This document discusses evaluating infants with motor delays, including:
1. Comparing approaches to evaluating motor delays using case studies and examining tone patterns, primitive reflexes, milestone delays, and deviances.
2. Reviewing brain MRI abnormalities and how they relate to patterns of motor impairment.
3. Discussing the purpose and team members of the Neuromotor Team which evaluates infants and young children with motor impairments.
This document discusses evaluating infants with motor delays, including:
1. Comparing approaches to evaluating motor delays using case studies and examining tone patterns, primitive reflexes, milestone delays, and deviances.
2. Reviewing brain MRI abnormalities and how they relate to patterns of motor impairment.
3. Discussing the purpose and team members of the Neuromotor Team which evaluates infants and young children with motor impairments.
This document discusses evaluating infants with motor delays, including:
1. Comparing approaches to evaluating motor delays using case studies and examining tone patterns, primitive reflexes, milestone delays, and deviances.
2. Reviewing brain MRI abnormalities and how they relate to patterns of motor impairment.
3. Discussing the purpose and team members of the Neuromotor Team which evaluates infants and young children with motor impairments.
This document discusses evaluating infants with motor delays, including:
1. Comparing approaches to evaluating motor delays using case studies and examining tone patterns, primitive reflexes, milestone delays, and deviances.
2. Reviewing brain MRI abnormalities and how they relate to patterns of motor impairment.
3. Discussing the purpose and team members of the Neuromotor Team which evaluates infants and young children with motor impairments.
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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 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 Disorders of brain function Cognition : MR/LD
11.03.03 Neuromotor Team 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 But how do you apply this disparate knowledge and be helpful to this child and family? Developmental Progress
Move from chaotic pieces of knowledge
A systematic approach To of identification, evaluation, and intervention A Systematic Approach
Examine Diagnose Treat
Screen References 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 References 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 Features 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 The Pediatric Neurodevelopmental Exam Gross Motor findings
Fine Motor findings
Language findings Expressive Receptive
Social/Behavioral findings Focused exam findings Tone patterns Low tone: mild or severe?
High tone: is it symmetric?, is it typical
(LE>UE)?
weird tone : ataxia, tremor, fluctuating
(dystonia) Gross Motor Exam Findings Focused exam Reflexes; High or absent Primitive reflexes see figure
Postural or protective responses
Lateral, anterior, posterior supports parachute Examples 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 Postural (or protective) responses
Lateral support: Parachute response:
(appears at 6 months) (appears at 10 months)
Anterior (comes 1st) , lateral (2nd), and
posterior (3rd) support responses Parachute response Increased tone
11.03.03 gross motor examination This child presents with delays in gross motor milestones. His tone is likely low Differentiate between tone and strength Focused 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)
Gross motor testing: standardized measures of gross motor function Purpose Frequently used tools Further diagnostic Peabody Developmental information Motor Scales
Qualifying children for Bayley Scales of Infant
therapeutic services Development
Developmental Gross Motor Function
measure or mark in Scale time TIMP
Alberta Infant Motor
Scales Motor Assessment Tools Test Age Range Description Sens/Spec Time frame/cost Test of Infant Preterm (>34 Early Sens 83-96% 30 minutes Motor weeks) to 4 identification of Spec 78 65% Performance months adj age infants with (2002) neuromotor dysfunction
Alberta Infant 0 18 months Useful in high Sens 74 86% 20 minutes
Motor Scales risk infants for Spec 81 93% (1994) screening gross motor function
Peabody Birth 6 years Measures of At 4 mo: sens 20 -30 minutes for
Developmental gross and fine 25%, spec 73% each subtest Motor Scale 2nd motor skills, has At 8 mo: sens ed. (2000) subtests, gives 86% spec 46 age equivalent 60%
Bayley Scales 1 42 months Frequently used 15-20 minutes
of Infant by NICU follow- Development: up programs (PDI) and outcome studies Narrowing 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 Medical Diagnostic Considerations Case # 1 10 month old not sitting or rolling
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?
Imaging? CT vs. MRI
Metabolic Studies?
Genetic Studies? Case # 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 L<R, language delay How 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 (n=264)
(dyskinetic CP 100%, quadriplegia 98%, hemi 96%, diplegia 94% ataxic 75%) How 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. What 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 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 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? 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
Cure vs. maximize
functional abilities
Only one cure in my
clinical years National 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) Neuromotor 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
Sensory Processing Profile Among A Sample of Egyptian Children With Different Types of Delayed Language Development Correlations of Different Variablesegyptian Journal of Otolaryngology
Sensory Processing Profile Among A Sample of Egyptian Children With Different Types of Delayed Language Development Correlations of Different Variablesegyptian Journal of Otolaryngology
