Delayed achievement of Delayed achievement of Childhood milestones: Childhood milestones: A reason for concern?A reason for concern?

Robyn SmithRobyn SmithDepartment of PhysiotherapyDepartment of Physiotherapy

UFSUFS20122012

Remember the areas Remember the areas of development ?of development ? Gross motorGross motor Speech & languageSpeech & language Fine motor & perceptionFine motor & perception Socialisation & behaviourSocialisation & behaviour

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

What is a What is a developmental delay?developmental delay?

Not a specific condition. Not a specific condition. A A A A lag in developmentlag in development or or slower rate of slower rate of

developmentdevelopment in which a child exhibits a in which a child exhibits a functional level below functional level below

the norm for his agethe norm for his age

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

Types of Types of developmental delaydevelopmental delayImportant to differentiate betweenImportant to differentiate between

Global developmental delayGlobal developmental delay = = significant significant delays in at least two of – or all delays in at least two of – or all developmental areasdevelopmental areas

Specific developmental delaySpecific developmental delay = in a = in a single area of development e.g. gross motor single area of development e.g. gross motor delaydelay

Which Children at risk Which Children at risk developmental delay developmental delay

““red flags” in a red flags” in a newborn babynewborn baby

Arousal level altered –Arousal level altered –lack of alertness & lack of alertness & poor sleeping poor sleeping

Abnormal cry – high Abnormal cry – high pitchedpitched

Feeding problems and Feeding problems and droolingdrooling

Poor quality of active Poor quality of active movement - movement - stereotypedstereotyped

Abnormal muscle toneAbnormal muscle tone Abnormal head shape Abnormal head shape

and sizeand size Jittery movement or Jittery movement or

tremorstremors

““red flags” in babiesred flags” in babies Altered level of arousalAltered level of arousal Micro/MacrocephalicMicro/Macrocephalic Delayed social smileDelayed social smile Poor head control at 3-4 Poor head control at 3-4

monthsmonths Persistent primitive reflexes Persistent primitive reflexes

after 6 months-dominant ATNRafter 6 months-dominant ATNR Persistent fisting or palmar Persistent fisting or palmar

thumbingthumbing AsymmetryAsymmetry Delayed milestonesDelayed milestones Abnormal muscle toneAbnormal muscle tone Scissoring of LLScissoring of LL

Risk factors for Risk factors for developmental delaydevelopmental delay The following conditions should The following conditions should

be noted as red flags for possible be noted as red flags for possible developmental problems developmental problems

= possible causative or = possible causative or contributing factors in contributing factors in developmental delaysdevelopmental delays

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

Grade II or III HIE (asphyxia)Grade II or III HIE (asphyxia) Very low birth weight (≤ Very low birth weight (≤

1500g)1500g) Premature infants Premature infants

(gestation ≤ 37 completed (gestation ≤ 37 completed wks)wks)

Metabolic disorders e.g. Metabolic disorders e.g. persistent metabolic persistent metabolic acidosis, hypocalaemia, acidosis, hypocalaemia, hypoglycaemiahypoglycaemia

Convulsions/seizures and Convulsions/seizures and epileptic syndromesepileptic syndromes

Intraventricular Intraventricular haemorrhage (IVH), haemorrhage (IVH), periventricular leucomalacia periventricular leucomalacia (PVL) (PVL)

MeningitisMeningitis

Congenital neurological Congenital neurological abnormalities and abnormalities and genetic disorders e.g. genetic disorders e.g. Down syndrome Down syndrome

Dysmorphism Dysmorphism Congenital rubellaCongenital rubella CMVCMV ToxoplasmosisToxoplasmosis Arthrogryposis multiplex Arthrogryposis multiplex

congenitacongenita Maternal substance Maternal substance

abuseabuse CHDCHD

Congenital Congenital RubellaRubella= “ = “ German measles”German measles”

Viral infection Viral infection Most people are immunised against rubella Most people are immunised against rubella

and few cases now seenand few cases now seen Dangerous when contracted by mother during Dangerous when contracted by mother during

11stst trimester of pregnancy trimester of pregnancy May result in developmental abnormalities May result in developmental abnormalities

such as microcephaly, IUGR, cataracts, such as microcephaly, IUGR, cataracts, retinopathy, blindness, heart lesions (PDA) and retinopathy, blindness, heart lesions (PDA) and mental retardation, sensorineural hearing lossmental retardation, sensorineural hearing loss

Perinatal CMVPerinatal CMV

= = CytomegalovirusCytomegalovirus

Virus part of Virus part of herpesherpes family family Common 50 -80% of people acquire it in Common 50 -80% of people acquire it in

their lifetime, often harmless in adults and their lifetime, often harmless in adults and children –children –but not in a foetus!!!!but not in a foetus!!!!

Transmitted via body fluidsTransmitted via body fluids Prevalent in immuno-compromised patientsPrevalent in immuno-compromised patients One of most common congenital One of most common congenital infections

transmitted in utero, in the birth canal or even via breast milk

10 % neonates infected are symptomatic10 % neonates infected are symptomatic May result in IUGR, hearing loss, mental May result in IUGR, hearing loss, mental

retardation, cerebral palsy, impaired visionretardation, cerebral palsy, impaired vision Infants that survive usually develop severe Infants that survive usually develop severe

developmental disabilities and mental developmental disabilities and mental retardation retardation

Should be followed up for hearing deficitsShould be followed up for hearing deficits

ToxoplasmosisToxoplasmosis

Infection caused by parasite Infection caused by parasite toxoplasma gondiitoxoplasma gondii

Transferred through Transferred through cat litter cat litter and and undercooked meatundercooked meat..

Foetus at risk if Foetus at risk if toxoplasmosis is contracted toxoplasmosis is contracted by mother in early gestationby mother in early gestation

Congenital form is Congenital form is characterised by liver and characterised by liver and brain involvementbrain involvement

May result in cerebral May result in cerebral calcification, convulsions, calcification, convulsions, blindness, microcephaly, blindness, microcephaly, hydrocephaly or mental hydrocephaly or mental retardationretardation

Arthrogryposis Arthrogryposis multiplex congenitamultiplex congenita ““Curved- or hooked joint”Curved- or hooked joint” Fibrous stiffness or Fibrous stiffness or

contracturescontractures of one or of one or more joints present at more joints present at birthbirth

Often Often incomplete incomplete development of muscles development of muscles around jointsaround joints

Cause unknownCause unknown Rare 1/3000Rare 1/3000 Often associated with Often associated with

other conditions other conditions Prognosis depends on the Prognosis depends on the

degree of other system degree of other system involvement e.g. involvement e.g. syndromes and CHDsyndromes and CHD

Group B Streptococcus Group B Streptococcus infectioninfection BacteriaBacteria found in the human genital found in the human genital

and gastrointestinal tractsand gastrointestinal tracts Causes Causes bacteremiabacteremia during pregnancy during pregnancy

resulting in premature labourresulting in premature labour Baby is then also born with Baby is then also born with strep B strep B

septicaemiasepticaemia leading to shock, leading to shock, respiratory failure, and even death. respiratory failure, and even death.

CNS involvement e.g. CNS involvement e.g. strep B strep B meningitismeningitis with neurological sequelae with neurological sequelae and and high risk of deafnesshigh risk of deafness

Foetal abstinence Foetal abstinence syndromesyndrome

Maternal use of Maternal use of narcotic narcotic substancessubstances or or alcoholalcohol (Foetal (Foetal Alcohol Syndrome)Alcohol Syndrome) can result can result in foetal dependence in foetal dependence

Narcotics e.g. heroine, Narcotics e.g. heroine, cocaine and prescription pain cocaine and prescription pain killers –neonate goes into killers –neonate goes into withdrawalwithdrawal after birth after birth

Can lead to Can lead to premature labourpremature labour Child is also SGA and may Child is also SGA and may

have cognitive impairment, have cognitive impairment, ADHD and behavioural ADHD and behavioural problemsproblems

DismorphismDismorphism

Abnormal anatomy or Abnormal anatomy or morphologymorphology

Facial dysmorhismFacial dysmorhism e.g. recessed hairline, e.g. recessed hairline, brachycephalic, small brachycephalic, small low set ears, broad low set ears, broad nose, full lips, short nose, full lips, short broad neck broad neck

Often associated with Often associated with genetic syndromesgenetic syndromes

E.g. Down syndromeE.g. Down syndrome

Are other infants and Are other infants and young children at risk?young children at risk?

Infective conditions e.g. HIV positive childrenInfective conditions e.g. HIV positive children Neuromuscular disordersNeuromuscular disorders e.g. DMDe.g. DMD Deaf Deaf BlindBlind Autistic infantsAutistic infants Environmental factors e.g. lead poisoningEnvironmental factors e.g. lead poisoning Severe cases of malnutrition e.g. marasmus and Severe cases of malnutrition e.g. marasmus and

kwashiorkorkwashiorkor Deprivation Deprivation Lack ofLack of appropriate stimulation appropriate stimulation at homeat home Chronically ill Chronically ill Prolonged hospitalisation Prolonged hospitalisation DCD-Clumsiness, learning and behavioural problems at DCD-Clumsiness, learning and behavioural problems at

schoolschool Toe walkersToe walkers

So how do we handle parents So how do we handle parents questions pertaining to questions pertaining to development ????development ????

Why is my child not reaching Why is my child not reaching his milestones ?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

“ “ Late bloomer”Late bloomer”

No suspicious birth No suspicious birth historyhistory

No obvious No obvious neurological pathologyneurological pathology

Positive family history Positive family history of achieving of achieving milestones later than milestones later than expectedexpected

Normal components of Normal components of movement are presentmovement are present

No indication as to No indication as to why child delayedwhy child delayed

Eventually Eventually completely completely

““catches up”catches up” with with their developmenttheir development

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

If crawled normally he/she If crawled normally he/she may be placed in a may be placed in a walking ring for a walking ring for a maximum period of 30 maximum period of 30 minutes to 1 hour per day.minutes to 1 hour per day.

If the child was a “bum If the child was a “bum shuffler” or experienced shuffler” or experienced difficulty in crawling he difficulty in crawling he should not be placed in a should not be placed in a walking ring.walking ring.

Builds up abnormal tone Builds up abnormal tone over ankleover ankle

Encourages “toe walking”Encourages “toe walking”

Why are they not Why are they not recommended?recommended?

Hips are flexed and the Hips are flexed and the back is rounded and the back is rounded and the knees are flexed. This knees are flexed. This position is contrary to position is contrary to those utilized when those utilized when walking.walking.

Teaching these patterns in Teaching these patterns in a walking ring postpones or a walking ring postpones or delays the child’s walking.delays the child’s walking.

It is rather advisable to let It is rather advisable to let a child play on the mat a child play on the mat where he will learn to pull where he will learn to pull to stand, stand holding, to stand, stand holding, cruise and later walkcruise and later walk

My child is toe walking, My child is toe walking, should I be concerned ?should I be concerned ?

Common in children up until 18 Common in children up until 18 months due to poor balance and months due to poor balance and wide based gait in absence of any wide based gait in absence of any other pathologyother pathology

May become a habitual pattern May become a habitual pattern If no underlying pathology a child If no underlying pathology a child

usually grows out of it by 3 years of usually grows out of it by 3 years of age as gait improvesage as gait improves

Common in children spend a lot of Common in children spend a lot of time in a jolly jumper and walking time in a jolly jumper and walking ringring

My child is toe walking, My child is toe walking, should I be concerned ?should I be concerned ?

If toe walking persists consider If toe walking persists consider other neurological conditions need other neurological conditions need to be considered:to be considered:

early signs of spastic diplegia early signs of spastic diplegia neuromuscular disease such as neuromuscular disease such as

DMDDMD Spina bifidaSpina bifida Tethered cord or cauda equina Tethered cord or cauda equina

lesions (MRI)lesions (MRI) Autism Autism Sensory integration disordersSensory integration disorders

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

Stretching of the TAStretching of the TA Ankle ROM exercisesAnkle ROM exercises Gait trainingGait training Strengthening of muscles around Strengthening of muscles around

ankle an footankle an foot

Orthotics e.g. AFO and serial Orthotics e.g. AFO and serial castingcasting

Orthopaedic intervention e.g. Orthopaedic intervention e.g. soft tissue releasessoft tissue releases

Tethered cord Tethered cord syndromesyndrome Early stages of a pregnancy, the spinal cord of the Early stages of a pregnancy, the spinal cord of the

f0etus extends from the brain to the coccygeal region. f0etus extends from the brain to the coccygeal region. As the pregnancy progresses, the bony spine grows As the pregnancy progresses, the bony spine grows

faster than the spinal cord, so the end of the spinal faster than the spinal cord, so the end of the spinal cord appears to rise, or ascend, relative to the cord appears to rise, or ascend, relative to the adjacent bony spine. By the time a child is born, the adjacent bony spine. By the time a child is born, the spinal cord is normally located opposite the disc spinal cord is normally located opposite the disc between the between the 1 1stst and 2 and 2ndnd lumbar vertebrae lumbar vertebrae and is and is unattachedunattached. .

In cases where there is abnormal development the In cases where there is abnormal development the phylum terminale is pinned down in the sacral region,phylum terminale is pinned down in the sacral region, resulting in resulting in tension being placed on the spinal cordtension being placed on the spinal cord, as , as the child grows “tethering” of the cord can occurthe child grows “tethering” of the cord can occur

Tethered cord Tethered cord syndromesyndrome Persistent back pain Persistent back pain Increasing curvature of the Increasing curvature of the

spine (scoliosis) spine (scoliosis) Loss of sensation in the legs Loss of sensation in the legs

or feet or feet Unequal changes in size of the Unequal changes in size of the

legs or feet legs or feet Stumbling or walking changes Stumbling or walking changes Weakness in legs or feet Weakness in legs or feet Bowel and bladder Bowel and bladder

dysfunctiondysfunction

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

increases muscle tone in increases muscle tone in the lower limbsthe lower limbs

Completely contra-Completely contra-indicated in children indicated in children with spastic lower limbs. with spastic lower limbs. Often your “leopard Often your “leopard crawler”crawler”

A child who has crawled A child who has crawled normally may be placed normally may be placed in a jolly jumper for only in a jolly jumper for only short periods of time.short periods of time.

ReferencesReferences

Images courtesy of GOOGLE (2009)Images courtesy of GOOGLE (2009) Smith, R. 2009. Paediatric dictate, UFS (unpublished)Smith, R. 2009. Paediatric dictate, UFS (unpublished) E. Brown.NDT course work (unpublished)E. Brown.NDT course work (unpublished) Harel, S. approach to a child with neurodevelopmental Harel, S. approach to a child with neurodevelopmental

Disability. Available at Disability. Available at http://www.scribd.com/doc/6701564/Approach-to-a-Child-http://www.scribd.com/doc/6701564/Approach-to-a-Child-With-a-Neurodevelopmental-Disablity. With-a-Neurodevelopmental-Disablity. Retrieved on 27 Retrieved on 27 August 2009August 2009

Versaw-barnes, D & A. Wood. The infant at risk of Versaw-barnes, D & A. Wood. The infant at risk of developmental delay in Pediatric Physical Therapy. developmental delay in Pediatric Physical Therapy. Tecklin, J.S. (Eds) in Pediatric Physical Therapy. Lippincott, Tecklin, J.S. (Eds) in Pediatric Physical Therapy. Lippincott, Williams & Wilkins. Baltimore pp101 -175Williams & Wilkins. Baltimore pp101 -175

Smith, R. 2005. The prevealence of neurological sequelae Smith, R. 2005. The prevealence of neurological sequelae in infants with moderate to severe neonatal asphyxia. in infants with moderate to severe neonatal asphyxia. MSc.dissertation (unpublished). MSc.dissertation (unpublished).

Mayhew, A & Price, F. 2007.Neonatal Care in Poutney, Mayhew, A & Price, F. 2007.Neonatal Care in Poutney, T(ed.) Physiotherapy for Children. Elsivier.Philadelphia 73-T(ed.) Physiotherapy for Children. Elsivier.Philadelphia 73-7979

Mosby’s medical dictionaryMosby’s medical dictionary