DELAYED GROSS MOTOR

DEVELOPMENT

By Nuramalina Binti Yahaya (10-5-257)

DEFINITION OF DEVELOPMENT
It means
Maturation of organ and system,
Acquisition of function and new skill
Ability of adaptation and assuming responsibilities

GROSS MOTOR DEVELOPMENT

It includes the posture and ability to control large body
movement as crawling, sitting, standing

FACTORS AFFECTING NORMAL GROSS

MOTOR DEVELOPMENT

Neurological
Endocrinal factor as thyroid hormone and growth hormone
Skeletal and muscular for postural and control precise
movement
Environmental & socioeconomic; overcrowding
Nutritional factors of mother and children during development
Physical activities as bed ridden and hypoactive may have
delay development

GROSS MOTOR MILESTONES

AGE

GROSS MOTOR MLESTONES

Birth 2 months

Raises head slightly off floor or bed when on

stomach.
Holds head momentarily when supported

3 5 months

Lifts head & chest when on stomach

Rolls from side to side
Pushes with feet
Sits briefly with arm supported
Makes crawling movement

6 8 months

Sits alone briefly

Rolls from back to stomach
Stands with support

9 11 months

Sits alone with trunk rotation

Creeps or crawl
Pulls to stand
Stand alone momentarily

AGE

GROSS MOTOR MILESTONES

12 15 months

Walks alone
Creeps up stairs
Crawls up on chair
Able to stand without support

16 18 months

Creeps downstairs
Walk sideway & backway
Stands on one foot with help
Kick large ball forward

19 24 months

Squats in play & stand back up

Jumps in place
Walks up & down stairs alone
Runs well

There is normal variation between individual. The ages mentioned in the table are average
of the child but may have early or some delay in acquisition of new motor skills.
There are also sex differences as girls usually have early development as a whole from
boys

ETIOLOGY OF DELAYED GROSS MOTOR

MILESTONES
1.
2.

3.

4.

Familial; Some delay may happen according in variation of every individual

and sex differences.
Genetic; Trisomy 21 appears physical phenotype of down syndrome as
mental retardation, hypotonia and other abnormalities of delay the
development.
Skeletal disorder; Rickets manifest as hypotonia of muscles and laxity of
ligament. The child may have bow legs and knock knees lead to delay
sitting, standing and walking.
Achondroplasia is a short-limbed dwarfism particularly have short stature
with short upper arms and thighs that limiting the range of movement.
Nutritional disorder; Severe protein malnutrition either marasmus or
kwashiorkor usually having muscle wasting which is hypotonic, weak and
unable to stand or walk. The child is hypoactive and lack interest in
surrounding.

5. Systemic disorder; Congenital heart disease have poor systemic blood flow
that lead to retarded growth and easily fatigue infant.
6. Perceptual disorder; blindness may interfere the normal pattern of gross
motor development.
7. Environmental factors; emotional deprivation or lack of stimulation due to
over protective parents.
8. CNS disorder;
Cerebral palsy is non progressive, permanent impairment of neuromuscular
system leading to motor disorder of movement, posture and coordination. CP
may manifests as paralysis of the limbs (hemiplegia or quadriplegia) that
prevent movement of the limbs and will delay gross motor development of the
child.
Mental handicap which have limitation in many adaptive skills and intellectual

9. Muscular disorder; any diseases that lead to

myopathies and muscle dystrophy also delay the normal
gross motor development of the child.
10. Metabolism; Phenylketonuria is the most common
amino acid disorders which manifest as severe mental
handicap. The child becomes hyperactive with purposeless
movement, rocking and athetosis.
11. Endocrinal; Cretinism (hypothyroidism) child usually
are sluggish physically and mentally. The child is passive
and lies quietly with little interest in surrounding also with
delayed developmental milestones, stunted height with
long trunk and short legs.

NUR ZAKIAH BINTI ZAHARI

10-5-260

HISTORY
Prenatal history:
~important especially if there is any
complication ( mother, baby )
~TORCH,

Behavior since birth:

~Behavioral disturbances
~abnormal behavior

Obstetrical history:
~difficulty during delivery eg: asyphyxia,
seizure,
~ evaluate using APGAR scores
Any sign of Infections (eg.GBS)

Family history:
~Relatives or sibling with
developmental delay, genetic
abnormalities,
~consanguinity

Past medical history and medications:

~History of taking Ototoxic antibiotics for
Social History:
example Gentamicin, previous surgery and past
~Evidence of neglected or abuse
delivery

DIAGNOSTIC APPROACH
1)
2)

Physical examination
Investigation

DIAGNOSIS

PHYSICAL EXAMINATION

Cerebral
Palsy

HEAD, FACE & NECK: Delayed closure fontanel

EXTREMITIES: Spastic quadriplegia,
NEUROLOGICAL EXAMINATION:
Hypotonia, Hypertonia,Dystonia, Muscle spasms, opisthotonus
Clonus muscular spasms with regular contractions
o Ankle/foot clonus spasmodic abnormal movement of the foot
o Wrist clonus spasmodic movement of the hand
GAIT: Tip toe

Down
Syndrome

HEAD, FACE & NECK: Flat occiput, Brushfield spots, hypertelorism, up slanting eye, epicanthic
folds, Depressed nasal bridge, Abnormal hair whorls, delayed teething, Macroglossia.
EXTREMITIES: Transverse palmar crease , Dry skin, Premature aging, Broad, short hands, feet,
and digits
NEUROLOGICAL EXAMINATION: Neuromuscular hypotonia

Ricket

HEAD, FACE & NECK: Delayed closure fontanel, Pseudotumor cerebri,

Craniotabes (before 8-10month), delayed teething, frontal bossing.
CHEST EXAMINATIO: Pigeon chest, rachitic rosary, Harrison groove
NEUROLOGICAL EXAMINATION: Neuromuscular hypotonia

Protein
Malnutrition

HEAD, FACE & NECK: Alopecia with dyspigmentation, old man face and sunken eye(marasmus),
edematous cheek and edematous eyelid (kwashiorkor)
EXTREMITIES: epiphyseal enlargement at wrist and ankles, marfan sign, bow leg, knock knee,
severe muscle wasting(marasmus), edema (kwashiorkor), decrease skin elasticity
ABDOMINAL EXAMINATION: Scaphoid abdomen

INVESTIGATION
Genetics:
Karyotyping
FISH analysis

Endocrinology:
TSH, free T4 in case of hypothyroidism
Metabolic:
Metabolic screening glucose, electrolytes, serum lactate, ammonia, liver function tests, pyruvate, albumin,
triglycerides, uric acid, serum quantitative amino acids, urine organic acids, creatine phosphokinase (if suspecting
myopathy), and calcium as in case of rickets or Protein energy malnutrition.

Neurology:
It can be EEG in case of affection of brain and mental retardation or head CT scan. While, X-Ray is useful especially
in case of rickets that will show positive expanded ends of radius and ulna, rarefied and cup-shaped and the bone is
poorly mineralized. While x-ray of the head will shows hair-standing-on-end which is a very characteristic sign. ECG is
also of help to detect any congenital heart disease. Neurological test is also important.

REFERENCES
REFERENCES

Madkour Essentials of Pediatrics (Paediatrics, Members of the Department of Paediatrics

Faculty Of Medicine- University Of Alexandria 12th Edition.

http://www.beststart.org/OnTrack_English/2-factors.html

http://www.brookshealth.org/motor-skills.pdf

http://education-portal.com/academy/lesson/what-are-gross-motor-skills-in-children-develo
pment-definition-examples.html#lesson

http://www.abilitypath.org/milestone-concerns/signs-of-possible-delays-gross-motor-and-se
nsory-development.html

http://www.healthline.com/symptom/developmental-delay

http://www.growingup.ie/fileadmin/user_upload/Conference_2010/Session_D_Factors_Affec
ting_Gross_Motor_Development_Outcomes.pdf

REFERENCE:
1-Basic clinical Pediatrics, 2009, second edition
Naseer Gamal
2-Illustrated Textbook of Pediatrics, 2012, fourth international
edition
Tom Lissauer, Graham Clayden
3-Madkours Essential of pediatric, 2012
Prof. Ahmed A Madkour
Members of Department of Pediatrics Faculty of MedicineUniversity of Alexandria Egypt
4-http://www.healthline.com/symptom/developmental-delay
5- http://emedicine.medscape.com/article/943216-clinical#a0256