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OBJECTIVES
A brief overview of developmental milestones Difference between the terms developmental delay and regression Cerebral palsy Etiology Presentation Treatment
DEVELOPMENTAL MILESTONES
DEFINITION: Important developmental skills attained over time are called developmental milestones
Median age
Limit age Adjustment for prematurity
(Illustrated textbook of Pediatrics, 3rd Edition)
AT BIRTH
Gross motor
Fine motor
Ventral suspension
Social
Comforted by mothers presence
AT 03 MONTHS
Gross motor
Fine motor
puts hands in mouth
recognizes mother
AT O6 MONTHS
Gross motor
Fine motor
Social
Changes position to localize sound
Social smile
AT 01 YEAR
Gross motor
Fine motor
Walks with one hand held
Social
AT 02 YEARS
Gross motor
Fine motor
Spectator play
AT 5 YEARS
Gross motor
Fine motor
Bends and touches the toe
Draws a person
DEVELOPMENTAL DELAY
DEFINITION: Global developmental delay implies delay in acquisition of all skill fields (gross motor, vision and fine motor, hearing and speech/language, social/emotional and behavior). It usually becomes apparent in the first 2 years of life
DEVELOPMENTAL REGRESSION
DEFINITION: A previously healthy child begins to deteriorate losing already attained skills with progressive loss of speech, hearing, vision and muscle strength for more than three months
CEREBRAL PALSY
DEFINITION
Cerebral
palsy is a diagnostic term used to describe a group of permanent disorders of movement and posture causing activity limitation, that are attributed to non progressive disturbances in the developing infant or fetal brain
INCIDENCE
Most common and most costly form of chronic motor disability
Incidence 3.6/1000 live births in developed nations Incidence 1.5 to 6/1000 live births in developing world.
M:F 1.4:1
Incidence greater in premature and twin births.
(United Cerebral Palsy Research and Education Foundation Cerebral Palsy Fact Sheet)
RISK FACTORS
ANTENATAL Low socioeconomic status Low birth weight/ fetal growth retardation(less than 1500g at birth) Treatment with thyroid hormone, estrogen or progesterone Multiple births Maternal fever
RISK FACTORS
RISK FACTORS
POST NATAL Meningitis Head injury car crashes violence Stroke
BRAIN DAMAGE
BRAIN DAMAGE
PRESENTATION
Delayed motor milestones Abnormal limb tone/trunk posture Slowing of head growth Feeding difficulties Abnormal gait Asymmetrical hand function Persistent primitive reflexes
Neuropathology/MRI
Periventricular leukomalacia Periventricular cysts or scars White matter scars Periventricular leukomalacia Multicystic encephalomalacia Cortical malformations Stroke; in utero or neonatal Focal infarct Cotical malformations
Major causes
Prematurity Ischemia Infection Endocrine/metabolic Ischemia, infection Endocrine/metabolic Genetic/developmental Thrombophilic disorders Infection Genetic/developmental Hemorrhagic infarct
SPASTIC QUADRIPLEGIA(20%)
HEMIPLEGIA(25%)
EXTRAPYRIMIDAL(15%)
Asphyxia; scars in putamen and thalamus Kernicterus; scars in globus pallidus, caudate, putamen
Legs are affected more than arms. Legs adducted and internally rotated.
COMMON ASSOCIATIONS
Learning difficulties (about 60%) Epilepsy (40%) Squints (30%) Visual impairment from errors of refraction and cortical damage (20%) Hearing impairment (20%)
INVESTIGATIONS
Neuroimaging Cranial USG MRI Brain MRI Spinal Cord CT Conduction studies Laboratory tests Blood tests Hearing and visual assessment
INVESTIGATIONS
INVESTIGATIONS
INVESTIGATIONS
INVESTIGATIONS
TREATMENT
Multidisciplinary approach
MEDICAL THERAPY
FOR SPASTICITY Benzodiazepines Baclofen Oral diazepam Dantrolene FOR DYSTONIA Levodopa Trihexyphenidyl Reserpine Tetrabenzene
MEDICAL THERAPY
Intrathecal baclofen
Botulinum toxin
SURGICAL THERAPY
Derotation osteotomy Dorsal root rhizotomy
REHABILITATION
REFERENCES
Nelson Textbook of Pediatrics, 19th Edition Nelsons Essentials of Pediatrics, 6th Edition Illustrated Textbook of Pediatrics, 3rd Edition Oxford Handbook of Pediatrics Forfars and Arneils Textbook of Pediatrics, 6th Edition Cerebralpalsy.com Illustrations from Developmental milestones Forfars and Arneils Textbook of Pediatrics Neuroimaging copyrights Indiana University All original photographs taken with parental consent Courtesy AFIRM