1. Brown Bag Lunch Monday, April 3, 2017
Gross Motor Delays
Brown Bag Lunch
Monday, April 3, 2017

2. Spring-Board ARTICLE
Clinical Report: Motor Delays: Early Identification and Evaluation. Pediatrics 2013
Rooted in Focus groups of pediatricians asking for more guidance on these issues
Audience: pediatric primary care providers
States that the most commonly used screening instruments have not been validated on children with motor delays…
Proposes algorithm for identification & early evaluation in the medical home based on surveillance, screening instruments, observation and additional w/u
Not evidence based per se

3. Existing Guidelines – AAP 2006
Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics. Bright Futures Steering Committee; Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home; an algorithm for developmental surveillance and screening. Pediatrics. 2006; 118(1):
For all development, not specific to gross motor
Currently being revised.

4. 2006 AAP Algorithm For Identifying Developmental Delays
Surveillance at all well visits
Scheduled/Reflex Dev Screening
Follow-up &/or Refer
THE BASICS OF WHAT WE DO
Limited details
Focus on identification & Refer

5. 2013 Proposed Algorithm Adjustments
Build on recommendations for surveillance & screening
If identify gross motor delays, initiate W/U by PMD
High tone  MRI and refer at the same time
Low or normal tone  CK and thyroid tests (to identify muscular dystrophies and/or acquired hypothyroidism)
Dysmorphic, heart failure, organomegaly  Genetics w/u with microarray & referral

6. 2013 Clinical Report ALGORITHM

7. But Let’s take a step back, What do we know?
Parents are reliable reporters of gross motor development, but surveillance & screening are important to identify what is normal/abnormal
Early identification can help outcomes
Physical therapy
Treatment for specific conditions
Prognosis
Family planning

8. DDX GROSS MOTOR DELAY
DDX: Central CNS, Peripheral CNS, NM disease, metabolic, genetic
Types:
Transient vs. persistent vs. progressive vs. regressive
Isolated vs. global development delays
Prevalence:
% with mild delays?
0.3% population with Cerebral palsy
less with NM disorders (muscular dystrophies, SMA, myasthenia gravis) and genetic disorders (storage disease, mitochondrial diseases, others)
Acquired hypothyroid
Developmental coordination disorders = 6% of kindergarteners

9. Proposed Algorithm - Surveillance
Address development at all check-ups
Listen & attend to parental concerns
Document & maintain development history
Make accurate observations of the child
Identify risk and protective factors
Maintain accurate record of the process & findings

10. Proposed Algorithm – DEFINING DELAY
Specific screening test at 9, 18 & 30 months (consider again at 48 months)
And at other ages if concerns identified
ASQ (Bell curve of normal)
See ASQ Questions

11. Proposed Algorithm – DefiniNG Delay
Observed skills, GROSS MOTOR DELAY if unable to do these things:
9 months: roll bilaterally, sit well, symmetric movements, no handedness, grasps & transfers
What about the 9 month old that doesn’t pull to stand?
What about the 15 month old that is not yet walking?
18 months: sits, stands, walks independently, grasps & moves small objects
30 months: loss of previous skills, subtle gross/fine and language skills
48 months: loss of skills

12. SURVEILLENCE & SCREENING – AVERAGE AGES
Marked delay beyond these ages warrants attention, but does not necessarily signify a neuro-motor disease…

13. EXPANDED HISTORY – FOCUSED ON MOtOR

14. EXPANDED HISTORY - MOTOR
BIRTH History (if < 36 weeks, correct until age 24 months)
PMH – Chronic medical conditions, failure to thrive, heart failure, features
FH – Genetic syndromes
SH – opportunities for gross motor development

15. EXAM PearLS
Watch posture, play and spontaneous movements during history
Growth parameters – failure to thrive? Head circumference?
HEENT – drooling, ptosis, feeding, facial features
RESP – tachypnea, retractions, airway control
CV – signs of heart failure
ABD - Organomegaly
NEURO-MUSCULAR:
CN - red reflex, facial expressions, EOM, PERRLA, tongue movements/fasciculations, shoulder shrug
Strength – observe function, body posture & movement, muscle bulk and atrophy, joint flexibility, grasp quality, Gower sign in older children
Tone – slip through, ventral suspension, truncal tone in young infant; scarf sign & popliteal sign, persistent primitive reflexes, reflexes
Movement – dyspraxia, coordination, gait, tremor
Vision/hearing screening

16. Deciphering Tone Increased tone flags: Low tone flags:
Reaches milestones early, asymmetric or out of order (roll to tummy 1st, handedness earlier than 18 months, stands before sits)
Upper motor neuron signs (increased reflexes, babinski positive, rigid)
 concerned for CP, get brain MRI
Low tone flags:
LMN signs (low reflexes, floppy baby, scarf sign and popliteal sign)
low muscle bulk and strength
 concerned for metabolic or NM disorder, get thyroid studies and CK levels, consider genetics microarray testing

17. RED FLAGS FOR PROMPT REFERRAL

18. Other next steps Mild abnormalities with no red flags
Observation with scheduled follow-up
Resources: Early Intervention +/-subspecialists
Prompt referral for red flags
Children with significant delays should be identified as having special needs
Trigger care coordination and chronic care management paradigms.

19. CritiqueS
1st: Took issue with statement that PEDS & ASQ were not validated for gross motor identification
2nd: 1) validity of screening tools is sufficient; 2) surveillance should include additional steps of interpreting, discussing and closing the loop on referrals; 3) No study has demonstrated the NNS for blood testing in children with gross motor delays; 4) Need more support with referral care coordination.

20. What does this mean for Us?
Who do you refer to early intervention or have closer follow-up?
Who do you refer to specialists?
Who do you test (MRI, thyroid, CK, microarray)?
Which specialists do you like?
Neurology
Genetics
PM&R?