In this post, I link to and excerpt from PedsCases’ Gross Motor Delay, by Devika Singh Jun, 27, 2022.
All that follows is from the above podcast and show notes.
This podcast will discuss gross motor delay. By the end of this podcast, learners should be able to recognize normal motor developmental milestones in children, develop a differential diagnosis, identify key tests and investigations to clarify the etiology and discuss the management options for gross motor delay. It was developed by Devika Singh, a second-year medical student at the Michael G. DeGroote School of Medicine at McMaster University, in collaboration with Dr. Lyn Sonnenberg, a Neurodevelopmental Pediatrician at the University of Alberta, where she is also the Associate Dean of Educational Innovation & Academic Technologies.
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The script for this episode has not been posted (404 error).What follow is a transcript I made.
Gross motor development refers to the movement and coordination of large muscles in the body, such as the legs, arms and torso.
Gross motor activities are important for physical activities like crawling, walking, running, jumping, etcetera. In this podcast, we will be specifically discussing an approach to gross motor delay.
You are working at a pediatrician’s office, when you see an 18-month-old girl named Korea K or K referred to you by her family doctor, you first year view her prenatal and postnatal history and note that she was born via spontaneous vaginal delivery at 38 weeks gestation. Following a birth complicated by Corio Ammonites, her newborn metabolic screening test was normal, her immunizations are up-to-date and she does not have any known allergies, her height, weight and head circumference have all been trending around the 50th percentile.
When playing with other children at the park in a daycare, her parents have noted that she does not seem to be the same levels or peers, specifically Korea has not started walking yet, they’re worried that she is a bit delayed.
Her parents have tried their best to coach her by holding her hand while walking, but it doesn’t seem to be working, she prefers to roll from her back or stomach in one direction, and has only recently started to pull herself to stand. Korea is trying her best to stand unassisted, but still needs to hold on to furniture or in adults hand.
Her parents mentioned that she has preferred to use the right hand since six months of age, but are not concerned since they are both right-handed.
They are not concerned about her cognition or communication as she is able to combine a few words and responds when spoken to you, although it’s a bit difficult to understand. The parents mentioned that there are two other children and were both able to walk before 18 months and they had no concerns with their development. They’re not aware of any developmental concerns for any other family members.
On physical examination, you watch her pull the stand, but she holds on to the chair for balance and is unable to take independent steps.
You notice that she is up on her toes on the left side, on the left hand appears more fisted compared to the right, her gastronomic muscle is tight with decreased range of motion at the left ankle or patella. Brachial, triceps and brachioradial reflexes are all three plus on the left and two plus on the right, indicating that she is hyper-relexic on the left side. Her plantar responses are up going on the left and down going on the right, there are no dysmorphic facial features.
0:04:09.4 S2: The rest of her physical examination is unmarked developmentally when engaging with her, she smells, but you can’t quite make out what she’s trying to say When offer deter on her left, she crosses her midline and reaches for it with her right hand, her parents are concerned that she’s not meeting her gross motor developmental milestones and his far behind children of the same age, you believe that she has a gross motor delay.
So what are the next steps?
So before we can recognize a gross motor delay, it’s important to understand the normal motor developmental of most children andt also review some red flags along the way
At two months, children should be able to lift their head and neck when lying on their front during tummy time.
At four months children should be able to roll over from their stomach to back and prop themselves up on their wrists and elbows when lying on their front.
At Six months, children should roll from back to stomach and sit.
A memory aid you can use is that children should be half upright by half a year.
it’s also a red flag if children do not have had control by this time,.
At nine months, they should be able to pull to stand using furniture and start crawling using any foreign mobility pattern, like for point command or BOM shuffling. these are all typical gross motor milestones. red flags at this age include a child unable to role both ways and not able to sit upright independently .
And by 12 months, children should be able to walk. Remember this by thinking first birthday, first steps. Remember, however, that there is some variation and it is not considered a red flag if they’re not walking quite yet.
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At 15 months most children should be able to walk.
It is a red flag if children are not able to pull to stand by 15 months.
By 18 months, most children should be able to walk upstairs while holding your hand or the railing. If children are not able to walk by this age, then it is a significant red flag.
At two years of age, they should be able to walk unassisted, skip, run and jump.
Remember that at two years old, they should have two feet off the ground, they may also be able to scoot along on a bike or a scooter using their feet as opposed to the pedals. They should also be able to pick toys off the floor and stand back up.
At two years, children can usually go up and down the stairs by holding onto the rail or a wall, or by holding someone’s hand, you can remember this by thinking two years… Two feet on the steps.
And at three years, children should be able to climb on and off furniture and use scooters or tricycles. A useful memory aid is: three wheels, three years. They should also be able to run, jump, balance on one foot and walk backwards, they can now catch and throw a ball.
Lastly at age four, children can walk up the stairs unassisted, alternating feet and can also run and jump and skip.
Now that we are familiar with normal motor developmental milestones, let’s discuss some possible causes of gross motor delay, there are many causes of gross motor delay, but we will cover the most common ones.
Cerebral palsy is the first. Cerebral palsy is a disorder that occurs as a result of damage to the developing brain, symptoms and signs include impaired movement and posture, including asymmetries such as early hand preference, decreased or increased tone, spasticity and or dystonia along with delayed motor milestones, of course.
Number two is muscular dystrophy. Muscular dystrophy is a genetic condition that results in impaired protein production and muscle resulting in increased muscle mass and weakness, this change can often be noted first in the calf muscles with what is referred to as pseudo-hypertrophy. This condition mostly occurs in boys, it’s very important to order a CK which leaks out of the impaired muscle, if you suspect muscular dystrophy.
[The third cause is spina bifida.] The neural tube normally forms early by the 28th day, however, in infants with spina bifida, the neural tube doesn’t develop or close typically causing defects in the spinal cord and in the bones of the spine.
Number four is spinal muscular atrophy.* Spinal Muscular Atrophy is an inherited neuromuscular disease that impacts voluntary muscle movement.
*Link to emedicine.medscape.com article on spinal muscular atrophy:
The spinal muscular atrophies (SMAs) comprise a group of autosomal-recessive disorders characterized by progressive weakness of the lower motor neurons.
In the early 1890s, Werdnig and Hoffman described a disorder of progressive muscular weakness beginning in infancy that resulted in early death, though the age of death was variable. In pathologic terms, the disease was characterized by loss of anterior horn cells. The central role of lower motor neuron degeneration was confirmed in subsequent pathologic studies demonstrating a loss of anterior horn cells in the spinal cord and cranial nerve nuclei. [1]
Since then, several types of spinal muscular atrophies have been described based on age when accompanying clinical features appear. The most common types are acute infantile (SMA type I, or Werdnig-Hoffman disease), chronic infantile (SMA type II), chronic juvenile (SMA type III or Kugelberg-Welander disease), and adult onset (SMA type IV) forms.
The genetic defects associated with SMA types I-III are localized on chromosome 5q11.2-13.3. [2, 3, 4, 5]
Number five: Additional genetic syndromes such as Down syndrome. Down syndrome, also known as Trisomy 21, causes developmental differences in distinctive facial features, the severity of this condition varies, but it’s typically results in a mild to moderate Intellectual Disability and hypotonia, Down syndrome is also commonly associated with other medical conditions, such as disorders of the GI system and heart.
Number six: Nutritional deficiencies. Lack of nutrients can result in an insufficient amount of energy reaching the muscles leading to gross motor delay. However, you would likely see other effects of nutritional deficiencies as well, such as failure to thrive along with the delayed motor presentation.
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