NEUROLOGY: Early detection of neuromotor disorders

Garey Noritz, MD, presented information on a clinical algorithm developed by the AAP to help guide pediatricians on screening and workup of children with suspected motor delays. The algorithm is included in a clinical report authored by an expert panel. The report and algorithm were created following assessments by focus groups that found that pediatricians needed guidance on motor development delay issues.

During the session titled “Early Detection of Neuromotor Disorders: Do We Know What to Look For?”, Noritz described the algorithm and emphasized key recommendations for pediatricians:

• Implement screening for all developmental delays including motor delays;

• Carefully assess the child’s tone using a validated screening instrument;

• Begin the initial workup for neuromotor delay in their practice;

• Check creatine kinase (CK) and thyroid-stimulating hormone levels in a child with low or normal tone;

• Order magnetic resonance imaging (MRI) of the brain in a child with increased tone;

• Refer the child for diagnosis and treatment simultaneously; and

• Look for red flags to determine which children with neuromotor delay need expedited referral to a specialist.

The red flags, he said, are identified in the algorithm and include: elevated CK levels to greater than 3 times the normal values; fasciculations; signs of facial dysmorphism, organomegaly, heart failure, and early joint contractures; abnormalities on brain MRI; respiratory insufficiency with generalized weakness; loss of motor milestones; and motor delays present during minor acute illness.

Garey Noritz, MD, FAAP, is a pediatrician at Nationwide Children’s Hospital, Columbus, Ohio.

The most helpful aspect of this AAP clinical report may be its expert guidance on how to perform a proper general and neuromotor exam and what red flags should necessitate a prompt referral to an appropriate medical subspecialist and an early intervention (EI) or early childhood special education (ECSE) agency. Whether evaluating a young child in the clinic or hospital setting, all pediatric providers need to know how to correctly assess muscle tone. Routinely ask yourself: Does this child have high, normal, or low muscle tone? Furthermore, all providers should be aware of the initial diagnostic approaches that this clinical report is recommending-approaches that vary based the child's muscle tone. 

Each clinician's general and neuromotor exam, along with the many other components of their less structured surveillance, must be thoughtfully combined with the results of a psychometrically sound (but also feasible) broadband/general screening instrument at 9, 18, 24 or 30, and 48 months plus as needed whenever developmental risk factors (eg, prematurity, low birth weight, in utero drug exposure, abnormal growth curve for head circumference) are present. Experts agree that false-negative screening results can be averted by using screening tools in combination with a good history and physical exam. For example, if the child's screening result is typical or borderline but your neuromotor exam is abnormal, then you should refer to an appropriate subspecialist and EI/ECSE. 

Kevin P. Marks, MD, PeaceHealth Medical Group, Eugene, Oregon.