Delayed achievement of Childhood milestones: A reason for concern?

1. Delayed achievement of Childhood milestones: A reason for concern? Robyn Smith Department of Physiotherapy UFS 2012

2. Remember the areas of development ? • Gross motor • Speech & language • Fine motor & perception • Socialisation & behaviour

3. So what exactly is a developmental delay?

4. Not a specific condition. A Alag in development or slower rate of development in which a child exhibits a functional level below the norm for his age What is a developmental delay?

5. Are there different types of developmental delay ?

6. 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

7. Which Children at risk developmental delay

8. “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

9. “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

10. 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

11. 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), periventricularleucomalacia (PVL) Meningitis Congenital neurological abnormalities and genetic disorders e.g. Down syndrome Dysmorphism Congenital rubella CMV Toxoplasmosis Arthrogryposis multiplex congenita Maternal substance abuse CHD 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):

12. = “ 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 Congenital Rubella

13. 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

14. Toxoplasmosis • Infection caused by parasite toxoplasmagondii • 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

15. 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

16. 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

17. 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

18. 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 Dismorphism

19. Are other infants and young children at risk? • Infective conditions e.g. HIV positive children • Neuromuscular disorderse.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

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

21. 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 Why is my child not reaching his milestones ?

22. 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 “ Late bloomer”

23. 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” 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 child’s 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 My child is not walking yet, so can I use a walking ring?

24. 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

25. 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 caudaequina lesions (MRI) • Autism • Sensory integration disorders

26. 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

27. 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

28. 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

29. 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.

30. 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-Child-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 • Mosby’s medical dictionary