By Nuramalina Binti Yahaya (10-5-257)

DELAYED GROSS MOTOR DEVELOPMENT

It means Maturation of organ and system, Acquisition of function and new skill Ability of adaptation and assuming responsibilities

• It includes the posture and ability to control large body movement as crawling, sitting, standing

DEFINITION OF DEVELOPMENT

GROSS MOTOR DEVELOPMENT

Neurological Endocrinal factor as thyroid hormone and growth hormone Skeletal and muscular for postural and control precise

movement Environmental & socioeconomic; overcrowding Nutritional factors of mother and children during development Physical activities as bed ridden and hypoactive may have

delay development

FACTORS AFFECTING NORMAL GROSS MOTOR DEVELOPMENT

AGE GROSS MOTOR MLESTONES

Birth – 2 months Raises head slightly off floor or bed when on stomach.Holds head momentarily when supported

3 – 5 months Lifts head & chest when on stomachRolls from side to sidePushes with feetSits briefly with arm supportedMakes crawling movement

6 – 8 months Sits alone brieflyRolls from back to stomachStands with support

9 – 11 months Sits alone with trunk rotationCreeps or crawlPulls to standStand alone momentarily

GROSS MOTOR MILESTONES

AGE GROSS MOTOR MILESTONES

12 – 15 months Walks aloneCreeps up stairsCrawls up on chairAble to stand without support

16 – 18 months Creeps downstairsWalk sideway & backwayStands on one foot with helpKick large ball forward

19 – 24 months Squats in play & stand back upJumps in placeWalks up & down stairs aloneRuns well

• There is normal variation between individual. The ages mentioned in the table are average of the child but may have early or some delay in acquisition of new motor skills.•There are also sex differences as girls usually have early development as a whole from boys

1. Familial; Some delay may happen according in variation of every individual and sex differences.

2. Genetic; Trisomy 21 appears physical phenotype of down syndrome as mental retardation, hypotonia and other abnormalities of delay the development.

3. Skeletal disorder; Rickets manifest as hypotonia of muscles and laxity of ligament. The child may have bow legs and knock knees lead to delay sitting, standing and walking. Achondroplasia is a short-limbed dwarfism particularly have short stature with short upper arms and thighs that limiting the range of movement.

4. Nutritional disorder; Severe protein malnutrition either marasmus or kwashiorkor usually having muscle wasting which is hypotonic, weak and unable to stand or walk. The child is hypoactive and lack interest in surrounding.

ETIOLOGY OF DELAYED GROSS MOTOR MILESTONES

5. Systemic disorder; Congenital heart disease have poor systemic blood flow that lead to retarded growth and easily fatigue infant.

6. Perceptual disorder; blindness may interfere the normal pattern of gross motor development.

7. Environmental factors; emotional deprivation or lack of stimulation due to over protective parents.

8. CNS disorder; Cerebral palsy is non progressive, permanent impairment of

neuromuscular system leading to motor disorder of movement, posture and coordination. CP may manifests as paralysis of the limbs (hemiplegia or quadriplegia) that prevent movement of the limbs and will delay gross motor development of the child.

Mental handicap which have limitation in many adaptive skills and intellectual function.

9. Muscular disorder; any diseases that lead to myopathies and muscle dystrophy also delay the normal gross motor development of the child.

10. Metabolism; Phenylketonuria is the most common amino acid disorders which manifest as severe mental handicap. The child becomes hyperactive with purposeless movement, rocking and athetosis.

11. Endocrinal; Cretinism (hypothyroidism) child usually are sluggish physically and mentally. The child is passive and lies quietly with little interest in surrounding also with delayed developmental milestones, stunted height with long trunk and short legs.

NUR ZAKIAH BINTI ZAHARI 10-5-260

Prenatal history:

~important especially if there is any complication ( mother, baby ) ~TORCH,

Obstetrical history: ~difficulty during delivery eg: asyphyxia, seizure, ~ evaluate using APGAR scores Any sign of Infections (eg.GBS)

Past medical history and medications:~History of taking Ototoxic antibiotics for example Gentamicin, previous surgery and past delivery  

Behavior since birth: ~Behavioral disturbances ~abnormal behavior

Family history:~Relatives or sibling with developmental delay, genetic abnormalities, ~consanguinity 

Social History: ~Evidence of neglected or abuse

HISTORY

DIAGNOSTIC APPROACH

1) Physical examination 2) Investigation

DIAGNOSIS PHYSICAL EXAMINATION

Cerebral Palsy

HEAD, FACE & NECK: Delayed closure fontanel EXTREMITIES: Spastic quadriplegia, NEUROLOGICAL EXAMINATION: Hypotonia, Hypertonia,Dystonia, Muscle spasms, opisthotonusClonus – muscular spasms with regular contractions

o Ankle/foot clonus – spasmodic abnormal movement of the footo Wrist clonus – spasmodic movement of the hand

GAIT: Tip toe

Down Syndrome

HEAD, FACE & NECK: Flat occiput, Brushfield spots, hypertelorism, up slanting eye, epicanthic folds, Depressed nasal bridge, Abnormal hair whorls, delayed teething, Macroglossia. EXTREMITIES: Transverse palmar crease , Dry skin, Premature aging, Broad, short hands, feet, and digitsNEUROLOGICAL EXAMINATION: Neuromuscular hypotonia

Ricket HEAD, FACE & NECK: Delayed closure fontanel, Pseudotumor cerebri, Craniotabes (before 8-10month), delayed teething, frontal bossing. CHEST EXAMINATIO: Pigeon chest, rachitic rosary, Harrison groove NEUROLOGICAL EXAMINATION: Neuromuscular hypotonia

Protein Malnutrition

HEAD, FACE & NECK: Alopecia with dyspigmentation, old man face and sunken eye(marasmus), edematous cheek and edematous eyelid (kwashiorkor) EXTREMITIES: epiphyseal enlargement at wrist and ankles, marfan sign, bow leg, knock knee, severe muscle wasting(marasmus), edema (kwashiorkor), decrease skin elasticity ABDOMINAL EXAMINATION: Scaphoid abdomen

 Genetics:

Karyotyping FISH analysis  Endocrinology:

TSH, free T4 in case of hypothyroidism

Metabolic:

Metabolic screening – glucose, electrolytes, serum lactate, ammonia, liver function tests, pyruvate, albumin, triglycerides, uric acid, serum quantitative amino acids, urine organic acids, creatine phosphokinase (if suspecting myopathy), and calcium as in case of rickets or Protein energy malnutrition.  Neurology:

It can be EEG in case of affection of brain and mental retardation or head CT scan. While, X-Ray is useful especially in case of rickets that will show positive expanded ends of radius and ulna, rarefied and cup-shaped and the bone is poorly mineralized. While x-ray of the head will shows hair-standing-on-end which is a very characteristic sign. ECG is also of help to detect any congenital heart disease. Neurological test is also important.

INVESTIGATION

REFERENCES

Madkour Essentials of Pediatrics (Paediatrics, Members of the Department of Paediatrics Faculty Of Medicine- University Of Alexandria 12th Edition.

http://www.beststart.org/OnTrack_English/2-factors.html  http://www.brookshealth.org/motor-skills.pdf  http://education-portal.com/academy/lesson/what-are-gross-motor-skills-in-children-de

velopment-definition-examples.html#lesson  http://www.abilitypath.org/milestone-concerns/signs-of-possible-delays-gross-motor-an

d-sensory-development.html  http://www.healthline.com/symptom/developmental-delay  http://www.growingup.ie/fileadmin/user_upload/Conference_2010/Session_D_Factors_A

ffecting_Gross_Motor_Development_Outcomes.pdf

REFERENCES

REFERENCE:

1-Basic clinical Pediatrics, 2009, second edition Naseer Gamal2-Illustrated Textbook of Pediatrics, 2012, fourth international edition Tom Lissauer, Graham Clayden 3-Madkour’s Essential of pediatric, 2012 Prof. Ahmed A Madkour Members of Department of Pediatrics Faculty of Medicine- University of Alexandria Egypt4-http://www.healthline.com/symptom/developmental-delay5- http://emedicine.medscape.com/article/943216-clinical#a0256