1. Early warning signs of CMD Robyn Smith Department of Physiotherapy UFS 2012

2. So what have you learnt so far about essential aspects normal development?  Takes place against the background of normal muscle tone  Stability of the behavioural & physiological states  Ability to move and interact with environment is paramount  Presence of competing patterns of movement  Gradual development of postural control

3. Early alarm or warning signs

4. Early alarm signals Are often detected when the child deviates from typical development Below follow some of the more common early alarm signs

5. 1. Behavioural state disturbances  Infant is jittery, irritable and crying (high pitched voice)  Inability to habituate or self soothe  Sleep disturbances  Unstable postures – constantly moving  Continual (overactive) startles & Moro  Under-responsive – sleeps constantly and is apathetic. Lack of awareness and orientation

6. 2. Feeding problems  Weak sucking  Tongue thrust  Takes excessively long to feed  Coughing or choking during feeding (inability swallow safely)  Reflux (GERD = gastroeosophageal Reflux disease)

7. What is reflux ? Backward flow of stomach (food and acid) contents into the esophagus Causes: immature GIT (lower esophageal sphincter muscle), common in children with neurological damage Symptoms: resists feeding, crying during feeding, oral regurgitation feeds Anything you can do about reflux?

8. 3. Poor interaction with the environment  Resists handling, thrusts away, cannot “cuddle”  Poor visual and/or auditory orientation  Visual disorders e.g nystagmus, squint  Constant moving in a search for sensory input – poor sensory integration (self stimulating type behaviour)

9. 4. Disturbances of muscle tone  Obvious hypotonia- feels like they “slip through” your hands when you pick them up. True hypotonia rare. Most children with CMD start out with hypotonia, but can also be due to metabolic disorders, primary muscle disease, sensory deficits or even Down Syndrome  Obvious hypertonia – early severe hypertonia is rare but can be seen in cases of severe HIE, anencephaly (neural tube defect) or microcephaly  NB !!!! Most often a combination of truncal hypotonia and distal hypertonia

10. 5. Disturbances of movement  NB!!!  Persistent asymmetry  Poverty (lack) of movement.... Poor quality of movement  Dominant flexion over extension and vice versa  Persistent palmar thumbing (fisting), especially if it is asymmetrical

11. 6. Caregiver/parent report  These factors are identified during the parent interview  Difficulty changing nappy (e.g. spastic)  Difficulty with dressing, bathing and feeding the infant  Lack of cuddling and bonding with infant  Cannot self-quiet or self-soothe  Always/never hungry  Dislikes prone position

12. 7. Persistent primitive reflexes  Present at birth  Maturation CNS in particular cortex exerts inhibitory effect on primitive reflexes  Must disappear in order for the postural reactions and control and equilibrium reactions can develop properly  Persistence may indicate cortical immaturity or damage

13. Characteristics elements observed in a atypically Developing child

14. Often difficult to initially distinguish between normal and abnormal development in an infant EXCEPT In severely affected infants e.g. severe spastic quadruplegia Diagnosis of neurological impairment is seldom made before the age of one year

15. Differentiating between developmental delay vs. Neurological impairment  Slower integration primitive reflexes & development of postural control  No pathological reflexes noted  Initial low tone may be present in case e.g. Premature infant, DCD, ADHD, ASD  Sequencing most of the time is typical  “Scattered” milestones  Persistent or reappearing of primitive reflexes  Presence pathological postural reflexes TLR, STNR, ATNR  Increasing muscle tone over time  Abnormal sequencing (habitual/stereotypical movement patterns)

16. If present the following are reason for concern in children with atypical development:  Poor interaction between flexion and extension control poor head & trunk control poor anti-gravity control poor rotational control poor equilibrium reactions  Persistent primitive reflexes  Presence of pathological reflexes tonic reflexes ATNR/STNR/TLR overactive phasic reflexes

17. If present the following are reason for concern in children with atypical development:  Abnormal muscle tone (high/low)  Poor quality of/and abnormal movement patterns or Habitual patterns  Sensory disturbance (primary or secondary)

18. References  Images courtesy Google  Brown, E. 2009. Evaluation and treatment of infants with CMD (coursework: unpublished)  Brown, E. 2001. NDT (coursework: unpublished)  Paediatric dictate UFS (2009)