CASE REPORT

SOCIAL PEDIATRICS ASPECT IN A CHILD WITH

GLOBAL DEVELOPMENTAL DELAY, EPILEPSY,
MICROCEPHALY, AND UNDERWEIGHT

By:
Eka Satria Anandita

Supervised by:
Dr. dr. Hesti Lestari, Sp.A(K)
 1

CORRECTION
Page 25:

Developmental delay is a subset of developmental disabilities defined as

significant delay in two or more of the following developmental domains (fine

motor skills, gross motor skills, personal social, and language) according to the

age where the majority of other normal children can perform these skills.
 2

INTRODUCTION
not able to show the age-appropriate
development

DEVELOPMENTAL
DELAY two or more of the domains

social/personal behavior
Fine motor
speech and language
Gross motor
 3

INTRODUCTION

impair Central Nervous System (CNS)

Congenital CMV
Microcephaly / Macrocephaly
 4

INTRODUCTION

Chronic disorder

Epilepsy Most cases idiopathic

often accompanied by neurological

disorders
 5

INTRODUCTION

multiple causes
Malnutrition
Management requires
understanding
 6
CASE REPORT

Medical Record : 45.58.60

Name : NAS

Date of birth : September 29, 2015

(1 year and 1 month)

Gender : Female

Ethnicity : Ternate

Religion : Moslem

Address : Tuminting, Kecamatan Islam Lk. I

 7
HISTORY OF ILLNESS
4 months old 5 months old
(January (February September October November 1,
2016) 2016) 2016 2016 2016

Got seizues for the Seizure attacks was Come to outpatient

1st time Reffered
realized from
becomePancaran
more clinic
frequentKasih
for past few
Every 2 3 days months
4 5 times / day
Feverless
for about 5Developmental
Generalized
Lasting EEG, CT
minutes delay was Depakene 1.6 ml, twice
scan
Luminal
Rehabilitati
noted onatherapy
day
 8
HISTORY OF PRENATAL CARE AND BIRTH
Full - term Regular Ante Natal
Spontaneous Caredoses of anti tetanus
Two
delivery
Birth weight: 3000 immunization
Not tested for TORCH
grams
Birth length: 46 cm
Head circumference at birth: not
known

HISTORY OF PAST ILLNESS

Feverless seizure since 4 months old
Developmental delay noted since 5 months old
 DEVELOPMENTAL FEEDING 9
MILESTONES HISTORY
Social smile : 4 months
Lifting head : 9 months Breastfed : birth 2 month-old
Turning into prone position :10 Formula milk : 1 month-old now
monthsnot at par with Milk porridge : 4 month-old now
Soft rice porridge : 9 month-old now
Crawling age
:-
Sitting :-
Standing :-
Saying mama papa :-
IMMUNIZATION

BCG :-
not completed
Pentabio : twice
Oral polio : twice
 10

SOCIAL, ECONOMIC AND

ENVIRONMENTAL CONDITIONS
The only
Father child
25 y.o
Senior High Mother
Senior
23 yoHigh
School
Janitor Housewife
School
Permanent
1 room House
2 adults and 1 Governmental electrical

child
Restroom company
Governmental water
inside company
Garbage
burnt
Indonesia Welfare
Program
FAMILY TREE 11
 PHYSICAL EXAMINATION
November 1, 2016 at the Outpatient Clinic
12

Anthropometry :
Actual body weight : 6.5 kg
Body length : 69 cm
Weight for height (girl, birth to 2 years) (Z-score): between -2 SD and -3 SD underweight
General condition : Looked well
Consciousness : Conscious (Compos mentis)
Vital sign : Blood pressure : 90/60 mmHg
Pulse rate : 106 times/minutes, regularly
Respiratory rate : 28 times/minutes
Temperature : 36.5 C
Head : Oval-shaped, black-colored and not easily pulled out hair
Head circumference : 42.5 cm (< -2 SD, microcephaly)
Eyes : anemic conjunctivae -/- , icteric sclerae -/-
13
Round, isochoric pupils with diameter of 3 mm-3 mm and light reflex +/+
Ears : Clear external auditory canal, discharge -/-
Nose : edematous conchae -/-, discharge -/-

Mouth : perioral cyanosis (-), T1/T1 tonsils without inflammation, hyperemic pharynx (-)

Teeth : dental caries (-)

Neck : lymph node enlargement (-)

Chest : Symmetrical respiratory movement, retraction (-)

Heart :
Inspection : visualization of ictus cordis (-)
Palpation : Ictus cordis was not palpable
Percussion : Left margin : linea midclavicularis sinistra
Right margin : linea parasternalis dextra
Upper margin : 2nd -3rd intercostal spaces (ICS)
Auscultation : Normal rate, regular rhythm, murmur (-), gallop (-)
 14
Lungs :
Inspection : Symmetrical respiration movement on both hemithorax, retraction (-)
Palpation : Vocal fremitus right = left
Percussion : Sonor percussion right = left
Auscultation : Bronchovesicular breath sound, -/- rales, -/- wheezing

Abdomen : Flat, soft, tympanic percussion, with normal bowel sound

Liver and spleen were not palpable

Extremities : Warm, cyanotic (-), capillary refill time of less than 2 second
Normal muscle tone, pitting edema (-) normal physiologic reflexes, pathology reflexes (-)

Genitalia : Female, normal looking external female genital, lesion (-)

Skin : purpura (-), hypopigmentation (-), hyperpigmentation (-)

 CRANIAL NERVES
DDST II 15
NI =EXAMINATION
cannot be evaluated
N II = cannot be evaluated
N III, IV, VI = round, isochoric pupils of 3-3
mm,
WITHIN
normal lightNORMAL
reflex, strabismus (-)
NV = within normal limit
N VI LIMIT
= within normal limit
N VII = within normal limit Personal social : equal to 5
N VIII = no hearing abnormality months
N IX = within normal limit Adaptive-fine motor : equal to 4
Global Developmental
NX = within normal limit months
N XI = within normal limit Language :Delay
equal to 6 months
N XII = within normal limit Gross motor : equal to 3
months
 LABORATORY
FINDINGS 16

(NOVEMBER 1,
2016)
Hemoglobin 13,1 g/dl (10,7-13,1)
Hematocrit 40,0 % (35-43)
Leukocyte 9,500/mm3 (6,000-17,000)
Platelet 466,000/mm3 (229,000-553,000)
AST WITHIN
20 U/l NORMAL
(< 56)
ALT 13 U/l (< 39)
Sodium
LIMIT
138 mmol/L (132-145)
Potassium 4,2 mmol/L (3.1- 5.1)
Chloride 108 mmol/L (96-111)
Calcium 10 mg/d (8.4-10.4)

URINALYSIS & STOOL ANALYSIS:

Within normal limit
 1. Determination of nutritional status :
DIAGNOSIS Actual body weight : 6,5 kg
Ideal body weight for length : 8 kg
17

Global developmental delay Body length : 69 cm

(R62.8) WHO z-scores chart for weight for length
Epilepsy (G40.319) girls birth to 2 years between line -2 to
Microcephaly (Q0.2) -3 SD Underweight
Underweight (R63.6)
2. Determination of needs :
based on Recommended Daily Allowance
(RDA) :
THERAPY Calories : 102 kcal/kgBW/day = 816
kcal/day
Protein : 1,23 gr/kgBW/day = 10 gr/day
Depakene 2 x 1,6 ml Liquid : 115-125 mL/kgBW/day = 920-
(25 mg/kg/day) 1000 mL/day

3. Determination of feeding : Enteral (oral)

4. Type of foods: Polymeric
5. Monitor and evaluate body weight, food
acceptance and tolerance, and adverse
reaction
 PLAN OF
18
EXAMINATION
- Consult to neurology department
- Consult to nutrition and metabolic disease department
- Consult to ENT department
- Consult to ophthalmology department
- Laboratory:
Complete blood count, AST, ALT, Sodium, Potassium,
Chloride, Calcium, TORCH, urinalysis, stool analysis.
Complaint : fever (-), intake (+), November
seizure (-) 2 - 3, 2016 (Home
FOLLOW UP
General conditions : Looked well visite) 19
Consciousness : Conscious (Compos mentis)
Vital sign
Blood pressure : 90/60 mmHg Diagnosis
Pulse rate : 104 times/minutes, regular
Respiratory rate : 28 times/minutes
Determination of needs (based on RecommendedGlobal developmental delay
Daily Allowance)
Temperature : 36.5 c
Body Weight: 6.5 kg, Ideal body weight for length: (R62.8)
8 kg, Body length:
69 cm Epilepsy (G40.319)
Eyes : anemic conjunctivae -/-, icteric sclerae -/-
Round, isochoric (20%
pupils=with diameter ofkcal
3 Microcephaly (Q0.2)
Breakfast
Calories kcal)
: 102 kcal/kgBW/day : 163 = 816 kcal/day
mm-3mm and light reflex +/+ Underweight (R63.6)
(Divided to 50-60% carbohydrate, 15-20% protein(60
Porridge (rice 100 grams) + steamed chicken grams)
& 30% fat)
Mouth : T1/T1Snack tonsils(15%
without = inflammation,
kcal) : 122 kcal
Protein : 1,23 gr/kgBW/day = 10 g/day
hyperemic pharynx a (-) of milk
glass
Liquid : 115-125 mL/kgBW/day = 920-1000 mL/day
Chest : Symmetrical
Lunch respiratory
(30% = movement,
kcal) : 245 kcal
Fat : 30% of total calories = 245 kcal / day = 27Therapy g/day
retraction (-) porridge (rice 150 grams) + tempe (soybean cake) (25 grams) +
Determination of feeding : Enteral (oral)
Heart : Normal rate, (2
spinach regular
cups) rhythm, murmur (-),
Given
gallop(-), thrillSnack
(-)
as daily meal 3x1 portion/day with snack 2x1 Depakene 2 x 1,6 ml
portion/day
(15% = kcal) : 122 kcal
Lungs : Symmetrical respiration (25 mg/kg/day)
half glass of milk movement,
+ 60 grams of papaya
retraction (-) Dinner (20% = kcal) : 163 kcal
Bronchovesicular
porridge breath sound,
(rice 100 -/- rales,
grams) + steamed fish (40 grams)
wheezing -/-
Abdomen : Flat, soft, tympanic percussion, normal
bowel sound
Complaint : fever (-), intake (+), seizure November
(-) 4, 2016
FOLLOW UP
General conditions : Looked well (Outpatient clinic) 20
Consciousness : Conscious (Compos mentis)
Vital sign
BloodLaboratory Finding
pressure : 90/60 Consultation
mmHg (November from4, neurology department: Diagnosis
Pulse2016)
rate Taper
: 102 down gradually
times/minutes, the dose of valproic acid.
regular
Patient:rate Start
Respiratory : 28tapering down into dose of 20 mg/kg/day,
times/minutes
Hemoglobin Determination 12,2 of needs
g/dl (based on RecommendedGlobal developmental delay
Daily Allowance)
Temperature Body then
: 36.6 observe
c for 2 weeks. If there is no seizure
Hematocrit during Weight:
Consultation
37,2the %6.5 kg, Idealtropical
from
observation
body weight
period, infectious
the dose can (R62.8)
for length: 8 kg, Body length:
disease
be
Leukocyte 69 cm department: Epilepsy (G40.319)
Eyes tapered8,000/mm3
: anemic conjunctivae down-/-, until 15 mg/kg/day.
icteric sclerae -/-
Platelet
Round, Suspect congenital
402,000/mm3
isochoric pupils withCMV. Checkof
diameter anti
3 Microcephaly (Q0.2)
CMV IgG again
Calories
after 1 : 102
month. kcal/kgBW/day = 816 kcal/day
Anti-Toxoplasma
mm-3 mm and IgG light : negative
Consultation
reflex +/+ from ENT Underweight (R63.6)
(Divided
Anti-Toxoplasma to
IgM 50-60%: carbohydrate,
negative 15-20% protein & 30% fat)
Mouth : T1/T1 tonsils: without department:
inflammation,
Protein
Anti-Rubella IgG(-) 1,23 gr/kgBW/day
: negative = 10 g/day
hyperemic pharynx Speech delay. Advice: do the BERA
Liquid
Anti-Rubella IgM : 115-125 : mL/kgBW/day
negative = 920-1000 mL/day
Chest : Symmetrical respiratory movement, test.
Anti-CMV Fat
IgG : 30% of total
: positive calories = 245 kcal / day = 27Therapy g/day
retraction (-) Determination of feeding : Enteral (oral)
Heart : Normal (concentration:
rate, 233,9)
Anti-CMV Given
IgM as regular
daily
:
rhythm,
meal
negative
murmur (-),with snack 2x1 portion/day
3x1 portion/day Depakene 2 x 1,3 ml
gallop(-), thrill (-)
Lungs : Symmetrical respiration movement, (20 mg/kg/day)
Patients
retraction (-) mother
Anti-CMV IgG : positive
Bronchovesicular breath (concentration:
sound, -/- rales,
152) -/-
wheezing
Anti-CMV
Abdomen IgMsoft,
: Flat, : negative
tympanic percussion, normal
bowel sound
Complaint : fever (-), intake (+),November
seizure (-) 5-6, 2016 (Home
FOLLOW UP
General conditions : Looked well visite) 21
Consciousness : Conscious (Compos mentis)
Vital sign
Blood pressure : 90/60 mmHg Diagnosis
Pulse rate : 104 times/minutes, regular
Respiratory rate : 28 times/minutes Global developmental delay
Temperature Determination
: 36.5 c of needs (based on Recommended Daily Allowance)
(R62.8)
Body Weight: 6.6 kg, Ideal body weight for length: 8 kg, Body length:
69 cm Epilepsy (G40.319)
Eyes : anemic conjunctivae -/-, icteric sclerae -/-
Round, isochoric pupils with diameter of 3 Microcephaly (Q0.2)
mm-3 Calories
mm and light: 102 kcal/kgBW/day
reflex +/+ Underweight (R63.6)
= 816 kcal/day
Mouth : T1/T1 (Divided
tonsils to 50-60%
without carbohydrate, 15-20% protein & 30% fat)
inflammation,
Protein(-): 1,23 gr/kgBW/day = 10 g/day
hyperemic pharynx
Liquid : respiratory
Chest : Symmetrical 115-125 mL/kgBW/day
movement, = 920-1000 mL/day
Therapy
retraction (-) Fat : 30% of total calories = 245 kcal / day = 27 g/day
Heart : Normal Determination ofrhythm,
rate, regular feeding murmur
: Enteral(-),
(oral)
gallop(-), thrillGiven
Depakene 2 x 1,3 ml
(-) as daily meal 3x1 portion/day with snack 2x1 portion/day
Lungs : Symmetrical respiration movement, (20 mg/kg/day)
retraction (-)
Bronchovesicular breath sound, -/- rales,
wheezing -/-
Abdomen : Flat, soft, tympanic percussion, normal
bowel sound
 Complaint : fever (-), intake (+), seizure November
(-) 7-8, 2016
FOLLOW UP
General conditions : Looked well (Outpatient clinic) 22
Consciousness : Conscious (Compos mentis)
Vital sign
Blood pressure : 90/60 mmHg Diagnosis
Pulse rate : 108 times/minutes, regular
Respiratory rate : 28 times/minutes Global developmental delay
Temperature : 36.6 c
Determination of needs (based on Recommended Daily Allowance) (R62.8)
Body
Eyes Weight:
: anemic6.65conjunctivae
kg, Ideal body weight
-/-, icteric for length:
sclerae -/- 8 kg, Body Epilepsy (G40.319)
Consultation PLAN: department:
from ophtalmology
length: 69Round,
cm isochoric pupils with diameter of 3 Microcephaly (Q0.2)
Mantoux test Delayed Visual Maturation
Measles mm-3 mm follow
vaccination and
on light
10 th reflex +/+
November 2016
Underweight (R63.6)
Calories Advice:
: 102tonsils up
kcal/kgBW/day after 6 months
= 816 kcal/day nd
Mouth
Third : T1/T1
dose of DPT, withoutB,inflammation,
Hepatitis Hib, oral polio on 24 November
(Divided
hyperemic to 50-60%
pharynx (-)carbohydrate, 15-20% protein & 30% fat)
2016
Protein : :1,23 gr/kgBW/day = 10 g/day
Chest
BCG on Symmetrical
one month respiratory
after measles movement,
vaccination ifmL/day
Mantoux test is
Liquid : 115-125 mL/kgBW/day = 920-1000 Therapy
retraction
negative (-)
Fat : 30%: Normal
Heart of total calories = 245
rate, regular kcal /murmur
rhythm, day = 27 (-),g/day
Determination
gallop(-), thrillof (-)feeding : Enteral (oral) Depakene 2 x 1,3 ml
Given
Lungsas :daily meal 3x1respiration
Symmetrical portion/day with snack 2x1 portion/day(20 mg/kg/day)
movement,
retraction (-)
Bronchovesicular breath sound, -/- rales,
wheezing -/-
Abdomen : Flat, soft, tympanic percussion, normal
bowel sound
PROGNOSIS 23

Ad vitam : ad bonam
Ad functionam : dubia ad malam
Ad sanationam : dubia
DISCUSSION 24

DEVELOPME increase in the ability of the body

NT structure and function for more complex
function
Denver Developmental Screening Test II
(DDSTII)
Internal personal social development
fine motor
factors
gross motor
External language
factors 2 or more domain appropriate for age
cannot be reached GLOBAL
Prenatal
DEVELOPMETAL DELAY
Natal
Postnata
l
 History & Physical 25
Examination

Social smile
Personal social ::equal
4 months
to 5 months
Lifting Global
head
Adaptive-fine Developmental
motor ::equal
9 months
to 4 months
Language
Turning into: prone
equal
Delaytoposition
6 months:10
Gross motor
months : equal to 3 months

can only turn into prone

position
lift the head
made unspesific noises
 CONGENITAL 26
similar to the common cold or even
CMV asymptomatic
INFECTION
TORCH testing important

Gold standard: sensorineural hearing

viral issolation from loss
urine and saliva developmental delay
taken within 3 Neurological
weeks after birth
PCR symptomps
IgG and IgM anti CMV Microcepha
ly
Seizures
Hypotonia
Lethargy
 27
Seizures
Developmental delay
Both mother and patient anti CMV
IgG are (+)
Consultation from tropical infectious disease
department:
Suspected congenital CMV. Check anti CMV IgG again
after 1 month.
Consultation from ophtalmology
department:
Delayed Visual Maturation
Head circumference: 42.5 Advice: follow up after 6 months
cm Consultation from ENT
microcephaly department:
Speech delay. Advice: do the BERA
test.
 28

25 % EPILEPSY Clinical
PATIENT
EPILEPSY manifestation

EEG
Not a gold
standart
Global developmental Determine the
Delay classification
Identify the epileptogenic
focus

CT scan
 29
NAS, 1 year and a month old girl

feverless seizure since 4

months of age
generalized
EEG while tonic clonic type
CT SCAN
sleeping: lasting for about 5 minutes
repeat Within normal
withinEEG while
normal occurred every two or three
sleeping limit
limit and days
awake is suggested
four to five times per day
30
31
EPILEPS achieve optimal quality of 32

Y life
THERAP "no seizures, no side
Y effects"
diagnosis of epilepsy has been
ascertained
family have understood the aim of
therapy and possible side effects
begins with monotherapy
starts on a low dose and then
increased gradually until the
effective dose is reached or side-
effects appear
 THIS 33

PATIENT
BEFORE:
Valproic acid 1.6 ml twice a
day (dose of 25 mg/kg/day)
for 3 days

tapered down to 1.3 ml twice

a day (dose of 20 mg/kg/day)

tapered down gradually until the minimum

therapeutic dose that can control the seizure
is reached
 Protein 34
Energy
Malnutrition Mild/Severe
(PEM)
younger than 2 years old,
WHO curve of weight-for-
length

BW: 6,5 kg BL : 69 cm.

Calories : 102 chart
WHO Z-score kcal/kgBW/day
for weight=for
816 kcal/day
Proteinlength: 1,23
-2gr/kgBW/day
to -3 SD = 10 gr/day
Liquid : 115-125 mL/kgBW/day = 920-1000
(underweight)
mL/day
35
 intentionally provides exposure to
Vaccinati 36
antigens derived from the
on pathogen
"a harmless mild
infection

Pentabio + oral polio twice

Plan:
Mantoux test
Measles vaccination on 10th November 2016
Third dose of DPT, Hepatitis B, Hib, oral polio on 24nd November
2016
BCG on one month after measles vaccination if Mantoux test is
negative
 37
PROGNOSIS

Ad vitam
ad bonam
Can Ad functionam
live even with
dubia ad malam
developmental delay
This patient has Ad microcephaly,
sanationam but her
parents
dubia eager to maximize patients
development
Medicationsbytaken
routinely
by thetaking
patienther to
is covered
physiotherapy
by Indonesia Welfare Program, so it is not
difficult to get. The incidence of repetitive
seizure depends on medication adherence
and proper dosing of medication