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  • Pre-language communication: ?
  • 9 months-->first start to speak
  • Holophrases: 1 word
    • Toddlers pass through a holophrastic stage early in life, during which they are able to communicate complex ideas using only single words and simple fixed expressions. As an example, the word "food" might be used to mean "Give me food" and the word "up" could convey "Pick me up".
  • 2nd year: telegraphic: loss of inessential words, only important words
    • The name derives from the fact that someone sending a telegram was generally charged by the word. To save money, people typically wrote their telegrams in a very compressed style, without conjunctions or articles. As children develop language, they speak similarly: when a child says "Water now!" it is understood that the child means, "I would appreciate a glass of water, immediately."
  • 2.5-3: proper sentences



  • Dadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadadada
  • Kids very top heavy and fall forward


This session aims to help students develop their understanding of:

  • The key stages of language development – pre-language communication, first words, holophrases, telegraphic speech, sentences;
  • The different stages of cognitive development, and how this development helps the child develop different interactions with their environment;
  • The determinants of normal cognitive development;
  • The reasons why cognition may be delayed. Activities:

Babies learn to talk through a range of predictable stages. The first part of this session will consider these stages of speech development.

We will also look at cognitive development and its stages, the requirements for normal cognitive development and causes of delay.

Key concepts

Key stages of language development, Baby-talk - its characteristics and its function, The different stages of cognitive development, The determinants of normal cognitive development, The reasons why cognition may be delayed

Resources needed

Nixon, D. and Gould, K. (1996). Emerging: Child development in the first three years. Katoomba: Social Science Press. Pages 83-92. &vl(freeText0)=UNSW_DigiTool97877

• Article printed in guide: Cognitive development of infants and young children by Clare Cunningham


From the pre-reading and the video you watched as preparation:

  • Why can't babies speak? Larynx is too high
  • What are babies able to do? Coing (?)
  • What are the key stages of language development? Holophrases, telegraphic, sentences

Summary of main stages of language development


  1. What is cognitive development?
    • A cognitive development of thinking or problem-solving behaviour
  2. What are the major underlying principles on Piaget based his theory of cognitive development?
    • Principles of Piaget about the theory of cognitive development
      • Child is an active learner
      • Child appreciates the challenge and novelty of learning
      • There is a formal progression to their development
      • Child uses language and motor skills to experiment and test schema
  • What are the broad stages of cognitive development proposed by Piaget?
    • Sensorimotor(0-30months) --> pre-operational (3-6years) --> concrete logical operations (6-10years) --> formal logical operations (can hide lies, realistic/working lies)
  • Cases:
    • Pretend making a cake in the sandpit– sensory motor
    • Pretend action heroes – preoperational
    • Santa is not real – concrete logical operations
    • Wide short cup has same volume as narrow tall–concrete logical operations
    • Rattle, intentionally shake to trigger noise – sensorimotor
    • "Shades of grey" concept – formal logical operations
    • High school graduates with formal logical operations – no, 35% of high school graduates haven't reached logical operations level
  • Object permanence
    • The idea that objects have an existence when out of sight
  • Causes of a delay in cognitive development
    • Genetic disease
    • Neglect/abuse
    • Malnutrition through years 2-3
    • Metabolic/endocrine function disorder

Other theories

  • See picture

Cognitive development of infants and young children

By “cognitive” development we mean the development of “thinking”, or problem–solving behaviour. How and by what stages does an infant come, firstly, to an understanding of the nature of the world around him/her, and, eventually, to higher and abstract thinking? Clearly, this is more difficult to track and observe than motor or even language progress, especially in the pre-language stages of infancy. One of the earliest and most influential researchers to examine this question was the Swiss psychologist, Jean Piaget, who studied the progression of thought, from infancy to adolescence, in the early years of the 20th Century. His work remains active today, as it is used in education and other areas.

Piaget showed:

  1. That the child, almost from birth, is an active learner, who initiates actions to increase information.
  2. That the child appreciates challenges and novelty, and in play, will challenge himself to add to information.
  3. That there is a formal progression in the child’s understanding of the world, which relates to maturation of the child’s physical and neurological development, and can be followed and tested at different stages.
  4. That the child uses motor and language skills as they develop to further his/her understanding and problem-solving: Piaget theorized that the child actively “experiments” to acquire new information, which is then used to expand, modify or discard existing “hypotheses” on the nature of the world, and even formulate new ones (Piaget gave the name “schema” to these mental structures).

Piaget proposed Stages of cognitive development:

  1. Sensorimotor stage: 0-~30 months: the child learns about the environment by using motor, fine motor and sensory abilities to explore objects and the world around him.
  2. Pre-operational stage: ~3-6 years: The child uses language and symbolic play to further understanding, but still relies on immediate perceptions; he/she shows “magical” thinking, i.e. posits unreal causes for events (e.g. the sun goes down because it is tired), and does not clearly distinguish fantasy from reality.
  3. Concrete logical operations: ~6-10 years: the child now spontaneously distinguishes fantasy from reality, increasingly demonstrates knowledge of the “rules” of the physical world, can see many points of view and consider alternative explanations.
  4. Formal logical operations: abstract thought, complex functioning, can reason logically, formulate and test hypotheses, thought no longer depends on concrete reality.

The Sensorimotor stage is further divided into phases:

  1. 0-2 months: emerging from reflex control: feeding, sleeping, but becoming visually aware of carers and environment; by 2 months has “special” response to carer, clearly distinguishing mother and father from other people.
  2. 2-6 months: active exploration of self and using that to reach out to the environment: watches own hands, wriggles hand, brings hands together and plays with fingers; then moves on to exploring other parts of body, begins to use hands to reach out, grasp and manipulate objects.
  3. 6-12 months: becomes more mobile: grasp refined to specialized index finger and thumb grasp: becomes interested in the ‘parts’ and detail of objects: e.g. explores wheels of toy car.
  4. 12-18 months: increasing knowledge of function of objects: pushes toy car along, uses pencil to mark paper, uses small toys on self; e.g. ‘drinking’ from toy cup
  5. 18-24 months: increasing language: symbolic play: uses toys on other toys: e.g. feeding small doll. Combines objects in many different ways: stacking, building, containers and lids.
  6. ~2-3: language used to guide play; in spontaneous language demonstrates understanding of relative size (big and little) of gender, and of early number concepts: ‘two’, more. Enjoys increasingly complex spatial games: formboards and puzzles.

Object permanence

One of the most studied aspects of infant thought is the progression in the child’s understanding that objects have an independent existence, even when they are out of sight. Almost all assessments of infant development include observations of this progression. Initially, a baby, though she may look with interest at a bright object, will not react when the object disappears from sight. Between 2 and 3 months, the baby will continue to look intently at the hand of an observer after the observer has dropped the toy. By 6 months, however, the baby looks to the floor for an object dropped from his own or another’s grasp, though he will not search more extensively for it.

Between 6 and 12 months, there is a progression in the search made by the child for a toy hidden while he watches: at first he will not lift a cloth placed over a toy, even when he has seen it placed, and is distressed by the ‘disappearance’ of the toy. At 8 or so months, he will discover it if it is only partly hidden. By 9 months, he will search for a toy completely hidden by another item (a cup), and by 12 months has no difficulty in finding a toy which he has seen hidden.

Between 21 and 24 months, the child has a much wider understanding of the permanence of objects, and will search for a favourite toy even if he has not seen where it was: thus he will look where he last had it (the bedroom floor), then where it is usually kept (the toy box) then more extensively if it is not there. Moreover, at this stage, the child delights in actively hiding objects himself, especially if he can see the adults anxiously searching for e.g. the car-keys; he delightedly reveals the hiding place.

Requirements for cognitive development:

  1. Intact nervous system
  2. Secure and loving attachment
  3. Opportunities for safe exploration and experimentation

Although babies use their motor skills to explore the environment, these cognitive progressions can develop even in children with motor impairment: e.g. some children with cerebral palsy or the children who were affected by thalidomide.

Delay in cognitive development may be caused by:

  1. Genetic conditions which impair or limit neurological development: e.g. Down Syndrome, though even in such syndromes there is wide variation between individuals.
  2. Neglect or abuse
  3. Severe malnutrition in the first 2-3 years of life
  4. Some metabolic or endocrine conditions: e.g. hypothyroidism

For some of these conditions, catch-up in development may occur if the condition is recognized and remedied appropriately early enough. However in some cases, even when treatment occurs and development progresses, subtle defects in learning and cognition may persist, with a significant effect on later learning and development.

DVD: mind games

  • Theory of mind - can appreciate others' point of view (developed by the age of 5). This allows you inside others' minds to imagine their thoughts/feelings.
    • No good relationships without it (can't make friends or understand other people)
    • Babies don't see other babies as not the same person. They think that thoughts and feelings belong to everyone (therefore feelings can be contagious)
      • Proliferation of misery has a positive side - humans have an inbuilt empathy for others
  • Before theory of minds can occur, people need to work out that there are different people in the world (think that mirrors are of different people).
    • At 2, you can see that a mirror represents yourself, but still act as if there's just one communal mind. They think their own way of thinking is the only way there is.
      • On the phone, babies assume everyone can see what they're doing and so don't try to describe things.
    • At 3, if you fill a piggy bank full of marbles, then you give the piggy bank to someone else, then the child who has seen the marbles enter the piggy bank will assume everyone else knows it's full of marbles despite their lack of knowledge
  • Older children are all confident that everyone else will think they have money in the piggy bank
  • Some children develop a theory of mind as young as three, and get a lot of friends, or become leaders (interpreting signals, non-verbal). When it doesn't develop fully, it is called autism.
    • Children with older siblings can do it quicker than those without. Theory of mind develops in boys more slowly.
  • Once they have theory of minds, they can deceive people
  • Kid steals some cake, and doesn't have theory of mind.
    • Plan A: deny
    • Plan B: blame someone else - problem: Alex is at school (because he doesn't know where Alex is, then he assumes the mother doesn't)
  • Once they develop a theory of minds, they can't be stopped lying.
  • Children don't know that anyone else can be deceived -- they can't lie (they assume everyone has the same knowledge)
  • People lie to lubricate social norms
    • To children, there are no moral shades of grey (they learn that lying is bad and they enforce it even when it is socially awkward)
      • Learning to make the white lies that make people feel better is the last step in deception
  • Lie to manipulate and to soothe/reassure


  • Theory of mind – the ability to know what others are thinking
    • Develops at 5 years of age (3-6 years)
    • Can use it to make friends
    • It is important because it's essential for normal social discourse and interaction
    • Might not develop as expected if the child has autism spectrum disorder
  • Imaginary friends - pretend friends: might be just imagined for one day or last for a long time
    • How does this relate to the theory of mind?
      • Associated with cognitive development
      • Can precede the development of Theory of Mind as children still view their imaginary friends as parts of themselves
      • Children with imaginary friends are reported to be more social and empathetic
  • 2 years old – don’t know what others are thinking, leads to conflict
    • Can’t understand other people/make friends
  • Babies – boundaries between themselves and other people not yet drawn
    • Feelings can be contagious
    • Instinctive empathy
  • Separate bodies and self-recognition
    • 18 months, self-identity
      • Mirrors, know that it corresponds to you
    • At 2 years, can control what image does – thus definitely identify self
      • Think only way of thinking is the only way there is
  • Ie: what s/he can see, everyone can see
    • 3years–assume everyone can see what he sees
      • Test: what is in the piggy bank? Money or marbles?
    • 4years–theory of mind
      • Think money is in piggy bank and can explain why
  • Theory of mind can occur as early as 3 years old, or as late as 6. Average 5
    • Uses:motivate/lead/make friends
    • 60-90% of communication is non-verbal
      • Reading minds aids this
    • If it doesn’t develop properly/fully – autism
    • Boys are slower than girls, younger siblings are faster
  • Can hurt people by knowing what they think/feel
  • Theory of mind is connected to lying
    • Know that people don’t know what you are thinking
    • Button test: hidden in one hand, guess: 50/50. Kid’s turn
      • No theory of mind: thinks everyone knows which hand button is in • After learning to lie, need to learn when it is appropriate to lie
    • Lies lubricate the social world
    • At 8 years old, can lie to soothe and reassure

Alternate case scenario 1


This scenario takes place in the past year before Catherine was born. You are a GP in a busy suburban clinic. Alex (from the plenary) is a 22-month-old male toddler at this time, who has been referred to the GP after the Early Childhood Nurse noted his pallor. His mother is pregnant (with Catherine) and says that Alex is a really fussy eater.

Alex’s past medical history

  • Born 40/40 (i.e. at term), NVD (normal vaginal delivery)
  • No family history of blood disorders, leukaemia


The blue book (baby record book) had the following measurements:

Age Length (cm) Centile Weight (kg) Centile Head Circumference (cm) Centile
Birth 55.6 97th 3.8 90th 35 50th
3/12 61.6 50th 6.9 75-90th
15/12 11.5 50-75th
22/12 84.3 50th 11.5 25-50th 47 50-98th


  • Only child at the moment.
  • Asian background. His father is from Hong Kong (he has a HK Chinese mother and Australian Anglo-Irish father). Alex’s mother born in Australia with Italian migrant parents. Only extended family in Sydney is father’s mother who is widowed and recently moved to Sydney from HK to live with them.
  • Father does shift work. Mother works most days of the week.
  • Alex is cared for at home by paternal grandmother. On waiting list for day care.
  • Family bilingual (Cantonese and English).


  • Very pale child and generally tired and lethargic.
  • No bruising/bleeding/limb pain or blood in stools.
  • Viral illness, leukaemias, thalassaemia and lead intoxication excluded.
  • Reaching developmental goals – crawled at 6/12, walked at 11/12. However, mother concerned that is not talking yet.



8.4 g/dl (10.4-13.2)

Fe 5.0 μmol/l (8.1-32.6)


3.3 g/dl (1.8-3.3)

Transferrin saturation

12% (20-52)
Ferritin 1 μg/l (20-300)


Hypochromasia Marked


  • transferrin – plasma transport protein used for iron delivery to cells.
  • transferrin saturation – the ratio of serum iron to iron-binding capacity, expressed as a percentage.
  • ferritin – a protein complex that is the main intracellular storage protein for iron. Serum levels correlate directly with total body iron stores.
  • microcytosis - a blood disorder characterized by the presence of microcytes (abnormally small red blood cells) in the blood; often associated with anaemia
  • hypochromasia - anaemic condition in which percentage of haemoglobin in red blood cells is abnormally low

Feeding history

  • Breastfed to 5/12
  • Changed to S26 Gold when cut teeth and continued on this to 13/12 when cow’s milk introduced
  • Solids introduced at 6 months (rice cereal, fruit, vegetables, pureed meat)

Feeding patterns

  • Fruit: apples. Will suck juice from oranges
  • Veg: corn, spinach (but only in soups)
  • Dairy: milk, custard, yoghurt
  • Meat: chicken (offered almost every day) but doesn’t always eat
  • Breads & Cereals: white bread and rice

Diet history

  • Breakfast 7.30am
    • 180 ml milk (out of bottle)
    • 3-4 tsp baked beans OR “Petit Miam” yoghurt (1⁄2 60g tub)
  • Morning tea 11.00am
    • 180 ml milk (then has a sleep)
  • Lunch 2pm
    • 180 ml milk
    • Slice plain bread or McDonalds fries (1⁄2 small pkt) Iced tea
  • Afternoon tea 5pm
    • 180 ml milk
  • Dinner 6.30pm
    • Chicken and spinach soup or chicken and corn soup with rice (1⁄4 - 1⁄2 ‘Chinese’ bowl) OR chicken sausages and rice (2-3 pieces)
    • 125 ml apple and blackcurrant juice (diluted with water 50/50)
  • Bedtime 9.30pm
    • 180 ml milk
  • Overnight ~3-4am
    • 180 ml milk

Mealtime Behaviours

  • Will only drink milk from a bottle but will drink orange juice from a spoon
  • Picks food off parents’ plates at dinner but doesn’t eat it
  • Does not feed self
  • Likes same foods every day, does not like new foods
  • Eats in lounge room on chair with TV on
  • Meals take up to an hour
  • Prefers puree textures – spits out or pockets lumps in mouth
  • Demands milk and becomes upset when he doesn’t get it


"What is happening here?" - Symptoms signs, investigations, blue book, measurements, feeding history, dietary history

  • What diet related condition explains symptoms?
    • Anaemia
      • Iron is low, Hb is low
      • Microcytosis is present (abnormally small blood cells)
      • Hypochromasia is present (percentage of haemoglobin in red blood cells is low)
      • Transferrin is high in an attempt to deliver all available iron to cells
      • Transferrin saturation (ratio of serum iron to iron binding capacity) is low
      • Ferritin (intracellular storage protein of iron) is low
  • Acute or long period?
    • Long period because:
      • Weight loss
      • Changes in red cells - there are stages of progression to anaemia, unlikely to be acute
      • Not talking – slow brain development
      • Diet is bad
  • Factors that contribute to condition
    • Medical and sociocultural
      • High milk intake, > 1L – causes baby to be full and not eat, thus not get appropriate nutrients
      • High calcium interferes with iron absorption
      • Not red meat in diet, low variety
      • Vitamin C, not enough
      • Tea – inhibits absorption o Social
      • Distractions while eating
      • Not drinking from a cup (easy to drink a lot of milk from a bottle)
      • Doesn’t feed self, pureed food
      • Wants milk – tantrums
      • Parents working a lot, cared for a lot by grandmother (mightn't be feeding her a lot during lunchtime etc)
    • Behavioural
      • Distractions during eating, eating in front of TV, picking food off parent's plate
      • Fussy eater
  • Recommendations
    • Medical
      • less milk, max 600ml/day
      • encourage red meat/other iron sources
      • variety, vitamin C, fibre
      • iron supplements
      • solid food
    • social
      • Eat as a family without TV
      • Persist with new foods
      • Bedtime, avoid midnight snacks

Wiki stuff

Question 1

Alex appears to have iron deficiency anaemia, due to a poor diet. Several overlapping causes for this can be inferred from the case history: Intake issues Alex is reluctant to try new foods, he likes the same foods every day. This limits the range of nutrients his body is taking in. This is compounded by the fact that Alex prefers pureed foods and tends to spit out tougher types of food. Such behaviour stops Alex from eating red meat, leafy green vegetables and beans, which are all strong dietary sources of iron. At his age, he is consuming too much milk in his diet (6 times a day, total >1L ). This not only fails to provide enough sustenance for him, and leaves little room for other food intake, but calcium in the milk also interferes with iron uptake from the gut. There are many studies that support the notion that an overconsumption of cows milk, especially in toddlers is associated with iron deficiency anaemia Alex has fast food (chiefly 'McDonald's fries') for lunch, which is high in saturated fat and added salt, and usually has poor nutritional content. Ideally, Alex should be consuming wholegrain cereals (e.g. wholegrain breads) rather than purely white bread and rice, as they have higher fibre content and low glycemic index (will prevent energy "spikes" due to slow release). Iron-rich foods such as spinach, are probably overcooked (e.g. in soups), losing their vital nutrients. Not enough vitamin C consumption - which promotes iron absorption

Behavioural factors: Alex does not feed himself, and is clearly a very fussy eater. Such behaviour not only reduces the variety of food Alex eats but also the quantity. Alex is also partial to sitting infront of the television to eat, which makes meals very slow and distracts him from the meal at hand. Young children have short attention spans, and food is not their highest priority, so such a distraction causes irregular/inexistent eating. Alex may even be influenced by the content on television, refusing to eat certain foods because they do not seem favourable relative to those shown on the television. Alex's grandmother may be hesitant to implement discipline regarding food behaviours (ie, food refusal, demands for milk etc) - there may be a lack of consistency between the parents and the grandmother which may be contributing to these behavioural factors.

Social factors: Alex’- s parents work a lot, so they have difficulty keeping up with him and ensuring he has eaten the right amount and variety of food; sometimes it is easier to just give him what he wants than to go through the hassle of making him eat something else. This would also mean that they probably have less meal time together as a family Although he has a grandmother looking after him, it may be that she is quite old and unable to force Alex to eat properly, or unwilling to take an assertive role to ensure Alex eats well. She also may not feel the same level of responsibility for Alex's nutrition as a parent would, and may be more willing to give in to demands to make him happy throughout the day. Due to his father’s shift work, it seems meals are not eaten routinely in the house; this lack of structure could be contributing to Alex’s difficult eating habits.

Cultural: some cultures believe that milk is a nutritious food for children and can provide all their nutrition. Asian dietary intake includes an abundance of chicken (which he rarely eats) and lack of red meat leading to iron deficiency anemia. Social: family income (possibly low SES à reduced ability to purchase fresh foods), access (grandmother’s access to transport?), knowledge/education (possibly low awareness of foods available, where you buy and what the toddler needs)

What recommendations would you make for the nutritional management of this child?

(Remember to include practical strategies for his parents).

Question 2

Diet: A greater variety of foods should be introduced to Alex's diet, and iron intake in particular should be increased. Most children need to receive 8 - 10 grams of iron per day. Ideally, a child's diet should have:

  • Plenty of vegetables, legumes, and fruits
  • Plenty of cereals, preferably wholegrain
  • Lean red meat, fish, and poultry
  • Adequate dairy component - milk, cheese, yoghurt, and alternatives
  • Water should be the main drink.

Alex's iron deficiency should be treated with iron supplements, and his dietary iron intake increased. Iron supplements, such as iron sulfate, can be given orally and daily at dosages of 3 - 6 mg per kg of weight. Iron supplementation should continue even when blood counts return to normal to ensure that iron stores are replenished. Iron-rich foods include lean red meats (e.g. beef, lamb, veal), pate, fish-paste, iron-fortified rice cereal, eggs. dried fruits, and peanut butter. Because Vitamin C enhances iron absorption, a supplement or dietary source of Vitamin C can also be given (e.g. citrus fruits such as oranges).

A transition from puree textures in food to 'lumpy', more solid foods should also be encouraged, as it is important for developing chewing, biting, and speech skills. Foods that can be introduced include 'finger foods' such as fruit platters, cheese cubes, meatballs, and finger sandwiches.

Alex's intake of cows' milk should also be reduced, for nutritional and health purposes. Cow's milk has low iron levels, is filling and decreases appetite for other foods and also contributes to loss of iron from the small intestine. Strategies for achieving lower milk intake include putting less milk in his cup each time, giving fewer cups of milk, restricting 'milk times' to morning and evening, and progressively diluting his milk with water. Fast foods, such as McDonald's fries, should not be a regular component of meals, as they are high in saturated fats, added salts and sugars. Rather, they should be emphasised as an occasional food. Likewise, fruit juice has high sugar content and insignificant nutritional value, while tea contains tannins which can restrict vitamin intake. Therefore, water should be the main drink given, while juice and tea intake should be reduced. Furthermore, the 'cereals component of Alex's diet can also be improved by replacing white bread and rice with wholegrain alternatives, which offer greater nutrition and lower GI.

Behavioural and Feeding Changes: This includes educating carers (e.g. grandmother and parents) about a child's proper nutritional requirements and feeding strategies, as well as Alex himself. Healthy eating habits can first be encouraged by involving Alex in meal preparation and increasing his interest in nutritious foods by explaining their origins (e.g. how they are cultivated) and methods of cooking.

Carers can also serve nutritious meals in a positive and attractive environment, with colourful foods and utensils to increase interest and enjoyment during meals. Establishing a routine for mealtimes, eating together as a family with rules for table behaviour additionally reinforces healthy eating as a social and fun experience which the child will want to repeat. Other strategies for encouraging variety in Alex's diet include serving new foods with familiar ones, and removing distractions during mealtimes such as TV. Moreover, techniques for teaching self-feeding include allowing Alex to 'play' with and experience new foods, persevering with diet changes, and initiating a transition from bottle to cup drinking using 'sippy cups' as an intermediate.

Education: In order to manage Alex's case, it would be vital to educate both parents as well as the grandmother regarding the importance of iron intake as well as the important sources. Additionally, it should be explained why Alex's diet was inadequate - ie, too much milk, not enough iron sources etc. The clinician should also explore the socio-cultural factors, and ensure any issues regarding knowledge, access or availability of food are resolved. A more structured plan for feeding and meal times should be agreed upon, with consistency from both parents and the grandmother vital for achieving optimal nutritional outcomes.

Question 3

  • (i). What other problems may occur with cows milk in the diet?
    • Kidney disease
    • Neurological problems due to deficiencies in vitamin E (leading to poor nerve conduction) and deficiencies in essential fatty acids (required for brain development).
    • Tooth decay
    • Internal bleeding and blood in stools
    • Cow's milk allergy
    • Lactose intolerance
  • (ii). What are the causes?
    • Cow’s milk has a lot of extra protein, sodium, potassium and chloride, which will put increased strain on the kidneys
    • Cow's milk is a poorer source of these nutrients compared to breastmilk or formulas, especially lacking in vitamin E, zinc and iron
    • Overconsumption of milk, which contains milk sugars such as lactose, can lead to dental caries.
    • Cow's milk proteins irritates the intestinal lining resulting in micro haemorrhaging
    • The sugar in cows milk is lactose. Lactose intolerance occurs as one ages - coinciding with a loss in lactase enzyme activity (which normally breaks down lactose sugars in the gut into glucose and galactose for absorption). When there is insufficient lactase enzyme, lactose sugars accumulate in the gut and act as an osmolyte, drawing out water. In addition, bacteria in the large intestine ferment the sugars, resulting in production of gas. Hence, diarrhoea, bloating and gas occur upon cows milk consumption.
    • Allergic reaction to cow's milk proteins.
    • Affects 1 in 50 children, however, many outgrow this allergy by the age of 2.
    • Signs and symptoms include eczema, rash, abdominal pain, vomiting and diarrhoea.
  • (iii). Of these problems, which is the least likely to afflict Alex at this age?
    • Renal problems. Since Alex is 22 months old, it is probable that his kidneys have sufficiently developed to handle the extra proteins and solutes present in cow's milk.
    • Lactose intolerance is unlikely as children and infants generally have high levels of lactase, and this level declines with age.

Question 4

  • How useful is the BMI (body mass index) in children?
    • Body Mass Index (BMI) is calculated as weight in kg over height squared in metres (i.e. BMI = kg/m^2).
    • BMI can be a useful measure in children, however its application is more complicated than in adults.
    • In adults, the 'healthy range' for BMI is considered to be 20-25, regardless of gender or age. This single range is not a suitable measure for children because:
    • For adults who have stopped growing, an increase in BMI tends to indicate an increase in body fat.
    • Children however are still growing and developing, and their body 'fatness' (i.e. BMI) changes over the years that they grow.
    • Further, boys and girls differ in BMI as they grow.
    • To correct this, a child's BMI is compared against age and gender percentile charts – with this measure being known as 'BMI-for-age'.
    • These charts are similar to centile charts for other measures such as weight and height (an example of a BMI-for-age chart for girls is shown below).
    • Plotting the BMI on these charts is useful for assessing underweight, healthy, overweight and obese states in children over the age of 2, although they are used as a guide and there is no specific ‘cut-off’ values defining obesity.
    • Further, it should always be remembered that BMI is not diagnostic of obesity and that other factors need to be considered, including skinfold thickness measurements.

Question 5

  • The whole case group should learn how to design genograms and be prepared to teach this to the rest of the group. Your task is to add to the scenario genogram – adding in the rest of Alex’s family as mentioned in the case and explain fully the structure and symbols used as well as the usages of genograms (i.e. who uses them and why?).
  • Research has demonstrated a link between family function and the physical and mental wellbeing of an individual. The genogram is used to help integrate family information into the medical diagnosis.It can be used to help visualise any patterns in family illnesses as well as identify family related stressors by combining both medical and social history.
  • Ultimately, the purpose of a genogram is to help facilitate hypothesis generation, differential diagnosis and the creation of a management plan for the patient (much in the same way as an x-ray or other test may be used).
  • Structure and symbols
    • Genograms use standardised symbols. The coding is shown below:
    • Genograms are often initially completed as a 'skeleton' with only basic information such as family structure, significant events in the family and family health problems. This is usually only done for two generations. Expanded genograms including more relational details and three generations may be used in more complex cases.
  • An example of an expanded genogram:
  • The information shown on this genogram includes:
    • Paternal grandfather suffered from alcoholism. Maternal grandmother deceased.
    • Father of patient is deceased and suffered from alcoholism and stomach cancer. He has a conflicted relationship with the patient.
    • Mother of the patient had Crohn's disease and is deceased.
    • The patient is the second oldest of 5 children. She recently broke up with her boyfriend.
  • Criticisms
    • The main complaint with genograms is more often the time it takes to complete them (which can extend consulation times markedly). However, physicians who use them successfully claim that the benefits outweigh the added time it takes for the genogram. Further, a genogram is rarely completed in one visit, which spreads the increased consultation time over multiple visits, thus minimising its impact.
    • Another criticism is the lack of research evidence of the clinical utility of genograms. However, studies have shown that they can capture more psychosocial and biomedical information than traditional history taking; and physicians should not be discouraged from using them.
  • The following shows the genogram for Alex's case:
    • This genogram was created at the time of Alex's presenting complaint, when he was 22 months old. Alex, the first child of James and Elise, is identified as the patient, and as Catherine was not born yet, Elise is shown as pregnant with Catherine. James' father is shown as deceased, and the dotted line around James, his mother, Elise, Alex and Catherine show that they are the members of the same household. There are no details given in the scenario about Elise's parents.
  • Usage of genograms
    • Genogram --> clinical tool to integrate a patient’s family information into the medical problem-solving process for better patient care
    • Used by family physicians
    • Why are they used?
    • Close relationship between family functioning and physical/emotional well-being of patient
  • Examples of use
    • G- Biopsychosocial issues
    • Anxiety, depression, panic attacks
    • Substance abuse
    • Multiple somatic or vague complaints
    • Non-compliance
    • Psychosocial issues
    • History of physical, sexual or emotional abuse
    • Childhood behaviour problems
    • Difficult life cycle transition
    • Doctor-patient issues --> escape from unproductive relationship, process shows patient they are being listened to and cared for
    • Angry or demanding patient
    • Patient whom physician dislikes
  • Aims and advantages
    • Provides knowledge of family (generational), biomedical and psychosocial issues/patterns à useful in diagnosis and management
    • Determining whether presenting complaint is connected to family/psychosocial issues
    • Assist in assessing risks for family related illnesses or stressors (e.g. diabetes, HT, CHD, substance abuse, depression)
    • Visual impact showing recurring patterns (e.g. alcoholism/CVD) strikes patients, encouraging increased awareness and urgency in managing issues and complying with treatment
    • Highlights supports and obstacles to compliance
      • Quick/easy (visual) access to family medical and social history from patients
      • Expanding understanding of presenting problems through understanding patient’s basic context
    • Allows doctor to be more empathic to patient’s needs/behaviours àincreasing rapport and improving patient-doctor relationship
    • Shows patient that the doctor is interested in addressing ongoing family/psychosocial issues
    • Non-threatening way for both doctors and patients to explore sensitive issues (e.g. sexual abuse/alcoholism)
    • Able to see how these issues affect patient’s ability to cope with illness or other significant life stresses
  • Disadvantages
    • Time
    • Impractical in busy practices
    • Increases length of visits but extra time is advantageous for the reasons mentioned previously
    • Information can be used for future visits à often expanded/referred to on subsequent visits
    • No research to prove clinical utility
    • But studies show it collates more psychosocial/biomedical information than traditional history taking

This genogram outlines the basic family-related biomedical and psychosocial issues related to Alex’s treatment. Key features highlighted include; heritage of the patient’s parents and grandparents, patient’s age and patient’s parent’s ages, parent’s employment, deceased relatives, home living arrangement and social relationships between relatives. In addition to medical uses (evaluate health risks, establish family-linked and genetic disease, calculate risk), genograms are used in sociology, social work, family therapy, education, research (eg, plant species research etc) and geneaology (record family history)


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