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ally, the legs are rmly exed, but in either instance relatively few movements are made When hypotonia is a forerunner of an extrapyramidal motor disorder (eg, so-called double athetosis, another type of cerebral palsy), the rst hint of abnormality may be an opisthotonic posturing of the head and neck However, involuntary choreic movements usually do not appear in the upper limbs before 5 to 6 months of age and often are so slight as to be overlooked They worsen as the infant matures and by 12 months assume a more athetotic character, often combined with tremor Tone in the affected limbs is by then increased but may be interrupted during passive manipulation When hypotonia is a prelude to a cerebellar motor defect, the ataxia becomes apparent when the infant makes the rst reaching movements Tremulous, irregular movements of the trunk and head are seen when the infant attempts to sit without support Still later, as the infant attempts to stand, there is unsteadiness of the entire body In distinction to the gross de cits in motor development described above, there is a relatively small but distinct group of young children who exhibit only mild abnormalities of muscle tone, clumsiness or unusual postures or rhythmic movements of the hands, tremor, and ataxia ( ne motor de cit ) Such awkwardness in the somewhat older child are referred to as soft signs and have been extensively described by Gubbay and colleagues in what they called the clumsy child Like speech delay and dyslexia, ne motor de cits of this sort are more frequent in males Tirosh found that intranatal problems were more prevalent among children with ne motor de cits (compared to those with gross motor de cits), as were minor physical anomalies and seizures Systemic diseases in infancy pose special problems in evaluation of the motor system The achievement of motor milestones is delayed by illnesses such as congenital heart disease (especially cyanotic forms), cystic brosis, renal and hepatic diseases, infections, and surgical procedures Under such conditions one does well to deal with the immediate illnesses and defer pronouncements about the status of cerebral function The brain proves to be simultaneously affected in 25 percent of patients with serious forms of congenital heart disease and an even higher proportion of patients with rubella and Coxsackie B viral infections In a disease such as cystic brosis, where the brain is not affected, it is advisable to depend more on the analysis of language development than on assessment of motor function, because muscular activity may be generally enfeebled.

funduscopy Faulty vision becomes increasingly apparent in older infants when the normal sequences of hand inspection and visuomanual coordination fail to emerge Retention of pupillary light re exes in a sightless child signi es a defect in the geniculocalcarine tracts or occipital lobes conditions that may be con rmed by MRI and testing of visual evoked responses With respect to hearing, again there is the dif culty in evaluating this function in an infant Normally, after a few weeks of life, alert parents notice a brisk startle to loud noises and a response to other sounds A tinkling bell brought from behind the infant usually results in hearkening or head turning and visual searching, but a lack of these responses warns only of the most severe hearing defects The detection of slight degrees of deafness, enough to interfere with auditory learning, requires special testing To make the problem even more dif cult, both a peripheral and a central disorder may be present in some conditions, such as kernicterus Brainstem auditory-evoked responses (BAERs) are particularly helpful in con rming peripheral (cochlear and eighth nerve) abnormalities in the infant and young child After the rst few months, impaired hearing becomes more obvious and interferes with language development, as described further on

A considerable portion of neuropediatric practice is committed to the diagnosis and management of children with learning disabilities These problems usually come to light in the school-age child (hence the term school dysfunction), whose aptitude for classroom learning is thought to be inferior to his general intelligence The medical referral may be from a parent, teacher, or psychologist The clinician s objective is to determine by history and examination whether there is (1) a general congenital developmental abnormality impairing intelligence; or (2) a speci c de cit in reading, writing, arithmetic, or attention, any one of which may interfere with the child s ability to learn; or (3) neither of these for example, a behavior disorder or home situation that interferes with schooling; or (4) a primary sensory defect, particularly in audition Once diagnosis is achieved, the goal of management, undertaken in collaboration with psychologists and educators, is to fashion a program of remedial exercises that will maximize the child s skills to a point commensurate with his talent and aptitude, and restore his self-con dence (see Rosenberger)

All the new frontend features are only available with the new NW BI 70 component Objects created with the new 70 tools can no longer be edited with the 3x BEx tools The 3x BEx tools are delivered to support editing of existing scenarios

Failure to see and to hear are the most important sensory defects affecting the infant and child When both senses are affected, a severe cerebral defect is usually responsible; only at a later age, when the child is more testable, does it become apparent that the trouble is not with the peripheral sensory apparatus but with the central integrating mechanisms of the brain Failure of development of visual function is usually revealed by a disorder of ocular movements Any defect of the refractive apparatus or the acuity of the central visual pathways results in wandering, jerky movements of the eyes The optic discs may be atrophic in such cases, but it should be pointed out that the discs in infants tend naturally to be paler than those of an older child In congenital hypoplasia of the optic nerves, the nerve heads are extremely small Defects in the retina and choroid are detectable by

In the pediatric age period and extending into adult life, one encounters an interesting assortment of developmental disorders of speech and language Many patients with such disorders come from families in which similar speech defects, ambidexterity, and lefthandedness are also frequent Males predominate; in some series, male-to-female ratios as high as 10:1 have been reported Developmental disorders of speech and language are far more frequent than acquired disorders, ie, aphasia The former include developmental speech delay, congenital deafness with speech delay, developmental word deafness, dyslexia (special reading disability), cluttered speech, infantilisms of speech, and stuttering or stammering, and mechanical disorders such as cleft-palate speech Often in these disorders, the various stages of language develop-

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