MC is a 9-month-old African female who comes to your outreach family practice clinic for an initial evaluation. She is accompanied by her mother who speaks Arabic and English. The mother is concerned MC is not developing like other children her age. The family emigrated from Sudan one year ago through a church program. They now live 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 with MC.
Further Information:
Your review of MC’s birth history reveals the following information: MC was born 11 weeks early and weighed only 2 ½ pounds. According to the mother, the doctors were surprised to see what a strong and active girl she was. However, when MC 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 several tests to find out what had happened, but they couldn’t find anything wrong. The remainder of MC’s time in the hospital was uneventful and she went home after 2 months.
Once at home, MC’s mother noted that MC drooled and choked easily when she drank from her bottle. As months went by, MC’s mother noted other findings that were odd. MC 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.
MORE INFORMATION
The mother responds that she had limited access to prenatal care. She denies use of alcohol, cigarettes, or drugs. The pregnancy progressed normally except for onset of premature labor and rupture of membranes. MC spent 2 months in the NICU. Since discharge MC has not had any hospitalizations, surgeries, or injuries. MC is frequently congested and easily becomes ill with respiratory infections. The family history of diseases is unremarkable.
The infant is currently not taking any medications. She is behind in her immunizations because MC has not received her 6-month series. She previously received immunizations at a local health department, but medical care has been sporadic because the family moved shortly after MC came home from the NICU. The family has limited resources and has been unable to locate a primary care provider. Interim care has been obtained through multiple urgent visit clinics or emergency departments.
The mother gives MC baby formula (20cal/oz) and offers baby food two to three times daily. She believes MC doesn’t like the baby food because she frequently coughs while eating and/or drinking and drools a lot. As for elimination, the mother reports five wet diapers a day with a bowel movement consisting of balls of stool every other day. MC’s sleep has improved although she continues to wake during the night, crying and arching her back. The mother notes her legs become stiff.
Developmentally, MC has a social smile, makes a few vocalizations, and enjoys being held. She is able to pick up small objects with her hands but does not transfer them. The mother feels she makes good eye contact and tracks objects. Her motor and oromotor skills were described earlier.
Maya is cared for by her mother and grandparents during the day. The mother has a few neighbors with children of similar ages but does not share babysitting time or interact socially with them.
Questions
1.What part of the physical examination will be particularly important for this child?
- Dose MC have development delays for a 6-month corrected age infant? If so, in what areas?
- List the five categories of development milestones.
- Describe the management of an infant with a motor delay.
Title: Evaluation and Management of a 9-Month-Old Infant with Developmental Delays
Introduction
MC, a 9-month-old African female, has been brought to an outreach family practice clinic by her mother, who expresses concerns about her child’s developmental progress. MC’s family emigrated from Sudan a year ago through a church program, and they currently live in low-income student housing while the father pursues graduate studies. MC was born 11 weeks prematurely, weighing only 2 ½ pounds, and spent two months in the neonatal intensive care unit (NICU). This essay will address the importance of the physical examination, assess MC’s developmental delays, discuss the five categories of development milestones, and outline the management of an infant with motor delays.
- Importance of Physical Examination
Given MC’s complex medical history, a thorough physical examination is crucial. Particular attention should be paid to:
a. Neurological Examination: Assess MC’s muscle tone, strength, and reflexes. Evaluate for any signs of cerebral palsy or other neurological disorders.
b. Oromotor Examination: Examine MC’s mouth, tongue, and palate for structural abnormalities that may affect feeding and swallowing. Observe her while drinking and eating to assess for aspiration or choking risks.
c. Respiratory Examination: Investigate her frequent congestion and susceptibility to respiratory infections. Check for any signs of chronic respiratory conditions or anatomical issues.
d. Growth Assessment: Monitor MC’s growth parameters, including weight, length, and head circumference, to identify any failure to thrive.
e. Musculoskeletal Examination: Evaluate her posture, joint mobility, and muscle development to detect any abnormalities that could contribute to motor delays.
- Developmental Delays for a 6-Month Corrected Age Infant
MC’s corrected age should be considered, accounting for her prematurity. Developmentally, she does exhibit delays compared to a 6-month-old infant. Key areas of concern include:
a. Motor Skills: MC cannot hold her head up, roll, or sit with support, which are typical milestones achieved by most infants at this age.
b. Feeding and Oromotor Skills: She has difficulty with drinking, coughs during feeds, drools excessively, and shows signs of discomfort while eating, suggesting possible oromotor and feeding difficulties.
c. Behavioral Issues: MC’s excessive crying and stiffness could be indicative of irritability and difficulty self-soothing.
- Five Categories of Development Milestones
Developmental milestones are typically categorized into five areas:
a. Gross Motor Skills: These involve large muscle groups and include activities like rolling over, sitting, crawling, and walking.
b. Fine Motor Skills: These pertain to the use of small muscles and include activities such as grasping objects, transferring items from one hand to the other, and manipulating small objects.
c. Language and Communication Skills: This category encompasses an infant’s ability to babble, make vocalizations, respond to sounds, and eventually develop language.
d. Cognitive Skills: Cognitive milestones involve memory, problem-solving, and object permanence, which is the understanding that objects continue to exist even when out of sight.
e. Social and Emotional Skills: This includes forming attachments, recognizing and responding to familiar faces, and expressing emotions such as happiness, fear, and anger.
- Management of an Infant with Motor Delay
Management of an infant with motor delays involves a multidisciplinary approach, including:
a. Early Intervention: Referral to early intervention services is crucial for addressing developmental delays. Physical therapy, occupational therapy, and speech therapy may be needed to target specific areas of delay.
b. Comprehensive Medical Evaluation: MC should undergo a thorough medical evaluation to rule out any underlying medical conditions that may contribute to her developmental delays.
c. Nutritional Assessment: A feeding specialist should assess MC’s feeding difficulties to ensure she receives adequate nutrition and hydration.
d. Supportive Care: Providing the family with support and guidance is essential, given their limited resources and recent immigration. They may benefit from connecting with social services and support groups for parents of children with developmental delays.
e. Continuity of Care: Establishing a consistent source of primary care and immunizations for MC is crucial to monitor her health and development effectively.
Conclusion
MC, a 9-month-old infant with a complex medical history and developmental delays, requires comprehensive evaluation and management. A thorough physical examination, consideration of her corrected age, assessment of developmental milestones, and a multidisciplinary approach to intervention and support will be essential in helping her achieve her developmental potential. By addressing her unique needs and circumstances, healthcare providers can work collaboratively with MC’s family to ensure she receives the best possible care and support as she continues to grow and develop.