Motor Outcomes in Premature Infants

Maureen Connors Lenke, BS, OTR/L

Disclosures

NAINR. 2003;3(3) 

In This Article

Follow-up Visit Schedule

Aclinic visit at about 4 months corrected age is important in the assessment of early motor development. Motor milestones that should be present at 4 months corrected age include visual tracking in a 180° plane, batting and grasp of a rattle, and midline hand activity. Active head righting in lateral and anterior/posterior planes and neck extension in prone with emerging weight shift for rolling prone to supine should also be present. Following the 1992 American Academy of Pediatrics sleep position guidelines for supine positioning for sleep to prevent sudden infant syndrome, there has been a significant increase in the numbers of infants with poor neck extension and intolerance of prone positioning.[11,12] This finding is frequently a result of limited opportunity and experience in prone position, rather than a true motor delay.

Transient patterns of movement that may persist at the 4-month corrected age visit may include mild asymmetry of the head and trunk. Preterm infants demonstrate a preference for head turning to the right spontaneously and in response to stimulation.[13] Infants with a preference may keep their head rotated to the right 70% to 80% of the time in supine.[13] Random extremity movement may be high and slightly jerky or arrhythmic in quality. Mild startling may be present in response to any change in position or outside stimulation such as ringing a bell or presentation of a visual stimulus. Passive movement may be resisted, with slightly limited mobility at end ranges. Head control may be decreased with the infant being unable to maintain a chin tuck with pull to sit or extend the neck past 45° in prone. With ventral suspension, the infant may be flexed with arms, head, and legs below the horizontal plane of the body.

Abnormal findings at the 4-month visit may include persistent asymmetries of movement patterns or obligatory patterns that the infant cannot easily move in and out of. Marked hypertonia with persistent fisting of hands in all positions, or an early consistent preference for one hand, would also be abnormal. Marked hypotonia with full head lag and a complete absence of head righting reactions is also abnormal at this visit. As previously noted, most extremely premature or medically fragile infants will initially be hypotonic, but if the hypotonia does not begin to improve in the first 4 months, an abnormal finding is recorded.

Between NICU discharge and the 4-month visit, a small percentage of infants will develop early spasticity, usually proximally through the shoulders and hips. Infants with spastic quadriplegia that is moderate to severe may be detected as early as 4 months corrected age.[6] Early signs of spastic quadriplegia include marked flexor hypertonia of the upper extremities with pronounced scapular elevation and retraction and increased extensor tonus of the lower extremities.

Persistent fisting of the hands is also present. The infant with emerging cerebral palsy may roll over early in a reflexive log roll rather than the segmental rolling that is typically developing at 4 months corrected age. The infant may be very irritable and have a low sensory threshold. Early referral to appropriate early intervention services is indicated to maximize the infant's function.

A clinic visit at 8 months corrected age is an appropriate developmental age to confirm the presence of neurologic abnormalities or the presence of CP.[10] Normal motoric findings that would be expected at the 8-month follow-up visit include directed upper extremity reach, transference of objects from one hand to another, and finger prehension for raking a fine object.

At 8 months corrected age, independent sitting with good trunk control, reciprocal crawling on the abdomen, or creeping in quadruped, and the emergence of transitioning in and out of sitting, should be present.

Transient patterns of movement that may persist in the extremely premature infant may include mild hypertonia or hypotonia.[6] Transitioning in and out of sitting may be difficult because of a delay in the development of trunk rotation and trunk strength. Reciprocal crawling may be delayed. Occasionally, abnormalities in movement patterns with normal muscle tone is present at 8 months.

It is very important to determine why the movement pattern is abnormal. If the child has had little opportunity to engage in an activity such as prone play, development may be delayed because of lack of experience rather than a neurological deficit. Infants whose primary means of mobility is an infant walker or infants who spend long periods of the day in an infant exersaucer may also exhibit motor delays. These children often demonstrate delays in crawling and may also demonstrate plantar flexion in standing, decreased ankle dorsiflexion, decreased trunk control, and decreased trunk rotation as a result of the developmentally inappropriate movement experiences provided by the walker or exersaucer.

Abnormal motor findings at the 8-month visit include the exaggeration or persistence of the transient signs noted at the 4-month visit. The failure to long-sit independently, inability to dissociate the legs for side-sitting and transitional positions, and an inability to alternate the legs for reciprocal crawling would indicate spastic diplegia. The infant with spastic diplegia typically commando crawls and stands on tiptoes with stiffness through the lower extremities. A commando crawl is a crawl in which the infant uses the arms to drag the body forward while the stomach remains on the ground. Diaper changing may be difficult because of resistance to hip abduction. Spastic diplegia may not be detectable at the 4-month corrected age visit, but it will be more obvious with progressive motor development at the 8-month corrected age visit.

An inability to consistently transfer objects to one hand or asymmetry in forward parachute (the reflexive protective reaction of extending both arms when moved forward quickly) and sideways protective extension may be indicative of spastic hemiplegia at the 8-month visit. Fisting of one hand is often the first indicator of spastic hemiplegia. During crawling, the infant with hemiplegia tends to drag one side of the body rather than alternating arms and legs to progress forward.

Most neurologic findings either resolve or become more permanent during the first year of life.[6] By 15 to 18 months, most of the transient neurologic signs associated with prematurity will have resolved.[6] At 18 months corrected age, the child should demonstrate increasing fine motor coordination for refined activities such as block stacking, holding a crayon, and imitating vertical strokes. Independent ambulation with appropriate foot positioning and hip stability should be present. Abnormal findings at this age would include the persistence of any transient findings at the 4- or 8-month visit. Immature grasping patterns and uncontrolled release or strong asymmetry in hand usage is an abnormal finding. Decreased equilibrium reactions, instability in standing, or abnormal foot positioning in standing and walking would also be considered abnormal.

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