This case involves a 7-month-old male patient whose right leg was not moving with the same range of motion as the left. He was admitted for a workup, but X-rays and a skeletal survey came back negative. Although the nurse noted that the infant wasn’t moving his right leg with the appropriate intensity or range of motion, the infant was discharged without a diagnosis. The infant continued to experience issues moving his leg for 3 months before he was eventually referred for further investigation. Additional testing diagnosed the infant with a paraspinal tumor which was found to be a neuroblastoma. Because the tumor had compromised the infant’s nervous supply to the legs, he was rendered permanently paralyzed. An expert in pediatric care was sought to opine on whether there was a lapse in the standard of care for this infant.
Question(s) For Expert Witness
- 1. At 7-months of age, what is considered normal regarding the movement of lower extremities?
- 2. What should be the workup when an infant presents with decreased movement in their extremities?
- 3. How important are the nurse's notes for decision-making on a hospitalized patient?
Expert Witness Response E-014119
I have 30+ years of experience caring for children and adolescents with spinal cord injuries, including those due to neuroblastomas. I currently spend about 70% of my time in academia and administration, and the other 30% I spend in clinical or consulting practice. At 7 months of age, a baby should have symmetric legs movements. The nurses and parents would be an important source of documenting such an abnormality. A thorough physical evaluation and radiographs of the legs, in addition to an MRI and CT of the abdomen and spine, should be performed.
This highly qualified expert is board certified in pediatrics with a subspecialty in spinal cord injury medicine. This expert completed an internship and residency in pediatrics at a prestigious university and formerly served as the president of a spinal injury association and various pediatric societies. This expert has authored over 135 peer-reviewed journal articles and 22 book chapters. This expert currently serves as the chief of pediatrics at a prominent midwestern children’s hospital and is also a professor of pediatrics at a major medical school.
Expert Witness Response E-177337
I am an assistant professor and pediatric hematologist-oncologist. I am board certified in pediatrics and I have been practicing in an academic institution since 2015. At 7 months of age, a baby should be moving both legs equally and spontaneously. The baby should also be able to bear weight with support. If a parent brings in an infant with decreased movement in their extremities, I would perform an extensive neurologic exam, including neurology consultation, and obtain imaging of the affected joint plus spine. I tend not to rely on the nurse’s clinical documentation but rather on my own physical exam and assessment. I have treated a patient for neuroblastoma with a similar presentation. Imaging was obtained upon presentation to our emergency room, treatment was initiated, and the patient is now neurologically normal.