Pediatric Primary Care Case Studies (8 page)

Children with CP who receive no interventions have poorer functional abilities. Developmentally they make less progress and are at increased risk for contractures and deformities (Blosser & Reider-Demer, 2009). A common secondary complication of CP is hip subluxation. Increased tone causes muscular forces to be unbalanced, which can lead to structural straightening of the femoral neck (Alderman, 2001).

The prognosis of CP is uncertain in nearly all children at the time of diagnosis, particularly with respect to specific outcomes such as functional ability, language, or cognitive ability. CP does not become worse or better over time; however, it poses different kinds of problems at different stages of life. Treatments have to be changed and adjusted as the person grows older. Ongoing medical care is indicated at every stage of the disorder.

CP itself is generally not a cause of death; however, it can shorten a person’s life span for other, related reasons. Lung infections that can lead to pneumonia and other diseases are more common among people with CP. Poor nutrition can also contribute to the incidence of infections in this population.

The intellectual potential of a child born with CP often will not be known until the child starts school. People with CP are more likely to have some type of learning disability. The ability to live independently with CP also varies widely depending on the severity of the disability. Some individuals with CP will require assistance for all activities of daily living whereas others can live semi-independently, needing support only for certain activities. Still others can live in complete independence.

Is cerebral palsy preventable?

Preventive measures are aimed at improving prenatal care by routinely testing pregnant women for Rh factor in order to prevent blood incompatibility. Additionally, newborn jaundice is being treated by photo therapy in order to prevent severe brain damage from kernicterus. Other preventive programs are focused on preventing prematurity, reducing exposure of pregnant women to infections, and reducing unnecessary exposure to X-rays. Measures also are being taken to control maternal diabetes, anemia, and other nutritional deficiencies.

What resources are available for healthcare providers and families?

Parents whose child has been diagnosed with CP often ask questions that involve concern and anxiety about their child’s future. Families face many challenging demands, including both emotional and physical. Meeting the challenges of a disability requires families to rely upon their inner strength and the support of others. Equally important are the support and services the family and child receive from educational and other social service agencies.

Services for children with disabilities are now mandated from birth to 21 years under the Individuals with Disabilities Education Act (IDEA). IDEA requires that families be involved with the planning, development, and implementation of services throughout a child’s life. IDEA helps families in the development of an individualized family services plan (IFSP). Starting at age 3, an individualized education program (IEP) should be developed for children who previously had an IFSP. The IEP focuses on long-term goals and objectives for educating the child. Children with disabilities (including infants and toddlers) are entitled to receive special education and related services based on their individual needs, which are determined by an assessment and evaluation. Gross motor delays alone may grant eligibility for Supplemental Security Income, which, in turn, may (in most states) provide Medicaid eligibility (United Cerebral Palsy, 2008). The financial resources available for this family, which is only in the country temporarily, is less positive. What support might be available through the home country is an area the family could explore.

Key Points from the Case

1. Recognize delays early through periodic developmental screening.

2. Hear and interpret parental concerns.

3. Coordinate the family’s access to services and additional referrals for specialty care and treatment.

4. Be aware of cultural beliefs and practices in regards to treatment.

5. Advocate for the patient and family and offer ongoing emotional support

REFERENCES

Alderman, A. (2001). The physically challenged child. In C. Green-Hernandez, J. K. Singleton, & D. Z. Aronson (Eds.),
Primary care pediatrics
(pp. 217–228). Philadelphia, PA: Lippincott, Williams & Wilkins.

American Academy of Pediatrics. (1997). Committee on community health services. Health care for children of immigrant families.
Pediatrics, 100
(1), 153–156.

Blosser, C. G., & Reider-Demer, M. (2009). Neurologic disorders. In C. Burns, A. Dunn, M. Brady, N. Starr, & C. G. Blosser (Eds.),
Pediatric primary care
(pp. 634–672). St. Louis, MO: Elsevier.

Deloian, B., & Berry, A. (2009). Developmental management in pediatric primary care. In C. Burns, A. Dunn, M. Brady, N. Starr, & C. G. Blosser (Eds.),
Pediatric primary care
(pp. 53–70). St. Louis, MO: Elsevier.

Feldman, H. M. (2002). Developmental-behavioral pediatrics. In B. J. Zitelli & H. W. Davis (Eds.),
Atlas of pediatric physical diagnosis
(4th ed., pp. 58–86). Philadelphia, PA: Mosby.

Kimball, R. D. (2001). Healthy growth and development of the newborn/infant. In C. Green-Hernandez, J. K. Singleton, & D. Z. Aronson (Eds.),
Primary care pediatrics
(p. 93–128). Philadelphia, PA: Lippincott Williams & Wilkins.

Krigger, K. W. (2006). Cerebral palsy: An overview.
American Family Physician, 73
(1), 91–100.

LaHood, A., & Bryant, C. (2007). Outpatient care of the premature infant.
American Family Physician, 76
(8), 1159–1164.

Tervo, R. (2003). Identifying patterns of developmental delays can help diagnose neurodevelopmental disorders.
A Pediatric Perspective, 12
(3), 1–6.

United Cerebral Palsy. (2008).
Cerebral palsy—facts & figures
. Retrieved October 19, 2008, from
http://www.ucp.org/ucp_channeldoc.cfm/1/11/10427/10427/447

U.S. National Center for Health Statistics. (2009). Births: Final data for 2006.
National Vital Statistics Reports 57
(7), 1-101. Retrieved March 18, 2009, from
www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf

Wilson Jones, M., Morgan, E., & Shelton, J. (2007). Primary care of the child with cerebral palsy: A review of systems (Part II).
Journal of Pediatric Health Care, 21
(4), 226–237.

Wilson Jones, M., Morgan, E., Shelton, J., & Thorogood, C. (2007). Cerebral palsy: Introduction and diagnosis (Part I).
Journal of Pediatric Health Care, 21
(3), 146–152.

Chapter 3

A Toddler with Language and Social Delays

Brian T. Maurer

The ability to perform a thorough toddler developmental assessment is an essential skill that needs to be cultivated by all pediatric healthcare providers. Particularly disturbing is the child who isn’t beginning to talk, because language development provides a window that reflects cognitive development. The provider needs to identify problems as early as possible in order to begin necessary interventions. The farther behind the child becomes, the more difficult it will be to bring him or her into the normal range again because normal children are progressing rapidly at this time. Currently, children with language and social delays are appearing all too often in primary care practices, and many parents are frightened of the possibility of autism as a diagnosis for their once normal-appearing child whose language is now delayed.

Educational Objectives

1.   Review the developmental milestones for toddlers.

2.   Describe the screening and assessment strategies to identify a child with language and social delays and a child who needs to be screened for autism.

3.   Describe the primary care provider’s role in coordination of services and family support for children with autism or other developmental delays.

   Case Presentation and Discussion

Ms. Jones brings her twin boys into the office for their 18-month well child visit. Peter and James are fraternal twins, born vaginally at 36 weeks gestation. To date, with the exception of several minor colds, both boys have enjoyed good health. A quick review of the records shows that both boys have grown well, although Peter ranks slightly higher in his growth parameters (height, weight, and head circumference) than James.

You greet Ms. Jones as you enter the exam room and begin to explore the boys’ developmental progress with several open-ended questions, knowing that developmental surveillance is a recommended part of all well child visits, especially at the 9-, 18-, and 30-month visits. Furthermore, you are aware of the American Academy of
Pediatrics’ recommendations to use an autism-specific screen at the 18-month visit (American Academy of Pediatrics [AAP], 2006).

Toddler and Preschooler Development

What specific developmental milestones should be sought out at the 18-month visit?

Speech and expressive language skills begin to emerge by 15 months of age. Most toddlers engage in active jargoning, laying down underlying speech patterns through vocal inflection and intonation, by their first birthday. In addition, many 15-month-olds use the words “dada” and “mama” specifically to indicate their father and mother, as well as three other words. They also engage in verbal play, pointing to body parts when named and producing animal sounds when asked. The child with no documented expressive speech at 16 months of age is delayed in this area. By 18 months of age, most toddlers will have a vocabulary of 15–20 words. Additional developmental milestones are delineated in
Table 3-1
.

Given that these twins are fraternal, would you expect to find any marked differences in their development?