CBD:

MOTOR DELAY
Group 2 (Cohort 9A):
Kubendran A/L T Athiberan SUKD1801062
Pijitra Kuboonya-arak SUKD1801299
Rishani A/P Jegathiswaran SUKD1701390
 CASE SCENARIO
A nurse refers Ah Beng, 2 years old boy, to LKHMCC Agape for inability to
walk. Ah Beng is able to stand with support eg. holding on to furniture. Ah
Beng can so far say >10 words including “nen-nen, baba and mama”.
There is no history of regression and he is otherwise healthy with no
medical illness. Antenatal history was uneventful, however he was born
premature at 33 gestation weeks because of premature labour. His
birthweight was 1.8kg and his neonatal period was eventful with 2 weeks
stay in SCN to establish feeding & weight gain. His growth parameters
have been along the same centiles since birth. On further questioning, his
father was said to be a “late walker”.
 QUESTION 1
WHAT ARE THE COMMON CAUSES OF MOTOR DELAY
IN YOUNG CHILDREN?
 Causes of Motor Delay
● Prematurity
● Developmental conditions
○ Autism
● Rare diseases and genetic syndrome
○ Downs syndrome
○ Achondroplasia
○ Pitt-Hopkins syndrome
○ Russell-Silver syndrome
● Neurodevelopmental disorders
○ Cerebral palsy
○ Muscular atrophy
● Environment and care
○ Lack of physical movement/exercise
○ Child neglect
 QUESTION 2
WHAT FURTHER HISTORY WOULD YOU LIKE TO
EXPLORE IN ORDER TO ELICIT THE CAUSE OF DELAY?
 Further history
● Consider the child’s age and then focus your questions on the areas of
likely current developmental progress.
● Offer the child suitable toys to find out about skills through play.
● Observe how the child uses the toys and interacts with people.
 PRENATAL HISTORY
● Alcohol ingestion — Fetal alcohol syndrome
● Radiation exposure — Damage to CNS
● Nutrition — Inadequate fetal nutrition
● Prenatal care — Index of social situation
● Injuries, hyperthermia — Damage to CNS
● Smoking — Possible CNS damage
● HIV exposure — Congenital HIV infection
 PERINATAL HISTORY
● Gestational age, birth weight - Biologic risk from prematurity and small for gestational
age
● Labor and delivery - Hypoxia or index of abnormal prenatal development
● APGAR scores → Hypoxia, cardiovascular impairment
● Whether neonatal resuscitation was necessary or not (asphyxia).
● Sepsis
○ Ask whether the baby cried immediately after birth
○ Any PROM / PPROM? Any foul smelling liquor?
○ Any GBS infection in mum and previous siblings?
○ Ask if mum had history of fever 24 hours before, during and after pregnancy
○ Any skin rashes
 NEONATAL HISTORY
● Illness such as seizures,respiratory
distress,hyperbilirubinemia,metabolic disorder - Increased risk of CNS
damage
● Malformations - May represent genetic syndrome or new mutation
associated with developmental delay
 FAMILY HISTORY
● Family member died young or unexpectedly - May suggest inborn error of
metabolism or storage disease.
● Family member requires special education - Hereditary causes of
developmental delay.
● Family member with developmental delay - Some children may develop gross
motor delay as a result from a lack of physical exercise and opportunities to
move which may be due to the result of neglect or limited resources
● Illnesses (e.g ; metabolic diseases)—Hereditary illness associated with
developmental delay.
 SOCIAL HISTORY
● Resources available (e.g ; financial, social support) - Necessary to
maximize child’s potential.
● Educational level of parents - Family may need help to provide
stimulation.
● Mental health problems - May exacerbate child’s conditions.
● High-risk behaviors (e.g ; illicit drugs, sex) - Increased risk for HIV
infection; index of caregiving risk.
● Other stressors (e.g ; marital discord) - May exacerbate child’s
conditions or compromise care
 ASSOCIATED ISSUES
● Head injury - Even moderate trauma may be associated with developmental
delay or learning disabilities.
● Serious infections (e.g ; meningitis) - May be associated with developmental
delay.
● Toxic exposure (e.g ; lead) - May be associated with developmental delay.
● Fits - Ask about frequency, duration, character (generalised or partial), whether
a/w fever, whether impaired consciousness after fits
● Physical growth - May indicate malnutrition; obesity, short stature, genetic
syndrome.
● Visual and auditory functioning — Sensitive index of impaired vision and
hearing.
● Nutrition — Malnutrition during infancy may lead to delayed development.
 QUESTION 3
WHAT ARE THE CHARACTERISTIC PHYSICAL FINDINGS
ASSOCIATED WITH THE CAUSE LISTED IN Q1?
Physical examination
- Head circumference, growth, dysmorphic features, neurocutaneous markers
- Neurological abnormalities
- Full developmental assessment
- Observation of behaviour, social interaction and play
- Neurological signs: dystonia, ataxia, chorea, focal signs, cranial neuropathy,
- Peripheral neuropathy, arthrogryposis/joint contractures
- Cerebral Palsy picture without a clear cause/history
- Ocular signs: cataract, nystagmus,
 QUESTION 4
WHAT INVESTIGATIONS WOULD YOU CONSIDER?
Cytogenetic - Comparative genomic hybridization microarray,
chromosome karyotyping
- Fragile X analysis
- DNA fluorescence in situ hybridization analysis (for
deletions of chromosomes 7, 15, & 22)

Metabolic - TFT, BUSE, blood film, LFT, bone chemistry, plasma

amino acids test
- Creatine kinase, blood lactate, blood gases, ammonia
test, urine tests

Infections - Congenital screening - TORCH infections

Imaging - CT & MRI scanning

- Cranial USG
- Skeletal survey, bone age
Neurophysiology - Electroencephalogram (EEG) - seizures, neurological
disorders, etc.
- Nerve conduction studies, electromyogram, visual
evoked potentials, electroretinogram

Histopathology or Histochemistry - Nerve, skin, muscle biopsy

Others - Hearing tests (audiogram/audiometry)

- Vision tests
- Clinical genetic testing (blood/bone/amniotic fluid
sample)
- Cognitive & behavioural assessment (clinical and
educational psychologist)
- Therapy assessment – physiotherapy, occupational
therapy, speech and language therapy
- Child psychiatry - counselling, mental assessment
- Dietician - nutrition
- Nursery/school reports - education, interactions &
communication, physical activity
 QUESTION 5
WHO WOULD YOU REFER AH BENG FOR EIP PROGRAM?
Early Intervention Program (EIP)
- A multidisciplinary programme that combines educational & therapeutic support services for
children discovered to have/are at risk of having special needs at a very young age
- Targeted towards developmental aspects:
● Physical & sensory
● Cognitive & educational
● Communication
● Self-help/Adaptive
● Social & emotional
- Continuous monitoring of children up to school - leaving age (16-19 yrs)
- Consists predominantly of health professionals (paediatrician, physiotherapist, occupational
therapist, speech and language therapist, clinical psychologist, specialist health visitor, dietician,
but often also includes social workers
- Multiagency: may include health, social services, education, volunteers, voluntary agencies,
parent support groups
 Reference
1. Paediatric Protocols, 4th edition
2. Illustrated Textbook of Paediatrics, 5th edition
3. What is Early Intervention Program (EIP)? Kidsogenius Child Development. Retrieved from
Early Intervention Program - Kidsogenius Child Development
4. Early Intervention Programme (EIP). RISE Intervention Programme (EIP). Retrieved from Early
Intervention Programme (EIP) - Rise Intervention
THANK YOU