Ebook Paediatrics and child health (3/E): Part 1

Paediatrics and
Child Health


To our children: Aaron and Rebecca Krom;
Sophie, Jake, and Naomi Lee;
Alysa, Katie, Ilana, Hannah and David Levene.
To our spouses: Michael, Sue, and Alison.
To those individuals who over the course of years have influenced our approach to
children in health and disease:
Ben Berliner, Victor Dubowitz, David Hall, Ze’ev Hochberg, Hugh Jolly, Jim
Littlewood, Esther Rudolf, Hedva Steiner, Myron Winick.


Paediatrics and
Child Health
Third edition

Mary Rudolf
Consultant Paediatrician and Professor of Child Health
Head of Studies, MSc in Child Health, University of Leeds
NHS Leeds and University of Leeds

Tim Lee
Consultant in Paediatric Respiratory Medicine
Organiser, MSc in Child Health, University of Leeds
Leeds Teaching Hospital Trust and University of Leeds

Malcolm Levene

Emeritus Professor of Paediatrics and Child Health
University of Leeds

A John Wiley & Sons, Ltd., Publication


This edition first published 2011 © 2011 by Mary Rudolf, Tim Lee and Malcolm Levene
Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been
merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.
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to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.
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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any
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assistance is required, the services of a competent professional should be sought.
Library of Congress Cataloging-in-Publication Data

Rudolf, Mary, author.
Paediatrics and child health / Mary Rudolf, Consultant paediatrician and Professor of Child Health NHS Leeds and
University of Leeds, Tim Lee, Consultant in Paediatric Respiratory Medicine, Co-organiser MSc in Child Health West
Yorkshire, Lead, Medicines for Children Research Network, Malcolm Levene, Leeds General Infirmary. – Third Edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-9474-7 (pbk. : alk. paper) 1. Pediatrics. 2. Children–Health and hygiene. I. Lee, Tim,
(Pediatrician), author. II. Levene, Malcolm I. (Malcolm Irvin), author. III. Title.
[DNLM: 1. Pediatrics. 2. Child Welfare. WS 200]
RJ45.R86 2011
618.92–dc22
2010047404
A catalogue record for this book is available from the British Library.
Set in 10/12 pt Adobe Garamond Pro by Toppan Best-set Premedia Limited


Contents
Preface to the third edition and acknowledgements
How to get the best out of your textbook

vii
viii

Part 1: About children
Chapter 1

Nature and nurture

3

Chapter 2

Health care and child health promotion

18

Chapter 3

Children with long-term medical conditions

35

Part 2: A paediatric tool kit
Chapter 4

History taking and clinical examination

51

Chapter 5

Developmental assessment

83

Chapter 6

Investigations and their interpretation

90

Part 3: An approach to problem-based paediatrics
Chapter 7

The febrile child

107

Chapter 8

Respiratory disorders

132

Chapter 9

Gastrointestinal disorders

157

Chapter 10 Cardiac disorders

191

Chapter 11 Neurological disorders

202

Chapter 12 Development and neurodisability

225

Chapter 13 Growth, endocrine and metabolic disorders

252

Chapter 14 Musculoskeletal disorders

283

Chapter 15 Renal and urinary tract disorders

295

Chapter 16 Genitalia

311

Chapter 17 Dermatology and rashes

318

Chapter 18 Haematological disorders

342

Chapter 19 Emotional and behavioural problems

352

vi / Contents

Chapter 20 Social paediatrics

362

Chapter 21 Emergency paediatrics

369

Chapter 22 The newborn

399

Chapter 23 Adolescence and puberty

433

Part 4: Your paediatric rotation and exams
Chapter 24 Getting the most out of your paediatric rotation and
achieving good marks

449

Chapter 25 Testing your knowledge

452

Index

474

Companion website
This book is accompanied by a companion website:

www.wiley.com/go/rudolf/paediatrics
with:
• Fully downloadable figures and illustrations


Preface to the third edition
Experience is the child of Thought, and Thought is the
child of Action. We cannot learn men from books.
Benjamin Disraeli.
Was Disraeli right? Are books a very limited resource?
Certainly the only way to become competent as a
doctor is to encounter children and their medical
problems on the wards, in clinics and their homes. It
is only through these Experiences that Thought and
understanding can lead you to the Action required to
meet children’s needs.
But of course reading must accompany experience. This book has always been seen of value in
complementing your paediatric rotation and ensuring
that you are well equipped for paediatric examinations
as well as clinical practice.
As before, it aims first and foremost, to provide
you with the necessary tools to arrive at a diagnosis
and to care for children in the context of their family
and school. Unlike most medical textbooks which use

diseases as their building blocks, this textbook uses
symptoms and signs at its core. Competences you

must acquire are highlighted in each chapter, a logical
approach to important presenting symptoms follows
and the correct technique you need to develop for
examining children is shown in the accompanying
video. The book ends with self assessment so you can
test your knowledge and understanding.
This third edition has been fully revised so that it
allows you to work through the curriculum organ
system by organ system. As before there are features
that allow you to readily recognize the important,
common or serious conditions that you must not miss.
An exciting development has been the provision of
free access to a Desktop Edition so that you can view
and interact with the book electronically, including
videos on clinical examination. A companion website
allows you to download figures and illustrations.
The words of Benjamin Disraeli are a reminder
that no book can substitute for clinical experience but
we hope that this book can indeed ‘learn’ students,
and help you get the most out of your paediatric
experience, guiding you to appropriate Thought and
Action.

Acknowledgements
We are grateful to the following who have contributed
illustrations: Dr Rosemary Arthur, Mr P.D. Bull,
Dr Tony Burns, Professor Martin Curzon, Dr Mark

Goodfield, Dr Phillip Holland, Mr Tim Milward,
Dr P.R. Patel, Dr John Puntis, Mr Mark Stringer,
Dr David Swirsky, Ms Clare Widdows, Dr Susan
Wyatt and Dr Jane Wynne. We would like to thank
the Royal College of Paeditrics and Child Health
and Harlow Printing for permission to reproduce
their growth charts. We would like to thank the
following: Extract of ‘Henry King who chewed string
and was cut off in dreadful Agonies’ from Cautionary
Verses by Hilaire Belloc (Copyright © The Estate of
Hilaire Belloc 1930) is reproduced by permission
of PFD (www.pfd.co.uk) on behalf of the Estate of
Hilaire Belloc. Extract of ‘Rebecca who slammed
doors for fun, and perished miserably’ from Cautionary

Verses by Hilaire Belloc (Copyright © The Estate
of Hilaire Belloc) is reproduced by permission of PFD
(www.pfd.co.uk) on behalf of the Estate of Hilaire
Belloc. Extract from ‘Now We Are Six’ © A.A. Milne.
Published by Egmont UK Limited, London and used
with permission. Published by Dutton’s Children’s
Books, a division of Penguin Young Readers Group,
a member of Penguin Group (USA) Inc, 345 Hudson
Street, New York, NY 10014, and used with permission. All rights reserved. Extract from When We
Were Very Young © A.A. Milne. Published by Egmont
UK Limited, London and used with permission.
Published by Dutton’s Children’s Books, a division
of Penguin Young Readers Group, a member of
Penguin Group (USA) Inc, 345 Hudson Street, New
York, NY 10014, and used with permission. All rights

reserved.


viii / How to get the best out of your textbook

How to get the best out of your textbook
Welcome to the new edition of Paediatrics and Child Health. Over the next two pages
you will be shown how to make the most of the learning features included in the
textbook
▲

An interactive textbook

For the first time, your textbook gives you
free access to a Wiley Desktop Edition – a
digital, interactive version of this textbook.
You can view your book on a PC, Mac,
laptop and Apple mobile device, and it
allows you to:
Search: Save time by finding terms and
topics instantly in your book, your notes,
even your whole library (once you’ve
downloaded more textbooks)
Note and Highlight: Colour code
highlights and make digital notes right in
the text so you can find them quickly and
easily
Organize: Keep books, notes and class
materials organized in folders inside the
application

Share: Exchange notes and highlights
with friends, classmates and study groups
Upgrade: Your textbook can be
transferred when you need to change or
upgrade your computer or device
Link: Link directly from the page of your
interactive textbook to all of the material
contained on the companion website

▲

Video showing you how to
examine children

Simply log on to
www.wiley.com/go/rudolf/paediatrics
for full instructions on how to get started

A unique feature of the textbook is a detailed
video taking you step by step through the
examination of the child. Salient features are
captured and the correct technique
demonstrated for each organ system –
essential for eliciting signs, coming to a
diagnosis and showing your competence in
OSCE examinations.


How to get the best out of your textbook / ix

FREE companion website

Chapter 1: Nature and nurture / 3

CHAPTER 1

Nature and
nurture

Your textbook is also accompanied by a FREE companion website
that contains:

Physical growth
Psychomotor development
and social interaction
Parenting and parenting skills
Nutrition
Child care and education
Inequality and social
disadvantage

• Fully downloadable figures and illustrations

4

And one man in his time
plays many parts,
His acts being seven ages. At first
the infant,
Mewling and puking in

the nurse’s arms.
And then the whining schoolboy, with
his satchel, And shining morning face,
creeping like a snail
Unwillingly to school.
William Shakespeare

Chapter 5: Developmental assessment / 83

CHAPTER 5

Developmental
assessment

5
7
8
16
16

Gross motor development
Fine motor development
Speech and language
development
Social skills
Essential milestones
and when to worry

Log on to www.wiley.com/go/rudolf/paediatrics to find out more

When I was One,
I had just begun.
When I was Two,
I was nearly new.
When I was Three,
I was hardly me.
Now We Are Six,
AA Milne

85
87
87
88
89

COMPETENCES
You must . . .
Know

Be able to

Appreciate

• The factors that affect
growth
• The influence that the
quality of parenting has
on a child’s
development
• The advantages of

breast-feeding
• The components of a
balanced healthy diet
• The effects of poverty
on health

• Make up a formula feed

• The difference between
growth and
development
• How development
progresses from
babyhood to childhood
• How challenging
parenting can be
• The ethical issues that
arise when working
with children
• When a young person
is able to consent to
treatment

COMPETENCES
You must . . .

Paediatrics and Child Health, Third Edition. Mary Rudolf, Tim Lee, Malcolm Levene.
© 2011 Mary Rudolf, Tim Lee and Malcolm Levene. Published 2011 by Blackwell Publishing Ltd.

Features contained within your textbook

Know

Be able to

Appreciate

• The key developmental
milestones and at what
age they are usually
achieved
• At what age to be
concerned if a milestone has not been
achieved
• How to measure and
weigh children
accurately

• Engage the child and
establish a rapport
• Carry out a developmental evaluation on a
toddler by taking a
history and observing
the child

• That there is variability
in the age when
developmental milestones are achieved
• That you may need to
repeat an evaluation

before you can
conclude that a child’s
development is
concerning

Paediatrics and Child Health, Third Edition. Mary Rudolf, Tim Lee, Malcolm Levene.
© 2011 Mary Rudolf, Tim Lee and Malcolm Levene. Published 2011 by Blackwell Publishing Ltd.

▲

Chapters are organized by organ system. Each opens with
the competences you need to acquire as well as the key
topics covered. The first part of each chapter goes through
the most important symptoms and guides you through the
differential diagnosis and the features of the history, examination
and investigations that will help you come to a competent
diagnosis. Full details of common and important conditions and
disorders follow.

150 / Part 3: An approach to problem-based paediatrics

▼

Throughout your textbook you will find a series of icons highlighting the learning features in the book:

Red flags: Worrying symptoms and signs
indicative of serious conditions that you
must not miss are highlighted with red
flags.
Clues to the diagnosis boxes: The

conditions you need to consider when
encountering a sick child are shown with
clues for key symptoms and signs that
will help you come to the correct
diagnosis.
At a Glance boxes: These boxes concisely
summarize the aetiology, clinical
features, investigations and management
of common and important conditions for
quick re-cap.
Key points boxes: Key points boxes
highlight the `take-home’ messages you
need to remember.

Chapter 8: Respiratory disorders / 151

Cystic fibrosis at a glance

2

3

4
Pancreas

:

Chapter 4: History taking and clinical examination / 57

An approach to examination

The remainder of this chapter provides you with a
system by system approach to examining children,
along with an explanation of how to elicit signs and
interpret them..

Growth

Consistent technique is necessary to estimate standing
height accurately (Figure 4.3). Check the heels are
against the wall and the feet flat on the floor with the
knees straight. Gently extend the neck and ensure the
eyes are in line with the external auditory meatus.
Head (occipitofrontal) circumference (OFC)

Accurate measurement of height, weight and head
circumference is a vital part of the assessment of all
children referred for a medical opinion. Growth can
only accurately be assessed by taking at least two measurements of various growth parameters (e.g. length,
weight and head circumference) and observing the
relative points at which these measurements fall on a
growth chart appropriate to the child’s age and sex.
Weight

▼

Use a weighing scale that has been calibrated accurately. Infants should be laid in a pannier scale and
older children weighed standing up. Babies should be
weighed naked without a nappy, and older children
in light clothing or (preferably) underwear only.

This should be measured accurately to the nearest
millimetre. Use a flexible, non-stretchable tape
measure and measure around the occipitofrontal circumference. Take three successive measurements at
slightly different points. The widest is taken to be the
OFC (Figure 4.4).

Figure 4.4 Measurement of head circumference.

Growth standards
In order to interpret a child’s growth, comparison
must be made with population standards. These
standards are presented in the form of growth charts,
which demonstrate the population’s growth as centiles. The growth charts currently in use in the UK are

0-1 year

49

50 cm

Age in weeks/ months

91st

75th

d

45
44

43
42

33
32
31
30

27
26

41
40
39
38
99.6th 37
98th
36
91st
35
75th
50th
25th
9th

Gestation in weeks

32 34 36 38 40 42

Head board sitting on vertex of skull

and at right angles to backrest

Plotting preterm infants
Use the low birthweight
chart for infants less than 32
weeks gestation and any
other infants requiring
detailed assessment.

2nd

34

62

Gestational age
(7 weeks preterm)
Actual age
Gestational correction
Plot actual age then draw a
line back the number of
weeks the infant was preterm
and mark the spot with an
arrow; this is the gestationally
corrected centile.

Observer exerts
gentle pressure
on mastoids to
extend neck

5.5

Birth Weight

th
99.6
98th
91st
75th
50th
25th
9th
2nd
h
0.4t

Weight (kg)

3

2
1.5
1

10.5
10
9.5
9

6

Gestation in weeks

40 cm

82 cm

th
leng

99.6th
98th 4.5
91st
4
75th
50th 3.5
25th
3
9th
2.5
2nd
0.4th
2
1.5

80

76
74

72

9th

70

2nd

0.4th

12 13 14 15 16 17
1/
1

52 cm
50
48
46

19 20 21 22 23 2 25 26 27 28 29

2

head

99.6th
98th
91st
75th
50th

25th
9th
2nd
0.4th

31 32 33 34 35
1

2

116

98th

108

cm
195
99.6th

6.2
6.0

75th

5.11

50th

104 5.10

5.9

25th

100
96

2nd

0.4th

5.6
5.5

92

5.4
5.3

gth

Figure 4.3 Measurement of standing height.

9th

190
185
180
175
170

2nd
165
160

26

58 cm

76

14 kg

72

99.6t
98th
91st
75th
50th
25th
9th
2nd
0.4th

len

13
12.5

11.5
11

91st

10.5

25

60 cm
24 kg

24

23

99.6th

10

75th

ht

weig

50th

9.5
9

22

23
22

21

98th

21

8.5

25th

8

9th

7.5

2nd

7

0.4th

6.5

20

20
91st

19
18

19
18

75th
6

17

17

5.5
5

50th

16

t
eigh

75th
4.5

15

4
3.5
3

14
13

2.5
2

98th

12

91st

1.5

Age in weeks/ months
1
1
2
3
4
5
6
7

8
9
10
11
0.5 kg
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

11

75th

10

50th

1
0.5 kg

25th

9th

w

99.6th

2nd

0.4th

16
15
14
13
12
11
10

25th

9

9th
2nd

8

0.4th

Figure 4.2 Measurement of length using a frame.

25th

64

80

8

Heels against

backstop

91st

50th

0.4th

88

68

84

9

Straight legs

98th

75th

5.8
5.7

9th

Plot child’s
height centile on
84 cm

the blue lines
above; the black
30 kg numbers show
average male
adult height for
29
this centile;
80% of children
will be within
28
±6 cm of this
value.
27

h

62

98th

25th
9th
2nd h
0.4t

ft/in
6.5
6.4
6.3

112

6.1

91st

92
88

60

124 cm Prediction
120

99.6th

t

h
heig

66

Adult Height

BOYS
1-4 years

Age in months/ years

42
40 cm
96 cm

68

64

37 38 39 40
3

2/

• Measure length until age 2; measure
height after age 2.
• A child’s height is usually slightly less
than their length.

44

78

13.5

Some degree of weight
loss is common after birth.
Calculating the percentage
weight loss is a useful way
to identify babies who
need assessment.

8

7
6.5

5.5

32 34 36 38 40 42

41

11 kg

5

2.5

42

25th

12

7.5

4
3.5

43

50th

99.6th

8.5

5
4.5

45
44

75th

2nd
h

64

46

2nd

91st

9th

32

47

25th
9th

0.4th

98th

25th

0.4t

50th

99.6th

50th

66 cm

99.6th 56
98th
54
91st
52
75th
50th
50
25th

48
9th
2nd
46
0.4th
44 cm

hea

75th

0.4th 31 cm

58
Use this section for infants
of less than 37 weeks
gestation. As with term
infants there may be some
weight loss in the early days.
From 42 weeks, plot on the
0–1year chart with
gestational correction.

External auditory meatus and lower
rim of orbit in horizontal line

th
99.6
98th
t

91s

33

60

48

98th

46

35
34

49

99.6th

47

36

the 1990 UK Child Growth Standards, which were
constructed from detailed data collected on children
across the country. In 2009 the charts for children
aged 0–4 years were updated. They are now constructed from World Health Organization data, which
was based on the growth of healthy breast-fed babies,
rather than bottle-fed babies as previously.
Separate charts are available for girls and boys. Age

is given along the x axis which, depending on the
chart, may be shown in months or decimally. Height,
length, weight and head circumference measurements
lie along the y axis. Nine centiles ranging from the
99.6th to the 0.4th centile are shown as continuous
or dotted lines (Figures 4.5–4.7). Body mass index
(BMI) should be calculated if there is any concern
about weight. This is calculated from the equation:
BMI = weight in kg/(height in metres)2

14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52
3
4
5
6
7
8
9
10
11

48

37

Height and length

▼

50 cm

Birth
Head Circumference

38

28

The measurement of height should be precise; it is
only accurate if made with care using the appropriate
equipment.
In the first 2 years of life, length is measured
on a measuring frame or mat (Figure 4.2). From the
age of two, providing the child can stand, height is
measured against a specially calibrated standing frame.

GIRLS

Preterm
39

29

Your textbook is full of useful photographs,
illustrations and tables. The Desktop Edition
version of your textbook will allow you to copy
and paste any photograph or illustration into
assignments, presentations and your own notes.

Obtain three successive

measurements and take
the largest to be the
occipitofrontal
circumference (OFC)

Use a flexible
non-stretchable
tape measure

Figure 4.5 UK-WHO growth chart showing a baby’s
growth at 28 weeks’ gestation until 1 year, corrected for
prematurity. © Child Growth Foundation. New charts for
children aged 0–4 years were introduced in the UK in
2009. They are now based on the growth of healthy
breast-fed babies.

7

7

6
5 kg
12 13 14 15 16 17

6

Age in months/ years
2

1/

1

2

19 20 21 22 23

2/

3

1

2

25 26 27 28 29

31 32 33 34 35

3/
1

2

37 38 39 40 41

5 kg
43 44 45 46 47 48

Figure 4.6 UK-WHO growth chart for children aged
1–4 years.

We hope you enjoy using your new
textbook. Good luck with your studies!

UK-WHO Chart 2009 ©DH Copyright 2009 Harlow Printing Limited Tel: 0191 455 4286 www.healthforallchildren.co.uk

Viral
Respiratory syncytial virus
Influenza viruses
Parainfluenza
Adenovirus
Coxsackie viruses

56 /

th

Clinical features. The child with acute pneumonia
presents with a short history of fever, cough and respiratory distress. Meningismus may be present, and
shoulder tip or abdominal pain can divert attention

Bacterial
ally in younger
Streptococcus pneumoniae (especially
children)
sidious
Mycoplasma pneumoniae (more insidious
onset)
n in Britain)
Haemophilus influenzae (uncommon

ccus
Group B beta-haemolytic streptococcus
(only in the newborn)

99.6

• congenital abnormality of the tracheo-bronchial
tree;
• inhaled foreign body;
• persistent lobar collapse;
• chronic aspiration;
• large left to right intracardiac shunt;
• immunocompromise.

Table 8.5 The commoner organisms
sms causing
pneumonia

98th

Pneumonia is caused by a wide range of viral and
bacterial organisms as shown in Table 8.5. Streptococcus
pneumoniae often causes lobar pneumonia.
Predisposing factors to acute pneumonia should
always be considered in children who present with
pneumonia. These include:

Non-respiratory problems:
• diabetes
• delayed puberty

• biliary atresia
• male infertility

75th 91st

Pneumonia

Prognosis/complications
Chronic deteriorating lung
disease
Life expectancy now 30–40 years
Usually reasonable quality of life
in childhood

25th 50th

Cystic fibrosis remains a life-limiting condition
although the outlook has improved greatly in recent
years so that average life expectancy is now 30–40
years. In general, with good treatment, most individuals can lead relatively normal lives in the childhood
years. Growth may slow down in later childhood and
puberty may be delayed. In adulthood, the slow progression of lung disease may eventually become disabling. Lung transplantation is considered in severe
cases.
Cystic fibrosis may affect other systems. Diabetes
develops in some children during adolescence. Most
males are azospermic, but have unimpaired sexual
function.

NB *Signs and symptoms are
variable

Confirmatory investigations
Elevated sodium (>60 mmol/L)
and chloride on sweat test
Screening of stool samples at
birth in some centres
Chronic changes on chest X-ray
Decreased stool chymotrypsin

Head Circumference (cm)

Malabsorption and diet
Children require dietary adjustment, pancreatic
enzyme replacement and supplementary vitamins to
correct their loss of pancreatic function and inadequate digestion of fat and protein. Pancreatic enzyme
supplements have to be taken with all meals and
snacks.

Prognosis

Physical examination
Poor growth (1)
Chest deformity
Wheezing and crepitations (2)
Clubbing (3)
Protuberant abdomen (4)

b

0.4th 2nd 9th

Respiratory tract
The aim of treatment is to clear secretions, prevent
infections and treat them promptly and effectively
when they occur. Parents are taught how to carry out
regular chest physiotherapy. Antibiotic therapy is
often required, intravenously or orally, at high dosage
for prolonged periods.

The diet needs to be high in energy and protein,
and there is no need to restrict fat. Dietary supplements are often needed at times of illness or if there
is anorexia, and all patients require supplements of the
fat-soluble vitamins A, D and E. Extra salt is also
needed in hot weather or if the child is febrile to
replace losses in sweat.

a

th

Figure 8.9 Chest X-ray of a boy with cystic fibrosis.
There is gross overinflation of the lungs with hilar
enlargement and ring shadows caused by bronchial
wall thickening and bronchiectatic change.

History
Chronic cough +/– wheezing (a)
Frequent chest infections
Failure to thrive (FTT)
Frequent, bulky, greasy stools (b)

History of meconium ileus*
Family history of cystic fibrosis*

91st 98th 99.6

Figure 8.10 High-resolution chest CT scan image of a
child with severe bronchiectasis caused by cystic
fibrosis.

Management
Lungs:
• physiotherapy
• frequent and prolonged
courses of antibiotics, often
needed IV
Nutrition:
• pancreatic enzyme
supplements
• high protein, high calorie diet
• fat soluble vitamins and salt
• dietary supplements at times

50th

Aetiology
Gene mutation affects sodium
and chloride transport across
secretory epithelial cells →
airway obstruction and
pancreatic insufficiency

Differential diagnosis
Other causes of chronic lung
disease
Other causes of malabsorption

1

0.4t 2nd 9th 25th 50th 75th 91st 98th 99.6
th
h

Epidemiology
Commonest cause of
suppurative lung disease in
UK children
One in 25 individuals are carriers



Part 1
About children



Chapter 1: Nature and nurture / 3

CHAPTER 1

Nature and

nurture
Physical growth
Psychomotor development
and social interaction
Parenting and parenting skills
Nutrition
Child care and education
Inequality and social
disadvantage

4

And one man in his time
plays many parts,
His acts being seven ages. At first
the infant,
Mewling and puking in
the nurse’s arms.
And then the whining schoolboy, with
his satchel,
And shining morning face,
creeping like a snail
Unwillingly to school.
William Shakespeare

5
7
8
16
16

COMPETENCES
You must . . .
Know

Be able to

Appreciate

• The factors that affect
growth
• The influence that the
quality of parenting has
on a child’s
development
• The advantages of
breast-feeding
• The components of a
balanced healthy diet
• The effects of poverty
on health

• Make up a formula feed

• The difference between
growth and
development
• How development
progresses from
babyhood to childhood

• How challenging
parenting can be
• The ethical issues that
arise when working
with children
• When a young person
is able to consent to
treatment

Paediatrics and Child Health, Third Edition. Mary Rudolf, Tim Lee, Malcolm Levene.
© 2011 Mary Rudolf, Tim Lee and Malcolm Levene. Published 2011 by Blackwell Publishing Ltd.


4 / Part 1: About children

Paediatrics is the branch of medicine that covers the
childhood years. In general, the younger the child the
more the physiology and metabolism differ from
those of adults, but in older children these differences
become less pronounced. There are, however, two
areas that are unique to paediatrics: physical growth
and development. A good understanding of how children change in terms of growth and development in
the early years is very important, and without this
understanding it is not possible to practice paediatrics
well. This chapter discusses how the child develops
physically, neurologically, psychologically and emotionally from birth through to full maturity. The
chapter also discusses the importance of parenting and
how this influences a child’s well-being, how nutritional needs change through childhood and how
poverty impacts on children’s health.

Physical growth
Growth vs. development
Growth and development are intimately related, but
are not necessarily dependent on one another. Growth
is a combination of increase both in the number of
cells (hyperplasia) and in the size of cells (hypertrophy). Development is an increase in complexity of the
organism due to the maturation of the nervous system.
A child may develop normally but be retarded in
growth, and vice versa. Brain injury does not necessarily cause impaired somatic growth, although many
children who are severely intellectually retarded are
small. Growth can be measured accurately, but the
measurement of development is much more difficult
to quantify.
Factors that affect growth (see Box 1.1)
Growth is influenced by a number of semi-independent
factors, but growth itself is a continuum from early
fetal life through to the end of adolescence. The following are the major factors affecting growth:

Box 1.1 Factors necessary for
normal growth
• Genetic potential (mid-parental height)
• Optimal intrauterine nutrition
• Appropriate postnatal nutrition
• Good health
• Normal psychosocial factors (nurture)
• Normal hormonal milieu

• Genetics. Growth patterns and final height are
largely determined by genetic factors. A normal child’s
final height can be predicted as falling close to the

centile midway between the parents’ centiles.
• Hormones. The principal hormones influencing
early growth are growth hormone and thyroid
hormone. Growth hormone in childhood and the sex
hormones play an important part in the pubertal
growth spurt. Disturbance of any of these affects a
child’s growth.
• Nutrition. World-wide, malnutrition is an important factor that influences children’s growth, and is the
major factor accounting for the differences in height
observed between populations in developing and
more developed countries. In many developed countries (including Britain and the USA), malnutrition is
still a cause of poor growth, and is sometimes associated with neglect. Overnutrition, a leading cause of
obesity, is on the increase.
• Illness. Illness causes a child’s growth to slow
down. If the illness is short-lived, rapid catch-up
occurs. Chronic illness can affect growth profoundly
and irreversibly.
• Psychosocial factors. Sociodemographically, children and adults from higher socioeconomic classes are
taller than their peers from the lower classes. An
adverse psychosocial environment, particularly if
there is emotional neglect, can have a profound negative effect on a child’s growth.
Growth in infancy
The rate of growth in the first year of life is more rapid
than at any other age. Between birth and 1 year of
age, children on average increase their length by 50%,
and triple their birthweight. Head circumference
increases by one third. During the second year of life
the rate of growth slows down and the baby changes
shape to take on the appearance of the leaner and
more muscular child.

Growth in the preschool and school years
In the preschool years a child continues to gain weight
and height steadily. Beyond the age of 2 or 3 years
until puberty, the growth rate is steady at about
3–3.5 kg and 6 cm per year.
Growth in adolescence
Adolescence is characterized by a growth spurt which
occurs under the influence of rising sex hormone
levels. During the 3 or 4 years of puberty boys grow
about 25 cm and girls 20 cm. Growth in the pubertal
years is discussed in Chapter 23.


Chapter 1: Nature and nurture / 5

Catch-up growth
During a period of illness or starvation the rate of
growth is slowed. After the incident the child usually
grows more rapidly, catching up towards, or actually
to, the original growth (‘catch-up growth’). The degree
to which catch-up is successful depends on the timing
of the onset of slow growith and its duration. This is
particularly important in infants who have suffered
intrauterine growth retardation (see pp. 407–9), and
who may have reduced growth potential.
In nutritionally compromised children, weight
falls before height is impaired, and head growth is the

last to be affected. If growth has been slowed for too
long or into puberty, complete catch-up is not

achieved. Early detection of children with abnormal
growth velocity patterns has important therapeutic
implications. Early treatment is more likely to ensure
that acceptable adult height is achieved.
Organ growth
Not all body systems grow at the same rate, and in
some respects the growth rates of some organs are
independent of others. Full maturation is not complete until the end of the second decade.

Differential organ growth at a glance
Brain growth
Neuronal development
complete by 20 weeks after
conception. Myelination
continues until mid-teens.
Synaptic development
throughout childhood

Dental maturation
Dental development occurs in
sequence (see Figure 1.1). By
the end of the second year the
child has 20 teeth. First tooth of
the permanent dentition appears
at the end of 6 years

Lymphoid tissue growth
Reaches maximum
development by 5 years

Skeletal growth
Bone development proceeds in
a regular sequence. ‘Bone age’
can be determined by a
radiograph of the wrist (see
Figure 1.2)

Adipose tissue growth
Fat increases rapidly during
the first year. Steady loss
until the age of 7 years.
Prepubertal growth spurt
with a rapid increase

Psychomotor development and
social interaction
Babies are born into a social world and learn to interact initially with their parents, then other close relatives and eventually with other children and adults.
In order to achieve full social development children
must achieve neurodevelopmental milestones that
help them make contact with the outer world.
Early social development is divided into discrete
periods corresponding to developmental landmarks;
each period is an important milestone leading towards
developing into a social being. More detail about
developmental milestones and how to assess them are

Gonads (see also Chapter 23)
Little development in
prepubertal years. At puberty
they change from the infantile to

the adult state over a period of
4 years

covered in Part 2. Here you are provided with an
outline of a child’s development through the stages of
childhood. It is important to remember that each
stage is dependent on the growing maturity of the
nervous system. Development cannot be accelerated
from outside, but external factors, particularly environment and to a lesser extent illness, can retard it.
Babyhood and the preschool years
0–2 months

Mothers of new babies learn to
‘bond’ with their baby during the
first hours and days after birth.
This is not an automatic process


6 / Part 1: About children

Complete at 2–2.5 years

Complete at 18–25 years

12–13 years

12–24 months

10–12 years

16–20 months
6–9 months
Primary dentition

7–8 years
6 years
Secondary dentition

Figure 1.1 Dental development, showing the age at
which teeth generally erupt.

babies often suffer feelings of guilt because they have
never been told that this is a common experience.
The infant is born with a variety of needs that must
be met by the parents. In the first 2 months the baby
starts to adapt his or her behaviour into states of
arousal. Sleep and wake cycles begin to emerge at this
time and are influenced by the routine in the house.
The longest period of sleep usually occurs in the night.
Infants show a great degree of alertness and are
particularly attracted to human faces and the spoken
word. Contact is achieved with the mother particularly during feeding. Mothers and babies coordinate
their behaviour and take turns to initiate contact by
means of alternating sucking with pauses for eye
contact. It appears that infants are programmed to
respond to their carers in particular ways, and in turn
the carer is profoundly influenced by her own programming to stimulate the infant and to respond to
the baby’s contact. A major milestone in the development of a baby as a social being in these early weeks
is the beginning of the first smile (at around 6 weeks).
2–5 months

Figure 1.2 X-ray of the left wrist taken for bone age.
The development of the various bones is assessed, to
give an estimate of the child’s skeletal maturity.

and is facilitated by close physical contact. Mothers
who are separated from their babies after birth (e.g.
because they are premature and require admission to
a neonatal unit) find bonding more difficult. For this
reason, parents should be encouraged to handle their
babies even when their baby is receiving intensive care.
Parents who find they do not immediately love their

A major developmental change
that occurs at the beginning of
this period is the infant’s visual
development. At 2 months a
baby can sustain eye contact and this is a vital stimulus
for parent–child interaction. Over time infants show
progressively more gaze interaction, and parents respond with facial expression, speech and intonation.
Another important milestone is the beginning of
vocalization. When babies start to babble, carers
respond as if engaging in ‘conversation’. They respond
to their baby’s sounds by questioning or talking to the
infant, with pauses for a response. Although infants
do not understand the meaning of their carer’s speech,
the pattern and interaction are essential for the child’s
own language and social development. Studies have
shown that if mothers do not respond appropriately
to their infants by smiling and talking en face, babies

become distressed and may withdraw from further
interaction. Sensitive parental response at this age is
essential for normal social development.
5–8 months

At this age children begin to pay
more detailed attention to objects.
They begin to reach for toys and so
start to explore the inanimate
world. Through interaction with
their carers, simple play starts to


Chapter 1: Nature and nurture / 7

emerge. At 6 weeks of age babies spend about 70%
of contact time regarding their carers, but by 6 months
two thirds of the time is taken up with regarding the
rest of the world. First contact with objects is by gaze
and later by pointing.
At this stage infants transform from being egocentric to realizing that they live in a world which is
shared with people and objects.
8–18 months

During this period mobility rapidly
develops and children start to leave the
safety of their carer to interact further
with the environment. They begin to
initiate contact rather than simply
reacting to it, and the concept of reciprocating begins to emerge. They can

initiate an enjoyable game such as ‘peek-a-boo’ and
can control the game by adapting their response to
the adult’s. They begin to ‘learn the rules’ of the game
and of social interaction in general. They begin to use
carers to obtain desired objects, and can also manipulate objects to attract adults’ attention.
At this stage children also learn to associate their
cry with response and, for example, know that if they
are uncomfortable due to a dirty nappy, relief will be
provided. Babies who are institutionalized become
apathetic if their cries are unanswered, because communication has been extinguished.
In the first half of the second year babies begin to
take more interest in other children. Initially children
play side by side, occasionally sharing a toy. By 18
months they may play together, but there is less vocal
contact than when they are engaged with an adult.
Carers, particularly parents, are the main influence in
social training at this stage.
18 months and beyond

By 18 months children begin
to communicate verbally using
speech to describe an event or
effect a wish. Make-believe play
develops by 2 years, when children use familiar objects to reconstruct events. They also develop the ability to recognize
shapes, including letters (which is the first stage of
reading), and then to copy shapes with a pencil.
School age children
Motor, language and social skills continue to develop
rapidly during the school years. Horizons are broad-

ened by starting school, and often for the first time
children need to learn to function outside the security
and safety of their own home. Expectations for
appropriate behaviour in a variety of situations
increase. During school years the child also begins to
develop a conscience and an understanding of right
and wrong.
Socialization is particularly important at this age,
and children need to learn to relate to a variety of
other children and adults. Play is an extremely important part of this process and brings benefits far beyond
its impact on physical development and motor skills.
It is necessary for children’s happiness and well-being,
impacts on the quality of friendships, cultural understanding and social, emotional and cognitive functioning, and allows the development of imagination,
creativity and exploration. Through play children
practice adult roles, learn a variety of competences,
enhance their academic performance, and work out
how to handle challenges, work in groups, make decisions and develop leadership skills.
Adolescence
Adolescence, the period which bridges childhood and
maturity, is a period of biological, psychological and
sociological maturation. This is discussed in detail in
Chapter 23.

Parenting and parenting skills
Parenting is arguably the most important factor contributing to the health and well-being of children. Yet
it is assumed that it comes naturally and does not need
to be taught. The breakdown of the extended family
compounds the situation as parents are often isolated
in bringing up children, and responsibilities go
unshared. Where parenting is good, children in quite

adverse circumstances develop resilience to the adversity. Where parenting is poor, particularly where it
is neglectful or abusive, difficulties are passed from
generation to generation.
Psychologists have defined four styles of parenting
as shown in Figure 1.3 depending on how responsive
a parent is to their child’s physical and emotional
needs and the extent to which they are ‘in charge’.
The authoritative style is optimal and involves being
sensitive and responsive while remaining in charge
and able to maintain appropriate limits for behaviour.
By contrast, the authoritarian style takes control to
extremes, and is coupled with low responsiveness.
Restrictions and demands are made without the


8 / Part 1: About children

+

−

Common parenting difficulties and how they can be
addressed are discussed in Chapter 19.

+

BEING RESPONSIVE

BEING IN CHARGE

AUTHORITATIVE
(firm but warm and accepting)

NEGLECTFUL

−

INDULGENT
(permissive)

AUTHORITARIAN
(strict disciplinarian)

Figure 1.3 Styles of parenting: the four styles relate to
how responsive parents are to the child and how much
they are in charge within the family.

Nutrition
Milk is the food of babies and it is capable of meeting
the infant’s nutritional needs for the first 6 months of
life. Breast milk is the ideal food for human babies,
but may be unavailable for some infants, in which case
alternative formulae are available.
Nutritional requirements in infancy
Water

child’s needs, feelings and preferences being taken into
account. An indulgent style is a kind but weak approach
to parenting, where the parent is responsive to the
child’s wishes and demands even when they are not

in the child’s best interests. It is linked to an inability
to set limits and maintain boundaries. A neglectful style
is one where the parent is neither in charge nor
responsive to the child.
The authoritative style is the ideal as it promotes
healthy development and a feeling of security where
children know that their needs will be respected and
their views considered within a consistent framework.
Research shows that authoritative parenting is linked
to a large number of positive outcomes such as social
development, self-esteem and mental health, higher
academic achievement, lower levels of problem behaviour, increased ability to self-regulate, less depression
and less risk taking, The other styles have been
associated with lower academic grades, lower levels
of self-control, poorer psychosocial and emotional
development, behavioural problems and substance
abuse.
It is now being recognized that parenting should
be taught to young people while at school. The curriculum should address emotional well-being and discipline as much as the practicalities of caring for
babies and young children. Schools are beginning to
acknowledge this, although it has to be said that teenagers may find it hard to relate to the issues. A further
opportunity to impart good principles and practice
comes at antenatal classes. An important part of well
child care is to support parents in developing their
parenting skills. Parenting groups are often available
for parents and the evidence is clear that they can be
helpful, particularly in improving the quality of home
life and the management of difficult behaviour.

Over 70% of a newborn infant’s weight is water, compared with 60% for an adult. Infants are less able to

conserve water and consequently their fluid requirements are considerably higher than those of older
children.
Energy

Newborn infants require approximately 110 kcal/kg
per day (462 kJ/kg per day) for normal growth, and
these energy requirements are provided by a balance
of carbohydrate, fat and protein.
• Carbohydrate. Almost all the carbohydrate in
both human and formula milk is lactose, and about
40% of the total energy requirement comes from carbohydrate sources.
• Fat. Fat is the most important source of energy in
milk and provides approximately one half of an
infant’s energy requirement.
• Protein. Milk protein can be divided into curd
and whey. Curd consists predominantly of casein and
precipitates in the stomach. Whey contains mainly
lactalbumin and lactoferrin. Colostrum is the very
thin watery milk produced by the breast in the first
few days after giving birth. It has a very high proportion of immunoglobulins.
Minerals

The mineral requirements change as babies mature.
At birth the renal conservation of sodium is poor and
newborn babies lose more in their urine than older
infants. Premature babies, in turn, require a higher
sodium intake than full-term babies because of the
functional immaturity of the kidneys.
Calcium and phosphate absorption in infancy is
high as a result of the rapid growth rate. The relative

ratio of these two minerals is important in determining adequate absorption.


Chapter 1: Nature and nurture / 9

Table 1.1 Factors associated with
successful breast-feeding
High socioeconomic class
Intention to breast-feed whilst pregnant
Paternal support
Whether the mother herself has been breast-fed

Figure 1.4 Mother breast-feeding her 6-week-old baby.

Vitamins

All babies require essential vitamins. Surprisingly,
breast milk is deficient in vitamin K. All newborn
infants should be given vitamin K at birth to prevent
haemorrhagic disease of the newborn.
Trace elements

There are a large number of essential trace elements
present in milk which are essential for normal growth
and development. Iron is one of the most important,
and breast milk contains sufficient iron for dietary
needs over the first 6 months of life.
Breast-feeding (see Figure 1.4)
The proportion of women breastfeeding varies widely throughout
the world. The World Health

Organization reports that in some
countries it is usual for all mothers
to breast-feed for up to 1 year. In
Britain only two thirds of women
offer their babies any breast milk at all, and less than
half continue to breast-feed by the time the baby is 4
months old. These figures are influenced by socioeconomic class: 97% of women in the highest socioeconomic class feed their first baby compared with less
than 50% in a group of less advantaged women.
In order to support breast-feeding more widely,
the World Health Organization and UNICEF established The Baby Friendly Initiative as a worldwide
programme to encourage maternity hospitals and
community services to promote successful breastfeeding and to practise in accordance with the
International Code of Marketing of Breastmilk
Substitutes. This has helped to ensure a higher stand-

ard of care for pregnant women and breast-feeding
mothers and babies.
The factors that predict successful breast-feeding
are shown in Table 1.1.
In developed countries the benefits of breastfeeding are psychological as much as physical. In
developing countries the argument for breast-feeding
is very strong: formula feeds may easily be contaminated by polluted water used in making up the feed,
with the risk of fatal gastroenteritis. Everywhere,
breast-feeding has the advantages of being free of cost
and convenient.
Physiology of lactation
During pregnancy there is a marked increase in the
number of ducts and alveoli within the breast, in
response to changes in maternal and placental hormones. The size of the nipple also increases. In the
third trimester prolactin sensitizes the glandular

tissue, causing small amounts of colostrum to be
secreted.
At birth, oestrogen levels fall rapidly while prolactin rises. This is stimulated further by the infant’s
sucking at the breast. The prolactin secretion from the
anterior pituitary maintains milk production from the
breast alveoli. The volume of milk produced relates to
the frequency, duration and intensity of sucking.
The flow of milk from the breast is under the
control of the let-down reflex. The baby’s rooting at
the nipple causes afferent impulses to pass to the
posterior pituitary, which secretes oxytocin. This acts
on the smooth muscle fibres surrounding the alveoli
so that milk is forced into the large ducts. As the baby
takes less milk, the stimulus for prolactin production
reduces and lactation is inhibited. The hormonal
maintenance of lactation is summarized in Figure 1.5.
The let-down reflex is stimulated by contact with
the baby, including hearing the baby cry and handling
the child. Dripping of milk from the breast not being
suckled is caused by reflex action; this diminishes
after the first few weeks. Anxiety and embarrassment


10 / Part 1: About children

INFANT
STIMULI

Hypothalamus
PRF

PIF
Anterior
pituitary

Posterior
pituitary

Nipple
stimulation

Oxytocin
Prolactin
Let-down reflex

Milk production

Figure 1.5 Physiology of lactation. PIF, prolactininhibiting factor; PRF, prolactin-releasing factor.

suppress the reflex by action of the sympathetic
nervous system. Every step possible should therefore
be taken to put the mother at her ease and avoid
unnecessary anxiety.
Colostrum. The milk produced in the first few days
after birth is called colostrum and is a thin, yellowish
fluid. It is particularly valuable for the establishment
of lactobacilli in the bowel and contains less fat
and energy but more immunoglobulins than later
milk.
The constituents of milk do not reach their mature
proportions until 10–14 days after birth. The secretion from the breast between colostrum and mature

milk is referred to as transitional milk.
Technique of breast-feeding
The majority of the milk taken by a baby from the
breast is consumed in the first 5 minutes of the feed.
Much of the rest of the time at the breast is spent in
non-nutritive sucking. Mothers should be aware of
the feeling of her breast being ‘emptied’ by her baby
shortly after commencement of suckling, but the
time spent at the breast following this is also very
important.

Mothers should be encouraged to put the baby to
the breast directly after birth. A normal baby immediately attempts to suck. Little milk is produced, but
the stimulation is important in the establishment of
lactation. Mothers should then be encouraged to put
the baby to the breast on demand and should also feed
the baby during the first night. The time the baby
spends on the breast should be gradually increased so
that the nipples become accustomed to the baby
sucking.
Trauma to the nipple in the first few days after
birth has to be minimized. The baby exerts strong
suction on the nipple and a baby should never be
pulled off the breast. The mother should be shown
how to release the baby by using her finger to depress
the breast away from the corner of the baby’s mouth.
Feeds should commence on alternate breasts.
Babies are often given complement formula feeds
in the early days of life by well-meaning staff in order
to let the mother rest, but this is counterproductive

and should be avoided. If a baby appears to be hungry
and it is considered not appropriate to put him or
her to the breast, a solution of dextrose and water may
be given.
It is common for mothers to encounter difficulties
in establishing breast-feeding in the first weeks, and
to feel that their milk is inadequate. The difficulties
often relate to positioning of the baby, and expert
support from breast-feeding counsellors can often
help resolve the problems.
Advantages of breast-feeding
The advantages of breast-feeding are summarized in
Table 1.2, and ways to encourage successful breastfeeding are shown in Box 1.2.

Table 1.2 Advantages of breast-feeding
Perfect balance of milk constituents
Little risk of bacterial contamination
Anti-infective properties
Ideal food for brain growth and optimal
development
Convenience
No expense to purchase milk
Psychological satisfaction
Possibly reduces risk of atopic disorders
Exposes baby to a variety of flavours


Chapter 1: Nature and nurture / 11

Box 1.2 Ways to encourage successful

breast-feeding
• Introduce the concept to both parents
antenatally
• Place the baby on the breast immediately after
delivery
• Allow the baby to feed on demand, in the early
days especially
• Avoid offering any formula feeds
• Ensure the mother receives good nutrition and
plenty of rest

Table 1.3 Role of anti-infective agents in
breast milk
Cells

Milk is teeming with white
cells, mainly macrophages,
polymorphs and both T- and
B-lymphocytes

Immunoglobulins

Secretory IgA is the
predominant immunoglobulin.
Particularly high
concentration in colostrum

Lysozyme

Lyses bacterial cell walls

Lactoferrin

Binds iron necessary for the
replication of some bacteria
and reduces bacterial growth

Interferon

Present in low concentrations
in breast milk and has
antiviral properties

Bifidus factor

The carbohydrate bifidus
factor encourages lactobacilli
to flourish in the bowel,
inhibiting overgrowth of
Escherichia coli

Breast-fed infants have a significantly lower risk of
respiratory and gastrointestinal infections in the early
months of life compared with formula-fed infants.
Breast milk has a number of important anti-infective
properties which are summarized in Table 1.3.
Contraindications to breast-feeding
For the average healthy infant there are no disadvantages to breast-feeding. Infants born with anomalies
such as severe cleft lip and palate and obstructive
bowel problems may not be able to feed, although

every effort should be made to provide them with
expressed breast milk rather than formula feeds.
Similarly, there are very few contraindications to
breast-feeding for the mother. The most important
reason to prevent a mother from breast-feeding is if
she is HIV-positive: the risk of transmitting the HIV
virus to her baby is doubled by breast-feeding. A
mother who is excreting Mycobacterium tuberculosis
should also not breast-feed.
Mastitis (inflammation of the breast) is a common
problem but, far from contraindicating, it is alleviated
by continued and frequent breast-feeding.
Drugs in breast milk
Most drugs given to the mother are excreted to some
degree in her milk, but the exposure to the infant is
usually so little that the risk is minimal. Examples of
drugs that are definitely contraindicated in a breastfeeding mother are tetracyclines (which stain developing teeth), antimetabolites (impair cell growth) and
opiates (drug addiction).
Formula feeds
Formula milks are based on cow’s milk, but are highly
adjusted to meet the basic nutritional requirements of
growing immature infants. A variety of components
of cow’s milk are utilized. Skimmed milk is produced
by removing the fat content, and the curd can be
separated, leaving whey and lactose together with
minerals. These are the building blocks of infant milk
formula.
Virtually all formula feeds have added carbohydrate, usually lactose or maltodextrins. Most milk
manufacturers replace the fat with polyunsaturated

vegetable oil or butterfat blend. This alters the fatty
acid profile to resemble breast milk more closely. The
protein base of formula milk is usually demineralized
whey to which the appropriate mixture of minerals,
vitamins and trace elements are added. Caseinpredominant milks are usually given as a supplement
to babies of 4–6 months who are perceived to be still
hungry. This process produces a formula milk product
that is similar in its basic proportions to that of mature
breast milk.
It is clear that although there are similarities
between breast and formula milks, the constituents
are chemically quite different. The protein in formula
milk is based on cow’s milk protein and the fat content
is quite different to breast milk fat content. The major
differences between breast and formula milk are
shown in Table 1.4.


12 / Part 1: About children

Table 1.4 Comparisons between breast and
formula milk
Breast milk

Formula milk

Sterile

May be contaminated
by ‘bad’ water

Contains anti-infective
properties (see p. 11)
Reduces risk of infection

out a little onto the back of the hand. The teat should
not be touched or it will become contaminated. The
hole in the teat should be large enough so that when
the bottle is inverted, milk comes out rapidly in drops,
but not in a stream. Too large a hole causes the baby
to choke on the feed, and too small a hole leads to
excessive air swallowing as a result of the baby’s vigorously sucking to obtain the milk.
Weaning (see Boxes 1.3 and 1.4)

No cost

Expensive

Perfectly adapted to
human babies

Foreign protein

Allergic disorders
reduced

May increase risk of
allergy

Non-human fat

content

Possible IQ enhancement
Some protection from
obesity

Additives
Formula or bottle-fed babies require no vitamin
supplementation.
Fluoride drops are advised for babies from 6
months if the drinking water is not fluoridated.
Preparation of feeds
The preparation of formula feeds is summarized in
Figure 1.6. Some parents find it more convenient to
make up the day’s supply of feeds at one time, and to
store the milk in a refrigerator. Parents need to understand and be instructed to use a level measure of
powder and not a heaped one, as this would produce
too concentrated a feed, especially in its electrolyte
content, and could lead to hypernatraemic dehydration (see p. 95). To obtain a level measure the excess
powder is removed with the blade of a knife.
Scrupulous attention should be paid to sterility:
bottles and teats should be sterilized either by boiling
or by an antiseptic solution such as mild sodium
hypochlorite (Milton). It is essential that the bottles
are filled with the solution and the teats are totally
immersed. The Milton solution should be made up
each day.
Most parents like to give the milk warm, although
babies will take a cold feed just as well. To ensure that
the feed is not too hot it should be tested by shaking

Healthy infants do not require weaning until 6
months of age. Breast or formula milk provide all their
nutritional requirements in the early months. Too
early an introduction of mixed feeding may be associated with obesity.
In developed countries there is a wide choice of
weaning foods. In Britain cereals and rusks are
the favoured first solid food, but package foods to
which water is added may also be used. All modern
cereals for babies are gluten free, and this may be
associated with a fall in the incidence of coeliac disease
(pp. 180–1). The semi-solid food is given by spoon
before offering the bottle or breast. Its timing should
be whatever suits the mother. Alternative weaning
foods are purées of cooked vegetables, fish or meat.
These can be purchased in pre-prepared containers or
be liquidized at home in a food blender.
Babies are conservative individuals and dislike
change. The earlier a new-tasting food is introduced,
the more likely it is to be accepted. It is often recommended that one new food should be introduced at a
time. Babies may well be reluctant to accept new tastes
at first, which can be interpreted as dislike. Repeated
offerings generally result in acceptance. When
weaning, cup and spoon feeding should be introduced
early in order to make the change easier and reduce
the possibility of the baby refusing to give up the
bottle (see Figure 1.7).
As children get older their diet will become more
like that of the rest of the family. The child will now
begin to try to hold the spoon him- or herself,

although he or she is likely to go through a stage of
wanting to use fingers only. A baby who has started
to chew his or her fingers, even before any teeth have
erupted, can be given toast or a hard rusk to chew on.
It is good to encourage self-feeding as this helps ensure
that the baby is not over- or underfed. At no time
should the child be left alone while feeding, however,
for fear of choking.
By the age of 9 months, most babies are ready to
eat at least one meal a day with the family. The food


Chapter 1: Nature and nurture / 13

Figure 1.6 Preparation of formula feed.

Box 1.3 Principles of infant nutrition

Box 1.4 The weaning process

• Breast milk is the ideal sole feed for the first
4–6 months
• Continue breast or formula milk for the first
year
• Introduce solid foods from 6 months
• Once a baby is able to chew, mashed and then
cut up food can be given
• Babies can usually feed themselves biscuits or
rusks at 7 months
• Cup feeds should replace breast-feeds, and

bottles be discouraged beyond the age of 1
year
• Vitamin supplements should be given once
weaning is well established

0–6 months
6 months

7–9 months

9–12 months

1 year and
beyond

Breast or formula milk only
Introduce solid foods –
pureed and finger
feeds
Give more soft feeds before
milk feeds. Encourage finger
feeding. Give fruit juices in
a cup
Mash food with a fork. Three
meals a day, at least one with
the family
Undiluted cow’s milk in a cup