Increase in weight, but falling height percentile suggests hypothyroidism

Head circumference may be disproportionately large when there is familial megalocephaly, hydrocephalus, or merely catch-up growth in a neurologically normal premature infant

Microcephalic = when the head circumference is less than the third percentile, even if length and weight measurements also are proportionately low.

The growth pattern of a child with low weight, length, and head circumference is commonly associated with familial short stature

Children who live in psychological deprivation develop short stature with or without concomitant FTT or delayed puberty, a syndrome called psychosocial short stature.

• polyphagia, polydipsia, hoarding and stealing of food, gorging and vomiting, and other notable behaviors.
• Depressed and socially withdrawn + endocrine dysfunction
• Removal from adverse environment.
  
  

A child who, by age, is preadolescent or adolescent and who starts puberty later than others may have the normal variant called constitutional short stature

• Careful examination for abnormalities of pubertal development ~ primary amenorrhea?
  
  

First, high growth percentiles, then lower percentiles @ 6 and 18 months of age (matching genetic programming). Usually no decrease more than two major percentiles + normal developmental, behavioral, and physical examinations. These children with catch-down growth should be followed closely.

• SGA or prematurity

Observation of any asymmetric movement or altered muscle tone and function may indicate a significant central nervous system abnormality or a nerve palsy

• Moro reflex is elicited by allowing the infant’s head to gently move back suddenly -> a startle, abduction and upward movement of the arms followed by adduction and flexion. Flexion in the legs.
• Rooting reflex is elicited by touching the corner of the infant’s mouth -> lowering of the lower lip on the same side with tongue movement toward the stimulus. The face also turns toward the stimulus.
• Sucking reflex occurs with almost any object placed in the newborn’s mouth -> vigorous sucking (later voluntary).
• Asymmetric tonic neck reflex is elicited by placing the infant supine and turning the head to the side -> ipsilateral extension of the arm and the leg into a “fencing” position. The contralateral side flexes.
  
  

Physical examination should indicate whether the deformity is fixed or can be moved passively into the proper position (if so, high chance of it resolving with growth/development).

Evaluation of vision and ocular movements is important to prevent the serious outcome of strabismus.

• Cover test and light reflex

FTT - malnutrition initially results in wasting (deficiency in weight gain). Stunting (deficiency in linear growth) generally occurs after months of malnutrition, and head circumference is spared except with chronic, severe malnutrition. FTT that is symmetric (proportional weight, height/length, and head circumference) suggests long-standing malnutrition, chromosomal abnormalities, congenital infection, or teratogenic exposures. Short stature with preserved weight suggests an endocrine etiology.

• Inadequate nutritional intake, malabsorption, increased metabolic demand
• Careful history and physical examination, developmental screening, complete psychosocial assessment of the child and family, complete neurological examination, Observation during feeding and home visitation -> guide the laboratory evaluation
• Nutritional management + psychosocial needs
• Children with FTT may suffer from a malnutrition-infection cycle, in which recurrent infections exacerbate malnutrition, leading to greater susceptibility to infection.
• Changes in serum electrolyte concentrations and the associated complications are collectively termed the re-feeding syndrome -> life-threatening cardiac, pulmonary, or neurological problems

Child abuse
Neglect is the most common form of child maltreatment and is broadly defined as omissions that prevent a child’s basic needs from being met.

• identification of both factors contributing to the neglect, as well as strengths that can be protective factors.
  
  

Physical abuse is second to neglect as the reason for child protective services reports and child maltreatment related fatality.

• History that seems incongruent with the clinical presentation of the child raises concern for physical abuse
• Approximately 10% of children hospitalized with burns are victims of abuse.
• Abdominal trauma is, therefore, the second leading cause of death from child physical abuse after head injury.
• Evaluation for occult injury as well as medical conditions that can mimic physical abuse.
  
  

Child sexual abuse is the involvement of children in sexual activities that they cannot understand, for which they are developmentally unprepared and thus cannot give consent.

• Sexual abuse is more common in girls than boys, although sexual abuse of boys is underrecognized and underreported.
• Disclosure, behavioral problems or accidental find.
• The diagnosis of most sexually transmitted infections in young children requires an investigation for sexual abuse
• Medical treatment for injuries and infections, and careful medical documentation of verbal statements and findings -> photographic documentation. Physicians should be aware of the potential long-term impacts of maltreatment on child health. Trauma-focused cognitive-behavioral therapy? Police?

Breast feeding jaundice or breast milk jaundice

Breast tenderness, engorgement, and cracked nipples are the most common problems encountered by breast feeding mothers.

If a lactating woman reports fever, chills, and malaise, mastitis should be considered. -> untreated, breast abscess

Appendicitis
"Vermiform appendix'
10% population at one point

• Obstruction - fecalith 'poop rock', undigested seeds, pinworm infection, lympoid hyperplasia
  
  

Mucus is still produced and will build up - swelling

Terms of movement
Dorsiflexion vs plantarflexion
Circumduction
Flexion vs extension
Abduction vs adduction
Medial rotation vs lateral rotation
Pronation (eversion; ankle leans inward) vs supination (inversion; ankle leans outward)

Pelvis and perineum
Greater/false pelvis; lower portion of the abdomen that lies between the flared iliac crests
Lesser/true pelvis; demarcated by the pelvic brim, sacrum, and coccyx
Pelvic inlet; circular opening where the lower abdominal cavity is continuous with the pelvic cavity and is the upper border of the lesser pelvis
Pelvic outlet; diamond-shaped and bounded by the pubis symphysis anteriorly, the pubic arches, the inferior pubic rami and ischial rami, the sacrotuberous ligament, and the coccyx. It is the lower border of the lesser pelvis.

Most common mental disorder in children (5% under 18yrs)
Boys>girls
More often in developed countries (perception towards ADHD between cultures)
Strong genetic component (76%), but still multifactorial in nature (prematurity, intrauterine exposure to tobacco, low birth weight, nutritional deficiencies, environmental toxins, and psychological factors)

1. Frontal-striatal dysfunction -> defect in performing functions + lack of inhibitory control.
2. Mutation in the genes encoding for GABA and catecholamines might lead to ADHD.
3. Cortex of children with ADHD develops later than in the control group - mainly in the attention region of the brain (lateral prefrontal cortex).
   
   

Teachers can compare children among each other -> refer the child

Based on clinical presentation
DSM-5 or ICD-11
Symptoms >6 months
Check with >1 person, because of environmental influences on the behavior + prevent subjective interpretation

Ask about medical history, development, relationships, presence of other mental disorders in the child, evaluate situation at home

Additional examinations if other disorders are suspected.
Rating scales to check effectiveness of therapy.

DSM-5

1. Predominantly inattentive
2. Predominantly hyperactive/impulsive
3. Combined
   
   

ICD-11
6A05 Attention deficit hyperactivity disorder (ADHD)
“Persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity that that is outside the limits of normal variation expected for age and level of intellectual development and has a direct negative impact on academic, occupational or social functioning. Symptoms vary according to chronological age and disorder severity.”

1. Predominantly inattentive
2. Predominantly hyperactive-impulsive
3. Combined

Symptoms
Infants/toddlers: playing for a short time, not listening, not finishing activities --> chaotic 'whirlwind' --> no sense of danger
Elementary school age: forgetfulness, short activities + quickly switching --> restless --> interupting others, breaking rules
Adolescence: diminished focus on details, shorter attention span, difficulty planning --> impatient --> reckless behavior, little control
Adulthood: forgetting appointments, not able to anticipate details --> subjective --> vehicle accidents, impatient, making bad choices.

Psychoeducation

• Ensuring the patient and the family understand what ADHD is;
• Enhancing therapeutic compliance by involving the patient and the parents in the treatment plan and making sure they understand the advantages and risks of certain drugs;
• Identification of barriers to the treatment.

Behavioral therapy
Identify problematic behavior - preceding factors/eliciting factors
Detailed plan on how to tackle
Less effective than pharmaceutical treatment

Neurofeedback
Train patients to improve their self-control over brain activity patterns (EEG) while focussing

Computerised Cognitive Training (CCT)
Enhancing accomplishments in neuropsychological functions ass. with ADHD (e.g. attention). However, has no effect on core symptoms.

Gamified, engaging, cognitive exercises from their own computers or mobile devices anytime anywhere

Targeted to improve overall cognition or specific domains (such as learning and memory, attention, speed, executive functioning), as well as daily living skills such as financial knowledge or driving performance.
They can potentially be adjusted and adherence supervised remotely.

Pharmacotherapy
Stimulants

1. Methylphenidate (Ritalin; first choice)
2. Dexmethilphenidate
3. Dextroamphetamine
4. Mixed amphetamine salts.
   
   

Long-acting medications are more expensive.
Side effects: insomnia, headache, agitation, irritability, nervousness, tremor, anorexia, nausea, weight loss

Ritalin can be stopped in summer to prevent growth retardation. It can cause sudden cardiac death in individuals with structural heart defects.
All stimulants have potential for abuse. Esp. in people with comorbid behavioral problems or disorders

Non-stimulants
Second line treatment (intolerance, contraindications, failure of 1st line treatment)

1. Atomoxetine (SNRI; secondary increase in dopamine levels. Good option if there are comorbid anxiety disorders)
2. Extended-release guanfacine or sustained release clonidine (alpha-2 agonists; used if there are comorbid tics or Gilles de la Tourette syndrome)

Guideline
Predominantly - inattentive presentation - dreamy, passive withdrawn, disorganized/forgetful, and easily distracted

Predominantly hyperactive/impulsive presentation - easily distracted, having difficulty sitting still or waiting their turn, hurrying, loud-players, ramblers, having difficulty listening, having difficulty following instructions, having extreme reactions, losing objects, having difficulty focusing, and often being in dangerous situations.

1. Phase 1 (preliminary phase): initial suspicion -> parents should be consulted
2. Phase 2 (the identification phase with generic instruments): physical examination, screening questionnaires (SDQ), consults GP/teachers + analyses history & behavior
3. Phase 3 (the identification phase with specific instruments): ADHD questionnaire (AVL)
4. Phase 4 (the diagnosis): peadiatrician, GP or youth mental care provider
5. Phase 5 (treatment & follow-up): education, medication and/or therapy (individual & family)
   
   

!!
ADHD will not disappear
Learn ways to deal with it/control it
Siblings may also have ADHD
Importance of environmental factors, structure, rules
Moving, exercising, rewarding good behavior
Positive self-image of the child

Criteria

• Limitations in social communication and itneraction, present in multiple contexts;
• Restricted or repetitive behavioral patterns, interests, or activities;
• Significantly restricted functioning;
• Characteristics present from early childhood;
• No other explanations for the deviant behavior.
  
  

Level 1: some form of support is required
Level 2: Substantial support is required
Level 3: Intensive support is required

Epidemiology
Global prevalence is around 1%
Better recognition -> increased prevalence
Boys > girls - 5:1
Early recognition -> better prognosis + early treatment + offer certainty
Increased risk if 1st degree family also has ASD

6 months: problems w/social interaction
2 years: difficulties social interaction, playing, language, and cognitive, sensory and motor development.

Impact on parents/guardians - phases

1. Parental intuition to diagnosis; uncertainty
2. Diagnosis to acceptance;
3. Acceptance to future perspective;
4. Raising/taking care of the child without help to accepting help (at ease)

Screening; M-CHAT (modified checklist for autism in toddlers) and CAST (childhood autism spectrum disorders test).
Watch out for false positives & negatives
Behavioral therapy does not work equally well for every child.

Etiology: Genetic factors + multiple etiological factors are involved.

• Large brain volume (both white & gray matter)
• Enlarged ventricles
• Deviant biochemistry in the brain
• Deviant conduction in the brain
• Abnormal parts of the cortex (patches) are found in other areas of the brain
  
  

Abnormal neuronal development - rapid growth of the brain in the first 2 yrs of life + formation of odd connections.

Environmental factors; vitamin D deficiencies + exposure to e.g. mercury and cadmium

Risk factors

• Siblings with autism/ASD;
• Parental history of psychosis, an affective disorder, or another mental/behavioral disorder;
• Maternal and paternal age over 40yrs
• Male gender;
• Prematurity;
• Threatened abortion under 20 weeks
• Birth weight <2500gr

Symptoms
Limited social interaction and communication
Difficulty looking into another person's face/eyes to read behavioral information
Less capable of following another person's gaze
"Joint attention" is lacking

Limited capability to apply the theory of mind - to put one in another's shoes and imagine their mental state.(needed for empathy, to share, and build relationships).
High degree of selectivity - one focus & loss of overview

Limited in the ability to start or maintain a conversation.
Language ability develops slowly or not at all.
Little spontaneity and fantasy
No use of other communication methods to compensate
Repetition of words (papegaaien/parroting/echolalia)

Sticking to specific patterns and activities; repeated sensomotoric activities (stimming) & limited interest

Profound interest in a certain subject.
Difficulty to be flexible + to socialize.

DDx

• Deafness
• Severe psychosocial shortcoming
• Cognitive impairment
• Rett syndrome
• Receptive-expressive language disorder
• Landau-Kleffner syndrome
• Selective mutism and abandonment anxiety
  
  

Older children

• Schizophrenia
• ADHD
• OCD
  
  

Prognosis
Serious cognitive impairment might influence the rest of their lives
Social problems often remain
Behavioral skills tend to improve with age

Rett syndrome
Development of the child stagnates; with firm gestures and poor social development. It is not included in the ASD spectrum as it is only present during a short period of development. It is an X-linked condition that almost only affects girls.

Landau-Kleffner syndrome
Congenital aphasia with epilepsy, and it is accompanied by a normal development until the age of 3, followed by a massive regression of language.

Arteries of the lower limb
Abdominal aorta --> left and right common iliac artery --> external iliac --> femoral artery --> deep femoral artery --> popliteal artery--> posterior tibial artery --> small fibular artery --> medial and lateral plantar artery

Treatment
Personalized, contextualized, and empowering
Involve the family + ask what support they would like to receive.
No cure for an autistic disorder
Behavioral changes work very well.
Risperidone - for severe irritation or difficult behavior

Focus on education, support, and access to all psychological and medical treatment options.
Medical treatment for comorbidities and challenging behavior

Nerves:
anterior thigh: femoral nerve
medial thigh: obturator nerve
Posterior thigh: sciatic nerve
Tibial nerve: part of the sciatic nerve: innervates
posterior leg and plantar foot
fibular nerve: innervates the lateral leg

Guidelines
Recognition + screening

• Lack of smiling, reacting, chatting, waving, and language skills
  
  

0-4yrs - CoSoS/ESAT in case of a suspected ASD

early screening (14 questions)

4+ yrs old - list of ASD warning signs is consulted. Positive result -> ASD-specific screening tool (SCQ or ASV)

Always examine medical history to look for potential causes.

Screening positive -> refer for diagnositcs and treatment.