Etiologic determination of childhood developmental delay

Etiology of Borderline Intellectual Functioning

Borderline intellectual functioning (BIF), characterized by intelligence quotient scores between 70 and 85, can lead to challenges in daily life. This review explored the multifaceted nature of BIF by examining the interplay between genetic predisposition, prenatal/perinatal factors, environmental influences, and underlying medical conditions.

Children, Adolescents, and Young Adults with Borderline Intellectual Functioning: Etiological, Neurophysiological, and Mri Findings in a Cohort of 651 Patients

This retrospective chart review study explored the etiology, use, and yield of the etiological investigations of 651 children and adolescents diagnosed with borderline intellectual functioning (BIF). Neurological, neurodevelopmental, or neuropsychiatric comorbidities were frequent, and in 23%, the BIF diagnosis evolved into an intellectual disability (ID) by the time of discharge. A primary etiological cause was found in 37.6%, the most prevalent causes being pre- or perinatal conditions, genetic syndromes/chromosomal abnormalities, fetal exposure to maternal substance use, cerebral dysgenesis, and neurological diseases. In total, 79.1% of patients went through one or more investigations during their follow-up. The best etiologic yield leading to a diagnosis in this study population was with exome sequencing, a specific gene panel, microarrays, electroneuromyography, and brain magnetic resonance imaging (MRI). Etiological investigations were performed more frequently among those children receiving an ID diagnosis. Yet, there was no statistically significant difference in the proportion of abnormal findings between the BIF and ID groups. This may mean that the current strategy for determining the need for etiological investigations or current means to gain an etiology is still indecisive. Considering that BIF is defined to include individuals performing between normal cognitive functioning and mild ID, this implies that the prevalence would be anywhere between 7 and 14%. Thus, it could be argued whether in-depth etiological investigations may be justified in cases other than ID in this age group of children over five. With these children and adolescents, the clinicians have to discern between those with a normal variation and those having major difficulties in adaptive behavior affecting everyday life in order to specify and prescribe the rehabilitation or other measures needed. We advocate for a targeted etiological search after careful history-taking and neurological examination. National guidelines that take into account the severity of developmental delay are warranted.

Early cognitive intervention using mediated learning for preschoolers with developmental delay: A randomized controlled trial

Background

The use of mediated learning in cognitive training has been shown to be effective in enhancing students’ cognitive development. Nonetheless, its effects on language development are less explored.

Aims

This study examined the effects of an early cognitive intervention (Think Bright program) in enhancing the cognitive and language development of Hong Kong preschoolers with developmental delay.

Method

Sixty‐eight children (48 boys and 20 girls; mean age = 58 months) with developmental delay were recruited from preschool rehabilitation centres and randomized to two groups (Think Bright training vs. active control). Each child in the Think Bright group received 12 sessions of 1‐hr individual training on thinking skills over 6 months. The control group received the same amount of training based on the regular training regimen adopted at the rehabilitation centres.

Results

After a 6‐month intervention, the Think Bright group significantly outperformed the control group in language, general cognition, analogical thinking, sequential thinking, and logical reasoning. The Think Bright teachers’ mediation skills significantly improved during the course of intervention and correlated moderately with the improvement in students’ language abilities.

Conclusion

This study has shown promising results on the effectiveness of using mediated learning in early cognitive intervention in enhancing both the cognitive and language development of preschoolers with developmental delay.

The Clinical Features of Preschool Children With Speech and Language Disorder and the Role of Maternal Language

Objective

To retrospectively review the characteristics of preschool children with speech and language disorders to determine their clinical features and compares the average degrees of language delay based on hospital visit purposes, language developmental delay causes, and maternal language.

Methods

One thousand one hundred two children (832 males, 270 females) with the chief complaint of language or speech problems who underwent language assessment for the first time were included. Their medical records, including demographic data, language environments, and family history of language problems and other developmental problems, were collected. Furthermore, the results of language and developmental assessments and hearing tests were collected.

Results

Among the children enrolled in this study, 24% had parental problems and 9% were nurtured by their grandparents. The average degree of language delay did not differ regarding purposes of hospital visits. The average degree of language delay was greatest in children with autism spectrum disorders and least in children with mixed receptive–expressive language disorders. In children with mothers who do not speak Korean as their native language, social quotients in the social maturity scale were less than 70.

Conclusion

Language environment is an essential factor that may cause speech and language disorders. Moreover, maternal language seems to affect the social quotient of the social maturity scale.

Salivary alpha amylase and cortisol levels as stress biomarkers in children with cerebral palsy and their association with a physical therapy program

INTRODUCTION

Cerebral palsy (CP) is one of the main causes of physical disabilities in childhood. There is evidence that CP children display high levels of stress, which could interfere with learning processes and interpretation of relevant sensory information during motor skills acquisition and socialization.

OBJECTIVE

This study aims to compare basal levels of stress biomarkers (cortisol and alpha-amylase) of healthy children (HC) and children with CP, and to investigate whether a physical therapy session using the neurodevelopmental technique (NDT) interferes with these levels.

METHODS

A cross-sectional design was used. A total of 86 children (HC: n = 45 and CP: n = 41) with matching age, sex, socioeconomic status, and sampling time. Salivary cortisol and alpha-amylase levels were measured by means of electrochemiluminescence and spectrophotometry methods. A single saliva sample was collected in the HC group to determine basal levels. For CP group three samples were collected: a first sample was taken 20-30 min prior to the intervention, while two post-intervention samples were collected (5 and 20 min) to evaluate individual changes in salivary stress biomarkers.

RESULTS

Higher basal cortisol concentration was found in CP children when compared to HC group. Moreover, CP children showed a significant reduction in cortisol levels 20 min after NDT intervention. No significant differences were observed in alpha-amylase values.

CONCLUSION

Present results show that CP causes alteration in basal cortisol values at childhood and suggest that CP children respond to environmental regulatory factors such as NDT, in attempt to reduce stress.

Identifying pattern in global developmental delay children: A retrospective study at King Fahad specialist hospital, Dammam (Saudi Arabia)

Global developmental delay (GDD) and intellectual disability are relatively common in pediatric neurology conditions. A retrospective study was designed to analyze risk factors and clinical features in children with GDD at our hospital. No previous data is available on GDD from Saudi Arabia. This study was conducted at king Fahad specialist hospital Dammam (KFSHD) of 134 GDD children (82, 61% males, 52, 39% females), (age 1-9 years). They were assessed by using Griffith Mental Development Scales for (0-2) years and 3-8 years old in locomotors, personal/social, communication, eye & hand co-ordination, performance and practical reasoning. Patients with ASD and non-cooperative behavior were excluded. 75% had developmental delay since birth while 84% had no problem during pregnancy. 22% had birth weight below 2.5 kg. 56% had epilepsy and 57 % had interfamily marriages. 51% were diagnosed cases in the present study. 40% had genetic cause, 25% had metabolic problem, 58% had neuroradiology abnormality and 45% had EEG abnormalities. There a variety of delays in development (speech and language variant, global delay, and the motor variant) noted and are commonly seen in a clinical practice in KFSHD. Longitudinal research beginning in early development will help to understand the developmental domains and neurological comorbidities in these children at high risk for neurodevelopmental disorders.

Sustained Release of Dexamethasone from Sulfobutyl Ether β-cyclodextrin Modified Self-Assembling Peptide Nanoscaffolds in a Perinatal Rat Model of Hypoxia-Ischemia

Inflammation plays a critical role in the development of hypoxia-ischemia (HI) induced newborn brain damage. A localized, sustained delivery of dexamethasone (Dex) through an intracerebral injection could reduce the inflammatory response in the injured perinatal brain while avoiding unnecessary side effects. Herein, investigated using anionic sulfobutyl ether β-cyclodextrin (SBE-β-CD) to load Dex in the (RADA)₄ nanofiber networks as a means of reducing the inflammatory response to HI injury is investigated. The ionic interaction between SBE-β-CD and (RADA)₄ dramatically affects nanofiber formation and the stability of the nanoscaffold is highly dependent on the SBE-β-CD/(RADA)₄ ratio. It is observed that the Dex release rate is affected by the concentration of SBE-β-CD and (RADA)₄ peptide. A higher concentration of SBE-β-CD or (RADA)₄ results in a higher drug encapsulation efficiency and slower release rate of Dex. This phenomenon may be related to the structure of fiber bundles. Animal studies show that nanoscaffold loaded with Dex inhibits both microglia activation and glial scar formation compared to controls (Dex alone or nanoscaffold alone) within 2 days of injury. It is thought that this is a step toward building a multifaceted nanoscaffold that can be used to treat HI events in perinates.

Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development: Terminology

BACKGROUND

Lack of agreement about criteria and terminology for children's language problems affects access to services as well as hindering research and practice. We report the second phase of a study using an online Delphi method to address these issues. In the first phase, we focused on criteria for language disorder. Here we consider terminology.

METHODS

The Delphi method is an iterative process in which an initial set of statements is rated by a panel of experts, who then have the opportunity to view anonymised ratings from other panel members. On this basis they can either revise their views or make a case for their position. The statements are then revised based on panel feedback, and again rated by and commented on by the panel. In this study, feedback from a second round was used to prepare a final set of statements in narrative form. The panel included 57 individuals representing a range of professions and nationalities.

RESULTS

We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term 'Language Disorder' is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, 'Developmental Language Disorder' (DLD) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD, (b) DLD can co-occur with other neurodevelopmental disorders (e.g. ADHD) and (c) DLD does not require a mismatch between verbal and nonverbal ability.

CONCLUSIONS

This Delphi exercise highlights reasons for disagreements about terminology for language disorders and proposes standard definitions and nomenclature.

Longer hypoxia-ischemia periods to neonatal rats causes motor impairments and muscular changes

Prematurity and hypoxia-ischemia (HI) can lead to movement disorders in infants. Considering that mild-moderate HI induced at postnatal day (PND) 3 has failed to produce motor disabilities similar to those seen in pre-term newborns, the main goal of the present study was to verify whether longer hypoxia periods would mimic motor function impairment, brain and muscle morphological alterations. Forty-nine Wistar rat pups of both sexes were randomly assigned to surgical control (CG) and HI groups. HI animals were submitted to the Levine-Rice model at PND 3, and exposed to 120 (HI-120'), 180 (HI-180') or 210 (HI-210') minutes of hypoxia (FiO₂: 0.08). Sensorimotor function was assessed as from PND 35-45, by means of grasping strength, adhesive removal, cylinder and ladder walking tests. Histological staining was used to quantify the striatal volume and the cross-sectional area (CSA) of skeletal muscles. Cylinder and adhesive removal test evidenced that HI-180' and HI-210' groups had asymmetrical use of the forepaws when compared to controls. HI animals showed a decrease in the step placement quality and an increase in step errors when compared to CG (P⩽0.05). Reduction in striatal volume correlates with behavioral assessment, HI-180' and HI-210' groups presented lower biceps brachii and tibialis anterior CSA. These results show that rats exposed to longer hypoxic periods at PND3 have encephalic and sensorimotor impairments that mimic those observed in preterm infants. Morphological changes in muscle tissue evidence a new pathophysiological characteristic of the HI model that might be of relevance for the study of sensorimotor deficits.

Functional Outcome of School Children With History of Global Developmental Delay

This study aimed to investigate the functional and developmental outcomes in school age children diagnosed with global developmental delay before 2 years old and to verify the association between their final diagnosis and environmental and biological factors. Forty-five Brazilian children (26 boys), mean age 95.84 (7.72) months, who attended regular school and were diagnosed with global developmental delay before they were 2 years old had their functions evaluated. Children with global developmental delay were diagnosed with several conditions at school age. Students with greater chances of receiving a diagnosis were those whose mothers were younger at the time their children were born (OR = 1.47, CI = 1.04-2.09, P = .03), who had impaired motor performance, specially balance (OR = 1.33, CI = 1.01-1.75, P = .04), and who needed help during cognitive and behavioral tasks at school (OR = 1.08, CI = 1.00-1.17, P = .048). Interdisciplinary evaluation contributed to defining the specific diagnosis and to identifying the necessity of specialized support.

Primary Care Providers' Initial Evaluation of Children with Global Developmental Delay: A Clinical Vignette Study

OBJECTIVE

To examine the decisions of pediatric primary care physicians about their diagnostic evaluation for a child with suspected global developmental delay (GDD).

STUDY DESIGN

A survey was mailed to a sample of pediatricians (n = 600) and family physicians (n = 600) randomly selected from the American Medical Association Physician Masterfile. The survey contained a clinical vignette describing a 9-month-old nondysmorphic boy with GDD. Participants were asked their initial evaluation steps (test, refer, or both test and refer) and what types of referral and/or testing they would pursue. We examined bivariate associations between physician/clinical practice characteristics and participants' evaluation decision.

RESULTS

More pediatricians than family physicians completed the survey (response rates: 55% vs 38%). Almost three-quarters of the respondents (74%) reported that their first step in a diagnostic evaluation would be to refer the child without testing, 22% would test only, and 4% would both test and refer. As their initial step, most physicians referred to a developmental pediatrician (58%), and only 5% would refer to a geneticist. The most commonly ordered test was general biochemical testing (64%). The most commonly ordered genetic test was a karyotype (39%).

CONCLUSIONS

When evaluating a child with GDD, few primary care physicians would order genetic testing or refer to a genetics specialist as a first evaluation step. Future studies should examine both barriers to and utilization of a genetic evaluation for children with GDD.

Seizures and EEG features in 74 patients with genetic-dysmorphic syndromes

Epilepsy is one of the most common findings in chromosome aberrations. Types of seizures and severity may significantly vary both between different conditions and within the same aberration. Hitherto specific seizures and EEG patterns are identified for only few syndromes. We studied 74 patients with defined genetic-dysmorphic syndromes with and without epilepsy in order to assess clinical and electroencephalographic features, to compare our observation with already described electro-clinical phenotypes, and to identify putative electroencephalographic and/or seizure characteristics useful to address the diagnosis. In our population, 10 patients had chromosomal disorders, 19 microdeletion or microduplication syndromes, and 32 monogenic syndromes. In the remaining 13, syndrome diagnosis was assessed on clinical grounds. Our study confirmed the high incidence of epilepsy in genetic-dysmorphic syndromes. Moreover, febrile seizures and neonatal seizures had a higher incidence compared to general population. In addition, more than one third of epileptic patients had drug-resistant epilepsy. EEG study revealed poor background organization in 42 patients, an excess of diffuse rhythmic activities in beta, alpha or theta frequency bands in 34, and epileptiform patterns in 36. EEG was completely normal only in 20 patients. No specific electro-clinical pattern was identified, except for inv-dup15, Angelman, and Rett syndromes. Nevertheless some specific conditions are described in detail, because of notable differences from what previously reported. Regarding the diagnostic role of EEG, we found that--even without any epileptiform pattern--the generation of excessive rhythmic activities in different frequency bandwidths might support the diagnosis of a genetic syndrome.

Predictors of severity and outcome of global developmental delay without definitive etiologic yield: a prospective observational study

BACKGROUND

Although several determinants of global developmental delay (GDD) have been recognized, a significant number of children remain without definitive etiologic diagnosis. The objective of this study was to assess the effect of various prenatal and perinatal factors on the severity and outcome of developmental delay without definitive etiologic yield.

METHODS

From March 2008 to February 2010, 142 children with developmental quotient (DQ) <70 and without definitive etiologic diagnosis, were included. Prenatal and perinatal risk factors known to be associated with disordered neonatal brain function were identified. Participants underwent a thorough investigation, an individualized habilitation plan was recommended, and the children were followed-up regularly for a period of 2 < years. The effect of prenatal and perinatal risk factors on the severity and outcome of GDD was assessed by regression analysis.

RESULTS

The mean age at enrolment was 31 ± 12 < months, and the mean DQ 52.2 ± 11.4. Prematurity and intrauterine growth restriction (IUGR) were found to be independently associated with lower DQ values. The mean DQ after the 2-year follow-up was 62.5 ± 12.7, and the DQ difference from the enrollment 10.4 ± 8.9 (median 10; range-10 to 42). DQ improvement (defined as a DQ difference?≥?median) was noted in 52.8% of the children. IUGR, low socio-economic status, and poor compliance to habilitation plan were found to be independently associated with poorer developmental outcomes.

CONCLUSIONS

Prematurity and IUGR were found to be significantly and independently related to the severity of GDD in cases without definitive etiologic yield. Poorer 2-year developmental outcome was associated with IUGR, low socioeconomic status and non compliance to habilitation plan. Prematurity was a significant determinant of the outcome only in association with the above mentioned factors.

Deletion 12p12 involving SOX5 in two children with developmental delay and dysmorphic features

The SOX5 gene encodes a transcription factor involved in the regulation of nervous system development and chondrogenesis. This article reports on two cases of 12p12.1 deletion involving SOX5 presenting with global developmental delay, intellectual disability, expressive language delay, mild motor impairment, distinct features, and multiorgan involvement. The first case involves a 32-month-old boy with de novo 53-kilobase interstitial deletion at 12p12.1, representing the smallest deletion reported, and presents with severe symptomatology. The second case is a 31-month-old girl with 3.2-megabase deletion at 12p12.2 p12.1 with severe neurodevelopmental disability and minimal organ involvement. These patients bear many of the characteristics previously reported in patients with SOX5 mutations. We propose a neurodevelopmental approach to a novel syndrome with dose- and location-sensitive SOX5 gene expression.

Evaluation children with global developmental delay: a prospective study at sultan qaboos university hospital, oman

OBJECTIVE

A prospective study was designed to analyze risk factors and clinical features in children with global developmental delay (GDD) at our hospital. No previous data is available on GDD from Oman.

METHODS

This study was conducted at Sultan Qaboos University Hospital from January 2008 until June 2009. All the children aged 5 years or less, referred with suspected GDD were included in the study. Data was analyzed to determine the underlying etiology. The children with neurodegenerative disease and muscular dystrophy were excluded from the study.

RESULTS

One hundred and ten children, 59 males (53.6%) and 51 females (46.4%) were included in the study. The mean age at initial evaluation was 13.29 months. An underlying etiology was determined in 79 (71.8%) children. Perinatal history was associated with significant difference in detection of etiology (p=0.039). Abnormal neurological examination was a significant factor in detection of the underlying etiology. Magnetic resonance imaging (MRI) in 105 children and metabolic screening in 93 children were the most frequently ordered investigations. Abnormal imaging, MRI (p=0.001), CT scan (p=0.036) and metabolic screening (p=0.034) were significantly associated with detection of etiology.

CONCLUSION

Etiology was detected in 71.8% of the children. MRI was the most significant investigation to detect the abnormality.

Neurodevelopmental outcome of fetuses with increased nuchal translucency and apparently normal prenatal and/or postnatal assessment: a systematic review

OBJECTIVES

To systematically review and, when feasible, pool, published data regarding the prevalence of childhood neurodevelopmental delay in fetuses with increased first-trimester nuchal translucency (NT), normal karyotype and absence of structural defects or identifiable syndromes.

METHODS

MEDLINE and SCOPUS searches using combinations of the terms 'nuchal translucency' AND 'outcome*' were complemented by perusal of the references of the retrieved articles and an additional automated search using the 'search for related articles' PubMed function. Only children with a normal karyotype and no structural defects or syndromic abnormalities were included in the analysis. Between-studies heterogeneity was assessed using the I(2) statistic.

RESULTS

The total prevalence of developmental delay in all 17 studies was 28/2458 (1.14%; 95% CI, 0.79-1.64; I(2) = 57.6%). Eight studies (n = 1567) used NT > 99(th) centile as the cut-off; 15 children (0.96%; 95% CI, 0.58-1.58%) were reported as having developmental delay (I(2) = 72.2%). Four studies (n = 669) used the 95(th) centile as the cut-off for increased NT; seven children (1.05%; 95% CI, 0.51-4.88%) were reported as having developmental delay (I(2) = 29.2%). Five studies used 3.0 mm as the cut-off for increased NT; the pooled rate of developmental delay was six of 222 children (2.70%; 95% CI, 1.24-5.77%; I(2) = 0.0%).

CONCLUSION

The rate of neurodevelopmental delay in children with increased fetal NT, a normal karyotype, normal anatomy and no identifiable genetic syndromes does not appear to be higher than that reported for the general population. More large-scale, prospective case-control studies would be needed to enhance the robustness of the results.

Profile of developmental delay in children under five years of age in a highly consanguineous community: a hospital-based study--Jordan

AIM

To assess etiologies and risk factors for global developmental delay (GDD) in children.

PATIENTS AND METHODS

Between January 2006 and 2007, a retrospective study was carried out at the Child Neurology Clinic of Jordan University Hospital on all 229 children under five years of age presenting with GDD. To assess risk factors for GDD, 229 age-matched healthy children were included as controls.

RESULTS

A definite etiology for GDD could be determined in 102 (44.5%) patients, while 127 (55.5%) patients remained undiagnosed .The most common category for the GDD was cerebral palsy (CP) seen in 72 patients (31.4%), of which the underlying etiology was determined in 50 patients (69.5%). The second most common category was metabolic disorders where a definite metabolic cause was reached in 15 (6.5%) patients and a possible metabolic cause was suspected in 16 (6.9%) cases. Other etiologies included other monogenic disorders in 12 (5.2%) patients, brain malformations in 7 (3.0%) patients, chromosomal abnormalities in 6 (2.6%) patients, and autism in 12 (5.2%) patients. History of perinatal complications and consanguinity were major risk factors (p<0.05).

CONCLUSION

To our knowledge this is the first and largest study on GDD in a highly consanguineous Arab population. Cerebral palsy and metabolic disorders were the most common causes of GDD in Jordan, while perinatal complications and consanguinity were the major risk factors contributing to GDD.

Value of clinical assessment in the diagnostic evaluation of Global Developmental Delay (GDD) using a Likelihood Ratio Model

OBJECTIVE

A selective approach is recommended for investigating children with GDD. Our objective is to identify clinical markers to improve the diagnostic yield of evaluation of children with GDD.

METHOD

Children with GDD (delay>2 S.D. in>1 domain) followed up in our centre were reviewed retrospectively. We selected nine clinical markers (sex, severity of GDD, parental consanguinity, family history, behavioral problems, head size, facial dysmorphism, non-facial anomalies and neurological deficits) and looked into the likelihood of finding an underlying etiology during follow-up.

RESULTS

There were 577 children with 63%, 33% and 4% having mild, moderate and severe grade GDD. An identifiable etiology is detected in 53%. Genetic disease (25%) was the commonest cause identified. We have found that severity of GDD (severe and moderate versus mild grade [LR+=1.92 (95% C.I.=1.49-2.48); LR-=0.72(0.64-0.81)], behavioral problems [LR+=0.24 (95% C.I.=0.17-0.34); LR-=1.67 (1.48-1.88)], facial dysmorphism [LR+=2.66 (95% C.I.=1.10-3.54); LR-=0.65 (0.58-0.73)] and neurological deficits [LR+=2.85 (95% C.I.=2.32-3.50); LR-=0.31(0.25-0.39)] were clinical markers associated with increased chance of identifying an underlying etiology by multivariate analysis.

CONCLUSION

These four clinical markers are useful in selecting patients with GDD for further diagnostic tests. Using the LR model, clinical markers in the first clinical evaluation of any child with GDD can potentially improve the etiological yield using targeted investigations.

Current management of the infant who presents with neonatal encephalopathy

Neonatal encephalopathy after perinatal hypoxic-ischemic insult is a major contributor to global child mortality and morbidity. Brain injury in term infants in response to hypoxic-ischemic insult is a complex process evolving over hours to days, which provides a unique window of opportunity for neuroprotective treatment interventions. Advances in neuroimaging, brain monitoring techniques, and tissue biomarkers have improved the ability to diagnose, monitor, and care for newborn infants with neonatal encephalopathy as well as predict their outcome. However, challenges remain in early identification of infants at risk for neonatal encephalopathy, determination of timing and extent of hypoxic-ischemic brain injury, as well as optimal management and treatment duration. Therapeutic hypothermia is the most promising neuroprotective intervention to date for infants with moderate to severe neonatal encephalopathy after perinatal asphyxia and has currently been incorporated in many neonatal intensive care units in developed countries. However, only 1 in 6 babies with encephalopathy will benefit from hypothermia therapy; many infants still develop significant adverse outcomes. To enhance the outcome, specific diagnostic predictors are needed to identify patients likely to benefit from hypothermia treatment. Studies are needed to determine the efficacy of combined therapeutic strategies with hypothermia therapy to achieve maximal neuroprotective effect. This review focuses on important concepts in the pathophysiology, diagnosis, and management of infants with neonatal encephalopathy due to perinatal asphyxia, including an overview of recently introduced novel therapies.

Aetiology of intellectual disability in paediatric outpatients in Northern India

AIM

To study the aetiology of intellectual disability in patients presenting to hospital and the diagnostic yield of a standardized examination.

METHOD

Over a 1-year period, the first three children presenting to the paediatric outpatients department (OPD) on 2 selected weekdays with developmental delay, suspected intellectual disability, or school failure were enrolled for study if they satisfied standard definitions of global developmental delay (GDD), or intellectual disability as tested by scales for Indian children: Developmental Assessment for Indian Infants, Binet Karnat Test, and the Vineland Social Maturity Scale (Malin's Adaptation). Detailed history, and physical and neurological examinations were recorded. An algorithmic approach to investigations was followed. Also, neuroimaging, thyroid function, electroencephalograph, karyotyping, and studies for fragile-X syndrome were conducted. Aetiological diagnosis was considered established only if clinical features were supported by investigations. Clinical features associated with a successful aetiological diagnosis were computed.

RESULTS

A total of 122 children were enrolled in a cross-sectional analytic study (mean age 43.5 mo [SD 40.66]; 84 males, 38 females). Of these, a definite aetiology could be assigned in 66 children (54.1%); 17 prenatal, 38 perinatal/neonatal, and 11 postneonatal. Factors associated with reaching a definite diagnosis included younger age at presentation, presence of seizures, microcephaly, adverse neonatal events, and abnormal motor signs. Clinical history and examination gave important clues to the aetiology in 89 (72.9%) patients. Neuroimaging was abnormal in 91 out of 114 children, with aetiological findings in 48 children.

INTERPRETATION

Perinatal/neonatal causes predominate as the cause of GDD or intellectual disability in India. The study highlights that a large majority of cases seen here were preventable.

Parents' reports predict abnormal investigations in global developmental delay

AIMS

To identify symptoms reported by parents that predict abnormal laboratory investigations in preschoolers with global developmental delay (GDD).

METHODS

A cross-sectional descriptive study of 81 boys and 38 girls, with a mean age of 43.5 months (SD = 13.4), with global developmental delay. All parents/guardians completed the following: (1) a semistructured interview about their child and family; (2) the Child Development Inventory (CDI); (3) the Possible Problems Checklist (PPC); and (4) the Child Behavior Checklist 1(1/2)-5 (CBCL).

RESULTS

There were 61 abnormal results: MRI 37 (31%); high-resolution chromosomes 8 (7%); fragile X molecular testing 4 (3%); and microarray comparative genomic hybridization 12 (10%). A total of 47 children had abnormal tests (40%): none, 72 (60%); one, 36 (30%); two, 8 (7%); three, (3%). Younger children with more developmental delays are more likely to have abnormal tests. They are clumsy, more passive, and less disobedience. They had lower total, externalizing, and internalizing problems scores. The odds of finding an abnormal investigation are increasingly greater as parent's report of language comprehension and social development ratios increase, and decrease in likelihood for every increase in the expressive language and fine motor ratios.

INTERPRETATION

Parent's reports predict abnormal tests and indicate quantifiable differences requiring investigation.

Korean Academy of Medical Sciences Pediatric Impairment Guideline for brain lesion

The permanent impairment evaluation for children in developmental stage is very difficult and it is even impossible in some cases. The impairment evaluation for developing children has not yet been included in the guideline of the American Medical Association. Due to frequent medical and social demands in Korea, we developed an impairment evaluation guideline for motor impairment, intellectual disability/mental retardation, developmental speech-language disorder and epilepsy caused by pediatric cerebral injuries, or cerebral lesions other than the developmental disorders such as autism. With the help of various literature and foreign institutions, we developed our in order to develop a scientific guideline for pediatric impairment that is suited to Korean cultural background and social condition.

Animal models of perinatal hypoxic-ischemic brain damage

Animal models are often presumably the first step in determining mechanisms underlying disease, and the approach and effectiveness of therapeutic interventions. Perinatal brain damage, however, evolves over months of gestation, during the rapid maturation of the fetal and newborn brain. Despite marked advances in our understanding of these processes and technologic advances providing an improved window on the timing and duration of injury, neonatal brain injury remains a "moving target" regarding our ability to "mimic" its processes in an animal model. Moreover, interfering with normal processes of development as part of a therapeutic intervention may do "more harm than good." Hence, controversy continues over which animal model can reflect human disease states. Numerous models have provided information regarding the pathophysiology of brain damage in term and preterm infants. Our challenges consist of identifying infants at greatest risk for permanent injury, identifying the timing of injury, and adapting therapies that provide more benefit than harm. A combination of appropriately suitable animal models to conduct these studies will bring us closer to understanding human perinatal damage and the means to treat it.

Treatment of the term newborn with brain injury: simplicity as the mother of invention

Neonatal brain injury remains a common cause of developmental disability, despite tremendously enhanced obstetrical and neonatal care. The timing of brain injury occurs throughout gestation, labor, and delivery, providing an evolving form of brain injury and a moving target for therapeutic intervention. Nonetheless, markedly improved methods are available to identify those infants injured at birth, via clinical presentation with neonatal encephalopathy and neuroimaging techniques. Postischemic hypothermia has been shown to be of tremendous clinical promise in several completed and ongoing trials. As part of this approach to the treatment of the newborn, other parameters of physiologic homeostasis can and should be attended to, with strong animal and clinical evidence that their correction will have dramatic influence on the outcome of the newborn infant. This review addresses aspects of newborn care to which we can direct our attention currently, and which should result in a safe and efficacious improvement in the prognosis of the newborn with neonatal encephalopathy.

Child health and parental stress in school-age children with a preschool diagnosis of developmental delay

Chronic disorders are known to have a wide-ranging impact on overall health and family dynamics. The objective of this study was to assess child health and well-being and parental stress in a cohort of school-age children diagnosed before school entry with either global developmental delay or developmental language impairment. In total, 65 children with preschool developmental delay were assessed at school age (mean +/- SD age: 7.3 +/- 0.7 years) with the Child Health Questionnaire and Parenting Stress Index, with a mean interval between assessment of 3.9 years. Almost all children who completed testing (60/62) continued to show developmental impairments across domains. On the Child Health Questionnaire, children showed the greatest impairment on the mental health scale (median z score: -0.9). The median Child Health Questionnaire psychosocial health score (40.7) was almost 1 SD below established normative values ( P < .001). More than 40% of parents had a Parenting Stress Index above the 85th percentile (clinically significant parenting stress). Using multiple linear regression analysis, high levels of parenting stress were best predicted by a child's Child Health Questionnaire psychosocial health score (r2 = 0.49, P < .001). Thus, 4 years after a preschool-age diagnosis of developmental delay, poor psychosocial health was a common comorbidity. Almost half the parents showed clinically significant levels of parenting stress. There is a need to both recognize and provide ongoing social and emotional support for young children diagnosed with developmental disability and their families.

Neuroimaging of the child with developmental delay

Developmental delay (DD) affects approximately 1% to 3% of all children in the United States. This diagnosis significantly impedes quality of life and full participation in the life of the family, school, and community. In this setting, the clinician's ability to detect, diagnose, and possibly treat the cause for DD in a timely manner depends on a multimodality approach to neuroimaging and a robust understanding of the various imaging algorithms aimed at determining the etiology of disease, structural and/or anatomic defects, functional activity, metabolic profiles, and genetic characteristics. Taken separately and in combination, these features are effectively depicted and analyzed using an array of brain imaging modalities: ultrasound, computed tomography, nuclear medicine, magnetic resonance (MR) spectroscopy, and a growing mix of sophisticated MR imaging (MRI) techniques, including diffusion-weighted imaging, diffusion tensor imaging, perfusion MRI, and functional MRI. Thus, equipped with these advanced imaging capabilities, pediatric neurologists and neuroradiologists are now positioned to diagnose with greater accuracy and speed; this, in turn, results in more effective treatment plans and improved patient outcomes as measured by progress in reaching developmental milestones and in ameliorating secondary conditions such as seizures, poor motor control, incontinence, and impulsivity. The purpose of this article is to present the numerous causes of pediatric DD, describe their respective neuroimaging findings, discuss various neuroimaging approaches for elucidating etiology, and offer specific guidelines for optimizing imaging results in the setting of multimodality imaging capabilities.

Office evaluation of the child with developmental delay

Developmental delays are a common problem in child health and a frequent reason for referral to a pediatric subspecialist. The office evaluation of the young delayed child has a number of objectives including primarily precisely categorizing the delay subtype together with rationally selecting investigations for determining a possible underlying etiology. Counseling the affected family regarding the diagnosis and its prognosis, identifying possible coexisting conditions that merit interventions, and ensuring appropriate rehabilitation service provision are also important objectives of this office assessment. An outline of the key features of the relevant history and physical examination together with guidelines regarding investigations are provided to best meet all these objectives within existing time and practice constraints.

Analysis of clinical features predicting etiologic yield in the assessment of global developmental delay

OBJECTIVE

Global developmental delay is a common reason for presentation for neurologic evaluation. This study examined the role of clinical features in predicting the identification of an underlying cause for a child's global developmental delay.

METHODS

Over a 10-year inclusive interval, the case records of all consecutive children <5 years of age referred to a single ambulatory practice setting for global developmental delay were systematically reviewed. The use of clinical features in predicting the identification of a specific underlying cause for a child's delay was tested using chi2 analysis.

RESULTS

A total of 261 patients eventually met criteria for study inclusion. Mean age at initial evaluation was 33.6 months. An underlying cause was found in 98 children. Commonest etiologic groupings were genetic syndrome/chromosomal abnormality, intrapartum asphyxia, cerebral dysgenesis, psychosocial deprivation, and toxin exposure. Factors associated with the ability to eventually identify an underlying cause included female gender (40 of 68 vs 58 of 193), abnormal prenatal/perinatal history (52 of 85 vs 46 of 176), absence of autistic features (85 of 159 vs 13 of 102), presence of microcephaly (26 of 40 vs 72 of 221), abnormal neurologic examination (52 of 71 vs 46 of 190), and dysmorphic features (44 of 84 vs 54 of 177). In 113 children without any abnormal features identified on history or physical examination, routine screening investigations (karyotype, fragile X molecular genotyping, and neuroimaging) revealed an underlying etiology in 18.

CONCLUSIONS

Etiologic yield in an unselected series of young children with global developmental delay is close to 40% overall and 55% in the absence of any coexisting autistic features. Clinical features are readily apparent that may enhance an expectation of a successful etiologic search. Screening investigations may yield an underlying cause.

Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening

Early identification of developmental disorders is critical to the well-being of children and their families. It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals. This statement provides an algorithm as a strategy to support health care professionals in developing a pattern and practice for addressing developmental concerns in children from birth through 3 years of age. The authors recommend that developmental surveillance be incorporated at every well-child preventive care visit. Any concerns raised during surveillance should be promptly addressed with standardized developmental screening tests. In addition, screening tests should be administered regularly at the 9-, 18-, and 30-month visits. (Because the 30-month visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age. In addition, because the frequency of regular pediatric visits decreases after 24 months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24-month visit.) The early identification of developmental problems should lead to further developmental and medical evaluation, diagnosis, and treatment, including early developmental intervention. Children diagnosed with developmental disorders should be identified as children with special health care needs, and chronic-condition management should be initiated. Identification of a developmental disorder and its underlying etiology may also drive a range of treatment planning, from medical treatment of the child to family planning for his or her parents.

Investigação das causas de atraso no neurodesenvolvimento: recursos e desafios

Com o objetivo de verificar o alcance da investigação de causas do retardo no desenvolvimento neuromotor (RDNM), apresenta-se a experiência no atendimento em Pediatria, Neurologia Infantil e Genética Clínica, em nível terciário, de 73 crianças de 1 a 47 meses, do Programa de Estimulação da APAE de Batatais-SP, entre 1999 e 2001. Utilizando-se método transversal, prospectivo, inicialmente identificaram-se 6 grupos, segundo a semiologia clínica dominante - distúrbios motores, dismorfias, desnutrição, macrocefalia, microcefalia e unicamente atraso motor. Analisando-se a proporção com que os antecedentes e exames contribuíram para o diagnóstico, nos grupos "distúrbios motores" e "macrocefalia" destacaram-se os exames de imagem; nos demais grupos, o exame físico na criança e antecedentes maternos. As causas do RDNM foram detectadas em 48 crianças (66%), sendo de origem ambiental 38,4% e genética 24,6%. Ressalta-se a relevância da avaliação especializada e necessidade de fluxo adequado de informações na rede de saúde.

ICF and ICD codes provide a standard language of disability in young children

BACKGROUND AND OBJECTIVES

The aim of this study was to examine the utility of a hierarchical algorithm incorporating codes from the International Classification of Functioning, Disability and Health--ICF (WHO, 2001) and the International Statistical Classification of Diseases-ICD (WHO, 1994) to classify reasons for eligibility of young children in early intervention.

METHODS

The database for this study was a nationally representative enrollment sample of more than 5,500 children in a longitudinal study of early intervention. Reasons for eligibility were reviewed and matched to the closest ICF or ICD codes under one of four major categories (Body Functions/Structures, Activities/Participation, Health Conditions, and Environmental Factors).

RESULTS

The average number of reasons for eligibility provided per child was 1.5, resulting in a population summary exceeding 100%. A total of 305 ICF and ICD codes were used with most (77%) of the children having codes in the category of Body Function/Structures. Forty-one percent of the sample had codes of Health Conditions, whereas the proportions with codes in the Activities/Partipication and Environmental Categories were 10 and 5%, respectively.

CONCLUSIONS

The results demonstrate that ICD and ICF can be jointly used as a common language to document disability characteristics of children in early intervention.

Contribution of proton magnetic resonance spectroscopy to the evaluation of children with unexplained developmental delay

Developmental delay (DD) in children is a common socioeconomic problem with a prevalence of 1-2%. The cause of DD in children is often unknown, and magnetic resonance imaging plays an important role in evaluating children with DD, estimating long-term prognosis, and guiding therapeutic options. The aim of our study on children with DD was to elucidate 1) whether magnetic resonance spectroscopy (MRS) reveals abnormalities in cerebral metabolism and 2) whether there is a correlation between the cognitive performance and the concentration of brain metabolites, especially N-acetylaspartate (NAA), named in the literature a neuronal marker. Using proton MRS of deep gray and central white matter, we measured concentrations of brain metabolites in 48 children, who were aged 1 mo to 13 y and had unexplained DD [developmental quotient (DQ) between <50 and 85] and normal magnetic resonance imaging examinations, and compared them with those of 23 age-matched normal control children. Children with DD were divided into three groups: mild (DQ 76-85), moderate (DQ 51-75), and severe (DQ <50). We found no significant differences in metabolite concentrations, neither among the three groups of children with DD nor between patients and age-matched normal control children. Independent of the degree of mental retardation, the NAA concentrations of handicapped patients and normal children were comparable. We conclude that 1) brain metabolites, especially NAA, in children with unexplained DD are within normal limits, and 2) in most cases, proton MRS adds little information concerning cause of unexplained DD.

Developmental and functional outcomes at school age of preschool children with global developmental delay

The later developmental trajectory of young children diagnosed early with global developmental delay was determined. Using a prospective study, preschool children diagnosed with global developmental delay were systematically reassessed during the early school years with standardized developmental and functional outcome measures (Battelle Developmental Inventory and Vineland Adaptive Behavior Scale). Of an original cohort of 99 children assessed and diagnosed at a mean age of 3.4 +/- 1.1 years, 48 were reassessed at a mean age of 7.3 +/- 0.9 years. Group performance on the Battelle Developmental Inventory overall was 66.4 +/- 4.3 (mean 100 +/- 15). Between 75% and 100% of the cohort performed at least 1.5 SD below the normative mean on the individual domains of the Battelle Developmental Inventory. Similarly, the group mean on the Vineland Adaptive Behavior Scale overall was 63.5 +/- 20.8 (mean 100 +/- 15), with between 61% and 76% of the cohort scoring more than 1.5 SD below the mean on each of the domains. Univariate and multivariate analyses on potential predictor variables identified a lack of an underlying etiology as predictive of poorer performance on the Battelle Developmental Inventory fine motor and motor domains and increasing severity of initial delay as predictive of poorer performance on the Vineland Adaptive Behavior Scale communication domain and overall score. Similarly, maternal employment and paternal postsecondary education improved Vineland Adaptive Behavior Scale communication scores, whereas paternal postsecondary education alone predicted better socialization and total scores on the Vineland Adaptive Behavior Scale. Children with early global developmental delay demonstrate persistent and consistently poor performance across all developmental and functional domains. Few variables are apparent at intake to predict later performance.

Outcomes at school age of preschool children with developmental language impairment

In a prospective study, preschool children diagnosed with developmental language impairment were systematically reassessed during the early school years with standardized developmental (Battelle Developmental Inventory) and functional measures (Vineland Adaptive Behavior Scale). Of an original cohort of 70 children assessed and diagnosed at a mean age of 3.6 +/- 0.7 years, 43 were reassessed at a mean age of 7.4 +/- 0.7 years. Group performance on the Battelle overall was 71.9 +/- 8.2 with the lowest sub-domain score in communication at 69.5 +/- 8.9. On the Battelle, 67% of children fell below the 1.5 standard deviation (S.D.) cutoff signifying significant developmental concerns. Between 36% (gross motor) and 83% (communication) of the cohort performed at least 1.5 S.D. below the normative mean on the individual domains of the Battelle. Seventy-four percent were impaired in two or more domains of the Battelle. The group mean on the Vineland overall was 81.1 +/- 16.9 with between 19% (socialization) to 48% (communication) of the cohort scoring more than 1.5 S.D. below the mean on each of the sub-domains. Almost half of the cohort (20/42, 48%) manifested functional impairment in at least two domains of the Vineland. Univariate and multivariate analysis of potential predictor variables identified only female sex as being predictive of significantly poorer performance on the Vineland communication sub-domain and the Vineland total score. Children with early developmental language impairment demonstrate persistent impairments in developmental and functional skills at school entry not limited to language. Deficits remain especially evident in the communication sub-domain. These results have implications with respect to later prognostication, family counseling, and devising a programmatic approach to this group of children.

Genome-wide SNP arrays as a diagnostic tool: Clinical description, genetic mapping, and molecular characterization of Salla disease in an Old Order Mennonite population

An Old Order Mennonite child was evaluated for gross motor delay, truncal ataxia, and slow linear growth. The diagnostic evaluation, which included sub-specialty consultations, neuroimaging, and metabolic testing, was long, costly, and did not yield a diagnosis. Recognition of a similarly affected second cousin prompted a genome-wide homozygosity mapping study using high-density single nucleotide polymorphism (SNP) arrays. SNP genotypes from two affected individuals and their parents were used to localize the disease locus to a 14.9 Mb region on chromosome 6. This region contained 55 genes, including SLC17A5, the gene encoding the lysosomal N-acetylneuraminic acid transport protein. Direct sequencing of SLC17A5 in the proband revealed homozygosity for the 115C --> T (R39C) sequence variant, the common cause of Salla disease in Finland. Three additional affected Mennonite individuals, ages 8 months to 50 years, were subsequently identified by directed molecular genetic testing. This small-scale mapping study was rapid, inexpensive, and analytically simple. In families with shared genetic heritage, genome-wide SNP arrays with relatively high marker density allow disease gene mapping studies to be incorporated into routine diagnostic evaluations.

Motor function at school age in children with a preschool diagnosis of developmental language impairment

OBJECTIVES

To evaluate fine motor (FM) and gross motor (GM) function shortly after school entry in children with a preschool diagnosis of developmental language impairment (DLI).

STUDY DESIGN

A cohort of children (n = 70) diagnosed at pre-school age with DLI was reevaluated in elementary school. Language, cognitive, and motor outcomes were assessed through the use of the Battelle Developmental Inventory (BDI). Language was further assessed through the use of the Vineland Adaptive Behavior Scale, Peabody Picture Vocabulary, and Expressive One Word Picture Vocabulary Tests. Performance below -1.5 SD of the normative mean on any test was considered to represent impairment.

RESULTS

Forty-three children (mean age, 7.4 +/- 0.7 years) underwent reassessment at a mean of 3.8 +/- 0.7 years after initial preschool assessment. Mean scores for BDI motor domains (FM, 78.3 +/- 11.4; GM, 84.9 +/- 13.3) fell below normative values. Twenty-two children (52%) had motor impairment (FM, 17 of 42; GM, 15 of 42); 35 of 43 (81%) continued to have language impairment. BDI communication raw scores correlated most strongly with FM (rho = 0.73, P < .001) and GM (rho = 0.58, P = .003) raw scores but showed only moderate correlations with cognitive raw scores (rho = 0.41, P = .05).

CONCLUSIONS

Impaired motor function is an important comorbidity in DLI. Factors critical to motor performance may also contribute to language deficits in DLI.

Late diagnosis in severe and mild intellectual disability in adulthood

BACKGROUND

The diagnosis of intellectual disability (ID) is highly dependent on a comprehensive personal and family medical history, a complete physical examination and a careful developmental assessment of the patient. Our study intended to: (1) classify the aetiology of mild and severe ID in an adult population of 140 Italian subjects; (2) evaluate the frequency of associated medical conditions; (3) evaluate the age of diagnosis in both groups; and (4) underline the importance of aetiological diagnosis for adult ID patients also.

METHODS

The study involved 140 consecutive adult Italian ID inpatients and outpatients neurologically investigated at the Neurological Institute C. Mondino of Pavia Service for Mental Retardation. A total of 80 patients had mild ID (MID group) (39 females, 41 males), mean age 34 years (range 19-61 years), mean IQ = 64 (range 51-75), and 60 had severe ID (SID group) (32 females, 28 males), mean age 30 years (range 19-69 years). They underwent a complete diagnostic work-up that comprised prenatal, perinatal and postnatal history, physical examinations, laboratory investigations, genetic survey and neuroradiological investigations to determine the aetiology of ID and to evaluate the presence of associated medical conditions.

RESULTS

ID aetiology was classified as prenatal in 34% of the MID and 28% of the SID group. Perinatal and postnatal events were found in 6% of the MID and in 5% of the SID group. Associated medical conditions were found in 97 patients (47% MID and 26% SID). A genetic diagnosis was possible in 6% of patients above 20 years of age and in 5% of patients above 40 years. A diagnosis of cerebral dysgenesis was possible in 5% of patients above 20 years and 4% of patients above 40 years.

CONCLUSIONS

A long interval between the diagnosis of ID and the aetiological definition can be observed in a significant percentage (24%) of our population, leading to unfortunate consequences of late diagnosis: late onset of a specific therapeutic program, genetic counselling that is frequently no more useful, and ineffective prenatal diagnosis, leading to the birth of other affected subjects (for familiar ID).