Theme 9:
Growth &
development
Summary
1
,Inhoud
Week 33: Growing up healthy ................................................................................................................. 5
Interprofessional collaboration in primary care ................................................................................. 5
Diabetes ........................................................................................................................................... 5
A history of social medicine................................................................................................................. 6
Health and culture ........................................................................................................................... 6
The rise of surveillance medicine .................................................................................................... 8
Healthy childhood ............................................................................................................................. 11
Lifestyle, children and community health policies ............................................................................ 12
GGD ............................................................................................................................................... 12
Health ............................................................................................................................................ 13
Early life stress ................................................................................................................................... 17
Stress network ............................................................................................................................... 17
Research: epigenetics .................................................................................................................... 17
Early detections of consequences of early life stress.................................................................... 18
Targets for preventative interventions ......................................................................................... 19
Week 34: Child with abnormal gait ....................................................................................................... 20
Paediatric orthopaedics..................................................................................................................... 20
Antalgic gait ................................................................................................................................... 20
Hiel vagus ...................................................................................................................................... 22
Leg length discrepancy .................................................................................................................. 23
Anatomy ............................................................................................................................................ 26
Movements ................................................................................................................................... 26
Musculoskeletal elements of the pelvis ........................................................................................ 27
The lower limb ............................................................................................................................... 31
Normal motor skills ........................................................................................................................... 60
Phases: ........................................................................................................................................... 60
Cerebral palsy ................................................................................................................................ 61
Developmental coordination disorder .......................................................................................... 62
Exercise poverty ............................................................................................................................ 62
Hip dysplasia ...................................................................................................................................... 63
Orthopaedic hips disorders ............................................................................................................... 68
Club foot ............................................................................................................................................ 70
Skeletal dysplasia: medical genetics.................................................................................................. 72
Spondyloepiphyseal dysplasia congenita ...................................................................................... 72
Osteogenesis imperfecta ............................................................................................................... 73
2
, Child rehabilitation ............................................................................................................................ 74
Cerebral palsy ................................................................................................................................ 74
Week 35: The developmentally delayed child ...................................................................................... 77
Normal growth .................................................................................................................................. 77
Disorders of growth........................................................................................................................... 79
Normal development ........................................................................................................................ 80
Physical development.................................................................................................................... 80
Developmental milestones............................................................................................................ 80
Disorders of development ................................................................................................................. 82
Developmental surveillance .......................................................................................................... 82
Evaluation of the child with special needs ........................................................................................ 85
Multifaceted team assessment of complex problems .................................................................. 85
Management of developmental problems ................................................................................... 86
Failure to thrive ................................................................................................................................. 87
Psychosocial short stature ............................................................................................................. 87
Child abuse and neglect .................................................................................................................... 88
Child maltreatment ....................................................................................................................... 88
Diet of the normal infant ................................................................................................................... 90
Obesity............................................................................................................................................... 92
Paediatric undernutrition .................................................................................................................. 93
Signs of nutritional deficiency disorders ....................................................................................... 94
Hypoxic-ischaemic encephalopathy, intracranial haemorrhage and seizures .................................. 96
Neonatal seizures .......................................................................................................................... 96
Intracranial haemorrhage.............................................................................................................. 97
Hypoxic ischaemic encephalopathy .............................................................................................. 97
Congenital infections ......................................................................................................................... 99
Oesophagus and stomach ............................................................................................................... 102
Gastroesophageal reflux ............................................................................................................. 102
Eosinophilic oesophagitis ............................................................................................................ 102
Oesophageal atresia and tracheoesophageal fistula .................................................................. 102
Oesophageal foreign bodies ........................................................................................................ 102
Caustic injuries and pill ulcers ..................................................................................................... 103
Pyloric stenosis ............................................................................................................................ 103
Peptic disease .............................................................................................................................. 104
Cyclic vomiting syndrome............................................................................................................ 104
Intestinal tract ................................................................................................................................. 105
3
, Malrotation ................................................................................................................................. 105
Intestinal atresia .......................................................................................................................... 105
Other congenital disorders .......................................................................................................... 105
Inflammatory bowel disease ....................................................................................................... 105
Coeliac disease ............................................................................................................................ 106
Intussusception ........................................................................................................................... 106
Appendicitis ................................................................................................................................. 107
Pancreatic disease ........................................................................................................................... 108
Pancreatic insufficiency ............................................................................................................... 108
Acute pancreatitis ....................................................................................................................... 108
Chronic pancreatitis .................................................................................................................... 108
Neurologic abnormalities ................................................................................................................ 109
Weakness and hypotonia ................................................................................................................ 115
Diseases of the upper motor neuron .......................................................................................... 115
Diseases of the lower motor neuron........................................................................................... 115
Neonatal and infantile hypotonia ............................................................................................... 116
Stroke in childhood...................................................................................................................... 117
Ataxia and movement disorders ..................................................................................................... 118
Ataxia ........................................................................................................................................... 118
Movement disorders ................................................................................................................... 118
Neurodegenerative disorders ......................................................................................................... 120
Hereditary and metabolic degenerative diseases ....................................................................... 120
Acquired illnesses mimicking degenerative diseases .................................................................. 121
Neurocutaneous disorders .............................................................................................................. 122
Neurofibromatosis type I ............................................................................................................ 122
Tuberous sclerosis complex ........................................................................................................ 122
Sturge-Weber syndrome ............................................................................................................. 122
Congenital malformations of the central nervous system .............................................................. 123
Congenital anomalies of the spinal cord ..................................................................................... 123
Congenital malformations of the brain ....................................................................................... 123
Week 36: Child with a behavioural disorder ....................................................................................... 124
Autism spectrum disorder ............................................................................................................... 124
Attention deficit hyperactivity disorder .......................................................................................... 127
Pharmacology in ADHD ................................................................................................................... 131
4
,Week 33: Growing up healthy
Interprofessional collaboration in primary care
= needed for adequate prevention: also role of the GP
Diabetes
= treated by the GP, but also:
• Primary care practice assistant
• Doctor’s assistant: measuring + checks
• Pharmacist
• Physiotherapist
• Podiatrist
• Dietician
• Internist
• Nurse practitioner
• Eye doctor
Combination of all these domains: huge improvement of diabetes care in the Netherlands
→ diabetes patients have a similar life expectancy as people without diabetes
Aim of diabetes treatment = prevention of cardiovascular disease
Time to change a sedentary lifestyle to an active one = 3-6 months → guidance of the
physiotherapist
5
,A history of social medicine
Health and culture
Time: continuity and change
Hippocratic/galenic medicine (450 BC- 1858 AD):
• Health = balance of humours
• Disease = disbalance of humours
6 “res non-naturales”
1. Airs, waters and places: environment
2. Food and drink: diet
3. Sleeping and waking
4. Exercise and relaxation/rest
5. Evacuations
6. Passions: state of mind
→ preserving balance by regulating these non-naturals: regiment for healthy living/ageing
= hygiene, exercise, diet and temperance
Health = “the good life” → big business!
Ca. 1800: increased attention for a healthy lifestyle → enlightenment ideals, industrialisation
and urbanisation: public health, sanitary reforms and public education
6
,1948-present:
• WHO definition of health: “a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”
• Positive health (Huber et al. 2011): “The ability to adapt and self manage in face of
social, physical and emotional challenges”
• 2 cultural shifts:
o Increasing preoccupation with health
o Individualisation of malleability and responsibility
“Doing better, feeling worse”: health + life expectany go up
→ but also
• Concerns about health
• Use of and dependence on healthcare provisions
• Worried well
Epidemiological transition:
• From infectious to chronic disease: ageing population → shift of objectives of
medicine
• Not only demography: different attitude towards chronic/degenerative diseases
• Paradigm of risk factors:
o Lifestyle factors
o Asymptomatic diseases
o Subjectively healthy but highly medicated individuals
o Blurring of distinction of health/disease
Diseases of affluence:
• Overweight:
1980: 16%
2000: 25%
• Beer consumption/year:
1900: 41 litres
2000: 85 litres
• Wine consumption/year:
1900: 2 litres
2000: 19 litres
7
, “What is most important in your life”: a shift
Social and cultural forces:
• Secularisation: the importance attached to health appears to be inversely related to
the acceptance of finiteness, transience and mortality (Ten Have et al.)
• Too high expectations of life, health and happiness:
o Medical progress
o Prosperity: cure model → health model = well-being
• Erosion of traditional authorities, structures and communities
• From collective measures to individual autonomy/responsibility
• Malleability of society → malleability of own life
• Commercialisation and technology
Commercialisation: Rathenau Institute
→ “The common objective used to be guaranteed in the doctor-patient relationship. But the
creators of apps have a commercial mindset. Soon the question will no longer be: ‘What is
health?’, but: ‘Who defines health?’.
The rise of surveillance medicine
Context: public health, state and society in the 20th/21th century
→ wisdom and sophistication regarding lifestyle medicine: model of surveillance medicine
as analytical tool
Expansion and increase of scale: medicine was traditionally small scale disaggregated,
restricted and piecemeal in its operations:
• Medicine used to be atomised, a jumble of patient-doctor transactions
• Practitioners were mainly self-employed, with at most a tiny back-up team
• Patient-doctor relations typically involved a personal contact initiated by the sick
person calling in a physician or a surgeon
→ Hippocratic triangle: doctor, patient and disease/illness
Medicine has now turned into the proverbial Leviathan:
• Comparable to military machine or the civil service
• In many case no less business and money oriented than the great oligopolistic
corporations
8
Growth &
development
Summary
1
,Inhoud
Week 33: Growing up healthy ................................................................................................................. 5
Interprofessional collaboration in primary care ................................................................................. 5
Diabetes ........................................................................................................................................... 5
A history of social medicine................................................................................................................. 6
Health and culture ........................................................................................................................... 6
The rise of surveillance medicine .................................................................................................... 8
Healthy childhood ............................................................................................................................. 11
Lifestyle, children and community health policies ............................................................................ 12
GGD ............................................................................................................................................... 12
Health ............................................................................................................................................ 13
Early life stress ................................................................................................................................... 17
Stress network ............................................................................................................................... 17
Research: epigenetics .................................................................................................................... 17
Early detections of consequences of early life stress.................................................................... 18
Targets for preventative interventions ......................................................................................... 19
Week 34: Child with abnormal gait ....................................................................................................... 20
Paediatric orthopaedics..................................................................................................................... 20
Antalgic gait ................................................................................................................................... 20
Hiel vagus ...................................................................................................................................... 22
Leg length discrepancy .................................................................................................................. 23
Anatomy ............................................................................................................................................ 26
Movements ................................................................................................................................... 26
Musculoskeletal elements of the pelvis ........................................................................................ 27
The lower limb ............................................................................................................................... 31
Normal motor skills ........................................................................................................................... 60
Phases: ........................................................................................................................................... 60
Cerebral palsy ................................................................................................................................ 61
Developmental coordination disorder .......................................................................................... 62
Exercise poverty ............................................................................................................................ 62
Hip dysplasia ...................................................................................................................................... 63
Orthopaedic hips disorders ............................................................................................................... 68
Club foot ............................................................................................................................................ 70
Skeletal dysplasia: medical genetics.................................................................................................. 72
Spondyloepiphyseal dysplasia congenita ...................................................................................... 72
Osteogenesis imperfecta ............................................................................................................... 73
2
, Child rehabilitation ............................................................................................................................ 74
Cerebral palsy ................................................................................................................................ 74
Week 35: The developmentally delayed child ...................................................................................... 77
Normal growth .................................................................................................................................. 77
Disorders of growth........................................................................................................................... 79
Normal development ........................................................................................................................ 80
Physical development.................................................................................................................... 80
Developmental milestones............................................................................................................ 80
Disorders of development ................................................................................................................. 82
Developmental surveillance .......................................................................................................... 82
Evaluation of the child with special needs ........................................................................................ 85
Multifaceted team assessment of complex problems .................................................................. 85
Management of developmental problems ................................................................................... 86
Failure to thrive ................................................................................................................................. 87
Psychosocial short stature ............................................................................................................. 87
Child abuse and neglect .................................................................................................................... 88
Child maltreatment ....................................................................................................................... 88
Diet of the normal infant ................................................................................................................... 90
Obesity............................................................................................................................................... 92
Paediatric undernutrition .................................................................................................................. 93
Signs of nutritional deficiency disorders ....................................................................................... 94
Hypoxic-ischaemic encephalopathy, intracranial haemorrhage and seizures .................................. 96
Neonatal seizures .......................................................................................................................... 96
Intracranial haemorrhage.............................................................................................................. 97
Hypoxic ischaemic encephalopathy .............................................................................................. 97
Congenital infections ......................................................................................................................... 99
Oesophagus and stomach ............................................................................................................... 102
Gastroesophageal reflux ............................................................................................................. 102
Eosinophilic oesophagitis ............................................................................................................ 102
Oesophageal atresia and tracheoesophageal fistula .................................................................. 102
Oesophageal foreign bodies ........................................................................................................ 102
Caustic injuries and pill ulcers ..................................................................................................... 103
Pyloric stenosis ............................................................................................................................ 103
Peptic disease .............................................................................................................................. 104
Cyclic vomiting syndrome............................................................................................................ 104
Intestinal tract ................................................................................................................................. 105
3
, Malrotation ................................................................................................................................. 105
Intestinal atresia .......................................................................................................................... 105
Other congenital disorders .......................................................................................................... 105
Inflammatory bowel disease ....................................................................................................... 105
Coeliac disease ............................................................................................................................ 106
Intussusception ........................................................................................................................... 106
Appendicitis ................................................................................................................................. 107
Pancreatic disease ........................................................................................................................... 108
Pancreatic insufficiency ............................................................................................................... 108
Acute pancreatitis ....................................................................................................................... 108
Chronic pancreatitis .................................................................................................................... 108
Neurologic abnormalities ................................................................................................................ 109
Weakness and hypotonia ................................................................................................................ 115
Diseases of the upper motor neuron .......................................................................................... 115
Diseases of the lower motor neuron........................................................................................... 115
Neonatal and infantile hypotonia ............................................................................................... 116
Stroke in childhood...................................................................................................................... 117
Ataxia and movement disorders ..................................................................................................... 118
Ataxia ........................................................................................................................................... 118
Movement disorders ................................................................................................................... 118
Neurodegenerative disorders ......................................................................................................... 120
Hereditary and metabolic degenerative diseases ....................................................................... 120
Acquired illnesses mimicking degenerative diseases .................................................................. 121
Neurocutaneous disorders .............................................................................................................. 122
Neurofibromatosis type I ............................................................................................................ 122
Tuberous sclerosis complex ........................................................................................................ 122
Sturge-Weber syndrome ............................................................................................................. 122
Congenital malformations of the central nervous system .............................................................. 123
Congenital anomalies of the spinal cord ..................................................................................... 123
Congenital malformations of the brain ....................................................................................... 123
Week 36: Child with a behavioural disorder ....................................................................................... 124
Autism spectrum disorder ............................................................................................................... 124
Attention deficit hyperactivity disorder .......................................................................................... 127
Pharmacology in ADHD ................................................................................................................... 131
4
,Week 33: Growing up healthy
Interprofessional collaboration in primary care
= needed for adequate prevention: also role of the GP
Diabetes
= treated by the GP, but also:
• Primary care practice assistant
• Doctor’s assistant: measuring + checks
• Pharmacist
• Physiotherapist
• Podiatrist
• Dietician
• Internist
• Nurse practitioner
• Eye doctor
Combination of all these domains: huge improvement of diabetes care in the Netherlands
→ diabetes patients have a similar life expectancy as people without diabetes
Aim of diabetes treatment = prevention of cardiovascular disease
Time to change a sedentary lifestyle to an active one = 3-6 months → guidance of the
physiotherapist
5
,A history of social medicine
Health and culture
Time: continuity and change
Hippocratic/galenic medicine (450 BC- 1858 AD):
• Health = balance of humours
• Disease = disbalance of humours
6 “res non-naturales”
1. Airs, waters and places: environment
2. Food and drink: diet
3. Sleeping and waking
4. Exercise and relaxation/rest
5. Evacuations
6. Passions: state of mind
→ preserving balance by regulating these non-naturals: regiment for healthy living/ageing
= hygiene, exercise, diet and temperance
Health = “the good life” → big business!
Ca. 1800: increased attention for a healthy lifestyle → enlightenment ideals, industrialisation
and urbanisation: public health, sanitary reforms and public education
6
,1948-present:
• WHO definition of health: “a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”
• Positive health (Huber et al. 2011): “The ability to adapt and self manage in face of
social, physical and emotional challenges”
• 2 cultural shifts:
o Increasing preoccupation with health
o Individualisation of malleability and responsibility
“Doing better, feeling worse”: health + life expectany go up
→ but also
• Concerns about health
• Use of and dependence on healthcare provisions
• Worried well
Epidemiological transition:
• From infectious to chronic disease: ageing population → shift of objectives of
medicine
• Not only demography: different attitude towards chronic/degenerative diseases
• Paradigm of risk factors:
o Lifestyle factors
o Asymptomatic diseases
o Subjectively healthy but highly medicated individuals
o Blurring of distinction of health/disease
Diseases of affluence:
• Overweight:
1980: 16%
2000: 25%
• Beer consumption/year:
1900: 41 litres
2000: 85 litres
• Wine consumption/year:
1900: 2 litres
2000: 19 litres
7
, “What is most important in your life”: a shift
Social and cultural forces:
• Secularisation: the importance attached to health appears to be inversely related to
the acceptance of finiteness, transience and mortality (Ten Have et al.)
• Too high expectations of life, health and happiness:
o Medical progress
o Prosperity: cure model → health model = well-being
• Erosion of traditional authorities, structures and communities
• From collective measures to individual autonomy/responsibility
• Malleability of society → malleability of own life
• Commercialisation and technology
Commercialisation: Rathenau Institute
→ “The common objective used to be guaranteed in the doctor-patient relationship. But the
creators of apps have a commercial mindset. Soon the question will no longer be: ‘What is
health?’, but: ‘Who defines health?’.
The rise of surveillance medicine
Context: public health, state and society in the 20th/21th century
→ wisdom and sophistication regarding lifestyle medicine: model of surveillance medicine
as analytical tool
Expansion and increase of scale: medicine was traditionally small scale disaggregated,
restricted and piecemeal in its operations:
• Medicine used to be atomised, a jumble of patient-doctor transactions
• Practitioners were mainly self-employed, with at most a tiny back-up team
• Patient-doctor relations typically involved a personal contact initiated by the sick
person calling in a physician or a surgeon
→ Hippocratic triangle: doctor, patient and disease/illness
Medicine has now turned into the proverbial Leviathan:
• Comparable to military machine or the civil service
• In many case no less business and money oriented than the great oligopolistic
corporations
8
