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22month baby unable to walk on his own. Cause?

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Hello Doctor,
My 22 month old son is not walking on his own yet. With a lot of encouragement, he manages to walk a few steps on his own and then falls down and starts crawling. Also we feel that he does not look straight at things and would usually move his head either to right or left before he focuses on an object. He sometimes tends to look at things through the corner of his eyes.

We recently did some blood tests on him (muscle tests and they seem to be showing certain deficiencies/excessive readings. I want to know what should i do next? Given these deficiencies/excessive readings can you kindly tell me what condition(if any) my son is suffering from and what treatment he needs to be put on?I am uploading the reports for your reference.

Just to give you a brief background, he was born prematurely(2-3 weeks) through a C-section and his birth weight was 2.4kgs. He only started crawling after 12-13 months and seems to have been late with his various milestones. We have seen him grow and develop even though at a delayed pace but we can definitely feel that he is making progress each passing day. He is very active otherwise and there is nothing untoward about his behavior other than his lack of confidence to walk on his own. He walks by holding hand with out any issues, crawls all the way up the stair case, stand up by holding on to something, walks along side the bed by holding on to it, stands for a long time while holding on to a table, is cheerful and speaks a few words like muma, papa etc. Everything looks fine other than what i have mentioned.

I would appreciate if you can take a look at the reports and let me know what i should do next?
Regards
Faisal
[email protected]

Category: Pediatric Neurologist

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Category: Pediatric Neurologist
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Dear Parent,
Thank you for your query at DoctorSpring.com
At the outset, the developmental milestones of your son are definitely delayed. As you have mentioned, he seems to be developing newer milestones albeit at a slower pace. He is also lagging behind his peers.
I am sure that you must have gone through a number of online sites on what constitutes normal development for a 22-month old. Let me also start by describing what it looks like. We can divide all milestones in four broad categories: Gross motor, Fine motor, Language and Psychosocial.
Gross motor: By 22 months, most children become independent in terms of their ability to navigate the world. They are old enough to walk and eat without any help and to play a little on their own. Must be able to run, walk up stairs, kick ball forward while standing, etc.
Fine motor: Must be able to build a tower of four cubes, must scribble with pen/pencil, must dump raisins into a container easily.
Psychosocial: Must be able to feed doll, remove clothing, use spoon/fork, help in household, drink from cup, etc.
Language: Most children have at least 50 words in their vocabulary by their second birthday, but some have as many as 200 at their disposal, talk in simple sentences, and even sing their ABC's. Your child should understand most of what you say and should be able to follow two-step directions, such as, 'Please go upstairs and get your shoes.' He should be starting to understand the meaning of prepositions like 'under,' 'in,' and 'around.' Must definitely use at least 6 words.
So based on these, in which sectors does your son lag behind? From your description, it is clear that he lags behind in gross motor, but what about the other sectors?
This would help us differentiate if its a sectoral delay or a global development delay.
After that is done, we would go on to the next step.
I also need to know the indication for the cesarean section, if it was an emergency decision or an elective one. What was the rationale for CS? Did he cry immediately after birth ? Did he remain lethargic or hyper irritable in the first 48 hours? Did he have any neonatal jaundice or any other issues during the newborn period or infancy? How many siblings does he have? Have you had any miscarriages or neonatal losses? Is there any family history of developmental delays? (Speak to your parents and that of your spouse) Are there any family members with any kind of neurological illness, seizures, etc? Is there any family history of mental retardation or children dying in a young age?
Assessment of developmental delay is not based on a a few blood tests and reports. It is based on a good history and thorough physical examination. Let us not get lost in the test reports and forget the child.
Regards.


Patient replied :

Dear Doctor,
Thanks for your reply, please see my answers to your questions with regards to his overall development as below:
Gross motor: He can kick the ball as long as someone is holding his from the back. Is playful generally and spends a lot of time playing with his toys. Fine motor: Can scribble with a pen/pensil. Opens and closes the lid of the pen.Can dump raisins in the container.Can transfer water from one cup to another. Can put 2 cubes together at a time but has not been able to put all of them together yet (we only introduced this to him today so think with practice he will get there) Psychosocial: He can drink from a cup, can use a spoon to feed himself albeit gets messy at times. Holds a doll and play with it.. Language: Does understand simple instructions (like dont touch it or come back or dont go there, show me your tongue, show me how to brush teeth). Does use atleast 6-8 words even more i would think (papa, mama, car, aja(come),pani(water),cat). See a dog and goes whoof whoof, picks up my phone and pretends to be talking to some one. I personally think he is doing okay with his language development.
With regrads to your other questions, please see my replies:
The reason for CS was an elective one (in consultation with a doctor). This was done as the first delivery was also a CS. The first time around the decision to go with CS was because my wife noticed some blood spotting. The second time around no such thing happenned but the doctor recomened to go with a CS.
Yes Arsh did cry when he was born, he had neonatal jaundice which took a few weeks to heal other than that no other issues were identified. Arsh has one elder brother. My wife has had no miscarriages. We dont have a family history of developmental delays or any other issues mentioned in your email.

I hope i have been able to cover your questions, in case you need any further information please feel free to let me know.
Regards


Dear parent,

Thank you for answering my queries. Definitely clarifies a lot of things. It appears that your child has a predominant delay in gross motor sector only. There is a mild delay in the other sectors, may be more prominent in fine motor. In this setting, most informative would be child's physical examination and neuroimaging.
1. Have you felt any tightness or floppiness of limbs? Have you felt any tightness of thighs while changing his diapers?
2. Have you noticed if he stands with tip toes? Seems to walk on toes?
3. You need to take him to the nearest pediatrician and get his DENVER II or DDST II assessment done.
4. We also need to look at his serum calcium, phosphorus and alkaline phosphatase.
4. We need to get a MRI Brain to look for any structural causes (PVL or HIE) associated with prematurity or other congenital causes of motor delay.
As far as the other investigations are concerned, slightly lower homocysteine levels are not of much significance. Serum bicarbonate needs to be repeated from a venous blood gas sample.
I would recommend that you visit a pediatric neurologist in person so that a thorough physical examination can carried out. For obvious reasons, that is a major drawback of online consultations. The visual impression and the loads of information available on a thorough bedside examination (tone, bulk, power, deep tendon reflexes,etc) are missing.
Regards.


Dr. Sudhir Kumar
Category: Pediatric Neurologist
Experience: 
Senior Residency, Fellowship: DM, Neurology, CMC, Vellore, 2001
Junior Residency: MD, Internal Medicine, CMC, Vellore, 1998
Medical School: MBBS, Christian Medical College, Vellore, 1995
Dr. Sudhir Kumar and 4 other Medical Specialists are ready to help you

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