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Demographic Details Child's Name: Krishna Shakya Age: 1 Year 1 Month 15 Days Gender: Male DOB: 2025-01-12 Mother’s age (years): 38 years Mother’s occupation: Homemaker Father’s age (years): 45 years Father’s occupation: Pvt jo0b Type of family: Joint Number of family members: 10 Number of siblings: 1 Details of siblings (Age and sex): 1- 8 years old female Address: Thatipur Contact: 7898803311 Referred By: Relative Informant: Parents Presenting Concerns Duration of symptoms: At 1 month- were told by pediatrician that child has down syndrome Interaction history: Interaction: Social interaction is good Behavioral history: Sensory Concerns: Auditory: Hyposensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Thyroid profile of child- normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Malpresentation Gestational Age: FT Birth Weight: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: No Others: Admitted twice for for acute diarrhea (once at 5 mon and then at 1 year age) Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 8 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 8 months Unidextrous grasp: Achieved Age of attainment: 8 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 8 months Babbling: Achieved Age of attainment: 11 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 8 months Babbling: Achieved Age of attainment: 11 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 8 months Stranger anxiety: Achieved Age of attainment: 1 years Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Predominantly milk by bottlefeeding Sleep History Total sleep duration (night): Total in 24 hours- 13-14 hours Afternoon nap: Yes Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Height: 67 cm Head circumference: 43.5 cm c. General Examination Dysmorphology: Downs facies Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: active, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tandon reflexes: KJ 2+/2+, AJ 2+/2+ If present details: Plantar flexor Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Bottlefeeding. IDP2/week +PMT 1/month Investigations: 2D ECHO, Ent Opinion, BERA, Ophthal examination General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Krishna Shakya
Age: 1 Year 1 Month 15 Days
Gender: Male
DOB: 2025-01-12
Mother’s age (years): 38 years
Mother’s occupation: Homemaker
Father’s age (years): 45 years
Father’s occupation: Pvt jo0b
Type of family: Joint
Number of family members: 10
Number of siblings: 1
Details of siblings (Age and sex): 1- 8 years old female
Address: Thatipur
Contact: 7898803311
Referred By: Relative
Informant: Parents

Presenting Concerns

Duration of symptoms: At 1 month- were told by pediatrician that child has down syndrome

Interaction history:

Interaction: Social interaction is good

Behavioral history:

Sensory Concerns:

Auditory: Hyposensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Thyroid profile of child- normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Malpresentation
Gestational Age: FT
Birth Weight: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: No Others: Admitted twice for for acute diarrhea (once at 5 mon and then at 1 year age)

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 8 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 8 months

Unidextrous grasp: Achieved

Age of attainment: 8 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 8 months

Babbling: Achieved

Age of attainment: 11 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 8 months

Babbling: Achieved

Age of attainment: 11 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 8 months
Stranger anxiety: Achieved

Age of attainment: 1 years
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Academic History:

Diet History:

Food preferences: Predominantly milk by bottlefeeding

Sleep History

Total sleep duration (night): Total in 24 hours- 13-14 hours
Afternoon nap: Yes

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Height: 67 cm Head circumference: 43.5 cm

c. General Examination

Dysmorphology: Downs facies Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: active, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tandon reflexes: KJ 2+/2+, AJ 2+/2+

If present details: Plantar flexor

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: Bottlefeeding. IDP2/week +PMT 1/month
Investigations: 2D ECHO, Ent Opinion, BERA, Ophthal examination
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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