What is the approach to a pediatric patient with difficulty ambulating (walking)?

Clinical Approach to Pediatric Patients with Difficulty Ambulating

The evaluation of a pediatric patient with difficulty ambulating requires a systematic, age-appropriate assessment focusing on neuromotor function, with prompt referral to specialists when red flags are identified.

Initial Assessment

• Begin with observation from a distance (10 feet away) before direct examination, as this can provide valuable clues about the child's condition without causing distress 1
• Assess vital signs and general appearance, noting level of interaction with the environment and general arousal, which may indicate systemic illness affecting motor function 2
• Carefully measure and plot head circumference, weight, and length/height on appropriate growth curves (CDC or WHO), as abnormal patterns may suggest underlying conditions 2
• Note any drooling, poor weight gain, or ptosis, which may suggest facial and oral motor weaknesses 2

Key Elements of Motor History

• Ask about delayed acquisition of skills: "Is there anything your child is not doing that you think they should be able to do?" 2
• Inquire about involuntary movements or coordination impairments: "Is there anything your child is doing that you are concerned about?" 2
• Question about regression of skills: "Is there anything your child used to be able to do that they can no longer do?" 2
• Assess strength, coordination, and endurance issues: "Is there anything other children your child's age can do that are difficult for your child?" 2

Neuromotor Examination

• Observe quality and quantity of movement, even in uncooperative children 2
• Examine cranial nerve function, including eye movements, visual response, pupillary reactivity, and facial expressions 2
• Assess oromotor movement by observing palate and tongue movement 2
• Evaluate strength through functional observation of antigravity movements appropriate for age 2
• Note any use of Gower maneuver (using arms to push up from floor) which suggests proximal muscle weakness 2
• Evaluate muscle bulk, joint flexibility, and presence/absence of atrophy 2
• Assess postural tone through ventral suspension in younger infants and truncal positioning when sitting/standing in older infants 2

Age-Specific Motor Milestones to Consider

• By 4 months: Rolling from prone to supine, supporting on elbows and wrists in prone position 3
• By 9 months: Rolling from supine to prone, sitting without support, pulling to stand, coming to sit from lying, and crawling 3
• By 12 months: Standing independently and taking first independent steps 3
• By 12-13 months: Most babies walk independently, with 75% walking by 14 months 3
• By 18 months: All children should be walking independently 3

Red Flags Requiring Immediate Evaluation

• Absence of independent walking by 18 months 3
• Loss of previously attained motor skills at any age 2, 3
• Asymmetry in motor movements or persistent use of only one side of the body 3
• Gower maneuver when rising from floor 2
• Abnormal muscle tone (hypertonia or hypotonia) 2
• Dysmorphic facial features or other congenital anomalies 2
• Failure to thrive or growth abnormalities 2

Diagnostic Approach Based on Presentation

For Acute Onset of Difficulty Ambulating:

• Consider trauma, infection, inflammatory conditions, or acute neurological events 4
• Evaluate for fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or elevated C-reactive protein, which may suggest infection 2
• Localize pathology based on site of pain, tenderness, presence of erythema, swelling, and positive physical maneuvers 2
• For non-focal symptoms with negative radiographs and persistent symptoms, consider bone scan or advanced imaging 2

For Chronic or Progressive Difficulty Ambulating:

• Consider developmental coordination disorder (DCD), cerebral palsy, muscular dystrophies, or genetic disorders 2
• For hypotonia with weakness, check creatine phosphokinase and thyroid-stimulating hormone concentrations to screen for conditions like Duchenne muscular dystrophy 2
• For children with neuromotor abnormalities plus failure to thrive, growth abnormalities, or dysmorphic features, consider chromosome abnormalities 2
• The American College of Medical Genetics and Genomics recommends microarray testing as the first-line chromosome study for appropriate cases 2

Referral Guidelines

• Refer to Early Intervention/Child Find services for any child with confirmed motor delays 2
• Consult appropriate pediatric subspecialists based on suspected etiology (neurology, orthopedics, genetics, etc.) 2
• For mild abnormalities without "red flags," close follow-up with a specific timeline is appropriate, but families should understand that clinical changes should prompt urgent reevaluation 2
• Regression of motor skills, loss of strength, or any concerns with respiration or swallowing warrant immediate medical attention 2

Common Pitfalls to Avoid

• Failing to correct for prematurity when assessing development (most experts recommend correcting for at least the first 24 months of life for infants born before 36 weeks' gestation) 2
• Overlooking subtle signs of increased tone, such as early attainment of motor milestones, asymmetric development, or development of handedness before 18 months 2
• Missing the diagnosis of hypotonic cerebral palsy in children with normal brain imaging and uneventful perinatal history 2
• Failing to consider vitamin D deficiency as a cause of diffuse myalgia and difficulty ambulating, especially in darker-skinned individuals 5
• Neglecting to evaluate for non-accidental trauma in cases with inconsistent history or unusual injury patterns 6