Pediatric Primary Care Case Studies (4 page)

4. A variety of complicating contextual factors makes assessment and management more difficult: developmental issues, family issues, comorbidities, and cultural variables.

5. Management should consider three basic elements: diagnostic, therapeutic, and educational plans, though not all will be necessary for a given patient.

6. Primary care providers need to use other specialists in a variety of healthcare, mental health, and educational fields to support and provide the care necessary to maximize the health of children and families in their practices.

REFERENCES

Burns, C. (2009). Child and family health assessment. In C. Burns, A. Dunn, M. Brady, N. Starr, & C. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 12–40). St. Louis: Elsevier.

Burns, C. (1992a). A new assessment model and tool for nurse practitioners.
Journal of Pediatric Health Care, 6
, 73–81.

Burns C. (1992b). Using a comprehensive taxonomy of diagnoses to describe the practice of pediatric nurse practitioners: Findings of a field study.
Journal of Pediatric Health Care, 7
, 115–121,

Burns, C. (1991a). Development and content validity testing of a comprehensive classification of diagnoses for use by pediatric nurse practitioners.
Nursing Diagnosis, 2
, 93–104.

Burns, C. (1991b). Parallels between research and diagnosis: The reliability and validity issues of clinical practice.
Nursing Practice, 16
, 42–50.

UNIT 1

Developmental Problems

Chapter 2

An Infant with Gross Motor Delays

Elissa Jones-Hua

A child’s acquisition of developmental milestones is a dynamic process, and early identification of infants and children with developmental delays is an important facet of primary care practice. Appropriate data collection, consideration of alternative diagnoses, and development of an individualized plan of care are important components, just as with management of diseases. Early identification of at-risk infants and children should lead to early intervention; delays may harm the child. The problem for the provider is deciding when early gaps in developmental progress merit added attention and perhaps referral versus patience with hope for gains that will keep the child within normal limits.

Educational Objectives

1.   List the five categories of developmental milestones.

2.   Identify at least three risk factors that contribute to developmental delays.

3.   Identify abnormal persistence of primitive reflexes.

4.   Describe the management of an infant with a motor delay.

   Case Presentation and Discussion

Maya Conteh is a 9-month-old African female who comes to your outreach clinic for an initial evaluation. She is accompanied by her mother who speaks Arabic and English. The mother is concerned that Maya is not developing like other children her age. The family emigrated from Sudan one year ago and now lives in low-income student housing because the father is in graduate school. This is their first child. The maternal grandparents are also temporarily living in the household and help out with Maya.

What questions will you ask Maya’s mother related to her concerns?

Your review of Maya’s birth history reveals the following information: Maya was born 11 weeks early and weighed only 2½ pounds. According to the mother, the doctors were surprised to see what a strong and active girl she was. However, when Maya was just a few days old, she stopped breathing and was put on a ventilator. After 24 hours she was able to breathe on her own. According to the mother, the doctors ran a myriad of tests to
find out what had happened, but they couldn’t find anything wrong. The remainder of Maya’s time in the hospital was uneventful and she went home after 2 months.

Once at home, Maya’s mother noticed that she drooled and choked easily when she drank from her bottle. As months went by, Maya’s mother noticed other things that were odd. Maya couldn’t hold her head up straight, roll, or sit with support. In fact, she still can’t do these things. She cries a lot and becomes stiff with rage.

What other questions do you need to ask?

Before answering this question, here is some more information about child development and acquisition of developmental milestones that you need to consider.

Development of Infants

Development is divided into five categories: gross motor, fine motor, language, cognition, and social/emotional growth. Refer to
Table 2-1
for a summary of infant developmental milestones by age in months.

Gross Motor Development

Gross motor skills occur in a typical sequence. The three general patterns of physical development are development occurs in a head to foot progression, strength and coordination of the limbs begin close to the body and move outward, and motor responses proceed from general to specific (Deloian & Berry, 2009).

Reflexes govern much of an infant’s behavior during the first 3 months of life. As the newborn reflexes fade, more purposeful movements replace them. Gaining strength and coordination in their muscles allows infants to explore and manipulate objects in their environment. A typical infant follows a known developmental progression, which starts at birth. A summary of primitive reflexes is found in
Table 2-2
.

Gross motor skills require large muscles or groups of muscles in order to carry out activities. When performing a task, these muscles should act in a coordinated way to accomplish a movement. An important element to consider when assessing gross motor skills is posture. Poor posture makes purposeful movements more difficult to perform. Examples of gross motor tasks in infancy are head control, sitting, rolling over, standing, crawling, and walking.

Tone is an important element in motor skills development. Muscular tone is the basic and constant ongoing contraction or muscular activity in the muscles. The three categories of tone are normal, hypotonic (decreased muscle tone), and hypertonic (increased muscle tone). Infants and children who are hypotonic appear floppy, similar to a rag doll. Hypotonic infants have difficulty maintaining posture against gravity. They often prefer to sit, lie on the floor, or lean against something. In contrast, infants and children with hypertonia appear stiff and do not move in a smooth, natural manner. An abnormality in muscular tone is a component of impaired motor skills. Infants and children with abnormal tone expend an enormous amount of energy to carry out movements and maintain postures (Alderman, 2001).

Table 2–1 Developmental Milestones for Infants (Birth–12 months)

Table 2–2 Primitive Reflexes

Some causes of gross motor delays include the following conditions: birth trauma, chromosomal abnormalities, inborn errors of metabolism, mitochondrial disorders, brain tumor, hypothyroidism, muscular dystrophies, abuse or neglect, sensory deprivation, shaken baby syndrome, sepsis, malnutrition or starvation, fetal alcohol syndrome, Werdnig-Hoffman disease, and lead or mercury poisoning.

Oro-Motor Development

Oro-motor development sometimes is considered a part of fine motor development because it requires the use of small muscles in a delicately coordinated fashion. Children with problems of drooling, choking, chewing, swallowing, and speech generally have neurological impairments in the area of the brain that controls these functions.

Developmental Delays

Multiple studies have established typical chronological ages at which specific milestones are reached, though with wide ranges. Influences from the social environment, nutrition, disease, and psychologic factors all interact with genetic factors to determine the speed and pattern of development. Individual differences in development are also strongly affected by opportunities to observe and practice specific movements. When children have not reached developmental milestones by the expected time period, they are considered to be developmentally delayed.

Motor delays in children are recognized when the child has a 25% delay in one area of typical development, such as gross motor (Wilson Jones, Morgan, Shelton, & Thorogood, 2007); for example, at 8 months the infant fails to do what a 6-month-old can do. Delays can occur in all five areas of development or may occur in one or two areas. Early motor delays are often a sign of neurological dysfunction.

Epidemiology

At least 8% of all preschool children from birth to 6 years have developmental problems and demonstrate delays in one or more developmental areas (Tervo, 2003).