Early warning signs of CMD

Robyn Smith

Department of Physiotherapy

UFS

2012

So what have you learnt so far about essential aspects normal development?

Takes place against the background of normal muscle tone

Stability of the behavioural & physiological states

Ability to move and interact with environment is paramount

Presence of competing patterns of movement

Gradual development of postural control

Early alarm or warning signs

Early alarm signals

Are often detected when the child deviates from typical development

Below follow some of the more common early alarm signs

1. Behavioural state disturbances Infant is jittery, irritable and crying (high pitched voice)

Inability to habituate or self soothe

Sleep disturbances

Unstable postures – constantly moving

Continual (overactive) startles & Moro

Under-responsive – sleeps constantly and is apathetic. Lack of awareness and orientation

2. Feeding problems Weak sucking Tongue thrust Takes excessively long to feed Coughing or choking during feeding (inability

swallow safely) Reflux (GERD = gastroeosophageal Reflux

disease)

What is reflux ?Backward flow of stomach (food and acid) contents into the esophagus

Causes: immature GIT (lower esophageal sphincter muscle), common in children with neurological damage

Symptoms: resists feeding, crying during feeding, oral regurgitation feeds

Anything you can do about reflux?

3. Poor interaction with the environment

Resists handling, thrusts away, cannot “cuddle”

Poor visual and/or auditory orientationVisual disorders e.g nystagmus, squint Constant moving in a search for

sensory input – poor sensory integration (self stimulating type behaviour)

4. Disturbances of muscle tone Obvious hypotonia- feels like they “slip through” your

hands when you pick them up. True hypotonia rare. Most children with CMD start out with hypotonia, but can also be due to metabolic disorders, primary muscle disease, sensory deficits or even Down Syndrome

Obvious hypertonia – early severe hypertonia is rare but can be seen in cases of severe HIE, anencephaly (neural tube defect) or microcephaly

NB !!!! Most often a combination of truncal hypotonia and distal hypertonia

5. Disturbances of movementNB!!! Persistent asymmetryPoverty (lack) of movement.... Poor

quality of movementDominant flexion over extension and vice

versaPersistent palmar thumbing (fisting),

especially if it is asymmetrical

6. Caregiver/parent reportThese factors are identified during the

parent interview Difficulty changing nappy (e.g. spastic) Difficulty with dressing, bathing and feeding the

infant Lack of cuddling and bonding with infant Cannot self-quiet or self-soothe Always/never hungry Dislikes prone position

7. Persistent primitive reflexes Present at birth Maturation CNS in particular cortex exerts

inhibitory effect on primitive reflexes Must disappear in order for the postural

reactions and control and equilibrium reactions can develop properly

Persistence may indicate cortical immaturity or damage

Characteristics elements observed in a atypically Developing child

Often difficult to initially distinguish between normal and abnormal development in an infant

EXCEPT In severely affected infants e.g. severe spastic

quadruplegia

Diagnosis of neurological impairment is seldom made before the age of one year

Differentiating between developmental delay vs. Neurological impairment Slower integration primitive

reflexes & development of postural control

No pathological reflexes noted

Initial low tone may be present in case e.g. Premature infant , DCD, ADHD, ASD

Sequencing most of the time is typical

“Scattered” milestones

Persistent or reappearing of primitive reflexes

Presence pathological postural reflexes TLR, STNR, ATNR

Increasing muscle tone over time

Abnormal sequencing (habitual/stereotypical movement patterns)

If present the following are reason for concern in children with atypical development:

Poor interaction between flexion and extension control

poor head & trunk controlpoor anti-gravity controlpoor rotational controlpoor equilibrium reactions

Persistent primitive reflexes

Presence of pathological reflexestonic reflexes ATNR/STNR/TLRoveractive phasic reflexes

If present the following are reason for concern in children with atypical development:

Abnormal muscle tone (high/low)

Poor quality of/and abnormal movement patterns orHabitual patterns

Sensory disturbance (primary or secondary)

References Images courtesy Google Brown, E. 2009. Evaluation and treatment of

infants with CMD (coursework: unpublished) Brown, E. 2001. NDT (coursework:

unpublished) Paediatric dictate UFS (2009)