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An Evaluation of the Infant with Motor Delays: When and How Much?. Sarah Winter, MD Neurodevelopmental Pediatrician Division of General Pediatrics University of Utah Terry Holden, PT CHSCN February 23, 2010. Objectives.

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An evaluation of the infant with motor delays when and how much

An Evaluation of the Infant with Motor Delays: When and How Much?

Sarah Winter, MD

Neurodevelopmental Pediatrician

Division of General Pediatrics

University of Utah

Terry Holden, PT CHSCN

February 23, 2010


Objectives
Objectives Much?

  • Discuss hallmarks of motor delays in infants such as tone patterns, primitive reflexes, milestone delays, and deviances

  • Using cases to prompt discussion, compare differences in the approach to evaluation

  • Review brain MRI abnormalities with patterns of motor impairment

  • Review the purpose of the Neuromotor Team


Developmental Disorders in Children Much?

Disorders of brain function


Neuromotor team children with special health care needs
Neuromotor Team Much?Children with Special Health Care Needs

  • Specialty team within the “Child Developmental Clinic”

  • Types of patients seen

    • Typically birth to 36 months

    • Older children with motor impairment with case management needs

  • Team members:

    • Sarah Winter, MD, Terry Holden, PT, Scott Jerome, PT, and Alison Seppi, RN

    • Oversight: Jim Taliaferro, LCSW


My developmental path to understanding gross motor delay
My developmental path to understanding gross motor delay Much?

dystonia

Tone

cerebral palsy

gross motor delay

gross and fine motor

hypotonia

gait

Developmental Discoordination Disorder

ataxia

GLobal Developmental Delay

selective control

posture

weakness

spasticity

hyperreflexia



Developmental progress

A systematic approach of identification, evaluation, and intervention

Move from chaotic pieces of knowledge

Developmental Progress

To


A systematic approach

Examine intervention

Diagnose

Treat

Screen

A Systematic Approach


References for screening
References for Screening intervention

  • 2001 AAP Policy Statement: Developmental Surveillance and Screening of Infants and Young Children

  • EPSDT: Early Periodic Screening, Diagnosis, and Treatment

  • 2006 AAP Policy Statement: Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An algorithm for Developmental Surveillance and Screening


References to screening and surveillance
References to Screening and Surveillance intervention

  • Society for Development and Behavioral Pediatrics website: www.dbpeds.org

  • Grand Rounds by Paul Young and Charlie Ralston

  • Podcast produced by Dr. Paul Carbone www.utah.edu/podcast


Features of a good developmental history
Features of a Good Developmental History intervention

  • Parents describe gross motor skill delays well

  • People; both parents and medical care providers, don’t tend to pay attention to fine motor skills e.g. when are kids supposed to have a hand preference?

  • Ask about language, it is a clue to cognitive development


The pediatric neurodevelopmental exam
The Pediatric Neurodevelopmental Exam intervention

  • Gross Motor findings

  • Fine Motor findings

  • Language findings

    • Expressive

    • Receptive

  • Social/Behavioral findings


Focused exam findings
Focused exam findings intervention

  • Tone patterns

    • Low tone: mild or severe?

    • High tone: is it symmetric?, is it typical (LE>UE)?

    • “weird” tone : ataxia, tremor, fluctuating (dystonia)



Focused exam
Focused exam intervention

  • Reflexes;

    • High or absent

    • Primitive reflexes – see figure

  • Postural or protective responses

    • Lateral, anterior, posterior supports

    • parachute


Examples of primitive reflexes
Examples of primitive reflexes intervention

  • The Moro is normal in a newborn and should be gone by 4 months

  • The ATNR is normal in a newborn and should be gone at 6 months


Postural or protective responses
Postural (or protective) responses intervention

Parachute response:

(appears at 10 months)

Lateral support:

(appears at 6 months)

  • Anterior (comes 1st) , lateral (2nd), and posterior (3rd) support responses

  • Parachute response


Increased tone intervention


Gross motor examination
gross motor examination intervention

  • This child presents with delays in gross motor milestones. His tone is likely low

  • Differentiate between tone and strength


Focused exam1
Focused Exam intervention

  • “Deviant” (atypical but not always delayed) motor patterns

    • “Bottom scooters”

    • Circling hands and feet while balanced on the bottom (hypotonia) Some confuse this for a sign of autism

    • Commando crawling (hemiplegia)


Gross motor testing standardized measures of gross motor function

Purpose intervention

Further diagnostic information

Qualifying children for therapeutic services

Developmental measure or mark in time

Frequently used tools

Peabody Developmental Motor Scales

Bayley Scales of Infant Development

Gross Motor Function Scale

TIMP

Alberta Infant Motor Scales

Gross motor testing: standardized measures of gross motor function



Narrowing the differential diagnosis
Narrowing the Differential Diagnosis intervention

  • Patient A: in top graph 18 months with negative past medical history.

  • Patient B: 12 month old with history of failure to thrive



Case 1
Case # 1 intervention

  • 10 month old not sitting or rolling

  • Pregnancy/Labor/birth HX: Uncomplicated pregnancy, NSVD, BW 8# 3 oz. Apgars normal

  • FHx: noncontributory


#1 intervention

  • Physical exam: cute blonde, fair skinned, growth parameters: weight >>95%, hgt 75%, OFC, 75% rest of exam normal

  • Neuro exam: low trunk tone, high extremity tone upper extremities more involved than lower extremities. Hyperreflexia throughout

  • Neurodevelopmental exam: GM: no sitting balance, prominent extensor thrust , FM: fisted hands, language: smiling, babbling


What is an appropriate work up
What is an appropriate work-up? intervention

  • Imaging?

    • CT vs. MRI

  • Metabolic Studies?

  • Genetic Studies?


Case 2
Case # 2 intervention

  • 24 month old with language delay, not using left arm as well as right arm

  • Pregnancy.labor /delivery: uncomplicated

  • Family History: negative

  • Physical exam:

  • Neuro exam: reflexes, tone, strength intact

  • Neurodevelopmental exam: walking, asymmetric use of hands L<R, language delay


How helpful is imaging
How helpful is imaging? intervention

  • Practice Parameter: Diagnostic assessment of the child with cerebral palsy…” Ashwal and Russman et al, Neurology (2004)

    • Yield of abnormal brain CT in children with CP: 77%

    • Yield of abnormal brain MRI in kids with CP: 89% and it is helpful in determining timing of injury

    • Depended on type (n=264)

      • (dyskinetic CP 100%, quadriplegia 98%, hemi 96%, diplegia 94% ataxic 75%)


How helpful are metabolic and genetic studies
How helpful are metabolic and genetic studies? intervention

  • In children with dx of CP

    • 0 – 4% of children have a metabolic or genetic cause (Ashwal, Russman)

    • In almost all cases there were atypical features

      • Hx suggestive of regression

      • Neuroimaging suggesting genetic or metabolic injury

      • Family history of childhood neurologic disorder

  • “If clinical history or findings on neuroimaging do not determine a specific structural abnormality or if there are atypical or additional features on the history or clinical exam, metabolic and genetic testing should be considered.”


What if the child doesn t have cp but a broader presentation of global developmental delay
What if the child doesn’t have CP but a broader presentation of global developmental delay?

  • Moeschler J, Shevell M and the Committee on Genetics Pediatrics, 2006

    • Describes what pediatricians can anticipate as an optimal clinical genetics evaluation

      • Karyotype, FISH for subtelomere abnormalities, Frag X, molecular genetic testing, imaging, metabolic testing

    • Report on the usefulness of high resolution chromosome studies (9 – 36%) in patients evaluated for DD/MR

    • Routine metabolic screening of all patients with DD/MR is not required


Gross motor delay and its relationship to other brain functions
Gross motor delay and its relationship to other brain functions

  • Cognition function and CP, depends of the type

  • For children with spastic quadriplegic CP (Strauss, DMCN, 2005)

    • 95% with MR

  • If had dyskinetic CP only 40% with profound MR and 20% no MR


Gross motor delay and its relationship to other brain functions

  • Cognitive Function and Developmental Coordination Disorder or mild motor delays

    • No good epidemiologic data


Using cp as a paradigm children who outgrew cp
Using CP as a paradigm… functionsChildren Who Outgrew CP

Nelson, Ellenberg Pediatrics, 1982

  • 229 infants age 12 months with diagnosis of CP

  • Examined again at 7 y. o.

  • 118 free of motor handicap

  • 13% of white children and 25% of black children with MR

  • Nonfebrile sz, abnormalities of speech, behavior, and extraocular movements were more frequent than controls


When do you not need a brain mri when evaluating a child with motor delays
When do you not need a brain MRI when evaluating a child with motor delays?

  • Mild delay

  • Looking for an inutero infection that would leave calcifications (CT is better)

  • Ultrasound in the NICU showed cystic encephalomalacia and development is consistent with this pattern of CP (generally SQ CP but can have mixed tone)


Treatment intervention
Treatment/Intervention with motor delays?

  • Cure vs. maximize functional abilities

  • Only one “cure” in my clinical years


National center for medical rehabilitation research
National Center for Medical Rehabilitation Research with motor delays?

(1995)

  • Model to assist in the direction of research

  • Paradigm for chronic disorders

  • Good fit for persons with motor disorders such as CP, muscular dystropy, spinal cord injury or birth defect (SB)


Neuromotor team evaluations
Neuromotor Team Evaluations with motor delays?

  • Medical Evaluation and Diagnosis

  • Therapy: PT performs PDMS for evaluation

  • Educational Concerns: frequent referrals to EI

  • Technology: assistive devices

  • Social Supports: referrals to programs as needed


Questions
Questions?? with motor delays?

Sarah Winter, MD

Phone : 801-581-7877


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