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Child Does Not Focus On Things, Does Not Follow Movements Consistently, Developmental Delay. BERA Test Normal. MRI Showed Gliosis. Best Treatment?
Question: Doctor sir
my daughter has become 10 months old. since 3 to 4 months back i started feeling that there is some problem with her. I showed her to local Doctor but they said everything is normal. but now 3 days back I went to another and he got some test done as she does not focus on things and also does not follow movements consistently. Her right eye starts looking outward and she seems squint. She is having development delay. She sits and has started trying to sit on his own from sleeping position. If something is touched by her hand or body then she immediately grabs that thing but when that thing is kept in front of her she does not grab or even does not try to grab that thing.Her BERA test was normal. also eyes seems to be physically ok as told by opthalmist. She stands with my both hands hold her hands. she had her hypogycemic of 24 count when she was 5 days old. Her soft spot also closed around 4 to 5 months. her head size is right now 41 cm. At 4.75 months her head size was 37 cm. she was bron at 35 weeks with LSCS due to one cord around her neck. her MRI has been done two days back. As per this, Quote "The MR findings are suggestive of cortical and subcortical gliosis involving bilateral parafalcine parieto - occipital lobes may suggest hypoxic ischemic / hypoglycaemic insult." Unquote - According to her paediatric present at the time of birth she did not have hypoxic ischemic. Sometimes she hold the head and sometime not. Sometimes she looks upward also. She says babababa…….,,, dadadadadada…………,,,, buabuabua……….papapapappapa………
Kindly suggest what may be the problem and what is best treatment ?
my daughter has become 10 months old. since 3 to 4 months back i started feeling that there is some problem with her. I showed her to local Doctor but they said everything is normal. but now 3 days back I went to another and he got some test done as she does not focus on things and also does not follow movements consistently. Her right eye starts looking outward and she seems squint. She is having development delay. She sits and has started trying to sit on his own from sleeping position. If something is touched by her hand or body then she immediately grabs that thing but when that thing is kept in front of her she does not grab or even does not try to grab that thing.Her BERA test was normal. also eyes seems to be physically ok as told by opthalmist. She stands with my both hands hold her hands. she had her hypogycemic of 24 count when she was 5 days old. Her soft spot also closed around 4 to 5 months. her head size is right now 41 cm. At 4.75 months her head size was 37 cm. she was bron at 35 weeks with LSCS due to one cord around her neck. her MRI has been done two days back. As per this, Quote "The MR findings are suggestive of cortical and subcortical gliosis involving bilateral parafalcine parieto - occipital lobes may suggest hypoxic ischemic / hypoglycaemic insult." Unquote - According to her paediatric present at the time of birth she did not have hypoxic ischemic. Sometimes she hold the head and sometime not. Sometimes she looks upward also. She says babababa…….,,, dadadadadada…………,,,, buabuabua……….papapapappapa………
Kindly suggest what may be the problem and what is best treatment ?
Dear XXXXXXX
The information you gave is consistent with some event that occurred in first week of life, which might have been hypoxic ischemic (as per MRI) but need not be related to birth issue. She had some issue related to prematurity that resulted in low sugar at day 4-5, this situation is enough to explain the MRI changes and her current vision deficit. Hypoglycemia characteristically affects vision pathways.
She may not or need not have physical eye defect. Squint may be developing secondary to vision defect. She need not have cataract either.
What one needs to see is:"consensual eye reflex" - as a doctor would examine for it, if present it will suggest that nerves leaving eyes towards brain and those coming back from brain to other eye are also intact and integrated. I do not expect any problem on direct examination of retina, but if your eye specialist finds some evidence of optic atrophy, then changes may be completely non modifiable at this age.
If these issues (perception) are normal, we will attribute the problem as related to the damage around occipital area due to low sugar. This damage is called vision recognition defect. Despite some damage, a normal "Visual Evoke Potential test (VEP)" will have some hopes that despite damage some nerve fibers are intact and may help take over some vision functions. These kids will need this VEP test and further plan depending on VEP towards sensory-visual integration therapy with the help and close supervision of occupational therapist.
Her other milestones appear normal, but surely need to be seen by therapist as a whole.
I hope this answers your query. Thanks.
The information you gave is consistent with some event that occurred in first week of life, which might have been hypoxic ischemic (as per MRI) but need not be related to birth issue. She had some issue related to prematurity that resulted in low sugar at day 4-5, this situation is enough to explain the MRI changes and her current vision deficit. Hypoglycemia characteristically affects vision pathways.
She may not or need not have physical eye defect. Squint may be developing secondary to vision defect. She need not have cataract either.
What one needs to see is:"consensual eye reflex" - as a doctor would examine for it, if present it will suggest that nerves leaving eyes towards brain and those coming back from brain to other eye are also intact and integrated. I do not expect any problem on direct examination of retina, but if your eye specialist finds some evidence of optic atrophy, then changes may be completely non modifiable at this age.
If these issues (perception) are normal, we will attribute the problem as related to the damage around occipital area due to low sugar. This damage is called vision recognition defect. Despite some damage, a normal "Visual Evoke Potential test (VEP)" will have some hopes that despite damage some nerve fibers are intact and may help take over some vision functions. These kids will need this VEP test and further plan depending on VEP towards sensory-visual integration therapy with the help and close supervision of occupational therapist.
Her other milestones appear normal, but surely need to be seen by therapist as a whole.
I hope this answers your query. Thanks.
Above answer was peer-reviewed by :
Dr. Shanthi.E
Thanx for reply i have something to say more -
HER CASE WORSENED IN LAST TWO MONTHS ONLY BEFORE THAT SHE WAS APPEARING QUITE NORMAL.
1. Since last two months her condition has deteriorated and more prominently in last one month. Will this worsen? Is this due to soft spot closing early in 5th months? Can this be treated by operation? does operation happens in India?
2. Will Head ultrasound help in her case to determine size of ventricles?
3. will vitamin B12 injection help her in her recovery?
4. due to coughing she was kept on nebulization for 4 days. was this may be the reason?
5. her mother had thyroid. her medication was on. after birth at 4 months her thyroid was checked due to becoming overweight which was normal. is it required to check the thyroid again for her?
kindly tell any best paed. neurologist in Ahmedabad for treatment of her.
HER CASE WORSENED IN LAST TWO MONTHS ONLY BEFORE THAT SHE WAS APPEARING QUITE NORMAL.
1. Since last two months her condition has deteriorated and more prominently in last one month. Will this worsen? Is this due to soft spot closing early in 5th months? Can this be treated by operation? does operation happens in India?
2. Will Head ultrasound help in her case to determine size of ventricles?
3. will vitamin B12 injection help her in her recovery?
4. due to coughing she was kept on nebulization for 4 days. was this may be the reason?
5. her mother had thyroid. her medication was on. after birth at 4 months her thyroid was checked due to becoming overweight which was normal. is it required to check the thyroid again for her?
kindly tell any best paed. neurologist in Ahmedabad for treatment of her.
Here are my answers XXXXXXX.
1. Since last two months her condition has deteriorated and more prominently in last one month. Will this worsen?
== Possible due to condition called amblyopia by which brain tries to disuse less used vision system as in this case.
Is this due to soft spot closing early in 5th months?
== No. It’s vice versa.
Can this be treated by operation? Does operation happens in India?
== If the closure is due to craniosynostosis (unlikely here. one may confirm by x-ray head) then only surgery may help. Here we have other obvious reasons.
2. Will Head ultrasound help in her case to determine size of ventricles?
==== Yes. If they monitor V H (Ventriculo-Hemispheric) ratio on 2 monthly basis.
3. Will vitamin B12 injection help her in her recovery?
== I would say 2%.
4. Due to coughing she was kept on nebulisation for 4 days. Was this may be the reason?
== Never. It’s safer.
5. Her mother had thyroid. Her medication was on. After birth at 4 months her thyroid was checked due to becoming overweight which was normal. Is it required to check the thyroid again for her?
== Best person to opine is endocrinologist. But usually we check yearly for 3 years if last reports were normal and no treatment is going on and no symptoms too.
Kindly tell any best paediatric neurologist in Ahmedabad for treatment of her.
== You may visit medical college there. One who can give time is best for you. Neurologist may give advice, not the therapy as what the child needs is a consistent occupational therapy program.
1. Since last two months her condition has deteriorated and more prominently in last one month. Will this worsen?
== Possible due to condition called amblyopia by which brain tries to disuse less used vision system as in this case.
Is this due to soft spot closing early in 5th months?
== No. It’s vice versa.
Can this be treated by operation? Does operation happens in India?
== If the closure is due to craniosynostosis (unlikely here. one may confirm by x-ray head) then only surgery may help. Here we have other obvious reasons.
2. Will Head ultrasound help in her case to determine size of ventricles?
==== Yes. If they monitor V H (Ventriculo-Hemispheric) ratio on 2 monthly basis.
3. Will vitamin B12 injection help her in her recovery?
== I would say 2%.
4. Due to coughing she was kept on nebulisation for 4 days. Was this may be the reason?
== Never. It’s safer.
5. Her mother had thyroid. Her medication was on. After birth at 4 months her thyroid was checked due to becoming overweight which was normal. Is it required to check the thyroid again for her?
== Best person to opine is endocrinologist. But usually we check yearly for 3 years if last reports were normal and no treatment is going on and no symptoms too.
Kindly tell any best paediatric neurologist in Ahmedabad for treatment of her.
== You may visit medical college there. One who can give time is best for you. Neurologist may give advice, not the therapy as what the child needs is a consistent occupational therapy program.
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Above answer was peer-reviewed by :
Dr. Shanthi.E
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