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Difficulty: Very hardNormal Growth and Development

A 15-month-old girl is brought to the pediatrician for a routine well-child visit. She was born at 28 weeks gestation via emergency cesarean delivery due to a placental abruption, and her neonatal course was complicated by respiratory distress syndrome requiring mechanical ventilation. Her parents are concerned about her development, noting that she cannot walk independently and her vocabulary consists only of the words "mama" and "dada." However, the parents proudly mention that she is "advanced in her motor skills on the right side," as she has consistently used her right hand to feed herself and reach for toys since she was 8 months old. On physical examination, the patient's growth parameters are at the 50th percentile for her corrected age. She can pull to a stand and cruise along furniture. She makes good eye contact, points to a desired toy across the room, and plays peek-a-boo. When a small block is placed on the examination table, she picks it up using a precise right-sided thumb and index finger grasp. Her left hand remains mostly fisted during the encounter, and there is noticeable resistance to passive extension of the left elbow. Which of the following is the most appropriate next step in management?

  1. Magnetic resonance imaging of the brainAnswer
  2. B
    Reassurance and routine developmental surveillance
  3. C
    Audiologic evaluation
  4. D
    Radiographs of the pelvis and lower extremities
  5. E
    Measurement of serum creatine kinase level

Answer

Magnetic resonance imaging of the brain
The correct next step in management is a brain MRI. This patient was born at 28 weeks gestation, meaning her chronological age of 15 months translates to a corrected age of 12 months. For a 12-month-old, her gross motor (cruising), fine motor (pincer grasp), language (mama/dada), and social (pointing) milestones are entirely age-appropriate. However, hand preference should not emerge until 18 to 24 months of age. Consistent right-handedness since 8 months of age, combined with a fisted left hand and left elbow hypertonia, is a major red flag for left-sided spastic hemiplegic cerebral palsy. Prematurity places her at high risk for periventricular leukomalacia, the most common cause of spastic cerebral palsy. A brain MRI is required to evaluate the extent of white matter injury or other structural brain abnormalities.

Step-by-Step Solution

1
Calculate the patient's corrected age to appropriately assess her milestones.
Chronological age (15 months) minus prematurity (12 weeks, or ~3 months) equals a corrected age of 12 months.
Premature infants must have their developmental milestones evaluated based on their corrected age until approximately 2 years of chronological age.
2
Evaluate the parents' concerns against the milestones expected for a 12-month-old.
Cruising along furniture, saying 1-2 words (mama/dada), pointing, and utilizing a mature pincer grasp are all perfectly normal milestones for a 12-month-old child.
This establishes that the patient does not have a global developmental delay or isolated speech delay, ruling out the need for hearing tests or reassurance for delayed walking.
3
Identify any red flags or pathologic findings in the history and physical examination.
The patient exhibits consistent right-hand preference since 8 months of age, a fisted left hand, and resistance to passive extension of the left elbow (hypertonia).
Hand preference typically emerges between 18 and 24 months of age. Hand dominance prior to 18 months is a major red flag indicating weakness or spasticity in the contralateral limb.
4
Determine the most likely diagnosis and the appropriate diagnostic test.
The clinical picture strongly suggests left-sided spastic hemiplegia, a form of cerebral palsy common in premature infants. A brain MRI is indicated.
Brain MRI is the neuroimaging modality of choice to evaluate for the underlying cause of cerebral palsy, such as periventricular leukomalacia or intraventricular hemorrhage sequelae.

Key Concept

Cerebral palsy presentation and corrected age milestones in premature infants
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Topics

Normal Growth and Development

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