Case V – Development.Pediatric Clerkship.

Dr. R. Jhagroo.

Vasha A. Ramgobin.Neil N. Roopchan.

Valmiki K. Seecheran.

Year V MBBS | Class of 2015.

Case summary.

• A 6 month old boy whom you have followed since birth arrives for a well child visit. The mother’s major concerns are that the baby is “floppy” in the sitting position and disinterested in reaching for toys. You noted at his 4 month well child visit that the boy’s head support appeared weak and that he had a persistent stepping reflex; previous visits were unremarkable. The mother’s pregnancy and vaginal delivery were uneventful.

Objectives.

– What are the initial steps in the evaluation of this child?

– What is the most likely diagnosis?– How would you classify this problem?– What is the next step in this evaluation?– What are the long term goals in treatment?

Patient history.• Demographics.

– Name – John Doe.– Age – 6 months old.– Gender – Male.

• Presenting complaint.– The baby is ‘floppy’ in the sitting position.– Disinterested in reaching for toys.

• Past medical history.– At the 4 month well child visit, his head support appeared weak and he

had a persistent stepping reflex. – All previous visits were unremarkable.

• Antenatal history.– Pregnancy and delivery (vaginal) was uneventful.

Initial evaluation.

• Gather a detailed history.– Pregnancy, birth, social, family & personal history.

• Developmental milestones achievements.• Perform a detailed neurological examination.

Detailed questions.

• Maternal health?– Any infections/ exposure such as; rubella, varicella, CMV,

toxoplasmosis, syphilis, methyl mercury, family history.• Infant illness?

– Bacterial meningitis, viral encephalitis, severe/untreated jaundice, head trauma, foetal stroke.

• Pregnancy/ birth complications?– Premature birth, low birth weight, breech births, multiple babies.

• Developmental milestones?– Sit without support, raise head to 45 degrees in prone, palmar

grasp, food in mouth.

Examination.

• Inspection.– Abnormal neck, excessive drooling, truncal tone,

asymmetric posture, strength, gait & coordination.• Physical indicators.– Joint contractures due to spastic muscles,

hypotonic to spastic tone, growth delay, primitive reflexes, difficulty in fine motor.

Diagnosis.

• Non spastic (extrapyramidal) Cerebral palsy.

• DDx-– Foetal stroke.– Tumours of Conus/ Cauda Equina.– Vascular malformations of spinal cord.

Classification.• Motor function.

– Spastic (Pyramidal) cerebral palsy – hypertonic.– Non- spastic (Extrapyramidal) cerebral palsy – hypotonic/ fluctuating muscle

tone.• Ataxic – coordinated movements.• Dyskinetic – involuntary movements.

• Topographical distribution.– Paresis – weakened.– Plegia/plegic – paralyzed.

• Severity.– Mild – move without assistance.– Moderate – need braces, medication & adaptive technology.– Severe – requires a wheelchair.– No CP – trauma/ encephalopathy.

Further evaluation.

• Brain imaging – reveal areas of abnormal development.– MRI.– CT scan.– Cranial ultrasound.

• Laboratory tests.– Rule out blood clotting disorders that can cause

stroke.• Electroencephalogram – presence of seizures.

Further evaluation.

• Refer to relevant specialists to test for:– Vision impairment.– Audio impairment.– Speech delays/ impairment.– Intellectual disabilities.– Movement disorders.

Long term goals – Treatment.• Multi-disciplinary team.

– Paediatrician • oversee treatment plan and management.

– Physical therapist • improve strength, walking skills.

– Occupational therapist • adapt to daily activities.

– Speech language pathologist • managing speech and language disorders.

– Developmental therapist • develop age-appropriate behaviours & social skills.

– Mental health therapist• counselling.

– Social worker• assists with finding services and planning for transitions.

– Special education teacher • addresses learning disabilities, determines educational needs.

Long term goals – Treatment.

• Medical.– Anticholinergic.

• Benztropine mesylate, glycopyrrolate.

– Anticonvulsants.• Gabapentin.

– Antidepressants.• Fluoxetine.

– Antispastic.• Diazepam .

– Pain management. • NSAIDs, Corticosteroids, Aspirin.

Long term goals – Treatment.

• Surgical– Orthopaedic surgery• Severe contractures or deformaties may need surgery

to correct joint/bone placement.• Lengthen muscles/ tendons.

– Severing nerves• Cut the nerves serving the spastic muscles.

Prevention.

• Vaccination – rubella (fetal brain damage)• Take care of yourself – Be safe during

pregnancy.• Prenatal care – Regular visits can prevent

premature birth, low birth weight and infections.

• Practice good child safety – Prevent head injuries with a car seat, helmets, bed rails and supervision.

Thank you.