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
Behavior : ADHD
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Movement : Cerebral Palsy
Sensation : Hearing /
Vision Impairment
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
To
A systematic approach
of identification,
evaluation, and
intervention
A Systematic Approach
Screen
Examine
Diagnose
Treat
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, don’t 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:
(appears at 6 months)
Parachute response:
(appears at 10 months)
• Anterior (comes 1st) , lateral (2nd), and
posterior (3rd) support responses
• Parachute response
Increased tone
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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
information
– Peabody Developmental
Motor Scales
– Qualifying children for
therapeutic services
– Bayley Scales of Infant
Development
– Developmental
measure or mark in
time
– Gross Motor Function
Scale
– TIMP
– Alberta Infant Motor
Scales
Motor Assessment Tools
Test
Age Range
Description
Sens/Spec
Time frame/cost
Test of Infant
Motor
Performance
(2002)
Preterm (>34
weeks) to 4
months adj age
Early
identification of
infants with
neuromotor
dysfunction
Sens 83-96%
Spec 78 – 65%
30 minutes
Alberta Infant
Motor Scales
(1994)
0 – 18 months
Useful in high
risk infants for
screening gross
motor function
Sens 74 – 86%
Spec 81 – 93%
20 minutes
Peabody
Birth – 6 years
Developmental
Motor Scale 2nd
ed. (2000)
Measures of
gross and fine
motor skills, has
subtests, gives
age equivalent
At 4 mo: sens
20 -30 minutes for
25%, spec 73% each subtest
At 8 mo: sens
86% spec 46 –
60%
1 – 42 months
Frequently used
by NICU followup programs
and outcome
studies
Bayley Scales
of Infant
Development:
(PDI)
15-20 minutes
Narrowing the Differential
Diagnosis
• Patient A: in top graph
18 months with negative
past medical history.
100
50
0
GM
FM
Lang Social/Beh
GM
FM
Lang
100
• Patient B: 12 month old
with history of failure to
thrive
75
50
25
0
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 doesn’t 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