Child health and development

chapter 55 Child health and development

INTRODUCTION AND OVERVIEW

Infancy and childhood are characterised by a range of issues that broadly fall into three categories (Box 55.1):

• acute problems—e.g. infections, trauma

• medium-term problems—e.g. epilepsy, nutritional and feeding problems

• long-term chronic diseases—e.g. diabetes, cerebral palsy, developmental disorders.

Clearly, some cross these boundaries. However, problems in childhood need not extend into adult life even though they may have had major life effects in the short term. A sensitive approach to intervention that includes a holistic or integrative approach may have significant health benefits later. At the same time, a preventative strategy can alter family behaviour to abort important behavioural problems that are likely to lead to a lifetime of social disability.

It is difficult to separate the health of the child from the health of the family and the wider community. The health of the child is based not only upon his or her genetic background but also upon the prenatal environment, which is influenced by the lifestyle and mental and emotional health of the mother. Some of the most important investments in a child’s later health can be made by investing in the mental and physical health of the mother during and after pregnancy.

While not an extensive overview of paediatric ill health, this chapter addresses a range of common problems presenting in a primary care setting, to illustrate the role of an integrative approach to children and their families that will support family cohesion and rally mutual physical, psychological and social supports underpinning a healthy approach to living.

SCREENING

General practitioners are well placed to screen opportunistically for potential health issues when children present for routine immunisations or minor illnesses. Growth monitoring is appropriate at routine visits.

Developmental assessments should include hearing, vision (including strabismus), language acquisition, fine motor skills, social skills and family dynamics. Enquiries need to be made about physical activity, nutrition, time spent watching television, accident prevention and sun protection.¹ Given their high incidence, screen for iron deficiency and vitamin D deficiency in at-risk groups.

Parents should be encouraged to maintain a child’s personal health record with entries made by healthcare professionals, and to keep copies of relevant test results.

Children have tended to be the objects of healthcare; their opinions have frequently been ‘downgraded’ by healthcare professionals. Yet children also ‘acquire health-related knowledge through informal learning at home … they use their knowledge to promote their own well-being, in the context of and in interaction with social and physical features of their environment’.² Children actively participate in the maintenance of healthy lifestyles (their own and others’). A child-to-child approach to health education (albeit with reference to older children) is in operation worldwide, and acknowledges children as active participants in health promotion and maintenance of healthy lifestyles.³

GROWTH MONITORING

It is considered good clinical practice to monitor height and weight through childhood, and head circumference for the first 3 years. Most general practice record programs have embedded growth and development charts to assist in identifying deviations from normal that should invoke a second look.

Growth monitoring in children already identified as having a problem is mandatory, but when and how often do you monitor the typically normal child? Importantly, overweight is now considered as important as underweight. In a growth monitoring context it is easier to address developing overweight than to deal with established obesity.

• Weight is relatively easy to measure using modern self-zeroing electronic scales on a hard, rather than soft, surface. Babies should be weighed without clothes and nappies, toddlers and children with lightweight vest and pants, and adolescents in very light clothing without shoes.

• Height is best measured standing after 2 years using a fixed measuring scale that can be checked regularly with a standard measure (usually 60 cm).

Between 0 and 18 months, supine length is the best measure and requires two people to accomplish a reliable result. Measuring boards are easy to construct, or more expensive devices are obtainable commercially.

• Head circumference is the largest measured length around the head using a disposable plastic or silicon device that does not stretch with repeated use.

Recording the measured growth parameters in the child’s personal health record is important, as this is the only record that moves with the child from one healthcare professional to the next.

Most parents are interested in their children’s growth and are keen to record progress over time. Maintaining growth records in the child’s personal health record beyond infancy can be very informative, particularly if the numbers have been plotted appropriately on the percentile charts. Lack of growth information even after frequent visits to any healthcare professional is a source of considerable frustration for the paediatrician.

Growth monitoring is important as a vehicle for providing health and nutrition advice, together with an opportunity for discussing lifestyle or childcare issues. It may also provide early identification of a range of diseases, including growth hormone deficiency, thyroid insufficiency, emotional or social deprivation and abuse, occult gastrointestinal disease, renal disease and a variety of syndromes including Russell-Silver syndrome, Turner syndrome and atypical mosaicism.

ATOPY

The prevalence of asthma and eczema among children (Fig 55.1) is increasing around the world.⁴ The notion of an ‘atopic march’ from eczema through to rhinitis has been coined,⁵ implying that early intervention may reduce the prevalence of disease in later life.

FIGURE 55.1 Incidence of different types of atopy

In our striving for cleanliness there is increasing evidence that skin sensitisation to known environmental allergens provokes immune responses that lead to eczema and, later, asthma. Immune provocation in susceptible individuals appears to trigger a cascade of events aggravated by early antibiotic exposure that may lead to medium- and long-term atopy.⁶

ECZEMA

Forty-six per cent of children with eczema have used complementary medicines by the time of presentation to a dermatologist,⁷ usually driven by their parents’ sense that standard advice has failed. Adverse effects of eczema include symptoms of itching and soreness, which cause sleeplessness. Sleep deprivation leads to tiredness, mood changes and impaired psychosocial functioning of the child and family, particularly at school and work. At the more severe end of the spectrum, embarrassment, comments, teasing and bullying may cause social isolation and may lead to depression or school avoidance. The child’s lifestyle is often limited, particularly with respect to clothing, holidays, staying with friends, owning pets, dietary exclusions, swimming or the ability to play or do sports. Restriction of normal family life, difficulties with complicated treatment regimens and increased work in caring for a child with eczema lead to parental exhaustion and feelings of hopelessness, guilt, anger and depression.⁸

Eczema usually presents by the age of 2 years, initially as an exudative vesicular rash on the face and hands, and later located at the antecubital fossae, neck, wrist and ankles. A generally dry skin is evident, together with signs of scratching and, later, lichenification.

TREATMENT

Intervention is targeted at four levels: resolving any complicating infection, relieving symptoms, reducing triggers and developing a long-term plan. Each of these must be addressed and sustained, for any intervention to be effective. A clear understanding of the triggers by both child and carers, together with a contract of engagement, will ensure likely compliance and a better outcome.

Low-grade infection is common and will retard resolution if not treated. Topical antibiotic cream may be used for localised disease, but for more widespread eczema a systemic, broad-spectrum antibiotic (flucloxacillin, erythromycin) is required.

Medical management includes:

• avoiding irritant clothing (wool etc, which abrades skin and stimulates mast cell degranulation)

• wearing cool and loose cotton garments

• avoiding overheating

• keeping scratching to a minimum (use gloves if necessary and keep fingernails short).

Emollients

Use aqueous cream (in a preparation that suits after trying several formulations) as a soap substitute. Greasy preparations are best at night and for particularly dry skin. Creams are best applied during the day and on areas of inflammation. Three to four applications per day are desirable to ensure maximum moisturisation.

Topical steroids

Topical steroids are best used in the short term to suppress inflammation at the beginning of a flare—the intention is to keep the rash under tight control. Parents are often reluctant to use steroids until the condition is more severe; however, parents and carers should be encouraged to use topical steroids at the first sign of redness or itching. Control at this point prevents the inevitable cycle of exacerbation, itch, scratch, infection and worse eczema. Use the minimum concentration to achieve an effect, with an application twice daily.

Chinese herbal medicine

Individualised concoctions of Chinese herbal teas have been shown to be efficacious in a small number of randomised controlled trials from one centre.⁹ In general there were about 10 plant extracts in each preparation and few side effects were noted. In other trials there was no clear benefit. However, there have been reports of hepatic and nephro-toxicity, and hypersensitivity reactions.

Other herbal medicines

Calendula, tea tree oil and chamomile have not been shown to be useful in atopic eczema, and may provoke contact dermatitis. Oatmeal baths may reduce pruritis.

Essential fatty acids

Patients with atopic dermatitis are thought to have a reduced rate of conversion from linoleic acid to gamma-linolenic acid (GLA), dihomo-gamma-linolenic acid, or arachidonic acid, compared with healthy subjects. Replacement of GLA, in the form of primrose oil or borage oil, may therefore benefit some patients. There are many randomised controlled studies assessing the effects of GLA, with most studies indicating an improved epidermal barrier on GLA application and others showing no effect, depending on the vehicle used for application.¹⁰,¹¹ Note that, in the latter study, evening primrose oil proved to have a stabilising effect on the stratum corneum barrier, but this was apparent only with the water-in-oil emulsion, not the amphiphilic emulsion for topical use. Oral evening primrose oil capsules do not, however, have a useful effect.

Other therapies

Acupuncture, homeopathy and colon cleansing are recommended by some but have no proven efficacy. Where family stressors appear to exacerbate scratching, these need to be acknowledged and addressed.

PREVENTION AND EDUCATION

Prevention and delay of symptoms are the cornerstones of appropriate management in a family setting, and pregnancy care is particularly relevant in this context.

• Prenatal cessation of smoking reduces allergy risk.

• Maternal omega-3 fatty acid supplementation may reduce the risk of food allergy and IgE-associated eczema during the first year of life in infants with a family history of allergic disease.¹²

• Some studies also suggest that babies whose mothers took probiotics during pregnancy and while breastfeeding were less likely to have eczema at up to 2 years of age ¹³ and beyond.¹⁴

• Higher maternal consumption of green and yellow vegetables, citrus fruit and beta-carotene during pregnancy may be protective against the development of eczema in offspring.¹⁵ Prolonged breastfeeding is important but has not been shown to reduce the risk of atopic eczema in the early years.¹⁶,¹⁷ Use of low-allergen milk in the first 6 months reduces the severity of eczema up to the age of 2 years in children with significant risk.

Supplementation with the probiotic Lactobacillus rhamnosus has been found to substantially reduce the cumulative prevalence of eczema, but not atopy, by 2 years in susceptible individuals with a family history of eczema when given to the mother during pregnancy and for 6 months after birth.¹⁸ Other probiotics are less effective and the choice of Lactobacillus in this context seems to be important.¹⁸

Recent recommendations delay introduction of dairy products, eggs, nuts, fish and shellfish up to 36 months ¹⁹,²⁰ in high-risk situations but not for infants with no family history. However, there is a contrary view that suggests that early antigen exposure in small amounts, in an immune tolerance exercise, might prevent disease later.²¹

High-dose steroids and immune modulation

Oral steroids and high-dose topical steroid treatment should be undertaken in consultation with a dermatologist. Topical calcineurin inhibitors (pimecrolimus 1% cream and tacrolimus ointment 0.1% and 0.03%) are potent topical immune modulators for more severe disease. They are non-steroid topical preparations that may reduce the need for potent topical steroids where poor control with standard treatment is evident.

SUMMARY

In summary, eczema is common and increasing. Dietary manipulation has little effect on outcomes except for those with more definitive family histories and where cow’s milk proteins are shown to have a causative effect in exacerbating the rash, or where a specific food sensitivity or allergy is identified. Topical treatments, both standard and CAM, are effective in improving skin barrier function and are generally safe. Fastidious attention to skin care, early treatment of emerging patches and appropriate clothing will reduce the stress of eczema in young children and will set the pattern for care later in life if the problem persists beyond childhood.

ALLERGIC RHINITIS

A diagnosis of allergic rhinitis should be considered in children who seem to have a ‘perpetual cold’, have frequent sore throats, mouth breathing, snoring, headaches, halitosis or poor concentration. Allergic rhinitis commonly occurs intercurrently with asthma, and control of allergic rhinitis may improve asthma control.

There is often a history of allergy in the child (infantile eczema) or the family.

A seasonal pattern of symptoms suggests that pollens or grasses are the allergen. Perennial rhinitis is most likely due to house dust mite or pet dander, mould or cockroaches. Food intolerance may be involved.

DIAGNOSIS

Arrange for radioallergosorbent tests (RAST) to test for specific allergens.

ASTHMA

(See also Ch 41, Respiratory medicine.)

Asthma is regarded as an inflammatory disorder of the airways, with oedema, hypertrophy of mucus glands, increased mucus secretion and smooth muscle constriction, resulting in recurrent episodes of cough, wheeze, chest tightness and breathlessness.

Symptoms tend to be worse at night or in the early morning, and may be triggered by exposure to allergens or changes in environmental temperature, emotional stressors or exertion. There is an inherited predisposition.

Between 100 and 150 million people around the globe suffer from asthma, and this number is rising. Worldwide, deaths from this condition have reached over 180,000 annually.²²

• Around 8% of the Swiss population suffers from asthma, as against only 2% some 25–30 years ago.

• In Germany, there are an estimated 4 million asthmatics.

• In Western Europe as a whole, asthma has doubled in 10 years, according to the UCB Institute of Allergy in Belgium.

• In the United States, the number of asthmatics has leapt by over 60% since the early 1980s, and deaths have doubled to 5000 a year.

• There are about 3 million asthmatics in Japan, of whom 7% have severe and 30% have moderate asthma.

• In Australia, one child in six under the age of 16 years is affected.

Asthma is not just a public health problem for developed countries. In developing countries, however, the incidence of the disease varies greatly.

• India has an estimated 15–20 million asthmatics.

• In the Western Pacific Region of WHO, the incidence varies from over 50% among children in the Caroline Islands to virtually zero in Papua New Guinea.

• In Brazil, Costa Rica, Panama, Peru and Uruguay, prevalence of asthma symptoms in children varies from 20% to 30%.

• In Kenya, it approaches 20%.

• In India, rough estimates indicate a prevalence of 10–15% in children aged 5–11 years.

It is important to distinguish between asthma and other causes of recurrent cough, particularly recurrent infective bronchitis. Misdiagnosis of childhood asthma leads to inappropriate treatment or overtreatment.

DIAGNOSIS

In children aged under 6 years, respiratory function tests are not practical or reliable. Diagnosis depends on careful history taking. A currently asymptomatic child is unlikely to have significant clinical signs.

In a child under the age of 12 months, wheeze is more likely to be due to respiratory syncytial virus (RSV) bronchiolitis or anatomically small airways, and a diagnosis of asthma is best withheld. Bronchodilators tend to be ineffective in this age group.

Once children are over the age of 2 years, persistent or recurrent wheeze or chronic nocturnal cough is more likely to be due to asthma.

Children aged over 6 years can have spirometry testing.

Allergy testing should be organised.

All children diagnosed with asthma will need an asthma management plan carefully developed with the child and their parents or carers, and conveyed to all carers and schools. The asthma action plan (Fig 55.2) chosen should be appropriate for the person’s age, educational status, language and culture.

FIGURE 55.2 Asthma management plan ²³

*Not recommended for children under 12 years of age

My Asthma Management Plan © Commonwealth of Australia, reproduced with permission.

Metered dose inhalers are difficult to administer to a child, so a volume spacer with a face mask is a preferable option (cannot be used in children under the age of 7 years, as coordination is inadequate). Proper use of spacers, preferably large volume, is important, although carrying one of these around is tiresome. A small-volume spacer should be used when out, and a large-volume spacer used when at home.

Management involves a strategy for preventing and relieving attacks, and for recognising deterioration in control and intervening with pre-formulated strategies.

PROPHYLAXIS

• Pregnancy—pregnant women should eat a diet rich in omega-3 fatty acids and take a supplement. It is not known definitively whether probiotics taken by pregnant women will have an effect on asthma incidence. Bottle-fed babies should be supplemented with Lactobacillus.

• Diet—encourage breastfeeding for the first 6 months. If there is a history of allergy or asthma in the family, wait until the baby is 12 months old before introducing cow’s milk and other dairy products, soy products, eggs, nut spreads (e.g. peanut butter) and fish. A formal supervised elimination diet may be indicated where food triggers are suspected.

• Ensure optimal nutrition. Encourage fresh fruit and vegetables and wholefoods.

• Eliminate food additives, colourings and preservatives.

• Medication—non-steroidal medications will be the preferred first-line preventer. These include sodium chromoglycate and nedocromil sodium (children over 2 years). They are less used in preference to Montelukast, a leukotriene antagonist (LTA), which is particularly useful in intermittent asthma associated with exercise. LTAs orally are an option in children aged over 6 years.

• If there is no clinical improvement after 4 weeks, consider using the lowest effective dose of inhaled corticosteroids.

• As in the case of topical steroids for children with eczema, many parents are naturally concerned about giving children with asthma inhaled steroids, and will need accurate information to encourage compliance with preventer medication.

• Environment—assess for environmental triggers. Eliminate exposure to tobacco smoke, pet fur and other pollutants. Keep bedrooms and bedding as dust-free as possible, preferably washable hard surfaces on the floor. Contrary to popular belief, feather doonas/duvets and pillows are preferable to synthetic varieties. Wash and thoroughly dry linen regularly. Eliminate cockroaches from the home. Avoid the use of aerosol insecticides.

• Mind–body—assess and deal with environmental stressors.

• Exercise—ensure regular exercise. Warm up slowly before vigorous activity. Use a bronchodilator before exercise, if exercise is a trigger for acute attacks.

SUPPLEMENTATION

Dietary supplementation with omega-3 fatty acids, zinc and vitamin C has been shown to significantly improve asthma control, pulmonary function tests and pulmonary inflammatory markers in children with moderately persistent bronchial asthma, either singly or in combination.²⁴ Similarly, adequate intake of vitamin D and sun exposure are important in reducing the risk of asthma.

Magnesium with supportive B-group nutrients assists smooth muscle relaxation, particularly when acutely affected by an asthma attack.

ANAPHYLAXIS IN CHILDREN

(See also Ch 21, Allergies.)

Anaphylaxis may occur as an acute allergic response to food allergens, medication, envenomation, vaccines, food additives and others.²⁷ In some cases the causative agent is not identified.

Investigation

Episodes of anaphylaxis need to be investigated so that identifiable triggers can be assiduously avoided. Skin prick tests for inhaled and food allergens.

Treatment

Whether in or out of hospital, help is called immediately and treatment initiated while awaiting advanced equipment and expertise. As soon as the clinical signs support the diagnosis of anaphylaxis, intramuscular adrenaline should be administered immediately while awaiting advanced equipment and expertise before an ambulance arrives.²⁸

In the event of a cardiac arrest following anaphylaxis, cardiopulmonary resuscitation should be commenced, with adrenaline given intravenously or intraosseously according to standard advanced paediatric life support guidelines. Concurrently, high-flow oxygen and intravenous access should be obtained so that rapid fluid resuscitation can be given, to restore intravascular volume.

Bronchospasm should be treated as per the emergency management of severe asthma.

For children at increased risk of anaphylaxis, formal assessment by a paediatric allergy specialist is required before providing an adrenaline auto-injector. All family members, teachers and carers need to be trained in avoidance of triggers, and in the first aid assessment and management of anaphylaxis, as they could be called upon to perform life-saving procedures.

IRON DEFICIENCY

Iron deficiency is the most common nutrient deficiency in preschoolers, despite dietary advice from a wide range of sources. The prevalence varies between 16% and 22%, and it is more common in underprivileged and ethnic minorities. It is also a useful marker for general nutrition, as other nutritional deficiencies often may coexist with iron deficiency.

It is recognised that iron deficiency is associated with a range of developmental and behavioural problems in infancy and childhood that are reversible with iron supplementation and correction of the iron deficiency. Intellectual deficits arising from iron deficiency in infancy do persist into later years, if treatment is delayed. A high degree of suspicion is useful in infancy, as anaemia is a late manifestation of iron deficiency. Risk factors include prolonged breastfeeding without supplementation, more than six breastfeeds per day after 6 months, high cow’s milk intake after 12 months and poor solid intake because of high milk intake. Primary prevention of iron deficiency in infants and toddlers can be addressed by a range of measures (Box 55.2), and screening after 12 months is reasonable, particularly in high-risk groups. While prolonged breast feeding is beneficial, without an appropriate solid intake after 6–12 months iron deficiency is much more likely, and so care is required in advising about nutritional supplementation. Some infants become more iron deficient than others, probably because of feeding practices after birth but also because of the degree of intrauterine iron accumulation in the last trimester before birth. Preterm birth and intrauterine growth restriction interrupt normal iron stores and therefore are likely to lead to frank deficiency later if not addressed earlier.

Tags: General Practice

Jun 3, 2017 | Posted by admin in GENERAL SURGERY | Comments Off

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