Approach to floppy infant

Gopakumar.HSpecialist Neonatology Trainee

Adelaide

Sign of both benign and serious conditions

Exhaustive differential diagnosis

Rare disorder

Overwhelming advances in diagnosis and management

Diagnostic challenge

Differential diagnosis of hypotonia in infants. 

Describe the differences between central and peripheral causes of hypotonia. 

Evaluation of hypotonia in infants.

Relevant terminologies and definitions

Tone is the resistance of muscle to stretch. Clinicians test two kinds of tone: phasic and postural.

Phasic tone - The rapid contraction in response to a high-intensity stretch , as in tendon reflex response .

Postural tone - It is the prolonged contraction of antigravity muscles in response to the low-intensity stretch of gravity. When postural tone is depressed, the trunk and limbs cannot maintain themselves against gravity and the infant appears floppy.

The maintenance of normal tone requires intact central and

peripheral nervous system . Hence hypotonia is a common

symptom of neurological dysfunction and occurs in diseases

of the brain, spinal cord, nerves, and muscles.

Definitions Motor unit - One anterior horn cell and all the muscle fibers that it innervates make up a motor unit . The motor unit is the unit of force. Therefore, weakness is a symptom of all motor unit disorders.

Neuronopathy - A primary disorder of the anterior horn cell body

Neuropathy - a primary disorder of the axon or its myelin covering

Myopathy - a primary disorder of the muscle fiber

Differential diagnosis

Two categories - Central and peripheral disorders .

Peripheral causes include abnormalities in the motor unit , specifically in the anterior horn cell (ie, spinal muscular atrophy), peripheral nerve , neuromuscular junction , and muscle

Central causes account for 60% to 80% of hypotonia cases and the peripheral causes occur in 15% to 30%.

Considerable overlap of involvement and clinical manifestations

Differential diagnosis for hypotonia

  Cerebral insult – Hypoxic ischemic encephalopathy ,

intracranial haemorrhage Brain malformations Chromosomal disorders – Praderwilli syndrome , Down

syndrome Peroxisomal disorders – cerebrohepatorenal syndrome

( Zellweger’s syndrome) , Neonatal adrenoleukodystrophy Other genetic defects – familial dysautonomia ,

oculocerebrorenal syndrome ( Lowe syndrome ) Neurometabolic disorders – Acid maltase deficiency ,

infantile GM1 gangliosidosis Drug effects ( ex Maternal Benzodiazepines ) Benign congenital hypotonia

Causes of Cerebral hypotonia

 

Infantile spinal muscular atrophy Traumatic myelopathy ( esp following

breech delivery ) Hypoxic ischemic myelopathy Infantile neuronal degeneration

 

Anterior horn cell disorders

Congenital hypomyelinating neuropathy Giant axonal neuropathy Charcot marie tooth disease Dejerine sottas disease

Congenital neuropathies

Myasthenia gravis ( Transient acquired neonatal myasthenia ,congenital myasthenia )

Infantile botulism Magnesium toxicity Aminoglycoside toxicity

Neuromuscular junction disorders

Congenital myopathy Nemaline myopathy Central core disease Myotubular myopathy Congenital fiber type disproportion

myopathy Multicore myopathy

Myopathies

Congenital muscular dystrophy with merosin deficiency Congenital muscular dystrophy without merosin deficiency Congenital muscular dystrophy with brain malformations

or intellectual disability Dystrophinopathies Walker Warburg disease Muscle – eye – brain disease Fukuyama disease Congenital muscular dystrophy with cerebellar atrophy /

hypoplasia Congenital muscular dystrophy with occipital agyria Early infantile facioscapulohumeral dystrophy Congenital

myotonic dystrophy

Muscular dystrophies

Disorders of glycogen metabolism ( ex Acid maltase deficiency )

Severe neonatal phosphofructokinase deficiency

Severe neonatal phophorylase deficiency Primary carnitine deficiency Peroxisomal disorders Neonatal adrenoleukodystrophy Cerebrohepatorenal syndrome ( zellweger ) Disorders of creatine metabolism Cytochrome c oxidase deficiency

Metabolic and multisystem disease

The most common central cause of hypotonia is hypoxic encephalopathy / cerebral palsy in the young infant. However, this dysfunction may progress in later infancy to hypertonia.

The most common neuromuscular causes, although still rare, are congenital myopathies, congenital myotonic dystrophy, and spinal muscular atrophy.

Disorders with both central and peripheral manifestations ex acid maltase deficiency (Pompe disease).

Central and peripheral causes

Common causes of hypotonia

History &

Clinical evaluation

Identify cause and the timing of onset Maternal exposures to toxins or infections

suggest a central cause Information on fetal movement in utero, fetal

presentation, and the amount of amniotic fluid.

Low Apgar scores may suggest floppiness from birth

Breech delivery or cervical position – cervical spinal cord trauma

Obstetric history

A term infant who is born healthy but develops floppiness after 12 to 24 hours – suspect inborn error of metabolism

Infants suffering central injury usually develop increased tone and deep tendon reflexes.

Central congenital hypotonia does not worsen with time but may become more readily apparent

Course of illness

Motor delay with normal social and language development decreases the likelihood of brain pathology.

Loss of milestones increases the index of suspicion for neurodegenerative disorders.

Developmental history

A dietary/feeding history may point to diseases of the neuromuscular junction, which may present with sucking and swallowing difficulties that ‘fatigue’ or ‘get worse’ with repetition.

Dietary / Feeding history

Developmental delay (a chromosomal abnormality)

Delayed motor milestones (a congenital myopathy) and

Premature death (metabolic or muscle disease).

Family history

Any significant family history – affected parents or siblings, consanguinity, stillbirths, childhood deaths

Maternal disease –  myotonic dystrophy Pregnancy and delivery history – drug or teratogen exposure

Decreased fetal movements Abnormal presentation Polyhydramnios/ oligohydramnios Apgar scores Resuscitation requirements Cord gases

History since delivery◦ Respiratory effort◦ Ability to feed◦ Level of alertness◦ Level of spontaneous activity◦ Character of cry

 

Salient points in History

When lying supine, all hypotonic infants look much the same, regardless of the underlying cause or location of the abnormality within the nervous system.

Lack spontaneous movement Full abduction of the legs places the

lateral surface of the thighs against the examining table, and the arms lie either extended at the sides of the body or flexed at the elbow with the hands beside the head.

General examination

General examination

Hip dislocation - The forceful contraction of muscles pulling the femoral head into the acetabulum is a requirement of normal hip joint formation.

Pectus excavatum indicates long standing long-standing weakness of the chest wall muscles

Infants who lie motionless eventually develop flattening of the occiput and loss of hair on the portion of the scalp that is in constant contact with the crib sheet.

Hip subluxation or arthrogryposis suggest hypotonia in utero .

Arthrogryposis varies in severity from clubfoot, the most common manifestation, to symmetrical flexion deformities of all limb joints. Joint contractures - a nonspecific consequence of intrauterine immobilization. As a rule, newborns with arthrogryposis who require respiratory assistance do not survive extubation unless the underlying disorder is myasthenia.

Arthrogryposis

High-pitched or unusual-sounding cry - suggests CNS pathology

A weak cry - diaphragmatic weakness

Fatigable cry - congenital myasthenic syndrome.

Quality of cry

A comprehensive neurologic evaluation

Assessment for dysmorphic features

Evaluation of the parents – may point towards specific diagnosis as in myotonic dystrophy .

Physical examination

  Detailed neurologic assessment - tone,

strength, and reflexes Assessment of tone – begin by examining

posture, and movement. A floppy infant often lies with limbs abducted and extended.

Neurologic examination

Evaluation of hypotonia

Traction response Vertical suspension

Horizontal suspension

Further evaluationOf

Hypotonia

Horizontal Suspension

Normal infant - keeps the head erect, maintains the back straight, and flexes the elbow, hip, knee, and ankle joints

Baby suspended in the prone position with the examiner’s palm underneath the chest

Hyptonia - infants drape over the examiner's hands, with the head and legs hanging limply

The most sensitive measure of postural tone Grasp the hands and pull the infant toward a

sitting position A normal term infant lifts the head from the

surface immediately with the body When attaining the sitting position, the head

is erect in the midline for a few seconds. During traction, the examiner should feel the

infant pulling back against traction and observe flexion at the elbow, knee, and ankle.

The Traction Response

The traction response is not present in premature newborns of less than 33 weeks' gestation

The presence of more than minimal head lag and of failure to counter traction by flexion of the limbs in the term newborn is abnormal and indicates hypotonia.

By 1 month, normal infants lift the head immediately and maintain it in line with the trunk.

Traction response

The examiner places both hands in the infant's axillae and, without grasping the thorax, lifts straight up

The muscles of the shoulders should have sufficient strength to press down against the examiner's hands and allow the infant to suspend vertically without falling through

Normal response – Head erect in the midline with flexion at the knee, hip, and ankle joints.

When a hypotonic infant is suspended vertically, the head falls forward, the legs dangle, and the infant may slip through the examiner's hands because of weakness in the shoulder muscles

Vertical Suspension

Decreased resistance to flexion and extension of the extremities

Exaggerated hip abduction & ankle dorsiflexion

Oral-motor dysfunction Poor respiratory efforts Gastroesophageal reflux Note the distribution of weakness ex .face

is spared versus the trunk and extremities.

Other pertinent findings

Deep tendon reflexes (DTRs) often normal / hyperactive in central conditions

Clonus and primitive reflexes may persist

DTRs - normal, decreased, or absent in peripheral disorders

Deep tendon reflexes Course of hypotonia

Course of hypotonia - fluctuating, static, or progressive discriminates between a static encephalopathy (as is seen in intellectual disability) and a degenerative neurologic condition (eg, spinal muscular atrophy). Distribution of hypotonia – Ex Face involvement

Distribution of hypotonia Ex facial involvement

Usually spares extraocular muscles, while diseases of the neuromuscular junction may be characterized by ptosis and extraocular muscle weakness .

Anterior horn cell diseases Versus neuromuscular junction disorders

Hepatosplenomegaly – storage disorders, congenital infections

Renal cysts, high forehead, wide fontanelles – Zellweger’s syndrome

Hepatomegaly, retinitis pigmentosa – neonatal adrenoleukodystrophy

Congenital cataracts, glaucoma – oculocerebrorenal (Lowe) syndrome

Abnormal odour – metabolic disorders Hypopigmentation, undesceded testes –

Prader Willi

Clues to specific diagnosis

Differentiating centralFrom

Peripheral hypotonia

Dysmorphic features Depressed level of consciousness or lethargy Abnormal eye movements or inability to track visually Early onset seizures Apnea Exaggerated irregular breathing patterns. Predominant axial weakness Normal strength with hypotonia scissoring on vertical suspension Fisting of the hands Hyperactive or normal reflexes Malformations of other organs

Clues to Central hypotonia

Hypoxic ischemic encephalopathy, teratogens, and metabolic disorders may evolve into hyperreflexia and hypertonia, but most syndromes do not.

Infants who have experienced central injury usually develop increased tone and deep tendon reflexes

Central hypotonia

Hypotonia, Generalized weakness Absent reflexes, Feeding difficulties

Classic infantile form of spinal muscular atrophyFasciculations of the tongue as well as an intention tremor. Affected infants have alert, inquisitive faces but profound distal weakness.

Clues to Anterior horn cell disorders

Alert infant and appropriate response to surroundings

Normal sleep-wake patterns Associated with profound weakness Hypotonia and hyporeflexia / areflexia Other features - muscle atrophy, lack of

abnormalities of other organs, the presence of respiratory and feeding impairment, and impairments of ocular or facial movement

Characteristics of peripheral causes of hypotonia

A systematic approach to a child who has hypotonia, paying

attention to the history and clinical examination, is paramount in localizing the

problem to a specific region of the nervous system.

Laboratory evaluation

Rule out sepsis first - complete blood count , (blood culture, urine culture, cerebrospinal fluid culture and analysis);

Measurement of serum electrolytes – calcium and magnesium Liver function tests Urine drug screen Thyroid function tests TORCH titers (toxoplasmosis, rubella, cytomegalovirus infection,

herpesvirus infections) and a urine culture for cytomegalovirus ( hepatosplenomegaly and brain calcifications )

Karyotype – Dysmorphism EEG – helps in prognostication Genetic studies - Array comparative genomic hybridization study,

methylation study for 15q11.2 (Prader-Willi/Angelman) imprinting defects, and testing for known disorders with specific mutational analysis  

Labortary evaluation

Complex multisystem involvement on clinical evaluation suggests - inborn errors of metabolism

Presence of acidosis - plasma amino acids and urine organic acids (aminoacidopathies and organic acidemias)

Serum lactate in disorders of carbohydrate metabolism, mitochondrial disease

Pyruvate and ammonia in urea cycle defects Acylcarnitine profile in organic acidemia, fatty acid

oxidation disorder Very long-chain fatty acids and plasmalogens -

specific for the evaluation of a peroxisomal disorder.

Labortary evaluation – Inborn error of metabolism

MRI

Delineate structural malformations Neuronal migration defects Abnormal signals in the basal ganglia (mitochondrial abnormalities) or brain stem defects (Joubert syndrome)Deep white matter changes can be seen in Lowe syndrome, a peroxisomal defect Abnormalities in the corpus callosum may occur in Smith- Lemli-Opitz syndrome Heterotopias may be seen in congenital muscular dystrophy. Magnetic resonance spectroscopy   Magnetic resonance spectroscopy also can be revealing for metabolic disease.

Radiologic evaluation

Diagnosis mainly by history and clinical examination

Molecular genetics – CTG repeats, deletions in SMN gene

Nerve conduction studies and muscle biopsy (Depending on clinical situation, may be delayed until around 6 months of age as neonatal results are difficult to interpret)

Peripheral causes

Creatine kinase (levels need to be interpreted with caution in the newborn, as levels tend to be high at birth and increase in the first 24 hours, they also increase with acidosis). 

Repeat after few days , if initial value is elevated

Elevated in muscular dystrophy but not in spinal muscular atrophy or in many myopathies.

Creatine kinase

DNA studies and electrophysiology Specific DNA

testing - for myotonic dystrophy and for spinal muscular atrophy ( SMN gene )

Electrophysiological studies - Shows abnormalities in nerves, myopathies, and disorders of the neuromuscular junction

Normal EMG usually suggest central hypotonia , with few exceptions

Helps to differentiate a primary myopathy from a neurogenic disorder

Helps to differentiate myopathies from muscular dystrophies Useful in the work-up of undiagnosed weakness Provide the diagnosis of specific muscular conditions, such

as a muscular dystrophy, metabolic or storage myopathies, and inflammatory myopathies.

Helps to differentiate active from inactive and acute from chronic conditions.

 Additional clues can be derived from ultrastructural changes seen with the electron microscope.

Various biochemical and genetic studies can be performed on fresh or frozen muscle tissue to measure enzyme levels and perform DNA studies for certain genetic diseases

Muscle biopsy with immunohistochemical staining

Hematoxylin and eosin (H&E) Trichrome , PAS (for glycogen) Oil red O (ORO) (for lipids) Acid phosphatise (for lysosomal activity) Congo red and cresyl violet (for amyloid) Myosin ATP ase Staining is useful for fiber-type differentiation Oxidative markers, such as nicotinamide adenine dinucleotide

reductase (NADH), succinate dehydrogenase (SDH), and cytochrome C oxidase(COX), are most effective in the diagnosis of enzymatic deficiencies

Myophosphorylase and myoadenylate deaminase (AMPAD) for enzyme deficiencies acetylcholinesterase silver stain, may be required in certain cases to show the motor endplates

Useful staining agents

Muscular dystrophy - subgroup of myopathies characterized by muscle degeneration and regeneration. Clinically, muscular dystrophies are typically progressive, because the muscles' ability to regenerate is eventually lost, leading to progressive weakness, often leading to use of a wheel chair and eventually death, usually related to respiratory weakness

Congenital myopathies - do not show evidence for either a progressive dystrophic process (i.e., muscle death) or inflammation, but instead characteristic microscopic changes are seen in association with reduced contractile ability of the muscles.

Muscle dystrophiesVersus

Congenital myopathies

Mainly supportive – feeding , neurodevelopment

Physiotherapy

Specific treatment – Pompe disease ( enzyme replacement therapy )

Management

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