Neurological Examination and Developmental Screening for

Infants with Possible Congenital Zika

Wednesday, March 21, 2018Thursday, March 22, 2018Saturday, March 24, 2018

6:00pm Atlantic Standard Time

OBJECTIVES

By the end of this webinar, participants will be able to:

1. Describe how to perform a comprehensive neurological examination of infants and youngchildren.

2. Understand recommendations for age-appropriate developmental surveillance and screening.

3. Identify where to find for the most up-to-date clinicalguidance, AAP recommendations and resources.

TECHNICAL SUPPORT

• Type issue into the chat feature

• Call 800-843-9166

• Email support@readytalk.com

Q & A• Submit questions at any time through the chat box

• Over the phone, call 866-519-2796 (US/Canada) or 1-323-794-2095 (International), ID #049641

• Dial *1 on your phone to ask a live question

PRA CREDITS STATEMENT• The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing

Medical Education (ACCME) to provide continuing medical education for physicians.

• The AAP designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• This activity is acceptable for a maximum of 1.0 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics.

• The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME. Physician assistants may receive a maximum of 1.0 hours of Category 1 credit for completing this program.

• This program is accredited for 1.0 NAPNAP CE contact hours of which 0 contain pharmacology (Rx) content, (0 related to psychopharmacology) (0 related to controlled substances), per the National Association of Pediatric Nurse Practitioners (NAPNAP) Continuing Education Guidelines.

FACULTY

James Bale, MDProfessorDivision of Pediatric Neurology Departments of Neurology and Pediatrics University of Utah School of Medicine

FACULTY

Sarah Mulkey, MD, PhD Fetal-Neonatal NeurologistDivision of Fetal and Transitional MedicineChildren’s National Health SystemAssistant Professor of Pediatrics and Neurology The George Washington University School of Medicine and Health Sciences

DISCLOSURES

• The presenters have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity.

• The presenters do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

Overview of Zika in the US Virgin Islands

•Jan 25, 2016 the first laboratory confirmed case in the US Virgin Islands

•37,000+ positive tests for Zika virus in the U.S. territories •~4500 are pregnant women •~290 infants born to Zika positive mothers in the U.S. Virgin Islands in the last 2 years

HOW TO PERFORM A NEUROLOGICAL

EXAMINATION IN INFANTS AND CHILDREN WITH

CONFIRMED OR SUSPECTED ZIKA VIRUS

• Apply the major components of the infant/child neurological examination.

• Record the infant’s or child’s responses.

• Recognize the neurological signs of congenital Zikasyndrome

• Anticipate neurological complications in infants with neurological signs consistent with congenital Zika syndrome

NEUROLOGIC EXAM COMPONENTS

• General observation• Mental State• Cranial Nerves• Motor

– Tone– Strength– Movement

• Reflexes– Deep tendon reflexes– Plantar reflexes– Primitive reflexes

• Sensation• Head size, shape and

fontanels/sutures

OBSERVATION AND MENTAL STATE

• Observe the infant or child. Is he/she awake or asleep? Is she/he quiet or irritable? Does the child make eye contact? Does the child respond to you or the parents?

• If the child is feeding, does he/she hold a bottle?Can the child pick up food?

• Does the child vocalize or say words? Can the child reach for or hold a toy? Does the child show handedness? Does the child sit or walk?

CRANIAL NERVE EXAMINATION OF

INFANTS

• Observe the infant during the awake state.

• Are the pupils equal and reactive? Are the red reflexes present bilaterally?

• Does the infant open the eyes spontaneously and have full eye movement in all directions?

CRANIAL NERVE EXAMINATION OF

INFANTS

• Does the infant hear?

• Does the infant display spontaneous and symmetrical facial movements?

• Does the infant suck and swallow appropriately when nursed or bottle fed? Is a gag present?

CRANIAL NERVE EXAMINATION OF

YOUNG CHILDREN

• CN II: Are the pupils equal and reactive? Are the red reflexes present and equal bilaterally?

• CN III, IV, VI: Does the child follow an object, such as a toy or flashlight?

CRANIAL NERVE EXAMINATION OF

YOUNG CHILDREN

• CN VII: Does the face movesymmetrically?

• CN VIII: Does the child hear?

• CN IX, X: Does the childsuck and swallow? Is a gagreflex present?

• CN XI: Can the child move the head to each side?

• CN XII: Does the tongue protrude normally?

MOTOR EXAMINATION IN INFANTS

• Is the infant’s posture appropriate for the gestational age? Are the arms and legs flexed if full term, extended if preterm?

• Does the infant move all extremities spontaneously?

MOTOR EXAMINATION IN INFANTS

• Assess flexor and extensortone at all joints.

• Assess head control and response to ventral suspension.

MOTOR EXAMINATION IN INFANTS

AND YOUNG CHILDREN

• Assess tone by observation as well as by passive or active movement.

ASSESSING DEEP TENDON REFLEXES

IN INFANTS AND CHILDREN

• Assess deep tendon (aka “muscle stretch”) reflexes at the biceps, brachioradialis, patellar and Achilles tendons. Grade 0 to 4 based on responses (0 = absent; 4 = clonus).

REFLEXES

• Assess the infant’s response to the Moro reflex. Are arm movements present, symmetrical, and full (displaying both extension and flexion)?

• Does the infant have symmetrical palmar and plantar grasp responses?

• Plantar reflex: an ‘up-going’ toe is typical until 9 -12 months of age

SENSATION

• Assess the response to touch, tickle and mild pain in all four extremities

https://www.cdc.gov/ncbddd/actearly/milestones/milestones-4mo.html

GAIT AND COORDINATION IN

TODDLERS

HEAD SHAPE AND MEASUREMENT

Adapted from Danmar Co., helmet sizing

PLOT THE INFANT’S HEAD

CIRCUMFERENCE ON A STANDARD

GROWTH CURVE• Head circumference is also

known as occipital-frontal circumference or OFC.

• Microcephaly = OFC <3rd

percentile.

• Normal OFC varies according to gestational age and gender.

• For a term infantmicrocephaly corresponds toan OFC of <32 cm.

See: https://www.infantchart.com/olsenheadforage.php

ABNORMAL HEAD SIZE

Microcephaly Macrocephaly

CRANIAL SUTURES

Sagittal suture synotosis Metopic suture synostosis

POTENTIAL ABNORMAL SIGNS IN

CONGENITAL ZIKA SYNDROME

• Microcephaly: measure and plot the infant’s head size.

• Chorioretinitis, optic atrophy: perform a retinal examination.

• Hearing loss: obtain the newborn hearing screen, usingotoacoustic emissions and automated auditorybrainstem response by 1 month of age.

• Abnormal muscle tone (spasticity, rigidity, hypotonia): perform a complete motor examination, assessing tone at all extremities.

• Congenital contractures, arthrogryposis multiplex congenita: observe posture, assessing range of motion at all extremities.

FOLLOW-UP FOR INFANTS WITH

CONGENITAL ZIKA SYNDROME

• Enroll infants in early intervention programs, including physical and developmental therapy.

• Refer infants for neurodevelopmental assessment.

• Head ultrasound, ophthalmology examination and hearing assessment (ABR) by 1 month of age.

FOLLOW-UP FOR INFANTS WITH

CONGENITAL ZIKA SYNDROME

• Monitor for seizures, including subtle or electrographic seizures in newborns and infantile spasms in infants 3 to 10 months ofage. An EEG may be necessary.

• Consider a brain MRI.

• Provide psychosocial support to parents andother family members.

AGE-APPROPRIATE DEVELOPMENTAL

SURVEILLANCE AND SCREENING FOR CHILDREN

WITH CONFIRMED OR SUSPECTED ZIKA VIRUS

• Developmental milestones should be assessed at each well child visit

• Four areas:

1. Gross Motor

2. Fine Motor

3. Language

4. Social

https://www.cdc.gov/ncbddd/actearly/milestones-app.html

GROSS MOTOR

• Control develops headto toe, as myelinationprogresses– Head control (no head

lag): 1-2 months

– Upper extremity (lifts chest up): 2-4 months

– Truncal control (sits onown): 5-6 months

– Lower extremity (supports weight standing): 9-11 months

FINE MOTOR

• Progresses from proximal to distal– Involuntary grasp (reflex)

▪ 0-1 month

– Hands to midline▪ 2-4 months

– Bring objects to body▪ 4-5 months

– Transfer between hands▪ 5-7 months

– Immature pincer grasp▪ 9 months

– Mature pincer grasp▪ 12 months

LANGUAGE-EXPRESSIVE

• Ability to producelanguage

• Cooing: 2-3 months

• Babbling (consonants +vowels): 6 months

• Jargon (intonation): 9-12 months

Bing images

LANGUAGE-RECEPTIVE

• Ability to comprehend language

• Startles to voice: at birth

• Turns head to sound: 4 months or more

• Responds to selective words (“no”): 9-12months

• Follows 1 step commands: 12-18 months

• Follows 2 step commands: 30 months

• Answers simple questions: 3.5 years

SOCIAL

• Social smile: 2 months

• Parental attachment: 6-8 months

• Stranger anxiety: 9-12months

• Pretend/parallel play: 2years

• Group play: 3 years

PERFORM AGE APPROPRIATE

DEVELOPMENTAL SCREENING

• Screening can help identify children with developmental disabilities

• Without screening, 70% of children with developmentaldisabilities may not be identified (Palfrey et al, 1994).

• Surveillance at every well child visit, developmental screening at each well child visit, autism screening at 16 months and older, behavioral/emotional screening annually

• Screening mechanisms:

– Provider exams– Parent/patient questionnaires

https://www.cdc.gov/ncbddd/actearly/ milestones/milestones-18mo.html

AGES AND STAGES QUESTIONNAIRE

(ASQ)• Developmental screening at each well child visit.

• Parent administered survey

• Screens multiple domains (communication, gross and fine motor, problem solving and social)

• Sensitivity 70-90% Specificity 76-91%

• Written at 4th grade literacy

• Available for multiple ages (if children miss a WCC visit for the recommended screening)

• Scored 10 points (always), 5 points (sometimes), 0 points(never)

M-CHAT (MODIFIED CHECKLIST

FOR AUTISM)

• Autism Screening at 16 months

• Parent completed or administered verbally

• Sensitivity 85% Specificity 93%

• PPV 36%

• There are f/u questions for Fails and f/u interview to improve specificity BUT about 50% of those who screen positive will not have ASD- some may have language, cognitive delays

RESOURCES

• AAP Zika Virus Web Page (www.aap.org/zika)

• AAP Key Information for Pediatricians (www.aap.org/zikakey)

• CDC Zika Virus Web Page (https://www.cdc.gov/zika/index.html)

• CDC Learn the Signs. Act Early. Developmental milestones(https://www.cdc.gov/ncbddd/actearly/milestones/index.html)

CME/MOC CREDIT

CME/MOC Credit:

• Complete the post activity survey.

• Only physicians can claim MOC Part 2

• Physicians must identify ABP ID number

AAP staff will email each person claiming CME/MOC 2 credit with their certificate of completion. Email DisasterReady@aap.org with any questions.

For those in the audience, here is a link to the CME/MOC survey: https://www.surveymonkey.com/r/USVIwebinar

QUESTIONS?

• Dial *1 on your phone to ask a live question.

• Phone: 866-519-2796 (US/Canada) or 1-323-794-2095(International)

• Conference ID: 049641

• Can ask questions through chat box in lower left corner. AAP staff or presenters will address unanswered questions via e-mail after the call.

Please e-mail DisasterReady@aap.org to

receive info on future events, or

follow-up as needed.

This webinar is supported by cooperative agreement number, 6NU38OT000167-04-06 funded by the Centers for Disease Control and

Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease

Control and Prevention or the Department of Health and Human Services.