SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE

Updated as of June 2013

CHILD HEALTH SURVEILLANCE

INTRODUCTION

It can be difficult to identify the child with emerging developmental problems when normal patterns and rates
are so varied.

Useful clinical tools are:

Ability to obtain information from parents or carers who are good observers of the child
Good working knowledge of normal child development
The child/s Health Booklet. Besides a form of documentation, it is also a good parent education tool.

The child health surveillance program in the polyclinics schedules a child who is otherwise well to be seen at
specific ages. Encounters would be as follows:

In this instance the child would be

Age of the child: attended to by the:

Nurse Doctor
Shortly after birth if the child presents for follow-up of
neonatal jaundice. This is usually the childs first visit to
the polyclinic.

3 months
4 months
5 months

6 months
9 months

12 months
15 months
18 months

3 years
4 years

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SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE
Updated as of June 2013

The Three Month Old Visit

In the first year, motor development is predominant.

History:
Note screening history taken by nurse:
1. Should feed well
2. Weight height & OFC according to centiles

Take vision history from parents

Get parents response to questions :

1. Can child keep head upright when held in a sitting position?
2. Can child respond to mothers voice by quieting down if crying, or by smiling?
3. Can child visually follow mothers movements including turning head from side to side?

Check suitability for vaccination (DPT if following National Schedule): no inter- current illness etc

Physical Examination:

Eyes:
1. Fixation on moving object
2. Pupillary light reflex
3. Red reflex
4. Cornea and lens
5. Nystagmus
6. Hirschbergs test for squint
7. Roving eye movements

Fontanelles:
1. Posterior closes first few months of life
2. Anterior persists up to 2 years

Heart, Lungs, Abdomen

Hips for unstable / dislocated hips
Femoral pulses & genitalia
Primitive reflexes
o Moro: present from birth, disappears by 3-4 months
o Tonic neck: present 1-4 months, disappears by 4 months
o Grasp reflex: present from birth, disappear by 2-3 months
o Walking/ stepping: present from birth, disappears by 6 weeks

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SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE
Updated as of June 2013

CHILDHOOD SURVEILANCE PROGRAM

The Three Month Old Visit

Milestones:
Personal & Social Fine Motor- Gross Motor Language
Development Adaptive

Normal Spontaneous social Unfisted for >50% Props on forearms Laughs/squeals

development smile at 6 weeks of time, reaches, when prone, head with pleasure, turns
Discriminate social hand regard steady when head to sound
smile at 6 months upright.

Red Flags Not smiling back by Persistent fisting at Significant head Silent baby, no
refer for 8 weeks age 3 months. lag, floppy or coos or gurgles.
further increased tone. If
evaluation Doesnt regard face Does not follow head lag is mild, Does not respond
/ Poor visual object movement may review at age (e.g. with eye
attention / eye past midline. 4 months but any movements,
contact persisting head lag change in breathing
at 4 months should pattern or activities)
be referred. to a sound from a
source out of sight
Does not move
both arms & legs
equally when lying
on the back.

The Six Month Old Visit

The child is brought in by appointment for the last dose of primary course of Hepatitis B.

Usually only seen by the nurse who may refer the child to the doctor if there are any concerns.

Nurse gets the parents response to questions:

o Does child roll over?
o Does child turn towards sound?
o Does child reach out for things?
If any answer to the above 3 questions is No, the child is referred to the doctor.

Milestones:

Personal & Social Fine Motor- Gross Motor Language

Development Adaptive

Normal Excites at toy by 5 Tracks 180 by 4 Bears weight on Babbles

development months. months. legs. Imitates speech
Stretches arm out Reaches for object. And the following sounds.
to be lifted. Palmar grasp. by 5 months:
Holds head up at
90 on prone.
Pulls to sit without
head lag.
Rolls over.

Red Flags As above in 3 Does not track 180 Head lag present. As above in 3
refer for month visit Unable to roll over. month visit
further
evaluation
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SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE
Updated as of June 2013

The 18 Month Old Visit

The child is brought in by appointment for the MMR (Measles Mumps Rubella) vaccine as well as
assessment, and is seen by both the nurse and the doctor.
nd
In the 2 year of life, language & social development are more important.

Milestones:
Personal & Social Fine Motor- Gross Motor Language
Development Adaptive

Normal Assists dressing. Scribbles by 16 Walks by 12 Says mama and

development Drinks from cup. months. months. papa specifically
Spoonfeeds self. Tower of 4 cubes. Walks alone by 16 by 12 months.
months. 10-20 single words.
Kicks ball. Stoops Points to pictures
to recover. and 2-3 body parts.

Red Flags Not recognizing No pincer grip by Not getting into No use of first
refer for familiar adults by 12 14 months. sitting position by words by 15
further months. Unable to build a 12 months. months.
evaluation Not recognizing tower of 2 cubes. Unable to walk 3 Not babbling or
own name by 12 steps independently using a variety of
months. by 18 months. sounds at 18
Persistent casting months.
or mouthing of Not recognizing use
objects after 18 of object by 18
months. months.

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SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE
Updated as of June 2013

Functional Screening and Assessment for Children above Age 6 Years

Screening questions include:

1. Do you have problems dressing?

To dress independently including buttoning, zipping back of dresses and tying shoe laces
If isolated - most commonly child not taught rather than serious organic disorder, TCU 3
months for review
If associated with other disorders : dysmorphism suggestive of a syndrome,
musculoskeletal disorders or social disorders like autism or ADHD, refer to appropriate
department.

2. Do you have problems walking?

Exclude acute and dangerous causes like infection and fractures both traumatic
(including child abuse) and non-traumatic (pathological like malignancy) which require
urgent referral
If associated with other disorders (as for dressing) refer to appropriate department

Physical Examination

1. Walk the child, is there a pattern to the abnormal gait:

antalgic - trauma / JIA
circumduction - JIA / hemiplegic cerebral palsy
spastic - upper motor neuron disease diplegic / quadriplegic cerebral palsy, stroke
ataxic - ataxic cerebral palsy, Friedreichs ataxia
Trendelenbergs - Perthes disease, slipped capital femoral epiphysis, developmental
dysplasia of hip, JIA involving the hip; muscle like dermatomyositis; neurological spinal
bifida, spinal cord injury, cerebral palsy
Toe-walking (Equinus) - diplegic cerebral palsy
Stepping lower motor neuron disease like spinal bifida and polio

It is important to decide whether the gait is abnormal and requires referral for evaluation or is a normal variant
which can be observed.

Some of the normal variants include:

Knock knee (genu valgus) most resolve by age 7 year-old
Flat feet usually resolve by age of 6 year-old

Regardless of findings, if there is significant parental concern, refer for further assessment

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SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE
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When to refer to the Child Development Clinic

1. Growth abnormalities:
weight, height and head circumference crossing percentiles over months

2. Gross Motor abnormalities:

persisting hypotonia, hypertonia or tremors
asymmetry of tone and movement
persisting head lag beyond 4 months

3. Fine Motor abnormalities:

persisting casting or mouthing of objects after 18 months

4. Visual abnormalities:
lack of visual alertness or difficulty with face to face gaze
persisting strabismus after 3 months

5. Speech & Language problems:

inattention to sound
loss of babbling after 6 months
absence of speech or presence of single-words-only after 2 years.
Unintelligible speech at 3 years of age

6. Personal / Social problems:

failure of social smiling after 8 weeks
abnormal behaviour suggestive of autism. To be assessed at 18-24 months.
- does not make eye contact, no social smile, does not snuggle when picked up, does not say single
words by 15 months or 2 word phrases by 24 months, regression in previously achieved skills
particularly in motor and language areas, stereotypic behaviour, obsessed with a few activities and
often doing them repeatedly throughout the day.

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SHP Doctors Guidebook: CHILD HEALTH SURVEILLANCE
Updated as of June 2013

Guidelines For Referral Of Speech And Language Disorders (to CDU, KKWCH)

Articulation Disorders

Child is not babbling, using a wide variety of sounds at 18 months.

Speech is unintelligible (in conversation) to familiar people at 3 years.
Disturbance of sucking, chewing or swallowing at any age, or if child dribbles a lot.
Child at 5 years has difficulty with early developing sounds (e.g. m,p,b,t,d,k,g) and/or later developing
sounds (l,ch,j,sh,s,z,r). The last sounds to develop are usually th (the later is usually substituted for
by t/d in Singaporean speakers of English) and sound blends (eg tr-,sl-,str-).

Language Delay / Disorders

Child is not using single words by 18 months.

Child is not using 2 word sentences by 2 years.
Vocabulary is limited to mainly nouns and verbs at 3 years.
Sentences are consistently faulty or immature at 4 years; eg Where the go?, confusion of names
of objects (eg chair for table, or vice versa)
Child has difficulty following spoken directions or understanding spoken messages.

Stuttering

Child has noticeable hesitations and repetitions of sounds/words/phrases.

Child prolongs sounds and syllables.
Child blocks on sounds.
Child shows tension/frustration during speech.

Voice Disorders

Child has intermittent or progressive change in his/her voice quality; e.g. hoarse, breathy, nasal,
monotonous, inappropriately loud/soft, high/low.
Child has a transient or complete loss of voice.

Others

Always refer children who seem conscious and/or frustrated about their ability to communicate
Always refer if parents are concerned.

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