Case in Progress
Anna - 1
Anna is a little girl who was born in January 1999. Her mother’s pregnancy was remarkable for insulin-dependent diabetes and HELLP Syndrome. Mom had been admitted to one hospital, but transferred to another that has access to a neo-natal intensive care unit when it became apparent that the baby was on its way at 33 weeks gestation.
Anna was born during an emergency caesarian section. She was a footling breech (meaning that her feet were the first thing in the birth canal) and because of the HELLP Syndrome it was necessary to do the c-section for both mom’s and the baby’s sake. Anna’s APGAR scores were 7 at one minute and 9 at five minutes. Her weight was 4 pounds, 11 ounces. Because her mother had been diagnosed with PIH-HELLP Syndrome, it was determined that this might have helped to mature the baby in-utero.
When Anna was admitted to the NICU she was placed on oxygen and IV feedings. The mother began to breastfed as soon as she was physically able, and at the end of her ten day hospital stay Anna was breast feeding quite well. Anna had an early bout of jaundice, which was controlled with two days of phototherapy.
Anna was allowed to go home at the age of ten days because she had been doing so well in the NICU. Anna’s first year was unremarkable except for colds and one incident of high fever and an ear infection which required antibiotics and Pediacare.
Anna was first referred to the regional center at the age of 13 months by a public health nurse who noted that Anna was just barely able to sit alone. It was also noted that Anna would not tolerate any weight on her legs and was not crawling. For mobility, Anna used scooting on her bottom, which has been since determined to be familial. Anna was still breast feeding but was not a good eater.
At this first assessment it was noted that Anna’s family had no concerns with her hearing or vision. Anna had fallen asleep earlier, but when awakened was eager to play and interact. When Anna was asked to perform certain gross motor tasks, however, she cried and it was apparent that this was an area of difficulty for her.
Anna was thirteen months old (11 months corrected age) at this first assessment. She presented as age appropriate for fine motor skills (using a pincer grasp, turning the pages of a cardboard book, placing pegs in a board). Skills were scattered to 20 - 23 months in the area of cognition. Her social and emotional development was quite good, especially with her family (parents and older siblings), but she was shy at first with the assessor. In this area she was performing tasks at 15 months old. Anna was still being breastfed but also was taking a bottle of formula periodically and was being fed some baby foods and soft table foods. She would finger feed, but could not use a spoon. She could drink from a cup that was held for her.
Anna’s delays were noted to be more prominent in that areas of communication, where she was placed at 9 - 12 months both expressively and receptively, and gross motor, where her skills were at 3-8 months. She could sit and pivot in sit, but she would not tolerate the prone (tummy) position. Mom had stopped putting her in this position because she would cry. Because of this she could bear very little weight in her upper extremities, nor could she crawl. The assessor noted that she displayed some increased muscle tone in her lower extremities.
It was recommended that she would benefit from an early intervention program. Mom did not feel that Anna was delayed, and stated that her other children did not crawl either. However, her mother was agreeable to intervention if that was going to be what was best for Anna.
Anna was seen a month later for evaluation by California Children’s Services. They also noted that Anna would show increased tone in her lower extremities when placed in prone or in a standing position. Again, a home program was recommended to assist Anna in the gross motor area.
And there it stayed for several months - five to be exact. Anna’s parents decided that an in-home program was not a necessity for Anna as she was developing in all other areas. Finally, in August, when Anna was still not walking or crawling, and had very few words or sounds, we were contacted to provide the in-home program.
When Anna was reassessed at that time her gross motor skills had improved to the 11 month (44 week) area. She could walk precariously with two hands held, but was very unstable in all other areas, such as cruising along the furniture or ring sitting. She was noted to have extremely abducted hips and legs, and a pronated right foot.
Her cognitive and fine motor skills, while still a strength, had not really grown since the original assessment (in other words, she had not made six months progress in six months time). Her social and emotional skills were her real strength, and she is a friendly and happy little girl who is shy at first, but then warms up quickly. Her communication skills remained weak, both expressively and receptively she was at 40 weeks (10 months).
We began working with Anna with a physical therapist seeing her weekly. She was soon able to walk independently, but she still would not crawl very well. Once that milestone was reached we put a speech therapist in to work with her. However, after a few sessions it was clear that her parents still were not worried about her speech, and that therapy has been deferred at their request until after her second birthday.
Today, at the age of 21 ½ months, Anna can walk well, squat and re-erect by herself, but still has quite a bit of trouble with stairs. She has made some good gains in cognition and fine motor skills. She has a few words, particularly names for her family members, and her family is trying to work with her on her speech. She has grown a lot, and is tall and well-nourished. She loves to eat and can eat with a spoon, but prefers her fingers. Anna does have quite a few colds and runny noses. With consistent therapy, Anna will continue to make good gains in all areas of development.
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