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

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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

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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

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Developmental Disorders in Children
Disorders of brain function
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Neuromotor 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

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My developmental path to understanding gross
motor delay
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• But how do you apply this disparate knowledge and
  be helpful to this child and family?

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Developmental Progress

• Move from chaotic pieces of knowledge

• A systematic approach of identification,
  evaluation, and intervention

To
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A Systematic Approach
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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

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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

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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

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The Pediatric Neurodevelopmental Exam

• Gross Motor findings
• Fine Motor findings
• Language findings
• Expressive
• Receptive
• Social/Behavioral findings

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Focused exam findings

• Tone patterns
• Low tone mild or severe?
• High tone is it symmetric?, is it typical
  (LEgtUE)?
• weird tone ataxia, tremor, fluctuating
  (dystonia)

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Gross Motor Exam Findings
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Focused exam

• Reflexes
• High or absent
• Primitive reflexes see figure
• Postural or protective responses
• Lateral, anterior, posterior supports
• parachute

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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

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Postural (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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Increased tone
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gross motor examination

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

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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)

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Gross 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

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Motor Assessment Tools
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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

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Medical Diagnostic Considerations
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Case 1

• 10 month old not sitting or rolling
• Pregnancy/Labor/birth HX Uncomplicated
  pregnancy, NSVD, BW 8 3 oz. Apgars normal
• FHx noncontributory

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1

• 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

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What is an appropriate work-up?

• Imaging?
• CT vs. MRI
• Metabolic Studies?
• Genetic Studies?

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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 LltR, language delay

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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 (n264)
• (dyskinetic CP 100, quadriplegia 98, hemi 96,
  diplegia 94 ataxic 75)

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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.

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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

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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

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Gross motor delay and its relationship to other
brain functions

• Cognitive Function and Developmental Coordination
  Disorder or mild motor delays
• No good epidemiologic data

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Using 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

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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)

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Treatment/Intervention

• Cure vs. maximize functional abilities
• Only one cure in my clinical years

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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)

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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

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Questions??

• Sarah Winter, MD
• Phone [phone]