A 9-month-old boy is brought to the office for a well-child visit. His parents are concerned that he has not been meeting milestones as quickly as his older brother. The patient has not started crawling and requires support from his parents to sit up. His mother states, "I think his lack of crawling is because he cannot roll over from his back to his stomach." The parents say that he sleeps well through the night and is a happy infant overall. The patient spits up occasionally after bottle feedings but less so than when he was a newborn. His diet is still primarily infant formula, but he has been self-feeding solid foods since age 6 months with no gagging or coughing. The patient was born at 35 weeks gestation via an uncomplicated delivery. Due to gestational age, the infant was observed in the neonatal intensive care unit; however, his stay was uneventful, and he was discharged from the hospital a week after delivery. Family history is negative for developmental delays or metabolic disorders; his 3-year-old brother is healthy with no chronic medical conditions. Height, weight, and head circumference are at the 75th percentile. The infant is alert and smiling and has no dysmorphic facial features. The anterior fontanelle is open and flat, and gaze is conjugate with no nystagmus. He reaches for small toys and laughs when they rattle. Musculoskeletal examination reveals increased tone in the bilateral lower extremities. When the infant is suspended by the axillae, his legs maintain a scissoring posture. Patellar reflexes are 3+. Sustained clonus is also noted in the ankles bilaterally. Which of the following is the best next step in management of this patient?

Question

A 9-month-old boy is brought to the office for a well-child visit.  His parents are concerned that he has not been meeting milestones as quickly as his older brother.  The patient has not started crawling and requires support from his parents to sit up.  His mother states, "I think his lack of crawling is because he cannot roll over from his back to his stomach."  The parents say that he sleeps well through the night and is a happy infant overall.  The patient spits up occasionally after bottle feedings but less so than when he was a newborn.  His diet is still primarily infant formula, but he has been self-feeding solid foods since age 6 months with no gagging or coughing.  The patient was born at 35 weeks gestation via an uncomplicated delivery.  Due to gestational age, the infant was observed in the neonatal intensive care unit; however, his stay was uneventful, and he was discharged from the hospital a week after delivery.  Family history is negative for developmental delays or metabolic disorders; his 3-year-old brother is healthy with no chronic medical conditions.  Height, weight, and head circumference are at the 75th percentile.  The infant is alert and smiling and has no dysmorphic facial features.  The anterior fontanelle is open and flat, and gaze is conjugate with no nystagmus.  He reaches for small toys and laughs when they rattle.  Musculoskeletal examination reveals increased tone in the bilateral lower extremities.  When the infant is suspended by the axillae, his legs maintain a scissoring posture.  Patellar reflexes are 3+.  Sustained clonus is also noted in the ankles bilaterally.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfec_a4bc_8f63_b18aba92da30_MD0005_00 Cerebral palsy (CP), a common complication of prematurity (birth at <37 weeks gestation), is characterized by an insult to the central nervous system resulting in nonprogressive motor dysfunction. Spastic CP, as seen in this infant, is the most common subtype. Early signs of CP include the delayed disappearance of neonatal reflexes (eg, tonic neck reflex), persistent or asymmetric fisting, and early hand preference (before age 1). Although infants with CP may initially have normal or low tone at birth, hypertonia (spasticity) develops within a few months and can result in contractures and scissoring of the legs. Hyperreflexia and sustained clonus are also typically present. In addition, infants often have delayed motor milestones based on a corrected gestational age. For instance, this infant with a corrected gestational age around 8 months should be rolling and sitting without support. By age 9 months, infants are expected to pull up to a stand and cruise. When clinical presentation is consistent with CP, MRI of the brain is recommended as the vast majority of patients have abnormal findings (eg, periventricular leukomalacia, brain malformation, ischemia). Comorbid epilepsy is common; but patients with no seizure-like activity do not require electroencephalography (Choice B). Treatment is primarily supportive with physical, occupational, and speech therapies for associated developmental delays. If oromotor dysfunction is severe, gastrostomy feeds may be required for adequate caloric intake and to prevent aspiration. Medications such as botulinum and baclofen can help to reduce spasticity and clonus. (Choice A) MRI is superior to CT scan of the head for identifying the location and timing of central nervous system insults. In addition, CT scan is typically avoided in children due to its associated radiation exposure. (Choice D) A nerve conduction study can diagnose lower motor neuron disorders that present with weakness, hypotonia, and hyporeflexia; they are not beneficial in a patient with an upper motor neuron disorder such as CP. (Choice E) Although children age <2 may have a few beats of clonus and upgoing toes on Babinski reflex, sustained clonus and spasticity with a scissoring posture are never normal. Reassurance and observation are not appropriate. Educational objective: Premature infants are at risk for cerebral palsy, which often presents as hypertonia, hyperreflexia (eg, sustained clonus), and delayed motor milestones. MRI of the brain evaluates for a potential etiology. References: MRI and motor outcomes in children with cerebral palsy. (http://www.ncbi.nlm.nih.gov/pubmed/26933597) MRI classification system (MRICS) for children with cerebral palsy: development, reliability, and recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/27325153)

A 9-Month-Old Boy Is Brought to the Office for a Well-Child