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, 2010Slide 2
Objectives Discuss signs of engine deferrals in babies, for example, tone designs, primitive reflexes, point of reference postponements, and deviances Using cases to incite examination, contrast contrasts in the approach with assessment Review mind MRI variations from the norm with examples of engine debilitation Review the reason for the Neuromotor TeamSlide 3
Developmental Disorders in Children Disorders of cerebrum capacitySlide 4
Neuromotor Team Children with Special Health Care Needs Specialty group inside the "Kid Developmental Clinic" Types of patients seen Typically birth to 36 months Older youngsters with engine impedance with case administration needs Team individuals: Sarah Winter, MD, Terry Holden, PT, Scott Jerome, PT, and Alison Seppi, RN Oversight: Jim Taliaferro, LCSWSlide 5
My formative way to comprehension net engine delay dystonia Tone cerebral paralysis net engine postpone gross and fine engine hypotonia stride Developmental Discoordination Disorder ataxia GLobal Developmental Delay particular control act shortcoming spasticity hyperreflexiaSlide 6
But how would you apply this divergent information and be useful to this tyke and family?Slide 7
A deliberate approach of recognizable proof, assessment, and intercession Move from disorganized bits of learning Developmental Progress ToSlide 8
Examine Diagnose Treat Screen A Systematic ApproachSlide 9
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: A calculation for Developmental Surveillance and ScreeningSlide 10
References to Screening and Surveillance Society for Development and Behavioral Pediatrics site: www.dbpeds.org Grand Rounds by Paul Young and Charlie Ralston Podcast delivered by Dr. Paul Carbone www.utah.edu/podcastSlide 11
Features of a Good Developmental History Parents portray net engine expertise defers well People; both guardians and restorative care suppliers, don\'t tend to focus on fine engine abilities e.g. at the point when are children expected to have a hand inclination? Get some information about dialect, it is a piece of information to intellectual advancementSlide 12
The Pediatric Neurodevelopmental Exam Gross Motor discoveries Fine Motor discoveries Language discoveries Expressive Receptive Social/Behavioral discoveriesSlide 13
Focused exam discoveries Tone designs Low tone: gentle or extreme? High tone: is it symmetric?, is it common (LE>UE)? "unusual" tone : ataxia, tremor, fluctuating (dystonia)Slide 14
Gross Motor Exam FindingsSlide 15
Focused exam Reflexes; High or truant Primitive reflexes – see figure Postural or defensive reactions Lateral, foremost, back backings parachuteSlide 16
Examples of primitive reflexes The Moro is ordinary in an infant and ought to be passed by 4 months The ATNR is typical in an infant and ought to be gone at 6 monthsSlide 17
Postural (or defensive) reactions Parachute reaction: (shows up at 10 months) Lateral support: (shows up at 6 months) Anterior (comes 1 st ) , parallel (2 nd ), and back (3 rd ) bolster reactions Parachute reactionSlide 19
Increased toneSlide 20
net engine examination This tyke presents with deferrals in gross engine developments. His tone is likely low Differentiate amongst tone and qualitySlide 21
Focused Exam "Degenerate" (atypical however not generally deferred) engine designs "Base bikes" Circling hands and feet while adjusted on the base (hypotonia) Some mistake this for an indication of a mental imbalance Commando creeping (hemiplegia)Slide 22
Purpose Further analytic data Qualifying kids for restorative administrations Developmental measure or stamp in time Frequently utilized instruments Peabody Developmental Motor Scales Bayley Scales of Infant Development Gross Motor Function Scale TIMP Alberta Infant Motor Scales Gross engine testing: institutionalized measures of gross engine workSlide 23
Motor Assessment ToolsSlide 24
Narrowing the Differential Diagnosis Patient An: in top chart year and a half with negative past medicinal history. Understanding B: 12 month old with history of inability to flourishSlide 25
Medical Diagnostic ConsiderationsSlide 26
Case # 1 10 month old not sitting or moving Pregnancy/Labor/birth HX: Uncomplicated pregnancy, NSVD, BW 8# 3 oz. Apgars ordinary FHx: noncontributorySlide 27
#1 Physical exam: adorable blonde, reasonable cleaned, development parameters: weight >>95%, hgt 75%, OFC, 75% rest of exam typical Neuro exam: low trunk tone, high furthest point tone furthest points more required than lower limits. Hyperreflexia all through Neurodevelopmental exam: GM: no sitting parity, conspicuous extensor push , FM: fisted hands, dialect: grinning, prattlingSlide 28
What is a suitable work-up? Imaging? CT versus X-ray Metabolic Studies? Hereditary Studies?Slide 30
Case # 2 24 month old with dialect delay, not utilizing left arm and additionally right arm Pregnancy.labor/conveyance: uncomplicated Family History: negative Physical exam: Neuro exam: reflexes, tone, quality in place Neurodevelopmental exam: strolling, awry utilization of hands L<R, dialect delaySlide 32
How supportive is imaging? Rehearse Parameter: Diagnostic appraisal of the kid with cerebral paralysis… " Ashwal and Russman et al, Neurology (2004) Yield of unusual mind CT in kids with CP: 77% Yield of strange cerebrum MRI in children with CP: 89% and it is useful in deciding planning of damage Depended on sort (n=264) (dyskinetic CP 100%, quadriplegia 98%, hemi 96%, diplegia 94% ataxic 75%)Slide 33
How accommodating are metabolic and hereditary reviews? In kids with dx of CP 0 – 4% of kids have a metabolic or hereditary cause (Ashwal, Russman) In all cases there were atypical components Hx suggestive of relapse Neuroimaging proposing hereditary or metabolic harm Family history of adolescence neurologic issue "If clinical history or discoveries on neuroimaging don\'t decide a particular auxiliary variation from the norm or if there are atypical or extra elements on the history or clinical exam, metabolic and hereditary testing ought to be considered."Slide 34
What if the youngster doesn\'t have CP yet a more extensive presentation of worldwide formative deferral? Moeschler J, Shevell M and the Committee on Genetics Pediatrics, 2006 Describes what pediatricians can foresee as an ideal clinical hereditary qualities assessment Karyotype, FISH for subtelomere anomalies, Frag X, sub-atomic hereditary testing, imaging, metabolic testing Report on the helpfulness of high determination chromosome thinks about (9 – 36%) in patients assessed for DD/MR Routine metabolic screening of all patients with DD/MR is not requiredSlide 35
Gross engine deferral and its relationship to other mind capacities Cognition capacity and CP, depends of the sort For kids with spastic quadriplegic CP (Strauss, DMCN, 2005) 95% with MR If had dyskinetic CP just 40% with significant MR and 20% no MRSlide 36
Gross engine postponement and its relationship to other cerebrum capacities Cognitive Function and Developmental Coordination Disorder or mellow engine defers No great epidemiologic informationSlide 37
Using CP as a worldview… Children Who Outgrew CP Nelson, Ellenberg Pediatrics, 1982 229 babies age 12 months with analysis of CP Examined again at 7 y. o. 118 free of engine incapacitate 13% of white kids and 25% of dark kids with MR Nonfebrile sz, variations from the norm of discourse, conduct, and extraocular developments were more successive than controlsSlide 38
When do you not require a mind MRI while assessing a youngster with engine delays? Gentle defer Looking for an inutero contamination that would leave calcifications (CT is better) Ultrasound in the NICU demonstrated cystic encephalomalacia and advancement is predictable with this example of CP (for the most part SQ CP however can have blended tone)Slide 39
Treatment/Intervention Cure versus expand useful capacities Only one "cure" in my clinical yearsSlide 40
National Center for Medical Rehabilitation Research (1995) Model to help with the bearing of research Paradigm for ceaseless issue Good fit for people with engine issue, for example, CP, solid dystropy, spinal line harm or birth deformity (SB)Slide 41
Neuromotor Team Evaluations Medical Evaluation and Diagnosis Therapy: PT performs PDMS for assessment Educational Concerns: visit referrals to EI Technology: assistive gadgets Social Supports: referrals to programs as requiredSlide 42
Questions?? Sarah Winter, MD Phone : 801-581-7877
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