Palmer OB/PEDS final exam

True! Ligaments are stronger than bone until adolescence

False! GREATER potential. Rapid growth leads to decreased strength in the epiphyses and decreased strength and flexibility

Age 20

age 35

after 2 months

Yes!

Stroke the ulnar aspect

Simian crease

Spina Bifida Myelomeningocele

Adam's Test

Idiopathic scoliosis

a fractured clavicle

pes planus (fat pad obscures arch)
Metatarsus adductus ( c shaped foot)

Reverse tailor position (where child sits with their feet behind them to the sides and their knees out in front)

3

Metatarsus Adductus

Intrauterine positioning

* child prone
* Flex knees 90 degrees
* Align the midline of the foot parallel to the femur
* Using thumb and index finger, grasp the medial and lateral maleoli
* Place other thumb and index finger on either side of the knee
* If your thumbs are not parallel to each other ---> Tibial Torsion

Tibial Torsion

*Child standing, ankles together
* Knees at your eye level
* Measure distance between the knees
* Genu Varum if 1 inch or more between the knees
* This is a common finding in toddlers up to 18 months.
* Tibiofemoral angle should stay symmetrical
* Evaluate further if asymmetry of the tibiofemoral angle or space between knees > 1.5 inches

* Child standing, knees together
* Measure the distance between the medial maleoli
* Genu Valgum if 1 inch space between the ankles
* Common in children 2-4 years
* Evaluate further if asymmetry of the tibiofemoral angle, or space between the ankles > 2 inches

Femoral Anteversion

1. Asymetrical thigh and buttock skin folds or creases
2. Decreased hip abduction
3. Allis' test (legs may appear to be different lengths)
4. Barlow's
5. Ortolani's
-- This assessment should be performed each time the infant is examined during the first year of life

Allis sign

Barlow's

Ortolani

* Hold infant upright with your hands under the axillae
* If infant maintains the upright position, there is adequate shoulder muscle strength
* If infant slips through your fingers, there is muscle weakness

2 months - Can raise head (prone)
4 months - Rolls from prone to supine
6 months - Sits using tripod position
9 months - Begins creeping (cross crawl)
12 months - Stands without support momentarily

Limited movement - Getting up
Function of joints - Jumping
Range of motion - Hopping
Bone stability - Climbing
Muscle strength - Playing with toys

Gower sign

Muscular dystrophy

Muscular dystrophy

Cleidocranial dysplasia

Erb's palsy

Startle reflex to a change in position

* large infant
* Shoulder dystocia

*Fractured clavicle
*Fractured humerus
*Subluxation (medical) of the cervical spine
* Cervical cord injury
* Facial palsy

Klumpke's Palsy

Radial head subluxation aka Nursemaid's elbow

1. Apply pressure at the radial head
2. Grasp wrist and apply slight traction
3. Supinate wrist (palm up) while flexing elbow to 90 degrees.

Developmental Hip Dysplasia

* Acetabular Dysplasia - Delay in ossification of the acetabulum (oblique and shallow) - Femoral head remains in the acetabulum
* Subluxation - Incomplete dislocation, femoral head remains in contact with the acetabulum, joint ligaments and capsule are stretched (allows displacement of the femoral head)
* Dislocation - Femoral head loses contact completely with the acetabular capsule, displaced over the fibrocartilaginous rim

Talipes Equinovarus (club foot)

* Associated with Talipes Equinovarus ("club foot")
* A series of manipulations and castings (usually 4-6, full leg cast, bent at the knee)
* Tenotomy (achilles tendon)
* Foot abduction brace aka Denis Browne Bar

Talipes Calcaneovalgus

Legg-Calve-Perthes

Osgood Schlatter

A neurological disorder that is categorized under the umbrella of "Pervasive Development disorders"

Characterized by "severe and pervasive impairment in several areas of development"

1) autism
2) asperger's disorder
3) childhood disintergrative disorder (CDD)
4) Rett's disorder
5) PDD - Not Otherwise Specified

NO SINGLE KNOWN CAUSE

Theories:
Heredity/Genetic
Problems during pregnancy and delivery
Viral Infectiosn and Metabolic imbalances
Exposure to environmental toxins
Vaccinations (MMR in particular)

MOST prevalent PDD

More common in the US than Down syndrome (1/800), juvenile diabetes and childhood cancer.

CDC 2002: 1/150
(Class: 1/133 or 1/126)

More Common in BOYS

Ex) Autism

May demonstrate any combination of behaviors or defining characteristics to varying degrees.

Thros the senses "off" causing them to be over or under active

Switch the "foreground" and "background"

pg. 121

-Insistence on sameness; resistance to change
-difficulty in expressing needs
-using gestures or pointing instead of words
-Repeatin gwords or phrases in place of normal language
-preference to being alone, aloof manner
-tantrums
-difficulty mixing with others
-not wanting to cuddle or be cuddled
-little or no eye contact
-unresponsive to normal teaching methods
-sustained odd play
-spinning objects
-obsessive attachment to objects
-apparent over/under sensitivity to pain
-no real sense of fear or danger
-noticable extreme over or under activity
-uneven gross/fine motor skills
-no response to verbal cues; acts as if deaf although hearing tests in normal range (pg. 121)

"Child Genious"

Autism and Sperger's Syndrome share common characteristics but one aspect that differentiates Aperger's Syndrome is LANGUAGE DEVELOPMENT.

Autism: language delays
Asperger's: grasp language quickly, sometimes advanced development but do NOT master the usual give and take of conversation.

pg. 122

"Autistic children don't make eye contact" *many do, perhaps less often or in a different manner.

"autistic children don't communicate" *May use sign language, pictures, or some form of functional language developed by the child.

"autistic children will grown out of it" *symptom smay lessen as child grows, they NEVER "outgrow" autism

"Autistic children can't love" *often then can and do show affection - in their own terms

pg. 122

YES, OF COURSE!

Theory: remove subluxation --> improve neurologic function (improve sensory integration)

pg. 122

the sudden death of an infant under 1 year of age, which remains unexplained after thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.

pg. 123

Unknown cause

Responsible for more infant deaths than any other cause (USA)

>50% reduction since 1992

rare during the 1st month

peaks between 2-3 months

pg. 123

2001: 0.56 deaths per 1000 live births

2002: 0.57 deaths per 1000 live births

Considerably higher rates are found in black and american indian/alaska native children, 2-3x more common(less likely to position baby supine)

pg. 123

-prone sleeping position
-sleeping on a soft surface
-maternal smoking during pregnancy
-overheating
-late or no prenatal care
-young maternal age
-preterm birth an/or low birth weight
-male gender

pg. 123

1) Placed supine for every sleep
2) Use a firm sleep surface, no pillows, quilts, comforters under sleeping infant
3) Keep soft objects and loose bedding out of the crib. Bumper pads should be thin, firm and well-secured. Use sleep clothing with no other coerage or infant sleep sacks.
Tuck blankets so they only reach the infants chest.
4) Do NOT smoke during pregnancy. Avoid 2nd hand smoke
5) Separate but proximate sleeping environment.
6) Offer a pacifier at nap and bedtime.
7) Avoid overheating. Lightly clothed for sleep. Room temp should be comfortable for a lightly clothes adult. Avoid overbundling, Infant should not feel hot to the touch.
8) Avoid commercial devices marketed to reduce the risk of SIDS.
9) Do no use home monitors as a strategy to reduce SIDS
10) Avoid development of positional plagiocephaly. Encourage "tummy time", upright "cuddle time", avoid excess time in car seat carriers and "bouncers", alter supine head position during sleep.
11) Continue the "Back to Sleep" Campaign. Public education to encouage sleeping supine. 2* education to child care providers, grandparents, foster parents, babysitters, black and american indian/alaska Native populations

pt. 123-126

Pre-Pubertal: Infectious, Tumors, Trauma

Pubertal: Tumors, trauma, idiopathic, inherited disorders

pg. 118

Infectious: diskitis, osteomyelitis

Tumors: spinal column, cord

Trauma: falls, MVA, some pars defects

pg. 118

Tumors: spinal column/cord

Trauma: spondylolysis/lystheses, disc herniation, lumbar strain/sprain

Idiopathic: scheuermann's Disease

Inherited disorders: asynchromous spinal development (facet tropism)

pg. 118

-Age: >12yrs
-Female more common
-extended TV watching
-sports participation
-previous back inujury
-sitting at school
-carrying backpacks: esp. on one shoulder
-familial tendency

pg. 118

History: mech of injury, exacerbating factors, freq, duration and severity of the pain

*Kids can be bad historians, establish a time-liine using events (birthdays, holidays), Ask parents, teachers, other caregivers, inquire about specific tasks (climbing stairs, running, etc.)

Inspection: cutaneous lesions

Postural Exam: scoliosis, kyphosis

Gait Analysis

Trunk & Hamstring Flexibility: kids should be able to touch their toes

Neurologica exam: motor strength, sensory, DTR's, nerve root impingement, UMN signs.

pg. 118

rule out pathology

diagnosis and choice of appropriate adjusting protocol frequently depends on the radiographic findings. ex) spondylolisthesis vs. facet tropism.

pg. 118

Elevated WBC count or sedimentation rate (infection, leukemia)

pg. 118

1) child is <4yrs old: infection, neoplasm
2) Causes functional disabllity: missing sports, recess.. pain is serious
3) duration > 4 week: musculoligamentous injuries should resolve by then
4) Fever: suggests infection, osteomyelitis should be ruled out
5)Antalgic Posture: disc herniation (not common in children), can be assoc. with bone tumor pain (osteoid osteoma)
6) Neurologic abnormality
7)Limitation of motion due to pain

back pain was traditionally considered an uncommon complain among children and therefore doctors have been inclined to use every available test to reach a diagnosis.

It is now recognized that there are many cases of back pain in children assoc. with less serious conditions and the D.C. must be albe to distinguish between the two.

-Schuermann's disease
-facet tropism
-spondylolysis
-spondylolysthesis
-musculoligamentous injury (vertebral subluxation)

pg. 119

S/S: fatigue and pain in UPPER back.
Exaggerated mid-thoracic kyphosis, cervical and lumbar lordosis and ant. pelvic tilt

diagnosis: X-Ray. Ant. vertebral body wedging, loss of disc height and irregularity of end plates (3+ adjacent segs)

Management: adjustments and soft tissue therapy
stretch hamstrings and strengthen abs and back muscles

pg. 119

S/S: specific site of palpable tenderness in the lumbars

Diagnosis: X-Ray - sagittally oriented facet which correlates w/ the side and level of pain (L4/5, L5/S1).
Essentially a lumbar lig. sprain; overuse; facet syndrome

Management: adjustments - avoid the sagittal facet, already hypermobile. Side posture may exacerbate symptoms; should be avoided
Strengthening exercises (abs), Short-term limitation of activities: avoid hyperextension and rotation of the lumbar spine

pg. 119

S/S: SBP aggravated by activity; asymptomatic in some cases. Increased lumbar lordosis, hamstring tightness, gait abnormalities

Diagnonsis: X-Ray: A-P, Lat, & Oblique. CT, BRI or bone scan may be necessary.
Uni/Bilateral: acquired interruption of the pars; Stress Fx.

Management:
Acute: bed res and restricion of activities. allow Fx to heal before displacement occurs
Radiographic follow-up yearly to assess progression, every 6 months in the adolescent b/c of increased risk of slippage.

pg. 119

S/S: often asymptomatic in children. During or after growth spurt: dull ache in LB, Buttocks and thighs during or after physical activity. Flattening of the post. sacrum and pelvis, shortening of the turnk, forward translation of the chest, lumbar hyperlordosis, changes in gait.

Diagnosis: X-Ray: Ant. Vertebral Slippage
Myerding grading(1-5)

Management:
Grades 1-2: carefully supervise activities
Grade 3+: refer for evaluation for possible surgery.

Subluxation is the most common cause of back pain seen in the chiropractors office

The DC must be careful to include all possible differentials in their clinical thinking..

avoid prolonged, painful, frustrating, expensive programs of care d/t inaccurate diagnosis

(*don't know what d/t is, that's word for word out of the book)

pg. 120

Migraine: majority of primary childhood headaches, see IHS critera

Tension-type headaches: "bandlike" sensation around the head. Assoc. with neck/shoulder pain. Can last for days. may be associated with stressful events

pg. 115

Underlying CNS Pathology: (minority of headaches) SOL, Inflammation, Increased ICP.

Worse in the AM and improve as the day progresses

Aggravated by sneezing, coughting, straining

pg. 115

-Last 1-48hrs
-Have at lease 2 of the following: 1) bilateral or unilateral 2) pulsating quality 3)moderate to severe intensity 4)aggravated by routine physical activities

-Accompanied by at least 1 of the following: 1) nausea and/or vomiting 2) photophobia and/or phonophobia

pg. 115

Acute

Acute-Recurrent

Chronic-Nonprogressive or Chronic Daily

Mixed Headache

Chronic-Progressive (*scary)

pg. 115

single episode of head pain w/o hisory of previous events

est. whether any neurologic symptoms accompany this HA

pg. 115

pattern of head pain separated by symptom-free intervals

most commonly migraines

pg. 115

frequent or constant headache

may have emotional or behavioral components; tension-type HA

pg. 115

acute-recurrent headache (usually migraine) superimposed on a chronic-daily background pattern

pg. 115

gradual increase in frequency and severity

most ominous pattern...

*SCARY

pg. 115

-URTI (with or without fever)
-sinusitis
-pharyngitis
-meningitis
-migraine
-hypertension
-substance abuse
-intoxicants (lead, CO)
-Medication (ritalin, OCP, steroids)
-ventriculoperitoneal shunt malfunction
-brain tumor
-hdrocephalus
-subarachnoid hemorrhage
-intracranial hemorrhage

pg. 116

-brain tumor
-hydrocephalus
-pseudotumor cerebri
-brain abscess
-hematoma
-aneurysm and vascular malformations
-medications: OCP, tetracycline, vit. A (high doses)
-intoxication (lead)

pg. 116

worsening of headache severity and/or frequency (especially rapid progression)

significant change in previously diagnosed headache syndrome

failure of an adequate trial of therapy

pg. 116

Vitals: Include BP and temp

Head and neck exam: sinus tenderness, thyromegaly, nuchal rigidity, head circumference (increased ICP)

Skin: signs of neurocutaneous syndrome --> intracranial tumors. neurofibromatosis and tuberous sclerosis

DETAILED NEUROLOGICAL EXAM

Key features of intracranial disease:
altered mental status
abnormal eye movements
optic disc distortion
motor and sensory asymmetry
coordination distrubances
abnormal DTR's

CT/MRI indicated in patients with:
1)Chronic progressive HA pattern
2) Abnormal findings in the neuro exam

*Neuroimaging studies should not be performed routinely

Also consider:
lumbar puncture
blood cultures
sinus radiography
psychologic evaluation

pg. 116

High Priority:
acute headache
worst headache of life
thunderclap headache
chronic progressive pattern
focal neurological symptoms
abnormal neuro exam
papelledema
abnormal eye movements
hemiparesis
ataxia
abnormal reflexes
presence of ventriculoperitoneal shunt
presence of neurocutaneous syndrome
Age younger than 3 years

Moderate Priority:
headaches or vomiting on awakening
unvarying lacation of headache
meningeal signs

pg. 117

1) Children < 3 years of age. Rarely have primary headache syndrome, neurologic and fundoscopic exam can be difficult.

2) Actue Headache with focal neurologic S/S. neuroimaging should be performed

3) Chronic-Progressive Headaches. Assoc. with increased ICP

*May depend on the doctor's experience and confidence.
pg. 117

Once determined , reassure that the headache is not due to brain tumor or CNS Pathology..

-quiet, dark room
-sleep
-manage stress: encourage family to develop a "schedule", relaxation techniques, biofeedback, phychotherapy
-diet (avoid triggers)

CHIROPRACTIC!

pg. 117

Migraine and tension headache have been associated with musculoskeletal dysfunction of the neck

Tensio-type headache: decreased lordosis of the C Spine associated with excessive suboccipital muscle tension

pg. 117

"Oblique Head" (Greek)

2 Types:

Nonsynostotic
&
Synostotic

Postional head Deformity (1/60)

External pressures on the rapidly developing skull from prolonged exposure to one postion

pg. 113

Premature closure of the lambdoidal suture (1/100,000)

pg. 113

If present at birth:
1) in-utero or intrapartum molding: uterine constraint (mult. birth infants), birth injury (forcepts, vacuum-assisted delivery), premature birth
2) craniosynostosis

If develops later:
1) torticollis
3) "Back to sleep" campaign: since 1992 there has been a significant increase in the diagnosis of plagiocephaly, one center reported a six-fold increase.*
3) Subluxation
*"Result of static supine positioning"
pg. 113

Physical Exam:
-palpate lambdoidal suture
-check ear position
-assess facial symmetry
-observe unilateral bald spot
-inspect by arial view

Skull Radiographs & CT if:
-atypical skull pattern
-moderate-sever skull deformity
-suspecting craniosynostosis

pg. 114

Postitional Head Deformity: -suture palpates WNL
-Ear on flat side appears more ant.
-ipsilateral forehead protrudes
-bald spot on side of flattening

Craniosynostosis:
-palpable ridge
-ear on flat side appears more post.
-forehead does not protrude
-no bald spot: no sign of external pressure

pg. 114

Most improvwe within 2/3 months.. if parents follow these guidelines:

-preventative counseling
-mechanical adjustments
-exercises
-skull molding helmets
-surgery

*Early recognition is important
*Preferred Position ~> torticollis

pg. 114

Parents should be counseled during the newborn period (2-4 weeks)

-alternate supine sleep positions (ex: L&R Occ)
-when awake and being observed, the infant should spend time in the prone postion
-minimal time in car seats (when not a passenger in a vehicle) or other seating that maintains supine position.

pg. 114

Rounded Side of the head is placed dependent against the mattress:
-change the postition of the crib in the room
-position toys, etc. to require the child to look away from the flattened side

Supervised "tummy time" when the infant is awake and being observed

If torticollis is present, parents should be taught specific exercises:
-head rotation and lateral bend: done at each diaper change, hold 10 seconds, 3 repetitions

pg. 114

Eliminated the tendency for the infant to continue to lie on the flattened area of the skull. Allows the rapidly growing skull to expand into areas unopposed by the helmet.

Research opinions are mixed

Best results 4-12 months of age.

"...opinion for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustment and postion changes."

pg. 114

Retrospective; 25 cases, mean age 3.47 months

Intervention: chiropractic pediatric adjusting techniques: spine & extremities

All 25 patients achieved complete resolution*
Mean Time to full resolution: 3.64 months
Mean number of adjustments 1.8

*Resolution: all criteria for establishing the diagnosis were no longer evident NAD a minimum period of 4 weeks in which the subluxation complex was no longer demonstrable.

pg. 115

Birth trauma with resultant hematoma formation followed by muscular contacture.

-trauma to soft tissue of the neck just before or during delivery
-Breech or difficult forceps delivery (MC)


Malpostion in utero resulting in intrauterin or perinatal compartment syndrome
-up to 20% of children with congenital muscular torticollis have congenital dysplasia of the hip as well.

pg. 112

LOCAL ETIOLOGY:
1) Congenital
-pseudotumor, hypertrophy or absence of cervical musculature, spina bifida, hemivertebrae, arnold-chiari syndrome
2) Otolaryngologic Causes:
-vestibular dysfunction, otitis media, cervical adenitis, pharyngitis, retropharyngeal abscess, mastoiditis
3)Esophageal Reflux
4)Syrinx with Spinal Cord Tumor
5)Traumatic Causes:
-Birth trauma, cervical fracture or dislocation, clavicula fx's.
6) Juvenile Rheumatoid Arthritis

COMPENSATORY ETIOLOGY:
1) Strabismus with fourth cranial nerve paresis
2) Congenital Nystagmus
3) Posterior Fossa Tumor

CENTRAL ETIOLOGY:
1) Dystonia
2) Cerbral Palsy

pg. 112

Sternomastoid Tumor AKA: "Pseudotumor"
-visible, sometime palpable swelling in the SCM
-painless, hard mass (1-3cm)
-appears at 2-3 weeks
-often persists until 1 year
-rarely bilateral

Head is tilted and flexed to the side of the fibrosis

pg. 112

Tumor is less discrete: SCM appears thickened and foreshortened along its entire length

Restricted rotation and lateral flexion of the neck

Postural Compensation: elevate shoulder to maintain a horizontal plane of vision, twist the neck and back to maintain a straight line of sight

pg. 112

Clinical Exam: Palpate the entire length of the SCM.
-determine if fibrosis is present
-generally stands out as a tight band. - alternative dDx must be considered if the muscle is neither short nor prominent.

Special Studies:
-Plain Film: Fx, subluxation
-CT/MRI (cervicals): Retropharyngeal abscess, neck masses
-MRI/CT with contrast (brain): brain tumor
-Ultrasonography
-Electromyography: define the degree of muscle or nerve involvement

pg. 112

Parental Physiotherapy:
-Passive Stretching (90% respond w/i the first year)
-changes in position; increase "tummy time"

Surgical management is generally avoided until at lease 1 year. May be considered if:
-Conservatitve methods are unsuccessful
-persistent SCM contracture limits head movement
-persistent SCM contracture accompanied by progressive facial hemihypoplasia
-other dDx have been excluded

pg. 112

Chiropractic Adjustments

Parental Education: Passive stretches, tummy time, positiona changes (car seat, sleeping, etc)

pg. 112

1)Plagiocephaly: asymmetric skull, flattening of occiput
2) Facial Hypoplasia: inhibition in the growth of the mandible and maxilla due to muscle inactivity
3) Musculoskeletal Effects: compensatory ipsilateral elevation of the shoulder, cervical and thoracic scoliosis, wasting of the muscles of the neck

pg. 112

Birth Trauma:
-Shoulder Dystocia
-In-utero positioning of the fetus
-Percipitous second stage of labor
-marernal forces: contractions & pushing

pg. 110

C5&C6

-Lack of shoulder motion
-arm is adducted and internally rotated
-elbow extended and the forearm pronated
-moro, biceps and radial reflexes absent

-normal palmar grasp
-no sensory loss

-Ipsilateral phrenic nerve paresis (5%)
-fractured clavicle

pg. 110

Klumke's Paralysis
Fractured Clavicle
Erb's Palsy
Cerebral Palsy
Fractured Humerus

pg. 110

Radiographic Studies: shoulder and upper arm to rule out bony injury

Chest Exam: rule out assoc. phrenic n. injury

Fast Spin-echo MRI: can define meningoceles

*CT Myelography is more invasive and offers few adv. over MRI
*EMG and nerve conduction studies are occasionally useful.

pg. 111

Prevent development of contractures:

Partial immobilization and appropriate positioning of upper extremity.

Supportive Wrist Splints

Active and Passive ROM exercises should be started by the end of the first week.

pg. 111

Neurosurgical consult should be obtained if the paralysis persists for more than 3-6 months. (injury prox. to brachial plx may indicate more severe damage and arrant earlier consult)

Electromyography and Nerve Conduction Velocities are not reliable indicators of injury severity

*Best surgical results in the first year

More research is needed.

Chiropractic Adjustments vs Natural History

-splinting
-active and passive ROM exercises

pg. 111

Usually "Spontaneous": May occur within 48 hours; can take up to 6 months

Nerve laceration may result in a permanent palsy

Possible long-term deficits: progressive body deformities, muscle atrophy, joint contracture, possible impaired growth of limb, weakness of shoulder girdle

***Be cautious in predictin gfull recovery and closely follow affected infants!!***

pg. 111

1) Recent, usually abrupt, onset of S/S of middle-ear inflammation and MEE

2) The presence of MEE that is indicated by any of the following:
-bulging of the tympanic mem.
-limited/absent mobility of the tympanic mem.
-air fluid level behind the tympanic mem.
-otorrhea

3) S/S of Middle-ear inflammation as indicated by either:
-distinct erythema of the tympanic mem. OR
-Distinct otalgia (discomfort clearly referalbe to the ear(s) that results in interference with or precludes normal activity or sleep.

pg. 107

-Vague Symptoms

-Undue reliance on one feature: redness of the tympanic mem

-Failure to assess tympanic membrane mobility: must use pneumatic otoscopy

-Inadequate visualization of the tympanic membrane: old otoscope bulbs, blockage of the ear canal by cerumen

pg. 107

"Watchful Waiting": symptomatic treatment for 24-48 hours before initiating antimicrobial treatment

Pain Management: Acetaminophen, ibuprofen, or topical otic anesthetic drops

Antibiotic Therapy: Reserve antibiotic therapy for specific cases. <6mos. age, severe illness (fever of >102.6, severe ear pain)

pg. 107

Wait and See: decreases the use of antibiotics, reductes cost and adverse effects (diarrhea), no serious adverse events reported, interrupts the cycle of parental expectations

pg. 107

<2 years with bilateral disease (not all children benefit from antibiotics as previously suggested)

Otorrhea (any age)

-Breastfeeding: min. 6 mos
-If bottle fed:avoid supine bottle feeding
-reduce or eliminate pacifier use (>6mos)

daycare - increased incidence or URTI
Tabacco Smoke

pg. 108

The presence of fluid in the middle ear withou signs or symptoms of acute ear infection.

Due to poor eustachian tube function OR inflammatory response following AOM.

Concerns: conductive hearing loss, potential impact on language and cognitive development

pg. 108

1) Cloudy Tympanic Mem.
2) Distinctly impaired mobility
3) air-fluid level or bubble may be visible.

Pneumatic otoscopy should be performed.

Document the laterality and uration of effusion and presence and severity of assoc. symptoms

pg. 108

Watchful waiting for 3 months

If persists longer than 3 months or if language delay, learning problems or sig. hearing loss is suspeced:
Hearing and Language Testing

Re-examine at 3- to 6- month intervals until:
-effusion is no longer present
-sig. hearing loss is identified
-structural abnormalities of the eardrum or middle ear are suspected.

pg. 108

Evaluate hearing, speech, language.

- speech and language therapy concurrent with managing OME
-hearing aids or other amplification device for hearing loss independent of OME
-insertion of typanostomy tube
-hearing testing after resolution of OME to document improvement.

pg. 108

NOT Recommended:
-antihistamies
-decongestants
-antimicrobials
-corticosteriods


-Tympanostomy tube insertion - preferred initial procedure

-Adenoidectomy: should not be performed UNLESS a distinct indication exists (nasal obstruction, chronic adenoiditis)

pg. 108

Marginally effective

-Improves hearing short term
-outcomes w/i 18mos, however, are the same
-tubes have NO EFFECT on language development
-Watchful waiting is a reasonable option in MOST of these children.

pg. 109

Evidence is promising for the potential benefit of manual procedures.

-Improvement with manual procedures
-feweer surgical procedures compared to usual medial care
-parent-reported positive side effects (relaxation, good nap)

-NO adverse effects were reported

Management Includes: Spinal adjusting (MC) Primarily Occiput, C1, C2 and cranials, significant number of non-spinal adjustment modalities

Limitations: small sample size

pg. 109

subluxation --> neurological compromise of the tensor veli palatini --> inadequate patency of the eustachian tube --> otitis


subluxation -->muscle spasm --> lymphatic blockage --> otitis

Diagram pg. 110

Inability to control urination.

Classification Schemes According to:
1) time of day
2) other symptoms
3) previous periods of dryness

pg. 105

passing of urine while asleep


pg. 105

leakage of urine during the day

pg. 105

normal voiding occurring at night in bed in the absence of other symptoms referable to the urogenital or gastrointestinal tract.

pg. 105

bed-wetting associated with daytime symptoms such as urgency, frequency, chronic constipation or encopresis

pg. 105

bed-wetting in a child who has never been dry

pg. 105

bed-wetting in a child who has had at least six months of nighttime dryness

pg. 105

-Genetic Predisposition(*most frequently supported)
-Bladder Problems
-Arginine Vasopressin
-Sleep Disorders

Other Factors (?): Familial or Psychologic

History: Be sure to ask detailed questions about enuresis.

pg. 105

NOT considered enuretic until 5 years of age.

Voiding dairy: 1 week or more

Physical Exam:
-Gait: neurological deficit
-Flanks/Ab: masses, enlarged bladder
-Lower back:cutaneous lesions, asymmetric gluteal cleft

Urinalysis: specific gravity, glucose level, infection, blood in urine

pg. 106

Alarms: Negative reinforcement or avoidace: anxiety, diruptive to family? May have to be used for up to 15 weeks. Effective, LOW relapse rate.

Pharmacological Treatment: not recommended for children under 6 years. Effective but HIGH relapse. Side Effects: desmopressin (nasal irritation, nosebleeds and headache), Imipramine (cardiotoxicity at high doses)

pg. 106

Inability to control urination.

Classification Schemes According to:
1) time of day
2) other symptoms
3) previous periods of dryness

pg. 105

passing of urine while asleep


pg. 105

leakage of urine during the day

pg. 105

normal voiding occurring at night in bed in the absence of other symptoms referable to the urogenital or gastrointestinal tract.

pg. 105

bed-wetting associated with daytime symptoms such as urgency, frequency, chronic constipation or encopresis

pg. 105

Positive Reinforcement Systems: earns points -->prize

Responsibility Training: ex) strip wet lines from the bed.

Other:
Elimination Diet, hypnosis, retention control, biofeedback, acupuncture, acheduled awakenings, caffeine restriction.

pg. 106

Evidence is insufficient at this time

-promising
-adverse effects were mild and self-limiting.

pg. 106

-Crying for more than 3 hours per day
-for more than 3 days per week
-for longer than 3 weeks
..in an infant who is well fed and otherwise healthy

Typically begins at 2 weeks of age and usually resolves by 4 months.

pg. 103

-Attacks of screaming in late afternoon and evening
-flushed face, furrowed brow, clenched fists
-legs pulled up to abdomen
-piercing, high-pitched screams
-prolonged bouts
-unpredictable, spontaneous (unrelated to environmental events)
-Cannon be soothed, even by feeding.

pg. 103

Gastrointestinal: "gas" does not seem to be the cause of colic (excessing crying may lead to aerophagia)

Psychosocial: not a sign of a "difficult temperament". Not related to maternal personality or anxiety

Neurodevelopmental: Upper end of the "normal distribution" (same temporal pattern, just more severe). Most infants "outgrow it"

pg. 103

<5% of infants presenting with excessive crying.

CNS: Chiari Type I malformation, Infantile migraine, subdural hematoma

Gastrointestinal: Constipation, cow's milk protein intolerance, GER, Lactose intolerance, rectal fissure

Infection: Meningitis, Otitis media, UTI, Viral Illness

Trauma: abuse, corneal abrasions, foreign body in the eye, fracture bone, hair touriquet syndrome.

*A diagnosis of exclusion
pg. 103

1) Low Allergen Diet (breastfeeding mothers) Eliminate mild, eggs, wheat and nuts
2) Hypoallergenic Formulas
3) Soy Formulas: may develop allergy to soy
4) Herbal tea: chamomile, vervain, licorice, fennel and balmmint
5) Reduce infant stimulation

NEW RESEARCH: Probiotice (lactobacillus reuteri): Improved colicky symptoms within 1 week, no adverse effects reported.

Limited/No evidence to support:
Simethicone (Mylicon), Lactase, Fiber-Enriched Formulas, Carrying the infant more, Car Ride simulators, Intensive parent training, sucrose

pg. 104

Evidence is adequate to support the "total package" of Chiropractic care as providing benefit to patients with colic.

Improvement with SMT

Improved parent-reported outcomes

No adverse effects reported

pg. 104

Parents Report: episodic or persistent coughting, wheezing, shortness of breath, rapid breathing or chest tightness, worse in the evening or early morning hours, associated with triggers (exercise, allergen exposure)

50-80% of children develop symptoms before 5yrs.

pg. 100

Wheezing is NOT present in ALL patients with Asthma!

Wheezing: Respiratory infections, rhinitis, sinusitis, vocal cord dysfunction

Consider: Foreign body aspiration, cystic fibrosis, heart disease

pg. 100

Primary diagnostic tool: Clinical Assessment

-Pulmonary function tests (spirometry) should be performed as soon as possible *more reliable after 3-4yrs of age

-Allergy Testing: Atopy is the strongest predictor for wheezing progressing to asthma.

pg. 100

Food Allergy-Associated GI Disorders and Dermatits (Infancy) --> Allergic Rhinoconjunctivitis (Early Childhood) --> Asthma

pg. 100

-Patient Education
-Trigger avoidance
-Drug Therapy

Compliance is a major problem:
route of administration, frequency of dosing, medication effects, risk or concern of side effects.

pg. 101

Evidence is adequate to support the "total package" of chiropractic care as providing bienfit to patients with asthma.

-symptoms were reported to improve
-medication use decreased
-one study showed improved peak expiratory volume (Guiney)

-no adverse effects were reported

pg. 101

-Reduce Symptoms (wheeze and cough)
-improve lung function
-minimize adverse effects of treatments.

?: reduce the risk and number of acute exacerbations, minimize sleep disturbances, minimize absences from school

pg. 101

Chiropractic Management included:
-Spinal adjusting (most common modality used): full spine, ribs, upper cervical

-Non-spinal adjustment modalities

Trigger Avoidance and Environmental Contol measures: evaluation of stress/environment, environmental pollutants, removal of dairy/wheat from diet, review of medication/side effect.

pg. 102
pg. 102

-allergens from dust mites or mold spores
-animal dander
-cockroaches
-pollen
-indoor and outdoor pollutants
-irritants (smoke, perfumes, cleaning agents)
-pharmacologic triggers (NSAIDS, sulfites)
-Physical triggers (exercise, cold air)
-physiologoic factors (stress, GER, URTI, rhinitis)

pg. 102

-remove carpets
-wash bedding and clothing in hot water (weekly)
-hypoallergenic mattress and pillow covers
-remove stuffed animals
-keep pets outdoors
-hypoallergenic furnace filters
-dehumidifier (household humitidy <50%)

pg. 102

-avoid dairy/wheat
-limit processed sugars
-avoid food additives and preservatives (MSG)
-relation techniques, stress control and reduction
-probiotics
-omega-3 FA's
-Calcium and magnesium
-Antioxidants

"As Low As Reasonably Achievable"

Should be applied to every patient.

pg. 95

-History
-Will the imagin give you any added clinical data?
-Benefits vs Risk

pg. 95

Gonads
Breast
Thyroid
Lung
Bone

pg. 95

Children!

*also have long life expectancy: a larger window of opportunity for expressing radiation damage.

pg. 95

No, NEVER!

-Will results change management?
-will the study confirm clinical suspicions?
-is it the appropriate study for what I'm trying to confirm?

pg. 95

Instructional Compliance

Motion: child should be stabilized by the parent

Recumbent radiographs are a necessity in young children: acute fractures

pg. 95

Must know the NORMAL radiographic appearance at each age for accurate interpretation
-atlas of normal developmental anatomy
-consult a DACCBR

Chiropractic Line Analysis: children are NOT small adults.. does the technique recognize this?

pg. 96

-Pseudosubluxation
-Pseudospread of C1 on C2
-ADI space
-Absence of cervical lordosis
-Normal appearance of ossification centers and epiphyses

pg. 96

Normal Variant

Occurs most commonly at C2/C3:
-40% of normal children <7 years of age
-24% of those under 16 years

Also occurs at C3/C4:
-20% of those <7 years;
-9% <16 years

Distinguishes pseudosubluxation from pathological subluxation

A line drawn connecting the anterior cortices of the spinous processes of C1 and C3 should intersect or lie within 1mm of the anterior cortex of the spinous process of C2.

If c@ is >2mm off this line = TRUE INJURY

pg. 96

normal variant

lateral mass displacement relative to the dens
-Up to 6mm is common <4 yrs
-can be seen up to 7 yrs

pg. 97

-ADI Space: Max of 4mm (NEW Literature)

-Absence of Cervical Lordosis: Common up to 16 yrs.

-Oval/Wedge Shaped Vertebrae: Do NOT confuse with Compression Fx

-Normal appearance of ossification Centers and epiphyses can simulate fractures.

pg. 97

Spaces between sacral segments are synchondroses composed of FIBROCARTILAGE, not discs

Bone starts to be deposited in the fibrocartilage starting at puberty

*They DO NOT move like vertebrae

pg. 97

Results from injury at the odontoid synchondrosis

Flexion/Extension Radiographs
Neurological Deficit?
Neurologist/Orthopedist Consult

pg. 98

Salter-Harris Classification

SEE PAGE 98 FOR DIAGRAM

Films play an important part in documenting physical abuse.

Physical, Sexual, Nutritional Abuse or Neglect--> MUST report to appropriate agency!

Remain professional and objective, be non-judgemental towards parents

Technical Considerations: reveal soft tissues well, high detail radiographs, sectionals, not "babygram"

pg. 98

-Metaphyseal "corner" fractures
-Mult. Fx's at various stages of healing
-Ribs, Scapula
-Head Injuries: Skull Fx, subdural hematoma, shearing injuries (MC cause of death and disability in child abuse)
-Soft tissue swelling and injuries (ex: contusions, burns, etc)

pg. 99

Spinal Infection

Common Problem in Infants
MC Lumbar Region, Lower Thoracics

S/S: Back Pain (often can't directly communicate) and difficulty walking or limping

***When one has exhausted all the the more common causes of limping, one should look to the lower thoracic and lumbar spine regions for the presence of discitis***

pg. 99

-Underdeveloped cervical lordosis
-low vertebral height
-horizontal facets (until age 10)
-undeveloped uncinates (until age 7)
-spine is flexible: cartilage, ligaments are more elastic, discs are expansile.

pg. 90 (see films)

C-Spine: minimize rotation

Reduce depth of thrust: Sometimes, pre-stress can effecct a correction

Pediatric vertebrae are much smaller: cervical spine of a newobrn is < 2" in length

*high degree of specificity is required
*contact points: pad of the finger-tip or thumb tip


pg. 90

problems breastfeeding, diaper habits, sleeping, won't cuddle, pulls away when held against shoulder, only comfortable in the "football hold"

pg. 90

Fixation b/w Occ/C1

Increased tension in suboccipital muscles (unilateral/bilateral)

*If significantly fixed, infant may become irritable even with light palpation.

Correction: Light cephalad traction with the fingertips. When released, infant becomes relaxed and may even fall asleep.

*PS Occ. is more common

pg. 90-91

Findings: Fixation @ C1, T&T, Instrumentation, etc.
(palpate atlas laterality seated/upright)

Correction: lateral tip of index finger against prominent C1 transverse. Laterally bend to the side of contact until end-range; quick, light, low-amplitude thrust is delivered to the tip of the C1 transverse toward the neutral position.

*NOT UNCOMMON for a young baby to cry 15-20 seconds (stimulates the Moro response)

pg. 91

Findings: Muscle Spasm (usually side of spinous process deviation) Fixation (spinous does not move away with lateral bend)

Correction: Tip of index finger on articular pillar, rotate head 25-30*, laterally bend the neck over contact finger, if no release is felt, apply a LIGHT thrust.

*LIMIT EXCESSIVE ROTATION

The joints of Lushka only begin to develop between 6-9 years of age.

pg. 91

Prone: If child will not lie quietly in the prone position move infant to edge of the table, support the legs over the edge.

Infant upright, chest to chest with doctor or patient.

Infant lying prone on top of parent.

pg. 91

Correction:
DTH - thumbs on either side of the spinous process

Anterior Adjusting - not recommended for children under 3 years of age (flexible rib cage)

pg. 92

Sagittal plane facet joints!

Correction: contact mammillary process with a light thumb contact:
P-A, I-S thrust

pg. 92

Correction: Contact the spinous process (side of spinous rotation) with light thumb contact. Apply ligh tpressure over the contralateral mammilary process (stabilization). thurst toward the spinous process

*Side Posture: reserved for children > 1 year

pg. 92

-Gluteal Cleft Deviation
-Hold infant upright, legs dangling: Ilium rotation
-Gluteal Fold Observation: sacral tilts

Correction: Prone or Side Posture - light thrust, direction appropriate to correct PI, AS, IN or EX.

pg. 92

pinch gluteal cheeks together, cleft should be MIDLINE

If it deviates:
May either be to the side of posterior-inferior SI subluxation (P-R, PI-R, P-L, PI-L) or to the side of anterior inferior sacral movement at the lumbosacral junction.

pg. 92

***Just because it sticks out doesn't mean it's subluxated***

Can be a challenge, be creative

Similar to adults but more subtle (smaller, squirming, etc)

pg. 92

Must consider variable growth rates in long bones

Make sure other findings match

pg. 92

Infants (in first 2 years of life): at least every month

Pre-School Children: at least every 2 months

School-Aged Children: at least every 3 months

pg. 86

-History
-Reverse Fencer Maneuver: heel swing, acetabular pump
-Supine Leg Check
-Instrumentation: Atlas Fossa Reading
-Posture Analysis
-Static Palpation
-Motion Palpation

Used only with infants (< 6 months old)

Less accurate once the child gains strength and control of the cervical spine musculature

Part 1: Heel Swing
Part 2: Acetabular Pump

Heel Swing:
-Hold infant upside down (solid grip on ankles)
-Release one foot slowly, watch the child's head turn to that side
-Repeat on other side
-Compare motion from side to side: restricted? twitching?

*Atlas/Occ on side of restriction

***Check pelvis stability before performing heel swing***

pg. 86

"Acetabular Pump"

-Infant supine, apply pressure along the shaft of the femur into the acetabular fossa
-compare the resistance on each side
-The "spongy" side is said to be the side of atlas laterality

*Spongy --> Atlas

***If they are EVEN: consider Occiput***

Infant arches backwards

Meningeal tension?

pg. 87

Lay the infant supine

gently straighten the legs: make sure the head is in a neutral position

compare medial malleoli, fat folds at the knee, etc.

Postural Evaluation: Glabella-Sternum Symphysis

pg. 87

DT-25 or Tytron

Remember to take nto consideration the way the child is being held, sitting in the sun in the car seat, against parent, etc.

pg. 87

Head tilt, head rotation, high shoulder ,scoliosis (assymetry in the arms?) , high ilium, genu varus and valgum, internal and external foot rotation

pg. 87

Bowlegs --> Knock-Knees --> Normal Valgus

pg. 87

Toe-In:
EX Ilium, tibial torsion, femoral anteversion, weal psoas or glut. max, cereral palsy (bilateral toe-in)

Toe Out:
IN Ilium, hypertonicity of psoas or glut. max

pg. 88

*Pay attention to the child

-T/T Fibers
-Muscle Spast: Common with congenital torticollis
-Sudoriferous changes: stickiness/dryness
-Temperature

L1

(Similar to adults T4)

pg. 88

Motion Palpation: similar to adults but much more subtle: ligament laxity, cartilagenous vertebrae

ROM: can be evaluated by "playing" with them

pg. 89

-they want to be in control of their world: importatnt to respect their need for automy but you also have to maintian control of the interaction.

-Use "positive language"

-give them a choice between two "acceptable" options

pg. 89

during the first year of life

pg. 74

Age 12-15

pg. 74

Cephalocaudal direction: control of the head and neck develops first, followed by trunk and extremities

orderly sequence to development, many milestones develop simultaneously

pg. 74

Posture: "flexed" (normal tone), hands held fiste for first 3 months.

Observe for spontaneous activity: symmetry and smoothness of motion

Coodinated sucking and swalling (cerebellum)

*Note any sustained asymmetric posturing and/or ryhthmic twitching (facial, extremity, trunk musculature)

pg 74

Associated with seizure activity.

pg. 74

-Gazes intensely at a close object or face.

-focuses on and tracks an object with both eyes

-optical blink REFLEX: shine a light at the infant's open eyes, observe quick closure of the eyes and dorsal flexion of the infant's head (*no response: poor light perception)

Doll's eye maneuver (CN VIII)

pg. 74

Rooting REFLEX: Touch corner of the mouth. Infant shoul dopen its mouth and turn it head toward the stimulation. (*If recently fed, minimal response is expected)
(Sensory V, Motor XII)

Sucking Reflex: Place your finger in the infant's mouth, feel the sucking action. Tongue should push up against your finger with good strength. Note: Pressure, stength, and pattern.

pg. 74

Observe the infant's facial expression with crying (Bell's Palsy is possible)

Not ability to wrinkle the forehead, symmetry of the smile.

pg. 74

Acoustic Blink Reflex: Clap your hands close to the infant's head. Note the blink in response to sound. Inant will habituate to repeated testing. (*No response after 2-3 days of age may indicate hearing problems)
-Moves eyes in direction of sound.
-Freezes postion with high-pitched sound

Doll's Eye Maneuver: Hold the infant under the axilla in an upright position (head held steady by parent, facing you). Rotate the infant, first in one direction and then the other. Infant's eyes should turn in the direction of rotation. when movement stops, eyes should move in the opposite direction.
(*If not, suspect vestibular problem or eye muscle paralysis)

pg. 75

swallowing

gag reflex

Coordinated sucking an swallowing ability.

Pinch infant's nose: mouth will open and tip of tongue will rise in a midline position

pg. 75

Use finger to tap the tendon.

Interpret finding as for adults.

*Ankle clonus is common in infants

Patellar reflex present at birth

Achilles and brachioradialis appear around 6 months.

Withdrawal of lims to painful stimulus. Ex) pin prick on heel --> should pull away.

May also use "primitive reflexes" - Appear and disappear in a sequence corresponding with CNS development. Used to evaluate posture and movement of the developing infant.

pg. 75

General Rule: Birth - 6mos.

Yawn, Sneeze, Hiccup, Blink at bright light and loud sound, pupillary constriction with light, withdrawal from painful stimuli

*As the brain develops, some primitive reflexes are inhibited as more advanced cortical functions and voluntary control take over

pg. 76

Present at Birth - Up to 2 years in a normal, healthy child

"Babinski sign" - fanning of toes and dorsiflexion of the great toe.

CAUTION: If reflex disappears then reappears... UMNL suspicion.

pg. 76

Infant's head midline. Touch palm of the infant's had from the ulnar side.
*Note: strong grasp around your finger

Sucking facilitates the grasp

Strongest: b/w 1-2 months

Disappears by 3 months

pg. 76

Touch the plantar surface of the infant's feet at the BASE of the toes

Toes should culr downward

*Strong up to 8 months

pg. 76

Infant supported in semi-sitting postion.
Allow head and trunk to drop back to a 30* angle.
Ovserve symmetric abduction and extension of the arms (fingers fan out and thumb and index finger form a C)
the arms then adduct in an embracing motion, followed by relaxed flexion

Legs follow a similar pattern

Dimishes in strength by 3-4mos.

pg. 76

Hold the infant upright. Touch the dorsum of the foot to the edge of a flat surface. Observe flexion of the hips and knees and lifting of the foot (as if stepping up)

Age disappearance varies

pg. 77

Hold the infant upright under the arms. Allow the soles of the feet to touch the surface of the table. Ovserve for alternate flexion and extension of the legs (walking)

Disappears before voluntary walking.

pg 77

Suspend the infant prone over your hand. Stroke paraspinally from the shoulders to the buttocks. Trunk should curve toward the side stroked.

pg. 77

Suspend the infant prone over your hand. Stroke over the spinous processes from sacrum to occiput. Infant extends head and brings knees to chest; urinates.

pg. 77

-Infant supine, turn head to one side
-ovserve for ipsilateral extension and contralateral flexion of the arms and legs
-Repeat, turning head to the other side

*Peaks around 2-3mos.
*Disappears by 6mos.

Concern if infant never exhibits the reflex or seems locked in the fencing position.

pg. 77

Totricollis, scoliosis, plagiocephaly, facial assymetry.

Frequent vomiting, problems swallowing

Colic with excessive crying.

pg. 78

-slow deveoopment of fine and gross motor skills
-poor posture and equilibrium
-delayed language development
-restlessness, ADHD and insecurity in older children.

pg. 78

-infant supine, turn head to the side
-observe the infant turn its whole body in the direction the head is turned

-appears around 3 months (after Ssymmetric Tonic Neck disappears)

pg. 78

Suspend the infant prone over both hands
-Ovbserve the infant's ability to lift it's head and extend it's spine on a horizontal plane

-dimishes by 18 months
-disappears by 3 years

pg. 78

-Hold the infant suspended (prone)
-Slowly loer it head first toward a surface
-observe the infat extend its arms and legs (protecting itself)

-this reflex should NOT disappear

pg. 78

1) Ask the child to pick a penny up off the floor: tests bision and balance
2)Stick a moistened coin to the child's nose and ask the child to walk across the room: ovserve gait and posturing
3)Have the child balance a penny on the noseand dorsum of each extended hand: tests Romberg

Coordination Skills: Heel-to-Toe, hopping and jumping (modify into games)

pg. 79

Beginner: wide-based gait

Older: feet closer together, better balance.

pg. 79

Nonfocal, functional neurologic findings.

Provide subtle cues to an underlying CNS deficit or neurological maturation delay

*Children with multiple soft signs are often found to have learning problems.

Ex) walking/running gait,
Motor Stance, One-foot standing, visual tracking, stereognosis, right-left discrimination, hopping in place, 2-pt. discrimination, heel walking, tip-toe walking, tandem gait, finger-nose test, graphesthesia, rapid thumb-to-finger, rapid alternating movements of hands

pg. 81-83

pg.81

Inflammatory process in the meninges: Bacterial/Viral

S/S: fever, chills, nuchal regidity*, headache, seizure, vomiting, altered level of cosciousness.

*Nuchal rigidity: 6-9 months
S/S Young Infant: very irritable and inconsolable, fever, diarrhea, poor appetitie, toxic appearance

pg. 84

Born with Fever

Inflammation of the brain and spinal cord (also meninges)

Onset is often a mild, febrile viral illness and a quiescent stae often precedes the disturbance in CNS function: headache, dowsiness, confusion, progressing to stupor and coma, motor function may also be impaired (severe paralysis, ataxia)

***Neuro Signs w/ Fever --> Bad***

pg. 84

abnormal growth or neural or nonneural tissue within the cranium.

Early S/S: headache, vomiting, change in cognition, motor dysfunction, seizures, personality changes

-Primary or metastatic cancer

Peak Age of incidence:
3-12 years
50-70 years

*threatened function by compression or destruction of tissue

pg. 84

Nonprogresing neuromuscular disorders: abnormal muscle tone, coordination

Caused by insult to the cerebellum, basal ganglia, or motor cortex

Disability depends on the extent of damage (some can expect near normal levels of functioning)

Signs Include: delayed gross motor development, altered muscle tone, abnormal posture, abnormal motor performance, abnormal reflexes

pg. 85

Progressive Encephalopathy

Unknown Cause
Affects girls between 6-18 months

Developmental Regression/Delay

S/S: loss of voluntary hand movement, loss of previously acquired hand skills, hand wringing movements, gradual development of ataxia and rigidity of the legs, growth retardation, seizures, loss of facial expression, deceration of head growth (5-48 mos)

pg. 85

Episodic, Sudden, Involuntary contractions of a group of muscles. Excessive discharge of cerebral neurons

May be cause by: systemic disease, head trauma, toxins, sroke, hypoxic syndromes

Affects 1% of population

75% new cases develop during childhood and adolescence

Disturbances in: consciousness behavior, sensation, autonomic functioning (urinary and fecal incontinence)

pg. 85

-Chiropractic
-Ketogenic Diets
-Greatly increase B6 dose in infants

*MD's realize long term side effects of medication are toxic.