observed. Breast feeding should be enquired about. 8 months (7-9) Enquire about parental concems regarding health and development. Ask specifically about hearing and vision. Carry out general physical. Check testes, and hips. Observe visual behaviour, look for squint. Check weight, length, head circumference. Carry out distraction hearing test.
21 months (18-24) Enquire about concerns particularly regarding behaviour, vision and hearing. Confirm normal gait, assess speech (words) and verbal understanding. No 'routine' test of vision or hearing - refer for diagnostic assessment if any concern or doubt.
the focus will be on nutrition, passive smoking, sleeping position, immunization, and prevention of accidents, particularly scalds and fires; at 6 weeks this information can be reinforced; at 6-9 months increasing mobility must be taken into account and discussion of gates and safety guards is appropriate as well as car safety. The desirability of preventing sunburn should be mentioned. Developmental needs should be dealt with; at 18-24 months the danger of falls from heights could be discussed, as well as the importance of a safe environment in the kitchen and the danger of accidental poisoning. Play and language stimulation are important. At 3 years road safety precautions are a suitable topic as well as nutrition, dental care and preparation for school (Hall, 1991).
Audit points 1. Proportion of registered children in the target age groups fully immunized (either by the practice or elsewhere). 2. Number of children with delayed diagnosis of a significant medical problem, for example undescended testicle discovered late, or undiagnosed sensorineural deafness becoming apparent at 2 years, or congenital dislocation of hip presenting in the second year. 3. The proportion of women who intended to breast feed who are still doing so at six weeks.
PART II: CHILD HEALTH SURVEILLANCE The following guidelines are for family doctors carrying out child health surveillance in the practice. Please read in conjunction with Part 1. Somewhat different schedules may be in use in different parts of the country and in many cases local training courses are available.
Organization of a surveillance programme As a rule, one half-day child health clinic is required each week for a practice with three principals. Ideally the clinic will need to be organized so that the general practitioner and health visitor can work together when carrying out developmental assessments. Any mothers who bring babies for physical problems, weight checks, simple advice on feeding problems, or immunization can be seen separately by the relevant person. I week
39 mionths (36-42) Enquire about concerns especially regarding development, vision, squint and behaviour. Discuss any possible special educational problems or needs and refer if appropriate. Carry out general physical examination, including testes, developmental assessment including speech and behaviour, height, weight; test vision if squint, family history of visual impairment or parental concern (Sonksen-Silver test recommended). Check hearing (Stycar or matched toy test). Each assessment provides an opportunity for health education. The topics will vary somewhat according to age. For instance, at the first asessment after discharge from hospital
Many mothers are discharged from hospital within a day or two of the birth of their baby. By 6 weeks the infant has passed its most vulnerable stage.
PhYsical examination: Has the initial weight loss now stopped? Are the baby's colour, tone and responsiveness normal'? Are all four limbs moving as they should? Do the heart and lungs appear to be working properly? Does the baby have a normal urinary stream'? Are the external genitalia normal and both testes in the scrotum? Are there any abnormal masses in the abdomen or malformations that have been missed? Are the hips normal? (Appendix 5). Note the head circumference.
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Within first month The health visitor makes a new birth visit to explain the services available and identify babies who are eligible for neonatal BCG (Appendix 3). 6-week check GENERAL HISTORY
* Does the mother appear to have a warm relationship with the child? * Is the baby contented and feeding and sleeping well? (Look out for possibility of postnatal depression.) * Indications of major organic disease are listed in Appendix 1. * Is weight gain satisfactory? * (Inco-ordination of sucking and swallowing may be associated with cerebral palsy.) * If breastfeeding has been initiated, is it continuing? DEVELOPMENTAL HISTORY
Allowance must be made for pre-term birth. Risk factors for hearing loss include: * neonatal intensive care for meningitis, perinatal infection or severe asphyxia * craniofacial abnormalities, eg cleft palate * family history of sensorineural loss If any of these factors are present the baby should be referred to the community paediatrician for further investigation. Ask whether the buiby is responding to household noises (give Hints for Parents if not already given by health visitors, Appendix 4). EXAMINATION
Before examining the baby ask whether the infant coos or vocalizes in response to the parent. Does the baby smile when the carer talks to him or her? Does she or he watch when being fed or spoken to? It is particularly important to assess nutrition at this age. Note the weight and length. 1. Awareness: Notice the baby's alertness. Can you elicit a smile in response to your own? 2. Head size: Measure the head circumference and note any abnormalities of shape, fontanelles or sutures. 3. Dysmorphic features (structural defects that develop before birth): Affected children may also have sensory defects or learning difficulties. Infants with more than one significant malformation will need a genetic assessment. 4. Skin: 50% of infants have temporary pink areas around the head or neck (salmon patches). Strawberry naevi (raised, red, compressible cavemous haemangiomas) appear in the first couple of months. 'Toxic erythema' is a harmless blotchy rash, sometimes with central pustules, which comes and goes in different areas, unlike staphylococcal skin lesions which may spread and do not resolve spontaneously. African and Asian babies may have 'blue spots', which can be confused with fading bruises. Their presence should always be noted. 5. Motor: Does the baby move all limbs actively and equally? Note any asymmetry or abnormal tone.
(a) In prone position, the 6-week baby reverts to the fetal position when asleep, with knees drawn up under his abdomen. When awake, hips are partly extended. (b) When pulled to sit, there is considerable head lag, but the head is briefly raised. (c) In ventral suspension, a normal 6-week-old baby can momentarily hold up his head in the same plane as the rest of his body.
6. Spine: Check for abnormalities such as sacral pits; some perhaps with overlying tuft of hair may be associated with a spina bifida occulta. This may rarely be associated with a spinal cord or nerve root lesion. 7. Hips: Congenital dislocation of the hip (CDH), commoner in females, is present in 2 per 1000 babies, although up to ten times this number may show instability in the first week of life. Late dislocations can also be associated with acetabular dysplasia. For this reason, the hips should be examined each time a child is seen for preschool developmental checks. A family history of CDH, breech delivery, postural deformities, oligohydramnios and fetal growth retardation all lead to an increased risk of CDH. Examination for CDH in the first three months of life is by the Ortoloni/Barlow manoeuvres (Appendix 5). 8. Cardiovascular system: The incidence of congenital heart disease (CHD) is 6 per 1000. Check the peripheral pulses, especially the femoral pulses (absent or weak pulses may be associated with coarctation of the aorta). Persistent breathlessness, which is worse on feeding, with sweating and inability to suck, is a significant sign of heart failure and may be accompanied by an enlarged liver. However, healthy infants have a very variable respiratory rate. Up to 50% of children may have benign, soft, systolic murmurs heard separated from normal heart sounds. These often vary with position and may disappear altogether. Soft systolic murmurs can be re-evaluated later in the first year. In addition to the presence of a murmur, fixed splitting of the second sound or its absence are important signs of a congenital heart disease such as an atrial septal defect. Many serious cases of congenital heart disease are not associated with a murmur. Central cyanosis is always significant. 9. Testes: Check that both are present. At birth 6% of males have one or both testes undescended and the rate is five times higher in low birth weight babies. Only 1.6% remain undescended at 3 months and after this time further natural descent is unlikely. Therefore, undescended testes should be checked again and referred for a surgical opinion if still undescended by 8 months of age. An early operation may improve fertility. 10. Eyes: Red reflex can be checked with the ophthalmoscope on plus 1 to plus 3: look at the eye from a distance of 16-30 cm. Opacities show clearly against the red reflex from the retina. Roving nystagmus is an important sign of ocular pathology. Minor differences in pupil size are common but usually insignificant. Vision is best tested in the supine position. The baby should follow a dangling ring or ball, held 20-30 cm from the face, from side to side. Indications for early reassessment or referral are: 1. Any major anxiety of the mother or doctor.
2. Suspected congenital heart disease. 3. Dysmorphic features (chromosomal studies may be needed). The child might also be deaf. 4. Be concerned if the head circumference is crossing the centile lines (using measurements that do not include the measurement at birth, as this may be affected by moulding). Most babies with a big head have inherited it. 5. Head lag or any abnormality or asymmetry of tone. 6. Visual abnormalities - cataract, nystagmus, inability to fix and follow. 7. Any major physical abnormality. 7-month hearing check Hearing during the first year of life is assessed by the distraction test. This requires two people working in collaboration and is usually carried out at 7 months of age often by health visitors in separate sessions devoted to hearing checks. A quiet environment is essential. (See Appendix 6 for details.) By about 7 months an infant can sit securely and turn to localize sounds at ear level. If this level of developmental maturity has not been reached, then the test cannot be used. By the age of 10 months a baby has developed object permanence, so that when a distractor's toy is hidden, the baby wants to get down and find it. In such circumstances the test is very difficult to perform. It is therefore essential to check hearing well before this age. Although in the remainder of these guidelines testing at four further ages is discussed, routine developmental testing on several occasions is not justified. Health visitors and general practitioners should concentrate their attentions on those children with social, physical or developmental factors causing concern.
8-month check This is a good age to make an assessment of the child's general development. At 8 months a child should: 1. Sit stably with no head lag using both arms to prop. 2. Use both hands equally readily to pick up small objects. Accept a cube and transfer it to the other hand. 3. If the child is not using both hands equally, especially if the underused hand is kept closed and the child does not prop with this hand, hemiplegia is a possibility. 4. The child will usually be able to point at and pick up a small object (eg a Smartie or raisin) with a pincer grip. 5. Look for fallen objects. EXAMINATION
1. Ask about the baby's general progress and social skills. He/she should be eating lumpy food, finger feeding and enjoying little games. 2. Check immunization status, measure weight, length, head circumference. 3. Carry out physical examination with particular reference to the cardiovascular system and abdomen, hips and position of testes in boys.
4. Motor screening: Different ethnic groups develop at slightly different rates (Afro-Caribbean children are normally more advanced than other groups). Look for asymmetry and hyper or hypotonia - does the baby seem to slip through your fingers when lifted? 5. Hearing: Assess this by parental history and distraction tests, if not done at 7 months or if that examination was failed. 6. Language: Double syllable, consonant babble - da da, good intonation patterns. 7. Vision: Does the child see across the street and pick up small crumbs from the floor? Is there a family history of squint or refractive error? EXAMINATION FOR SQUINT
For examination for squint, see Part I (page 80). REASONS FOR REFERRAL
Severe parental anxiety Squint Failure of hearing test Marked developmental delay, especially if baby sits like a pudding and shows only a fleeting interest in any toy 5. Developmental regression - loss of skills previously acquired 6. Suspected neurological abnormality such as hemiplegia 7. Persistent failure to thrive. Note: As the 7-month hearing test is a screening test for sensorineural loss (although many babies with moderate hearing loss due to CSOM will be identified), it is essential that 100% of babies are examined. If a child has missed the 7- and 8-month test, a health visitor or general practitioner should visit the parents and go over the age-appropriate questions in Hints for Parents. If there is any concern over the child's hearing, a referral should be made.
1. 2. 3. 4.
13-15 months 1. Measles, mumps, rubella vaccination (MMR). 2. Check testes if not examined at 8 months. 3. Ask about squint. 4. Is the baby walking; if so, are there any problems? 5. Check hips again. 6. Discuss with parents methods of avoiding accidents and the importance of simple play materials. 18-24 months This assessment may be done at home by the health visitor and is concerned particularly with parental guidance and education. 1. Immunization: Check all immunizations have been given. 2. Motor development: The child should be walking steadily.
3. Language development: Many children will have a vocabulary of between 50-200 words. They will be making simple 2-word utterances. The speech of 70% of children is intelligible most of the time, at least to the parents. However, many children will not be speaking. If they have normal comprehension then parents can be reassured that speech will follow. To test comprehension show the child 5 or 6 large toys (eg cup, spoon, brush, ball and car). Hand one at a time initially and see what he/she does with it. When all the toys have been shown, place them all in front of the child and request them one at a time. By 18 months a child should hand them all (but not name them) so at 2 years if a child cannot do this, language delay is present. If a child will co-operate with you, you can use miniature toys to see if she/he can understand commands that associate comprehension of two information-carrying words, eg put the baby to bed. Note whether the child spontaneously gives a doll a drink, brushes her hair, and so on. Refer to a speech therapist for full assessment at 24 months if: The child has few recognizable words . The child does not ask for things by gesture or pointing The child cannot hand the large toys on request. Children with language delay should be referred to the audiology clinic for hearing testing, which in this group is difficult to do satisfactorily in the practice clinic. 4. Hearing: Loss of hearing due to secretory otitis media is common at this age. If there is parental concern about the child's hearing and he or she is able to identify the common objects, then a simple speech discrimination test can be carried out using large pictures (eg spoon, shoe, cup, duck) or the five large toys. An alternative test of hearing is to ask children to point to parts of the body which are softly spoken 2 or 3 metres away. As with the toy test, children must be shown what to do first. 5. Growth and gait: If there are any concerns the height and weight must be plotted on the centile chart. Confirm that the child is walking with a normal gait.
3-year check (36-42 months) This is an ideal time to look at the child's progress before entry to nursery school. Check that all the necessary immunizations have been given. Have the parents any concerns about their child's vision, hearing, behaviour or development? Observe the relationship between the child and the parents and siblings if present. It is not too early to consider referral if the problems seem severe. LANGUAGE
By 3 years a child should use sentences with subject, verb and object, for example "we drive car", "dolly sit chair". Refer for a speech therapy assessment if: * unintelligible to those who know the child * not joining 3 words together * not understanding action words or prepositions * not handing 2 objects on request. The Egan Bus Puzzle is a quick standardized language screen that is useful between 2 and 4 years of age.
HEARING
The seven-paired toy test is very useful (see Appendix 7). Refer for audiology if a child fails several items or needs raised voice levels. If the mistakes are corrected on the second request and the child does not mouth breathe or snore, retest in 6-8 weeks' time. VISION
1. First check for squint. 2. Enquire about family history of refractive error and visual impairment; if either are present this suggests the need for testing. 3. Acuity. Plastic letters are easier than key cards at this age. At 3 years, 80-90% of children can use the single plastic letters and chart. Uni-ocular testing must be done if at all possible. The Sonksen Silver Screening test is based on Snellen equivalents and can be carried out at 3 metres (see Appendix 8). A less satisfactory alternative is to use single letters held up by the examiner. (This will not detect
astigmatism.) MOTOR
If there is parental concern about motor development observe gait and either kicking or throwing a ball. Between 3 and 4 years children begin to go first upstairs one foot/step and later downstairs one foot/step. Cognitive and fine motor development can be tested by asking the child to copy a train or bridge built from 1" bricks. Is the child also able to copy a circle and maybe a cross? Most children will complete a simple puzzle and be obviously right or left handed. PHYSICAL EXAMINATION
Measure height and weight and plot on centile chart. Check testes (if not checked since 8 months). Check cardiovascular system. If a child is deaf, language delayed, poorly co-ordinated, falling off growth centiles, has deficient cognitive skills or is delayed in all areas of development, refer to the local under 5s service.
The school examination If a child was seen at age 3 for a full assessment, routine examination at 4 is not necessary. However, parents should be asked if they have any concerns about their child's progress. All children will need the preschool booster of diphtheria, tetanus and polio. All will have a hearing and vision test by the school nurse when they begin school, but not until their second term. EXAMINATION
If a child was not seen at age 3 or is giving rise to concern, the following examination may be helpful: * Ask if there are any parental anxieties over hearing, speech, behaviour or physical problems.
85
* Measure height and weight; plot on centile chart. * Check for squint and check visual acuity and note whether there is a family history of visual problems. * Check hearing by toy test if there are any concerns or the child snores or mouth breathes. If there are concerns about motor development and coordination the following assessment can be undertaken: Gross motor: Ask child to stand on one foot and then the other. Ask the child to hop. About half will be able to do it alone, but most will make a good attempt if their hand is held. Fine motor co-ordination: Ask the child to copy a circle (by 3), a cross (by 4) and a square (by 5 years). The child should have a mature grasp of the pencil. Alternatively most children can draw a picture of their mother which includes a head, body, facial features and limbs (although not always emerging from the anatomically correct positions).
APPENDIX 2 EQUIPMENT General
Auroscope Ophthalmoscope Baby scales Height and length measuring equipment Tape measure Stethoscope
Hearing tests:
7 paired toys (14 items) Cup, spoon Manchester rattle
Vision tests:
Sonksen Silver screening test Plastic letters Red ball (2" diameter on string)
Miscellaneous: I " bricks, formboard Large and small toys
Stationery:
References Haggard M and Hughes E (1991) Screening Children's Hearing. London, HMSO. Hall DMB (ed) (1991) Health for All Children. 2nd ed. Oxford, OUP. Office of Population Censuses and Surveys, Social Survey Division (1991) General Household Survey 1989. London, HMSO.
Tanner-Whitehouse centile charts Head circumference charts Hints for Parents (hearing) Referral forms to Under 5s, Child Development Team, Special Needs Register and Audiology Spare parent-held records
APPENDIX 3 IMMUNIZATION Contra-indications to immunization are listed in Immunization Against Infectious Disease (DoH et al., 1992).
Recommended schedule
APPENDIX 1
Neonatal BCG - selected population, see below 2 months First diphtheria, tetanus, pertussis (DTP), oral polio, Haemophilus influenzae type B (Hib) 3 months Second DTP, oral polio, Hib 4 months Third DTP, oral polio, Hib 12-18 months Measles, mumps, rubella vaccine (MMR) 4 years Preschool booster diphtheria, tetanus (DT), polio Practice fridges should be checked at regular intervals to ensure that the interior temperature is maintained at about 4°C. BCG: Babies from the Indian Subcontinent and sub-Saharan Africa should receive this before 2 months of age. Note: Special training is usually needed for doctors wishing to give neonatal BCG. 0-2 months
CHILD ABUSE AND MAJOR ILLNESS Child abuse Indicators of possible child abuse are as follows: * Bruises and injuries which are either not adequately explained or where the story is inconsistent with the physical findings * Withdrawn behaviour - 'frozen awareness' * General appearance of neglect - unwashed, dirty clothes, failure to thrive * Poor bonding between parents and children * Onset of wetting, nightmares, etc. * Soreness of genitalia, inappropriate sexual behaviour.
HIV infection
Major illness in the first 3 months Possible indicators of major illness in the first 3 months are as follows: * Loss of interest in feeding, sucking and surroundings * Vomiting which is profuse or associated with other symptoms * Bile or bloodstained vomit * Loss of eye-to-eye contact with mother * Abnormal irritability * Loss of colour and tone * Abdominal distension * Dehydration * Persistent tachycardia * Associated fever or drowsiness.
All HIV positive babies should follow the normal protocol for immunization unless they develop signs of AIDS-related complex (ARC) or evidence of immune deficiency (AIDS). If an asymptomatic HIV + baby is in contact with measles, he/she should be given immunoglobulin even if he/she has received MMR. (Discuss with community paediatrician.) In households where there are adults with AIDS, oral polio vaccine may be given to babies, but caregivers should wash their hands carefully after changing nappies for 3-6 weeks.
Reference Department of Health, Scottish Home and Health Department, and Welsh Office (1992) Immunization Against Infectious Disease. London, HMSO.
86 APPENDIX 4 HINTS FOR PARENTS - TO DETECT DEAFNESS
Can your baby hear you? Here is a checklist of some of the general signs you can look for in your baby's first year:
Shortly after birth Your baby should be startled by a sudden loud noise such as a hand clap or a door slamming and should blink or open his/her eyes widely to such sounds.
By I month He/she should be beginning to notice sudden prolonged sounds like the noise of the vacuum cleaner and should pause and listen to them when they begin.
By 4 months He/she should quieten or smile to the sound of your voice even when he cannot see you. He may also turn his head or eyes towards you if you come up from behind and speak to him from the side.
By 7 months He/she should turn immediately to your voice across the room or to very quiet noises made on each side if he is not too occupied with other things.
* Leg posture - The thigh on the affected side is held in partial lateral rotation, flexion and abduction. * Limb shortening - There is above knee shortening and asymmetry of the skin creases. This is detected by measuring the distance from the anterior superior iliac spine to the medial malleolus.
APPENDIX 6 NOTES ON THE HEARING TEST FOR 7-MONTH BABIES The object of the test is to detect babies with hearing impairment due either to congenital sensorineural loss (2/1000) or to glue ear (5-10/100). The baby must be able to sit securely on his mother's lap and turn to localize sounds. Seven months is the optimum age for the test to be performed. Prior to testing, the parent should be questioned about the baby's hearing responses (Hints for Parents) and asked about any family history of deafness.
The room As quiet a room as possible should be used, preferably carpeted without any noisy clocks, lights or radiators. There should be no obvious shadows or flapping curtains. A suggested layout is given in Figure 1.
The lay-out
By 9 months He/she should listen attentively to familiar everyday sounds and search for very quiet sounds made out of sight. He should also show pleasure in babbling loudly and tunefully.
STIMULUS '.
By 12 months He/she should show some response to his/her own name and to other familiar words. He may also respond when you say 'no' and 'bye bye' even when he cannot see any accompanying gesture. A routine hearing screening test should be performed on your baby between 7 and 9 months of age and your health visitor or general practitioner will be able to help and advise you at any time before or after this test if you are concerned about your baby and his hearing or development.
APPENDIX 5 SCREENING FOR CONGENITAL DISLOCATION OF THE HIP
Method The pelvis is held still with one hand while the other grasps the thigh with the middle finger placed over the greater trochanter and the thumb pressing on the inner aspect of the thigh. The knee and hips are flexed and the hip abducted to about 45 degrees. Stability of the hip is tested by trying to move the femur in and dislocate it out of the acetabulum by applying forward and backward pressure with the finger and thumb. If the head of the femur is felt to move, with or without an audible clunk, then dislocation is present. Ligamentous clicks without movement of the head are common and do not indicate congenital dislocation of the hip (CDH). The classical signs of CDH are more obvious from about six weeks and easy to see in unilateral cases. These are: * Limitation of abduction - This is the most important sign of CDH. With the infant supine and hips flexed to 90 degrees the thighs will normally abduct to 75 degrees.
LOW TABLE W|. _
PARENT
|,'CHILD
.'
DISTRACTOR
STIMULUS . Figure I Suggested layout for the room.
It is good policy to chalk around the feet of the parent's chair so that it remains in the same position. Measure the distance of three feet from the approximate position of the child's ears on each side and draw a line. Ensure that the parent's chair is placed in such a position that there are no posters on the wall to divert the child's attention. Make sure that the tester and distractor are not wearing clothes that rustle, brightly coloured clothes, chunky, noisy jewellery or glasses that distract the child. Do not wear perfume or perfumed lacquer. Explain to the parent the purpose of the test and give a brief explanation of the procedure.
87 Make sure the baby is well, and is not tired or irritable. Do not attempt to test the baby if he has a heavy cold or a rattling, wheezy chest or cough that can drown the test sounds. Make sure the baby is not wearing restrictive, bulky clothes and is not too hot. The parent and distractor should face each other across a low table. The parent should sit upright with knees together. The baby should be held firmly but gently, sitting on the parent's knees, not resting against the parent's body, hands on the baby's waist on either side (Figure 2).
Figure 2
Correct position of mother and baby for hearing test.
In speech, the carrying power is given by the vowels, oo, ah, etc., which are low frequency. However, the intelligibility is given by the consonants, for example f, th, sh, and these sounds are always softer than the vowel sounds. Thus, loss at high frequencies has a profound effect on an individual's ability to understand spoken words. The tester should then take the cup and spoon. Allow the distractor to attract the child's attention onto the table. It is often helpful to use small toys and 'phase out' the baby's attention by covering them with the hands. The distractor should not look directly at the baby. Rub the spoon gently along the inside rim of the cup. If the child turns say 'Good', and repeat on the other side. If the child does not respond to the quiet sound, make it louder until the child turns and then say 'Good'. (Make the test sounds for 4 seconds and then stop for 2 seconds and repeat.) Then try the Manchester rattle. Hold the rattle by the handle, keeping it in a horizontal position and gently rotate it 45 degrees (a quarter of a turn) enough to make the beads move. Rotate it gently backwards and forwards for 4 seconds and then stop for 2 seconds and repeat. As soon as the child turns, stop the stimulus. Do not make the sounds any louder, or for too long, or the child will get bored. Try the other side. It does not matter in which order you present the remaining stimuli. Remember to praise the child. Regular monitoring of test sounds with a sound level meter is essential. Levels should be between 35 and 40 dB.
Pass/fail criteria The distractor should stand behind and to the side of the parent, ready to make the test sounds in the correct position, that is three feet away from the baby's ear, 6 inches behind (so out of the baby's line of vision) and on a level with the auditory meatus (Figure 3).
From above
3 FOOT
Figure 3 Correct position for distractor in relation to the baby's ear. Have a form and pen ready in a position on a table behind the tester so that each response can be recorded.
Refer to the audiology clinic if: 1. The baby responds to the cup and spoon and hum but not to the high frequency 'ss' and rattle on both sides 2. The baby does not respond to any sounds (either on one or both sides). If the baby responds to all sounds on one side but fails to respond to the high frequency sounds in the other ear he may be retested either by the health visitor or at the 8-month check, provided his parents have no anxieties over his hearing responses (see hints for hearing), and he is babbling normally. Any baby should be referred to the audiology clinic if there is either parental or health visitor concern about hearing. Note: A deaf child may be continually looking round and several dummy runs should be done to check that turns are in response to the sound stimuli. The distractor will use many different techniques according to the response of the child. Sometimes it is useful for the distractor just to make a quiet sound and then let the tester take over. On other occasions he might just bounce a ball and then hide it.
Nature of the sound stimuli
Cup and spoon The sounds generated cover a wide range of frequencies. Being familiar noise, young babies usually respond immediately. Hum This covers 1000 Hertz, ie low frequencies.
Manchester rattle 6000 Hertz - a specific high frequency.
'ss'- voiced sound High frequencies but less specific than the rattle.
APPENDIX 7 a
7-PAIRED TOY TEST The aim of routine screening is to separate the suspect from the normal through positive evidence of normality, not to decide whether or to what degree a loss exists. The Barry McCormick toy test (modified Kendall) can be carried out on children of 3 years and over. Acoustic conditions should be as quiet as possible. External sounds are not necessarily disturbing from the point of view of the child's field of interest. The test should be administered using minimally voiced speech at a distance of three feet. Two adults are needed, one to sit with the child and reassure him
88 (and to monitor the level of the voiced speech of the tester), the other to administer the test. The child should be seated comfortably at a table with the adult helper close by him. The toys should be placed in front of the child so that they are in direct view and can easily be touched by the child. The tester should then make sure the child identifies each toy correctly and knows the exact name the tester will be calling the toy, for example plane not aeroplane, lamb not sheep. Because of the difficulty of providing suitable toys, two items such as a saucer and sheep may have been supplied instead of plate and lamb - if so, say to the child who names the saucer "yes, but today we will call it a plate" and similarly lamb for sheep. The tester then kneels across the table from the child and asks him to point out a few toys, especially the three different animals. Once the child has got the idea of the test the tester then retreats to three feet and asks the child to show another toy. The tester covers his mouth so that the child cannot lip read. Remember when voicing the words that it is not enough to hear some parts of the word, the child must be able to hear every part of the word to distinguish them with certainty - use a very quiet conversational voice, not a whisper, and practise with a sound level meter to achieve 40 db. The toys may be asked in any order and from experience it is better to have the list of toys by you so you can tick off the toys as they are identified. It is crucially important to the test that the child succeeds on the paired items, for example: plane/plate man/lamb horse/fork house/cow tree/key duck/cup
shoe/spoon If no sound level meter is available, voice levels can be monitored by the helper, who should just fail to hear one or two words at a distance of 10 feet.
Note: Both testers should have normal hearing. Paired toys should not be next to one another.
Pass/fail criteria 1. Most normally hearing children of 3+ will be very fast and accurate. If developmentally delayed, they may fidget with the toys or fail to recognize some items (especially the animals). 2. If a child fails one or two items consistently, allow him/her to lip read (without raised voice levels). If this enables the correct choice to be made, review in 6-8 weeks. 3. If several items are failed, or raised voice levels are needed, then refer at once for a fuller assessment in the audiology clinic. 4. If there is any doubt about their hearing, children should be referred at once for assessment.
APPENDIX 8
VISION SCREENING The Sonksen Silver Acuity System (Keeler) can be used to test acuity in children from 3 years upwards. It comes in a compact plastic folder with full instructions. It is the best system available because: 1. It uses 3 metres as the test distance. 2. It incorporates a row of test letters and astigmatism is detected (the crowding phenomena). 3. It meets the Snellen standard specifications. If children will not allow each eye to be tested separately, they should be reviewed in 6 months' time. Near vision testing is not essential. Refer children with visual acuities of 3/6 or worse in either or both eyes. Retest in 3 months and then annually - children with only one line difference between the eyes and with acuities of 3/4.5 in the worst eye.
