LM209 - Pediatric Balance Assessment: It's as Simple as A-B-C

Abstract:
The evaluation of balance function in infants and young children often pose a challenge for diagnostic balance centers. Congenital and acquired balance conditions seen in children with and without SNHL are more common than previously thought. This presentation will focus on behavioral and electrophysiologic methods of evaluation of infants as young as 3 months of age, through video case studies highlighting maturational motor milestones with child-centered techniques as well as protocols with infants and children to produce reliable cVEMPs.

Summary:
The global acceptance and success of early neonatal hearing testing has significantly improved our ability to identify infants at risk for equilibrium dysfunction, due to the comorbidities of hearing loss and vestibular dysfunction. It is estimated that over 500 syndromes and non-syndromes are known to have an audiovestibular expressivity. Recent investigators have reported as high as 90% abnormal Vestibular Evoked Myogenic Potentials (VEMP) responses in children with congenital SNHL hearing loss. The emerging use of neonate and infant VEMP data suggests a much high incidence of vestibular dysfunction than the 30-50% previously estimated. We recognize the importance of normal hearing for acquisition of speech and language. Intact vestibular function is just as critical to the infant’s physical and motor development as is normal hearing for speech and language acquisition.

Children have audiovestibular systems, not just auditory systems. Congenital or acquired deficits can affect all or part of this system. The peripheral end organ of the vestibular system is actually the first sensory system to develop; it precedes cochlear development (the phylogenic development of the cochlea follows that of the saccule) and is developed by 49 days’ gestation. The neural connections with the central pathways continue to develop through the eighth month of gestation.

The majority of equilibrium problems in infants and children manifest as balance problems not as vertigo or dizziness. Delayed maturational motor milestones typically evidence the equilibrium dysfunction. It is important to ask the parents about the child’s motor development timeline as well as to make your own observations. Possible indicators of peripheral-central vestibular dysfunction may include the infant’s ability to hold the head upright, crawling, standing, and then walking. Benign paroxysmal vertigo of infancy (not to be confused with BPPV), a classification of migraine, is the condition most likely to produce symptoms of vertigo in children.

Although numerous investigators and authors have reported vestibular evaluation techniques and norms for children, these studies have primarily focused on the application and adaptation of adult tests i.e. VNG, Computerized Dynamic Posturography and Rotary Chair. Typically children in these studies have been 5 years of age or older, with the exception of the new normative VEMP data with age ranges from 3 months through the teen years. The focus of the presentation is to provide the audience with an overview of the most common causes of pediatric vestibular dysfunction, a review of common causes and a discussion of clinical and behavioral assessment tools which have both good sensitivity to underlying vestibular deficits and can be easily performed without the obstacles of technology or cost. This presentation will use video case studies to present a wide variety of infants and children with congenital and acquired balance conditions utilizing behavioral and electrophysiologic techniques and protocols.

Brief Summary of Clinical Takeaways:
Infants as young as 3 months of age may be evaluated.
Infants with and without SNHL may be screened/evaluated easily with behavioral milestones with high correlation with objective electrophysiological methods.