Delayed achievement of Childhood milestones: A reason for concern?

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Delayed achievement of Childhood milestones A
reason for concern?

• Robyn Smith
• Department of Physiotherapy
• UFS
• 2012

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Remember the areas of development ?

• Gross motor
• Speech language
• Fine motor perception
• Socialisation behaviour

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So what exactly is a developmental delay?
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What is a developmental delay?

• Not a specific condition.
• A A lag in development or slower rate of
  development
• in which a child exhibits a functional level
  below the norm for his age

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Are there different types of developmental delay ?
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Types of developmental delay

• Important to differentiate between
• Global developmental delay significant delays
  in at least two of or all developmental areas
• Specific developmental delay in a single area
  of development e.g. gross motor delay

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• Which Children at risk developmental delay

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red flags in a newborn baby

• Arousal level altered lack of alertness poor
  sleeping
• Abnormal cry high pitched
• Feeding problems and drooling
• Poor quality of active movement - stereotyped
• Abnormal muscle tone
• Abnormal head shape and size
• Jittery movement or tremors

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red flags in babies

• Altered level of arousal
• Micro/Macrocephalic
• Delayed social smile
• Poor head control at 3-4 months
• Persistent primitive reflexes after 6
  months-dominant ATNR
• Persistent fisting or palmar thumbing
• Asymmetry
• Delayed milestones
• Abnormal muscle tone
• Scissoring of LL

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Risk factors for developmental delay

• The following conditions should be noted as red
  flags for possible developmental problems
• possible causative or contributing factors in
  developmental delays

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Which babies are at risk? The following medical
conditions should be noted as red flags for
possible developmental problems (possible
causative factors in developmental delays)

• Grade II or III HIE (asphyxia)
• Very low birth weight ( 1500g)
• Premature infants (gestation 37 completed wks)
• Metabolic disorders e.g. persistent metabolic
  acidosis, hypocalaemia, hypoglycaemia
• Convulsions/seizures and epileptic syndromes
• Intraventricular haemorrhage (IVH),
  periventricular leucomalacia (PVL)
• Meningitis

• Congenital neurological abnormalities and genetic
  disorders e.g. Down syndrome
• Dysmorphism
• Congenital rubella
• CMV
• Toxoplasmosis
• Arthrogryposis multiplex congenita
• Maternal substance abuse
• CHD

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Congenital Rubella

• German measles
• Viral infection
• Most people are immunised against rubella and few
  cases now seen
• Dangerous when contracted by mother during 1st
  trimester of pregnancy
• May result in developmental abnormalities such as
  microcephaly, IUGR, cataracts, retinopathy,
  blindness, heart lesions (PDA) and mental
  retardation, sensorineural hearing loss

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Perinatal CMV

• Cytomegalovirus
• Virus part of herpes family
• Common 50 -80 of people acquire it in their
  lifetime, often harmless in adults and children
  but not in a foetus!!!!
• Transmitted via body fluids
• Prevalent in immuno-compromised patients
• One of most common congenital infections
  transmitted in utero, in the birth canal or even
  via breast milk
• 10 neonates infected are symptomatic
• May result in IUGR, hearing loss, mental
  retardation, cerebral palsy, impaired vision
• Infants that survive usually develop severe
  developmental disabilities and mental retardation
  
• Should be followed up for hearing deficits

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Toxoplasmosis

• Infection caused by parasite toxoplasma gondii
• Transferred through cat litter and undercooked
  meat.
• Foetus at risk if toxoplasmosis is contracted by
  mother in early gestation
• Congenital form is characterised by liver and
  brain involvement
• May result in cerebral calcification,
  convulsions, blindness, microcephaly,
  hydrocephaly or mental retardation

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Arthrogryposis multiplex congenita

• Curved- or hooked joint
• Fibrous stiffness or contractures of one or more
  joints present at birth
• Often incomplete development of muscles around
  joints
• Cause unknown
• Rare 1/3000
• Often associated with other conditions
• Prognosis depends on the degree of other system
  involvement e.g. syndromes and CHD

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Group B Streptococcus infection

• Bacteria found in the human genital and
  gastrointestinal tracts
• Causes bacteremia during pregnancy resulting in
  premature labour
• Baby is then also born with strep B septicaemia
  leading to shock, respiratory failure, and even
  death.
• CNS involvement e.g. strep B meningitis with
  neurological sequelae and high risk of deafness

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Foetal abstinence syndrome

• Maternal use of narcotic substances or alcohol
  (Foetal Alcohol Syndrome) can result in foetal
  dependence
• Narcotics e.g. heroine, cocaine and prescription
  pain killers neonate goes into withdrawal after
  birth
• Can lead to premature labour
• Child is also SGA and may have cognitive
  impairment, ADHD and behavioural problems

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Dismorphism

• Abnormal anatomy or morphology
• Facial dysmorhism e.g. recessed hairline,
  brachycephalic, small low set ears, broad nose,
  full lips, short broad neck
• Often associated with genetic syndromes
• E.g. Down syndrome

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Are other infants and young children at risk?

• Infective conditions e.g. HIV positive children
• Neuromuscular disorders e.g. DMD
• Deaf
• Blind
• Autistic infants
• Environmental factors e.g. lead poisoning
• Severe cases of malnutrition e.g. marasmus and
  kwashiorkor
• Deprivation
• Lack of appropriate stimulation at home
• Chronically ill
• Prolonged hospitalisation
• DCD-Clumsiness, learning and behavioural problems
  at school
• Toe walkers

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So how do we handle parents questions pertaining
to development ????
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Why is my child not reaching his milestones ?

• Development is individual to each child
• Acceptable variation of 1-2 months on either side
  of the normal expected age to attain milestones
• Several factors may impact on the child
  development
• If your child is delayed need to identify the
  cause and address the problem as soon as possible
• Often hard to make a formal diagnosis during the
  first two years of life. Signs are often
  transient e.g. late bloomers
• Milestones not as important as the quality and
  sequencing of movement

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Late bloomer

• No suspicious birth history
• No obvious neurological pathology
• Positive family history of achieving milestones
  later than expected
• Normal components of movement are present
• No indication as to why child delayed

• Eventually completely
• catches up with their development

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My child is not walking yet, so can I use a
walking ring?

• Why are they not recommended?
• Hips are flexed and the back is rounded and the
  knees are flexed. This position is contrary to
  those utilized when walking.
• Teaching these patterns in a walking ring
  postpones or delays the childs walking.
• It is rather advisable to let a child play on the
  mat where he will learn to pull to stand, stand
  holding, cruise and later walk

• If crawled normally he/she may be placed in a
  walking ring for a maximum period of 30 minutes
  to 1 hour per day.
• If the child was a bum shuffler or experienced
  difficulty in crawling he should not be placed in
  a walking ring.
• Builds up abnormal tone over ankle
• Encourages toe walking

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My child is toe walking, should I be concerned ?

• Common in children up until 18 months due to poor
  balance and wide based gait in absence of any
  other pathology
• May become a habitual pattern
• If no underlying pathology a child usually grows
  out of it by 3 years of age as gait improves
• Common in children spend a lot of time in a jolly
  jumper and walking ring

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My child is toe walking, should I be concerned ?

• If toe walking persists consider other
  neurological conditions need to be considered
• early signs of spastic diplegia
• neuromuscular disease such as DMD
• Spina bifida
• Tethered cord or cauda equina lesions (MRI)
• Autism
• Sensory integration disorders

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So what do I don in the interim with my toe
walking child?

• Home program
• Stretching of the TA
• Ankle ROM exercises
• Gait training
• Strengthening of muscles around ankle an foot
• Orthotics e.g. AFO and serial casting
• Orthopaedic intervention e.g. soft tissue releases

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Tethered cord syndrome

• Early stages of a pregnancy, the spinal cord of
  the f0etus extends from the brain to the
  coccygeal region.
• As the pregnancy progresses, the bony spine grows
  faster than the spinal cord, so the end of the
  spinal cord appears to rise, or ascend, relative
  to the adjacent bony spine. By the time a child
  is born, the spinal cord is normally located
  opposite the disc between the 1st and 2nd
  lumbar vertebrae and is unattached.
• In cases where there is abnormal development the
  phylum terminale is pinned down in the sacral
  region, resulting in tension being placed on the
  spinal cord, as the child grows tethering of
  the cord can occur

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Tethered cord syndrome

• Persistent back pain
• Increasing curvature of the spine (scoliosis)
• Loss of sensation in the legs or feet
• Unequal changes in size of the legs or feet
• Stumbling or walking changes
• Weakness in legs or feet
• Bowel and bladder dysfunction

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I am placing my child in a jolly jumper during
the day when I am busy, is it ok to do so?

• Constant jumping increases muscle tone in the
  lower limbs
• Completely contra-indicated in children with
  spastic lower limbs. Often your leopard crawler
• A child who has crawled normally may be placed in
  a jolly jumper for only short periods of time.

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References

• Images courtesy of GOOGLE (2009)
• Smith, R. 2009. Paediatric dictate, UFS
  (unpublished)
• E. Brown.NDT course work (unpublished)
• Harel, S. approach to a child with
  neurodevelopmental Disability. Available at
  http//www.scribd.com/doc/6701564/Approach-to-a-Ch
  ild-With-a-Neurodevelopmental-Disablity.
  Retrieved on 27 August 2009
• Versaw-barnes, D A. Wood. The infant at risk of
  developmental delay in Pediatric Physical
  Therapy. Tecklin, J.S. (Eds) in Pediatric
  Physical Therapy. Lippincott, Williams Wilkins.
  Baltimore pp101 -175
• Smith, R. 2005. The prevealence of neurological
  sequelae in infants with moderate to severe
  neonatal asphyxia. MSc.dissertation
  (unpublished).
• Mayhew, A Price, F. 2007.Neonatal Care in
  Poutney, T(ed.) Physiotherapy for Children.
  Elsivier.Philadelphia 73-79
• Mosbys medical dictionary