Title: An Evaluation of the Infant with Motor Delays: When and How Much?
1An 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
2Objectives
- 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
3Developmental Disorders in Children
Disorders of brain function
4Neuromotor TeamChildren 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
5My developmental path to understanding gross
motor delay
6- But how do you apply this disparate knowledge and
be helpful to this child and family?
7Developmental Progress
- Move from chaotic pieces of knowledge
- A systematic approach of identification,
evaluation, and intervention
To
8A Systematic Approach
9References for Screening
- 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
10References to Screening and Surveillance
- 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
11Features of a Good Developmental History
- Parents describe gross motor skill delays well
- People both parents and medical care providers,
dont 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
12The Pediatric Neurodevelopmental Exam
- Gross Motor findings
- Fine Motor findings
- Language findings
- Expressive
- Receptive
- Social/Behavioral findings
13Focused exam findings
- Tone patterns
- Low tone mild or severe?
- High tone is it symmetric?, is it typical
(LEgtUE)? - weird tone ataxia, tremor, fluctuating
(dystonia)
14Gross Motor Exam Findings
15Focused exam
- Reflexes
- High or absent
- Primitive reflexes see figure
- Postural or protective responses
- Lateral, anterior, posterior supports
- parachute
16Examples of primitive reflexes
- 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
17Postural (or protective) responses
Parachute response (appears at 10 months)
Lateral support (appears at 6 months)
- Anterior (comes 1st) , lateral (2nd), and
posterior (3rd) support responses - Parachute response
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19Increased tone
20 gross motor examination
- This child presents with delays in gross motor
milestones. His tone is likely low - Differentiate between tone and strength
21Focused Exam
- 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)
22Gross motor testing standardized measures of
gross motor function
- Frequently used tools
- Peabody Developmental Motor Scales
- Bayley Scales of Infant Development
- Gross Motor Function Scale
- TIMP
- Alberta Infant Motor Scales
- Purpose
- Further diagnostic information
- Qualifying children for therapeutic services
- Developmental measure or mark in time
23Motor Assessment Tools
24Narrowing the Differential Diagnosis
- Patient A in top graph 18 months with negative
past medical history. - Patient B 12 month old with history of failure
to thrive
25Medical Diagnostic Considerations
26Case 1
- 10 month old not sitting or rolling
- Pregnancy/Labor/birth HX Uncomplicated
pregnancy, NSVD, BW 8 3 oz. Apgars normal - FHx noncontributory
271
- Physical exam cute blonde, fair skinned, growth
parameters weight gtgt95, 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
28What is an appropriate work-up?
- Imaging?
- CT vs. MRI
- Metabolic Studies?
- Genetic Studies?
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30Case 2
- 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 LltR, language delay
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32How helpful is imaging?
- 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 (n264)
- (dyskinetic CP 100, quadriplegia 98, hemi 96,
diplegia 94 ataxic 75)
33How helpful are metabolic and genetic studies?
- 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.
34What if the child doesnt 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
35Gross 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
36Gross motor delay and its relationship to other
brain functions
- Cognitive Function and Developmental Coordination
Disorder or mild motor delays - No good epidemiologic data
37Using CP as a paradigmChildren 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
38When 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)
39Treatment/Intervention
- Cure vs. maximize functional abilities
- Only one cure in my clinical years
40National Center for Medical Rehabilitation
Research
(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)
41Neuromotor Team Evaluations
- 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
42Questions??
- Sarah Winter, MD
- Phone 801-581-7877