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MOT,PAEDIATRICS
NAME: HAZEL GRACE GEORGE (Name changed)
CURRENT AGE: 1.3 YEAR
CORRECTED AGE: 11 MONTHS
GENDER: FEMALE
THERAPY SERVICES ATTENDED : OCCUPATIONAL THERAPY
THERAPIST: MS. ATHIRA AJAYAKUMAR
REVIEWED BY: DR. JOSEPH SUNNY, MS. ANAKHA PISHARODY
Hazel came with her parents for assessment and therapeutic intervention when she was 8 months (corrected age 4 months) old. She is an active and pleasant child. She made eye contact with her parents inconsistently. She liked to lie on her back and play kicks and thrusts. She was referred to the OT department as she had gross motor delay. Hazel is one of the twins born to parents in a non-consanguineous marriage. Mother’s age at conception was 34 years and the child was conceived through IVF . Mother reported to have gestational diabetes during the 5th month of pregnancy. Mother also gives a history of excessive vomiting and influenza B infection during the pregnancy.
It was a preterm C-section delivery at 23 weeks and 6 days of gestation.The birth weight of the baby was 530g. Birth cry was delayed. Birth colour was normal. Breastfeeding and sucking were inadequate. The baby was admitted to the NICU for 4 months and was on ventilator support for the first 2 months. She also gives a history of hypernatremia ,hyperkalemia, hyperbilirubinemia and serratia infection while she was in the NICU.
Developmental History reveals that she had partial neck control and rest of the milestones were delayed. History of laser procedure for both eyes at the 3rd month of birth was reported by the parents. Later In the 9th month, they consulted a Doctor and it was identified that Hazel had hearing loss in both ears, Right ear 80db and left ear 90 db and hearing aid was prescribed in both ears and basic audio verbal therapy was suggested. Cochlear implants were advised before 1.6-2
years of age. In the 13 months they consulted a Doctor again and the level of loss was reduced to Right 65db and Left ear 80db. Presently they’ve suggested if the loss is not worsening, the need for a cochlear implant wouldn’t be there and can continue with audio verbal therapy.
Occupational Therapy
In the initial sessions, Hazel had difficulty adapting to the new environment, she showed very minimal interest towards the toys of her age, and social smiles were very limited. She recognised familiar faces and was able to hold an object for almost 10 to 15 seconds.
Assessment
The initial concerns of the parents were the delay in social smile, reduced neck control, difficulty to roll over and other delay in gross motor milestones.
Gross motor skills : During the initial assessment sessions, it was noted that Hazel had better head control while sitting. In a prone position, she was able to hold her neck for not more than 5 seconds. She favoured resting her head towards the left side mostly as she had tightness over the left side neck muscles. Her left shoulder and elbow flexors showed tightness and her range of movement were restricted in the left upper extremity. In the lower extremities, there was tightness in the calf muscle.
She was able to come from supine to sidelying independently but was inconsistent. Mostly, she needed minimal physical prompt to turn to one side. Roll over, sitting with support, crawling was not achieved.
Fine motor skills: She inconsistently reached for toys in the front. She could hold them for about 5 to 10 seconds after that she released it, however voluntary release was not present.
Cognitive perceptual and social emotional skills: She was able to identify her family members, Social smile was inconsistent.
Play skills : She responded very minimally to the toys that made sound, however she was interested in toys with vibrant colours and lights and she tried to grab it for a few seconds and then released it off.
According to Takata play classification, she is in the sensorimotor play epoch (0–2 years).
According to Parten’s play stages, she is in the transition from unoccupied play (0-3 months) to solitary play stage (0-2 years).
Activities of daily living;
Hazel was completely dependent and cooperative in the ADLs such as Bathing, Grooming, Toileting. In terms of feeding, She is bottle fed. According to the mother, she is fed in a sitting and semi-reclined position. She is able to suck and swallow milk.
No sleep disturbances were reported
Intervention
Hazel attended Occupational therapy sessions for a period of 4 months, 5 sessions per week, each session lasted for 45 minutes and each session was tailored to meet the specific goals set for Hazel. Additionally Hazel’s parents were counseled regarding the importance of implementing the therapeutic activities at home and how it impacts the progress of the child, Parents were instructed to actively participate throughout the session. Neuro developmental therapy techniques were used in the treatment approach inorder to normalise the tone and to improve her functional mobility, Play based therapy was incorporated in the therapy sessions as it reinforced the interest of the child to engage in the therapy sessions.
Occupational therapy SMART goals were taken to improve her neck control, functional positions like prone on elbows, Quadripod and Sitting with support and also to achieve rolling and crawling.
Subgoals were as follows
Outcomes
After four months of intensive Occupational therapy, Hazel had shown immense progress physically, emotionally, and cognitively with great efforts from her parents. She started responding to her parents by making sounds and smiling more frequently. She had started to voluntarily reach for toys and other objects and hold them for 50 to 60 seconds. She had also started to voluntarily grasp objects. She tracked toys from side to side. Tightness in the calf muscle and the shoulder extensors had significantly reduced, and she was able to move her left arm comparatively better than before. Tightness in the neck muscles had also reduced, and she was able to move her head to both sides. Regarding functional mobility, she was able to roll over from supine to prone and back with minimal physical and verbal prompts. She was able to come to a prone-on-elbow position with minimal physical and verbal prompts, and she had started to lift her trunk slightly by bearing weight on her arms independently. She was able to sit with support for about 3 to 5 minutes
independently. Overall, strength in the shoulder, neck, and trunk muscles had improved remarkably.
By the end of Fourth month, Hazel had started to sit without support for 1 to 2 minutes and did start to maintain quadruped position independently for more duration and she had started to crawl 2 to 3 steps to grab the toy in front of her. After 4 months, she was given a break from the therapy for a month for the generalization of the skills and came for follow up sessions after the break. Presently, she has started to crawl 10 to 15 steps without support and has started to stand with support and is trying to initiate small steps.
Discussion
Hazel attended Occupational therapy sessions for almost 4 months which has helped her to gain various positive changes in her areas of life. Continuous Occupational therapy interventions impacted different skill sets of her and in turn it improved overall quality of life. As the improvements not just get constrained to physical development rather it brought progress socio emotionally and cognitively too. And it also highlights how early intervention, active engagement and consistent implementation of home programmes can reinforce the progress of the child. Hence, it shows that Effective individualised and goal oriented Occupational therapy intervention can bring progress across physical, socio emotional and cognitive development of children with developmental delays and in turn it improves the overall quality of life. The case study is also in agreement with articles attached below.
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