Article Figures & Data
Figures
- FIGURE 1
Identifying children with motor delays: an algorithm for surveillance and screening.
- FIGURE 2
Examples of physical examination maneuvers. Adapted from Nercuri E, Haataja L, Dubowitz L. Neurological assessment in normal young infants. In: Cioni C, Mercuri E, eds. Neurological Assessment in the First Two Years of Life. London, UK: Mac Keith Press; 2007:30–31. a In term infants, these findings do not change significantly after 3 months of age.
Tables
Age Gross Motor Milestones Fine Motor Milestones 2 mo Lifts head and chest in prone 4 mo Rolls over prone to supine; supports on elbows and wrists in prone Hands unfisted; plays with fingers in midline; grasps object 6 mo Rolls over supine to prone; sits without support Reaches for cubes and transfers; rakes small object with 4 fingers 9 mob Pulls to stand; comes to sit from lying; crawls Picks up small object with 3 fingers 1 y Walks independently; stands Puts 1 block in a cup; bangs 2 objects together; picks up small object with 2-finger pincer grasp 15 mo Walks backward; runs Scribbles in imitation; dumps small object from bottle, with demonstration 18 mob Walks up steps with hand held Dumps small object from bottle spontaneously; tower of 2 cubes; scribbles spontaneously; puts 10 blocks in a cup 2 y Rides on toy without pedals; jumps up Builds tower and horizontal train with 3 blocks 2.5 yb Begins to walk up steps alternating feet Imitates horizontal and vertical lines; builds a train with a chimney with 4 blocks 3 y Pedals; climbs on and off furniture Copies a circle drawing; draws a person with head and one other body part; builds a bridge with 3 blocks 4 y Climbs stairs without support; skips on 1 foot Draw a person with 6 parts, simple cross; buttons medium-sized buttons Adapted from Capute AJ, Shapiro BK, Palmer FB, Ross A, Wachtel RC. Normal gross motor development: the influences of race, sex and socioeconomic status. Dev Med Child Neurol. 1985;27(5):635–643; Accardo PJ, Capute AJ. The Capute Scales: Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS). Baltimore, MD: Paul H. Brooks; 2005; and Beery KE, Beery NA. The Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) Administration, Scoring and Teaching Manual. Minneapolis, MN: NCS Pearson Inc; 2004.
↵a These milestones generally represent mean age of performance of these skills.
↵b It is recommended that a standardized developmental test be performed at these visits.
Key Elements of Motor History Example Delayed acquisition of skill Is there anything your child is not doing that you think he or she should be able to do? Involuntary movements or coordination impairments Is there anything your child is doing that you are concerned about? Regression of skill Is there anything your child used to be able to do that he or she can no longer do? Strength, coordination, and endurance issues Is there anything other children your child’s age can do that are difficult for your child? Red Flags: Indications for Prompt Referral Implications Elevated CK to greater than 3× normal values (boys and girls) Muscle destruction, such as in DMD, Becker muscular dystrophy, other disorders of muscles Fasciculations (most often but not exclusively seen in the tongue) Lower motor neuron disorders (spinal muscular atrophy; risk of rapid deterioration in acute illness) Facial dysmorphism, organomegaly, signs of heart failure, and early joint contractures Glycogen storage diseases (mucopolysaccharidosis, Pompe disease may improve with early enzyme therapy) Abnormalities on brain MRI Neurosurgical consultation if hydrocephalus or another surgical condition is suspected Respiratory insufficiency with generalized weakness Neuromuscular disorders with high risk of respiratory failure during acute illness (consider inpatient evaluation) Loss of motor milestones Suggestive of neurodegenerative process Motor delays present during minor acute illness Mitochondrial myopathies often present during metabolic stress Condition Inheritance Clinical Testing Clinical Caveats Angelman syndrome Sporadic Methylation testing for Prader-Willi/Angelman syndrome critical region, gene sequencing of UBE3A gene Infantile hypotonia and delayed motor milestones, usually present with global delays; dysmorphic features are subtle in infancy. Chromosome disorders Many sporadic; high recurrence risk for unbalanced translocations if 1 parent has a balanced translocation Chromosome analysis, single nucleotide polymorphism microarray Some patients will have multiple anomalies and will have global developmental delays. Some may present in infancy or early childhood with delayed motor and/or speech milestones. Down syndrome Chromosome mosaicism also seen. Klinefelter syndrome Rare deletions and duplications Deletion 22q11 syndrome (velocardiofacial syndrome) Autosomal dominant (most cases new mutations) Fluorescence in situ hybridization (FISH) for deletion 22q11.2 90% of cases new mutations. Feeding and speech disorders and cognitive impairment also seen. >50% will have a congenital heart defect. DMD X-linked recessive CK, sequencing of dystrophin gene Becker and Duchenne muscular dystrophies are caused by mutations in different regions of the dystrophin gene. Becker muscular dystrophy has a later onset of symptoms with a less severe course; 67% of cases are inherited, 33% are new mutations. Becker muscular dystrophy Fragile X syndrome X-linked Gene sequencing and methylation analysis of FMR1 gene Usually have global delays and cognitive impairment but may present in infancy or early childhood with predominantly motor delays. Males affected primarily, but females with FMR1 expansions may also be affected. Mitochondrial myopathies Autosomal recessive; Constitutional and mitochondrial genetic testing, lactate/pyruvate levels and ratio, serum amino acids Genetic heterogeneity. May not present in infancy. Also at risk for cardiomyopathy, vision loss, hearing loss, cognitive disabilities. X-linked recessive mitochondrial inheritance Myotonic muscular dystrophy Autosomal dominant Gene sequencing for DMPK gene May see anticipation with progression of phenotype in subsequent generations. Neurofibromatosis type 1 (NF1) Autosomal dominant Usually a clinical diagnosis, gene sequencing NF1 gene 50% new mutations. Hypotonia most evident in infancy and early childhood. Suspect NF1 if hypotonia seen with multiple café au lait spots. Noonan syndrome Autosomal dominant Gene sequencing for PTPN11 gene, genetically heterogeneous and multiple gene sequencing panels are available Genetic heterogeneity. Commonly associated with short stature, ptosis, learning and developmental delays, hypotonia, pulmonary stenosis, cryptorchidism, cardiomyopathy. Prader-Willi syndrome Sporadic DNA methylation testing for Prader-Willi/Angelman syndrome critical region Hypogonadism, especially in boys. Hypotonia most evident in infancy and may be profound. Spinal muscular atrophy, including congenital axonal neuropathy, Werdnig-Hoffmann disease, Kugelberg-Welander disease Autosomal recessive Gene deletion or truncation studies for SMN1 gene (95% to 98% of cases) Usually presents in early infancy with severe hypotonia. Milder forms identified at later ages. Services/Step in Algorithm Notes CPT Code Comments Pediatric preventive care visit All preventive care visits should include developmental surveillance; screening is performed as needed or at periodic intervals 99381–99394 (EPSDT) Developmental/medical evaluation: Office or Other Outpatient Services Codes; New Patient If performed by the physician as a new patient outpatient office visit 99201-99205 99204 is used for evaluations performed by the physician that are detailed and moderately complex or take at least 45 min (with more than half spent counseling); 99205 is used for evaluations that are comprehensive and highly complex or take 60 min (with more than half spent counseling) Developmental/medical evaluation: Office or Other Outpatient Services Codes; Established Patient If performed by the physician as an outpatient office visit 99210–99215 99214 is used for evaluations performed by the physician that are detailed and moderately complex or take at least 25 min (with more than half spent counseling); 99215 is used for evaluations that are comprehensive and highly complex or take 40 min (with more than half spent counseling) Developmental/medical evaluation/Office or Other Outpatient Consultations Codes If performed by the physician as an outpatient office visit 99241–99245 99244 is used for “moderate activities” of up to 60 min (with more than half spent counseling); 99245 is used for “high” activity of up to 80 min (with more than half spent counseling) Developmental screening Does not require any physician work; rather, clinical staff can score results and provide to physician for interpretation as part of E/M 96110 Reported in addition to E/M services provided on the same date Developmental testing Used for extended developmental testing typically provided by the medical provider (often up to 1 h), including the evaluation interpretation and report 96111 Reported in addition to E/M services provided on the same date Identify as a child with special health care needs, and initiate chronic condition management Children with special health care needs are likely to require expanded time and a higher level of medical decision-making found in these “higher-level” outpatient codes; these codes are appropriate for services in the office and for outpatient facility services for established patients; these codes may be reported using time alone as the factor if more than half of the reported time is spent in counseling 99211–99215 As above Prolonged services At any point during the algorithm when outpatient office or consultation codes are used, prolonged physician service codes may be reported in addition when visits require considerably more time than typical for the base code alone; both face-to-face and non–face-to-face codes are available in CPT 99354 99354 for first 30–74 min of outpatient face-to-face prolonged services 99355 99355 for each additional 30 min 99358 99358 for first 30–74 min of non–face-to-face prolonged services 99359 99359 for each additional 30 min E/M, evaluation and management; EPSDT, Early and Periodic Screening, Diagnostic and Treatment program.
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