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, 2010
 Objectives
Discuss hallmarks of motor delays in
infants such as tone patterns, primitive
reflexes, milestone delays, and deviances
Using cases to prompt discussion,
compare differences in the approach to
evaluation
Review brain MRI abnormalities with
patterns of motor impairment
Review the purpose of the Neuromotor
Team
 Developmental Disorders in
Children
Disorders of brain
function Cognition : MR/LD

Social skills: Autism Movement : Cerebral Palsy

Sensation : Hearing /
Behavior : ADHD
Vision Impairment

11.03.03
 Neuromotor Team
Children with Special Health Care
Needs
Specialty team within the Child
Developmental Clinic
Types of patients seen
Typically birth to 36 months
Older children with motor impairment with
case management needs
Team members:
Sarah Winter, MD, Terry Holden, PT, Scott
Jerome, PT, and Alison Seppi, RN
Oversight: Jim Taliaferro, LCSW
 My developmental path to
understanding gross motor delay
 But how do you apply
this disparate
knowledge and be
helpful to this child
and family?
 Developmental Progress

Move from
chaotic pieces
of knowledge

A systematic approach
To of identification,
evaluation, and
intervention
 A Systematic Approach

Examine Diagnose Treat

Screen
 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: An algorithm for
Developmental Surveillance and Screening
 References to Screening and
Surveillance
Society for Development and Behavioral
Pediatrics website: www.dbpeds.org

Grand Rounds by Paul Young and Charlie

Ralston

Podcast produced by Dr. Paul Carbone

www.utah.edu/podcast
 Features of a Good
Developmental History
Parents describe gross motor skill delays
well

People; both parents and medical care

providers, dont tend to pay attention to fine
motor skills e.g. when are kids supposed to
have a hand preference?

Ask about language, it is a clue to cognitive

development
 The Pediatric
Neurodevelopmental Exam

Gross Motor findings

Fine Motor findings

Language findings
Expressive
Receptive

Social/Behavioral findings
 Focused exam findings
Tone patterns
Low tone: mild or severe?

High tone: is it symmetric?, is it typical

(LE>UE)?

weird tone : ataxia, tremor, fluctuating

(dystonia)
Gross Motor Exam Findings
 Focused exam
Reflexes;
High or absent
Primitive reflexes see figure

Postural or protective responses

Lateral, anterior, posterior supports
parachute
Examples of primitive reflexes

The Moro is normal in a newborn and should

be gone by 4 months
The ATNR is normal in a newborn and should
be gone at 6 months
 Postural (or protective)
responses

Lateral support: Parachute response:

(appears at 6 months) (appears at 10 months)

Anterior (comes 1st) , lateral (2nd), and

posterior (3rd) support responses
Parachute response
Increased tone

11.03.03
 gross motor examination
This child presents
with delays in gross
motor milestones.
His tone is likely low
Differentiate
between tone and
strength
 Focused Exam
Deviant (atypical but not always delayed)
motor patterns
Bottom scooters

Circling hands and feet while balanced on the

bottom (hypotonia) Some confuse this for a
sign of autism

Commando crawling (hemiplegia)

Gross motor testing: standardized
measures of gross motor function
Purpose Frequently used tools
Further diagnostic Peabody Developmental
information Motor Scales

Qualifying children for Bayley Scales of Infant

therapeutic services Development

Developmental Gross Motor Function

measure or mark in Scale
time
TIMP

Alberta Infant Motor

Scales
 Motor Assessment Tools
Test Age Range Description Sens/Spec Time frame/cost
Test of Infant Preterm (>34 Early Sens 83-96% 30 minutes
Motor weeks) to 4 identification of Spec 78 65%
Performance months adj age infants with
(2002) neuromotor
dysfunction
Alberta Infant 0 18 months Useful in high Sens 74 86% 20 minutes
Motor Scales risk infants for Spec 81 93%
(1994) screening gross
motor function
Peabody Birth 6 years Measures of At 4 mo: sens 20 -30 minutes for
Developmental gross and fine 25%, spec 73% each subtest
Motor Scale 2nd motor skills, has At 8 mo: sens
ed. (2000) subtests, gives 86% spec 46
age equivalent 60%
Bayley Scales 1 42 months Frequently used 15-20 minutes
of Infant by NICU follow-
Development: up programs
(PDI) and outcome
studies
 Narrowing the Differential
Diagnosis
100
Patient A: in top graph
18 months with negative 50

past medical history.

0
GM FM Lang Social/Beh

100
Patient B: 12 month old 75
50
with history of failure to
25
thrive 0
GM FM Lang Soc/Beh
Medical Diagnostic Considerations
 Case # 1
10 month old not sitting or rolling

Pregnancy/Labor/birth HX: Uncomplicated

pregnancy, NSVD, BW 8# 3 oz. Apgars
normal

FHx: noncontributory
 #1
Physical exam: cute blonde, fair skinned, growth
parameters: weight >>95%, hgt 75%, OFC, 75%
rest of exam normal

Neuro exam: low trunk tone, high extremity tone

upper extremities more involved than lower
extremities. Hyperreflexia throughout

Neurodevelopmental exam: GM: no sitting

balance, prominent extensor thrust , FM: fisted
hands, language: smiling, babbling
What is an appropriate work-up?

Imaging?
CT vs. MRI

Metabolic Studies?

Genetic Studies?
 Case # 2
24 month old with language delay, not
using left arm as well as right arm
Pregnancy.labor /delivery: uncomplicated
Family History: negative
Physical exam:
Neuro exam: reflexes, tone, strength intact
Neurodevelopmental exam: walking,
asymmetric use of hands L<R, language
delay
 How helpful is imaging?

Practice Parameter: Diagnostic assessment

of the child with cerebral palsy Ashwal
and Russman et al, Neurology (2004)
Yield of abnormal brain CT in children with CP: 77%

Yield of abnormal brain MRI in kids with CP: 89% and it

is helpful in determining timing of injury

Depended on type (n=264)

(dyskinetic CP 100%, quadriplegia 98%, hemi 96%, diplegia 94%
ataxic 75%)
 How helpful are metabolic and
genetic studies?
In children with dx of CP
0 4% of children have a metabolic or genetic cause
(Ashwal, Russman)
In almost all cases there were atypical features
Hx suggestive of regression
Neuroimaging suggesting genetic or metabolic injury
Family history of childhood neurologic disorder

If clinical history or findings on neuroimaging do

not determine a specific structural abnormality or
if there are atypical or additional features on the
history or clinical exam, metabolic and genetic
testing should be considered.
 What if the child doesnt have CP but a
broader presentation of global
developmental delay?
Moeschler J, Shevell M and the Committee on
Genetics Pediatrics, 2006
Describes what pediatricians can anticipate as an
optimal clinical genetics evaluation
Karyotype, FISH for subtelomere abnormalities, Frag X,
molecular genetic testing, imaging, metabolic testing
Report on the usefulness of high resolution
chromosome studies (9 36%) in patients evaluated
for DD/MR
Routine metabolic screening of all patients with
DD/MR is not required
 Gross motor delay and its
relationship to other brain functions
Cognition function and
CP, depends of the type

For children with spastic

quadriplegic CP (Strauss,
DMCN, 2005)
95% with MR

If had dyskinetic CP only

40% with profound MR
and 20% no MR
 Gross motor delay and its
relationship to other brain functions

Cognitive Function and

Developmental
Coordination Disorder or
mild motor delays
No good epidemiologic
data
 Using CP as a paradigm
Children Who Outgrew CP
Nelson, Ellenberg Pediatrics, 1982

229 infants age 12 months with diagnosis of

CP
Examined again at 7 y. o.
118 free of motor handicap
13% of white children and 25% of black
children with MR
Nonfebrile sz, abnormalities of speech,
behavior, and extraocular movements were
more frequent than controls
 When do you not need a brain MRI when
evaluating a child with motor delays?
Mild delay
Looking for an inutero infection that would
leave calcifications (CT is better)
Ultrasound in the NICU showed cystic
encephalomalacia and development is
consistent with this pattern of CP
(generally SQ CP but can have mixed
tone)
 Treatment/Intervention

Cure vs. maximize

functional abilities

Only one cure in my

clinical years
 National Center for Medical
Rehabilitation Research
(1995)

Model to assist in the direction

of research

Paradigm for chronic disorders

Good fit for persons with motor

disorders such as CP,
muscular dystropy, spinal cord
injury or birth defect (SB)
 Neuromotor Team Evaluations

Medical Evaluation and Diagnosis

Therapy: PT performs PDMS for
evaluation
Educational Concerns: frequent referrals
to EI
Technology: assistive devices
Social Supports: referrals to programs as
needed
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 Questions??

Sarah Winter, MD
Phone : 801-581-7877