Neurodevelopment in children and .2-1.pptx

Developmental delay and normal neurodevelopment in children

1. Dr. Sarfaraz Ahmad Assistant Professor Pediatrics MMIMSR Neurodevelopment and developmental delay In Children

2. Growth vs Development Growth refers to an increase in physical size of the whole body or any of its parts. It is a net increase in the size or mass of tissues. It is simply a quantitative change & can be measured in physical units like Kg,centimeters, inches. Development : specifies the maturation of body functions.It is related to the maturation and myelination of the nervous system. It indicates the acquisition of various skills for optimal functioning of the body.It is a sequence of physical,hearing,vision, language,cognitive,social,behavioural and emotional changes that occur from birth to adulthood. It is a qualitative change in body functions. It can be measured through observation and assessment.

3. Physiological basis of neurodevelopment Development reflects the increase in brain size,formation of neuronal synapses and myelination. Neonatal brain is approximately 70-75% of adult brain size. No. of neurons increases with age and adult brain has approximately 100 billion neurons. Approximately 80-90 % of brain maturation is complete by 2 years of life and rest 10-20% is completed by 5 years. Each neurons make up approximately 15000 synaptic connections by 3 years of age . Formation of new neuronal synapses and myelination are essential for neurodevelopment.Consistent and appropriate stimulation leads to formation of new functional neuron connection networks ( plasticity) - prominent during early preschool years. Whereas deprivation of stimulation leads to loss of connections ( pruning) which can lead to neurodevelopment impairment. Myelination starts later in pregnancy and is complete by adulthood.

4. Laws of neuro-development Development is a continuous process,starting in-utero and progressing untill adulthood. It depends on the functional maturation & myelination of the nervous system. The sequence of attainment of skills is same in all the children . However, variation may exist in the rate of attainment . It progresses in cephalocaudal direction & proximal to distal directions. The attainment of certain skills requires that the relevant neonatal primitive reflexes dissappear. Specific actions replace the initial disorganized mass activity.

5. Factors affecting Neurodevelopment Prenatal factors: Genetic disorders like chromosomal abnormalities(down syndrome),single gene defects(congenital deafness)and metabolic disorders(phenylketonuria)can cause developmental delay. Maternal factors during in-utero period like maternal malnutrition, exposure to drugs,Teratogens and toxins,maternal diseases(Placental dysfunctions,hypothyroidism, anemia) & infections,impair brain growth causing developmental disability. Neonatal factors: Small for gestation age(SGA) & Prematurity (<37weeks). Perinatal asphyxia. Hyperbilirubinemia( Neonatal jaundice),infections, CVA.

6. Factors affecting neurodevelopment Postneonatal factors( birth to < 5 years): Infant & child nutrition:Severe calorie or nutrient deficiency, Congenital hypothyroidism and anemia are known causes of delayed development. Infectious like diarrhea, malaria, HIV ,parasitic infections, meningitis, encephalitis, brain trauma, CVA and near drowning can cause developmental delay. Environmental toxins exposure(also in utero). Sensory impairments during early childhood. Psychosocial factors: Parenting, nurturing conditions,violence and abuse,maternal depression ,poverty and institutional care ,can influence the neurodevelopment in children.

7. Nature vs Nurture A child's development is shaped by the interplay of brain nature (genetics) and nurture (environment), with epigenetics showing that environment can influence genes across generations. For optimal development, children need a secure, loving, and responsive environment tailored to their age: infants rely entirely on parents for physical needs and prefer few caregivers, primary school children can handle some physical needs and social interactions, and young people manage most physical needs but face complex social and emotional challenges.

8. Developmental domins: Includes four areas of functional maturation Gross Motor: Sitting,posture, walking, jumping,running and overall large muscle movements. Vision and Fine Motor: Eye hand coordination, manipulation of small objects using small hand and finger muscles,oromoter coordination. Hearing ,speech & Language (Expressive and Receptive): Hearing, understanding, and using language. Social (including self-care skills), cognitive,emotional and behavioural. Getting along with people and caring for personal needs.

9. Developmental milestones Chronological age, growth and development usually progress together. Just as there are normal ranges for growth, so there are for development. Important and easily identifiable skills during the continuous process of development are called as developmental milestones. E.g: head controll,turning over,sitting without support,reaching for objects,speaking words. The median age indicates when half of a population of children typically achieve a developmental milestone, serving as a general guide but not defining normalcy. The red flag age is the age by which a milestone should be reached; missing it prompts further assessment to determine if investigation or intervention is needed.

10. Clinical Assessment of development The main objectives of assessing a young child’s development are to confirm normal developmental progress or detect delayed development early in order to: Help the child achieve their maximum functional potential. Provide treatment or therapy promptly (particularly important for impairment of hearing and vision). Act as an entry point for the investigation, care and management of the child with special needs. In the preschool years,development is monitored: By parents, who are provided with guidance about normal development in their child’s Personal Child Health Record At regular child health surveillance checks. Whenever a young child is seen by a healthcare professional. In Older children development assessment includes inputs from school teacher

11. TOOLS NEEDED: 1. Red yarn pom pom wool ball 2. Bright color cubes 3. Rattle with narrow handle 4. Raisins 5. Cup, spoon 6. A 4 size paper 7. Big size color pencils 7. Picture cards, multiple picture books (like bird, fish, dog, bus, fruits etc) on same page, 8. Tennis ball 9. Small doll 10. Bell 11. Stickers, sweets for rewards

12. Developmental Assessment Gross motor At birth: Flexion attitude,symmetrical,head lag 3months: head support starts,complete by 4 months 6months: Sits momentary with round back, Supported by his arms,tripod

13. Gross motor 8months: Sits alone,without support, back straight 8-10months: Crawl > creep,cruises around furniture . 12months:Walks supported with One hand held Walks unsteadily, broad gait, hands apart

14. Gross motor 13-15months:Walks alone well & steadily 18months:-Seats himself in a small chair. -Ascend stairs With: One hand held. Runs ,explores drawers 24months:Runs Well. Ascends stairs alone With: 1 step at time ,Jumps

15. Gross motor 30 months:Ascends stairs: With Alternate feet. 3 years: Rides and pedals tricycle 4. descend stairs with alternate steps,hops on one foot 5 years- skips

16. Vision Follows moving object or face by turning the head at 6 weeks upto 90 degrees. They may have a transient squint Upto 3 months. By 7 months of age a baby can pick up and transfer toys from one hand to another; By 12 months they can pick up a 1-mm ’hundreds-and-thousands’ cake sprinkle. Clarity of vision matures; visual acuity improves from 6/200 at birth to 6/60 at 3 months and 6/6 at 5 years of age. Any obstruction to visual acuity, e.g. from a refractive error or cataract, will interfere with the normal development of the optic pathways and visual cortex unless corrected early in life. This type of visual loss is called amblyopia and can be permanent. Conjugated eye gaze and eye contact. No rowing eye movement, No squint, No nystagmus. Check red reflex(at birth & 6 wks) & white reflex. 6 weeks :follows moving objects At birth: blinks to flashing lights

17. Fine Motor: 3months:Opens hands spontaneously. Holds rattles 6-7months: tansfers objects from one hand To Another

18. Fine motor 8-9 months:( inferior Pincer Grasp) 18months:Builds tower of 3 cubes,scribbles Mature pincer :10-12 months

19. Fine motor

20. Hearing By 25–26 weeks’ gestation, a fetus responds to sounds, and at birth startles at loud noises. Early detection and treatment of hearing impairment improves the outcome of speech, language and behaviour. Newborn hearing screening is performed for early identification of hearing loss by AOAE and AABR. Referral criteria: any parental or professional concern about hearing , whenever there is speech and language delay, in global developmental delay,after significant head injury or skull base fracture, bacterial meningitis,if genetic syndrome associated with hearing loss is identified,if congenital infection, particularly congenital CMV, is diagnosed

21. Speech and Language: 6 months: Monosyllables- Ba, da, pa.

22. Language 4 years- tells stories 5 years - asks meaning of words

23. Social ,emotional and behavioural milestones 6months: Stranger anxiety

24. Social,emotional and behavioural milestones 5 years: helps in household tasks,dresses ,undresses

25. Primitive Reflexes

26. Developmental disorders Motor developmental delay. Global developmental delay. Autism spectrum disorders. ADHD. Learning Disabilities/ID. Specific learning disabilities. Cognitive impairment. Development coordination disorder. Hearing and vision impairments. Speech,language and communication delay

27. Developmental assessment Schedule Development screening/ assessment is done on each pediatric clinic encounter during 1st 5 years of life . Ideally at 1 ,2,4,6,9,12,15,18 months,2years,2.5 years,3 years,4 years and 5 years. Various development screening tests or clinical developmental milestones assessment and neurological examination are done to calculate DQ and define development status. Those children with developmental delay are assessed to find the cause and define treatment or referral. Developmental assessment and screening gives us developmental quotient ((DQ). DQ is calculated for each domain and DQ<70% is defined as delay in that domain.

28. Developmental Quotient Developmental delay is defined as delay in one or more developmental domains. Delay in two or more than two domains is called as global developmental delay whereas delay in only one domain is named as isolated developmental delay. Developmental assessment and screening gives us developmental quotient ((DQ): DQ is calculated for each domain and DQ<70% is defined as delay in that domain.

29. Causes of developmental delay / disorders

30. Approach to Developmental Delay( History) Assess to determine cause and management. Presentation Across Ages: Increasingly recognized antenatally. Neonatal period: Identified via abnormal neurology or dysmorphic features. Infancy/Early Childhood: Motor & vision problems: First 18 months. Speech/language issues: 18 months–3 years. Social/communication disorders: 2–4 years. Detailed developmental history. Prenatal, perinatal, postnatal events, including maternal health. Personal Child Health Record: Includes pregnancy, delivery, Apgar scores, birth metrics, newborn tests( metabolic screening), neonatal history,early childhood diseases. Comprehensive environmental, social, and family history: Focus on consanguinity, developmental problems, or learning difficulties (may indicate metabolic or genetic conditions).

31. Approach to Developmental Delay(examination) Growth parameters: Weight, height, head circumference (plot on centile chart – microcephaly/macrocephaly). Dysmorphic features: Family resemblance, unusual features(Down’s and other Trisomy, Fragile X.), abnormal body proportions. Skin abnormalities: Café-au-lait patches, axillary freckling → Neurofibromatosis Hypopigmented patches (ash-leaf macules) → Tuberous sclerosis Neurological observation: Movements, gait, running, signs of unsteadiness, asymmetry, weakness, spasticity Examine tone, power & reflexes. Examine back for spina bifida occulta.

32. Examination Motor abilities: Sitting, standing from supine, clearing floor on jumping → muscle weakness (e.g. muscular dystrophy). Eye examination: Eye movements, cataracts, nystagmus/wobbly movements → vision/neurological disorders,cataracts, refractive errors. Ear exam for recurrent/chronic OM ,secretory OM,Hearing loss. Tongue,oral cavity and palate examination Cardiovascular exam: Abnormalities linked to dysmorphic syndromes Abdominal exam: Hepatomegaly → metabolic or storage disorders

33. Evaluation & Investigations Baseline biochemical and pathological tests. Toxin levels and vitamin and mineral levels as indicated. Metabolic screening for IEMs. Neuroimaging (MRI vs CT) depending on neurologic findings and history. Thyroid function testing. Muscle enzymes CK, LDH. TMS-GCMS Genetics : Karyotyping, Chromosomal/Cytogenetic Testing . Genome sequencing, DD panels. EEG if suspected seizure activity/encephalopathy (Landau-Kleffner)/ EMG/ NCV.

34. Management approach Prevention of developmental delay depends on genetic counselling > good antenatal care>optimal case management at delivery > proper postnatal care>breastfeeding and prevention of infections,malnutrition, and insult to developing brain upto 2 years (1000 days concept by WHO) minimum,early correction of visual and hearing impairments. Early stimulation. Nurturing care(WHO) for optimal early childhood development: Involving good health, adequate nutrition,responsive caregiving, opportunities for early learning. Child guidance clinics : Multidisciplinary clinics to provide diagnostic and therapeutic services to children with developmental disorders, intellectual disability,learning disabilities and behavioural disorders. Effective Parenting using MCP card. Avoidance or proper usage of TV, mobile phones and media.

35. Treatment Treat underlying causes if treatable. Multidisciplinary treatment. Speech and Language therapy Treatment of hearing and visual impairments. Occupational and Physical Therapy Social Worker and parenteral involvement Psychological evaluation if needed Educational facilitator and special schooling Focus on need for services rather than diagnosis

36. Red flags and referral criteria

37. THANKS FOR YOUR ATTENTION