Archive for April, 2010

Hip Dysplasia

Posted by on Sunday, 11 April, 2010

Developmental dysplasia of the hip (DDH) is a deformity of the hip that can occur before, during, or weeks after birth.
At periodic checkups, a doctor will examine the baby’s hips to rule out DDH, which can cause hip dislocation and/or an abnormal walk. It’s important to recognize DDH early, so a child can receive timely treatment and avoid orthopedic problems later in life.

What Is DDH?

The hip is a ball-and-socket joint. In a normal-functioning hip, the rounded top of the thighbone, or femoral head, rests comfortably in the acetabulum (the cup-like hipbone socket). In mild cases of DDH, the femoral head moves back and forth within the socket, causing a child to have an unstable hip. In more serious cases, the head becomes dislocated, moving completely out of the socket, but sometimes can be put back in with pressure. In the most severe cases, the femoral head may not even reach the socket where it should be held in place. Hip dislocations are relatively uncommon, affecting just 1 in 1,000 live births. However, some degree of instability of the hip is seen in as many as 1 in 3 newborns. Girls are more likely to develop dislocations of the hip.

What Causes It?

The causes of DDH aren’t completely understood, but experts think that many factors are involved. The cramping of the fetus inside the uterus which is more likely to happen in first pregnancies when the uterus is tight, or in pregnancies where there is a decrease of amniotic fluid (liquid in the womb) can increase the likelihood of DDH. Other factors include abnormal positioning of the fetus inside the womb, such as being in the breech position (buttocks face the birth canal), especially when the knees extend out with the feet near the head (called “frank breech”). Having other conditions develop as a result of positioning, like metatarsus adductus (an inward curving of the foot), increases the odds of a child developing DDH. DDH also may be caused by the infant’s response to the mother’s hormones that relax the ligaments for labor and delivery, causing the baby’s hip to soften and stretch during labor. In 20% of cases, family history is a factor, and if it is, future children should be checked by ultrasound at 6 weeks of age.

Signs and Symptoms

DDH usually affects only one side of the body, most often the right side, and pain is rare.
Infants often don’t show signs that they have DDH, and there may be no signs at all. Still, doctors look for these indicators:

  • At birth, an inability to move the thigh outward at the hip as far as possible
  • An audible “click” during routine post-natal checkups
  • Different leg lengths
  • Asymmetry in the fat folds of the thigh around the groin or buttocks
  • After 3 months, asymmetry in the motion of the hip and obvious shortening of the affected leg
  • In older kids, an exaggeration in the spinal curvature that may develop to compensate for the abnormally developed hip
  • Limping in older children

Diagnosis

A doctor can determine whether a hip is dislocated or likely to become dislocated by gently pushing and pulling on the child’s thighbones, and determining whether they are loose in their sockets. In one commonly used diagnostic test, a child lies on a flat surface and his or her thighs are spread out in order to gauge the hips’ range of motion. A second test brings the knees together and attempts to push the femoral head rearward, out of the socket. It is during these tests that the doctor will hear a “click,” which may indicate a dislocation. These maneuvers are done at routine checkups until the baby is walking normally. Sometimes a doctor will recommend that a child undergo an X-ray or ultrasound to get a better view of a dislocated hip. Ultrasounds are recommended for babies under 4 months of age, while X-rays are performed on older kids. Prior to 4 months of age, hip tissue has not yet hardened (or ossified) from flexible cartilage to bone, and therefore does not show up on X-ray images that capture only bony anatomy and not cartilage.

Treatment

Treatment for DDH depends on the age of the child and the severity of the condition. Mild cases may correct themselves in the first few weeks of life. If an unstable hip is seen in newborns, the hip may be held in position with a Pavlik harness. This device keeps the femoral head in its socket by holding the knee up toward the child’s head. A shoulder harness attaches to foot stirrups to keep the leg elevated. The goal is to tighten the ligaments in the area and stimulate normal forming of the hip socket. Treatment with the Pavlik harness lasts about 6 to 12 weeks, and continues until the hip is stable and ultrasound exams are normal. After a child reaches 6 months of age the Pavlik harness will be ineffective. Older kids will need to undergo one of the following treatments:

  • Closed reduction. The bone is manually put back into place after the child is put under anesthesia. This treatment is usually preferred in children younger than 18 months.
  • Open reduction. The hip is realigned and the thighbone is placed back into the hip socket through surgery. During the procedure, tight muscles and tissues surrounding the hip joint are loosened and then later tightened up once the hip is back in place. This is the procedure of choice for kids older than 18 months.

After reaching age 2 or 3, a child might need surgery on the pelvis to deepen the hip socket (if it’s too shallow) or to shorten the thighbone or realign it. Following surgery, the child is put in a hip spica (body cast). About 1 in 20 babies with DDH needs more than the Pavlik harness to correct the condition.

DDH can’t be prevented, but if it’s recognized early and treated appropriately, most children will develop normally and have no related problems. DDH does not cause pain initially, but if left untreated it can result in significant impairment of function. Kids with untreated DDH will have legs of uneven lengths in adulthood, which can lead to a limp or waddling gait, back and hip pain, and overall decreased agility.


Hives

Posted by on Sunday, 11 April, 2010

Hives are an allergic reaction. The body’s immune system is normally responsible for protection from foreign invaders. When it becomes sensitized to normally harmless substances, the resulting reaction is called an allergy. An attack of hives is set off when such a substance, called an allergen, is ingested, inhaled, or otherwise contacted. It interacts with immune cells called mast cells, which reside in the skin, airways, and digestive system. When mast cells encounter an allergen, they release histamine and other chemicals, both locally and into the bloodstream. These chemicals cause blood vessels to become more porous, allowing fluid to accumulate in tissue and leading to the swollen and reddish appearance of hives. Some of the chemicals released sensitize pain-related nerve endings, causing the affected area to become itchy and sensitive.

A wide variety of substances may cause hives in sensitive people. Common culprits include:

  • Prescription and nonprescription drugs (Aspirin and penicillin are the two most commonly known causes of allergic reactions in adults.)
  • Nuts, especially peanuts, walnuts, and Brazil nuts
  • Fish, mollusks, and shellfish
  • Eggs
  • Wheat
  • Milk
  • Strawberries
  • Food additives and preservatives
  • Influenza vaccines
  • Tetanus toxoid vaccine
  • Gamma globulin
  • Bee, wasp, and hornet stings
  • Bites of mosquitoes, fleas, and scabies.

In addition, hives may also result from the body’s response to certain physical conditions, such as emotional stress, rubbing, cold wind, heat contact (prickly heat rash), wearing tight clothing, or exercise after a heavy meal.

Urticaria (hives) is characterized by redness, swelling, and itching of small areas of the skin. These patches usually grow and recede in less than a day, but may be replaced by others in other locations. Angioedema is characterized by more diffuse swelling. Swelling of the airways may cause wheezing and respiratory distress. In severe cases, airway obstruction may occur.
Hives are easily diagnosed by visual inspection. The cause of hives is usually apparent, but may require a careful medical history in some cases.

To deal with the symptoms of hives, an oatmeal bath may help to relieve itching. Chickweed (Stellaria media), applied as a poultice (crushed or chopped herbs applied directly to the skin) or added to bath water, may also help relieve itching.

Naturopaths or nutritionists will try to determine what allergic substance is causing the reaction and help the patient eliminate or minimize its effects. They may also recommend vitamin C, vitamin B12, and quercetin (a flavonoid) supplements to help control acute or chronic hives.

Mild cases of hives are treated with antihistamines, such as diphenhydramine (Benadryl). More severe cases may require such oral corticosteriods prednisone. Topical corticosteroids are not effective. In 2002, the Food and Drug Administration (FDA) approved the allergy drug Claritin for over-the-counter use for patients with urticaria. The drug comes in tablet and syrup form and carries little risk. Its release for over-the-counter use was delayed until the company that manufactures the drug could add instructions for patients about self-diagnosis of hives. They cautioned it should be used only for recurrent hives that had already been diagnosed by a physician, not for acute or severe urticaria. Airway swelling may require emergency injection of epinephrine (adrenaline).

Most cases of hives clear up within one to seven days without treatment, provided the cause (allergen) is found and avoided.
Preventing hives depends on avoiding the allergen causing them. Analysis of new items in the diet or new drugs taken may reveal the likely source of the reaction. Chronic hives may be aggravated by stress, caffeine, alcohol, or tobacco; avoiding these may reduce the frequency of reactions.


Turner’s Syndrome

Posted by on Sunday, 11 April, 2010

Turner syndrome (TS) is a medical disorder that affects about 1 in every 2,500 girls. Although researchers don’t know exactly what causes Turner syndrome, they do know that it’s the result of a problem with a girl’s chromosomes.

Most girls are born with two X chromosomes, but girls with Turner syndrome are born with only one X chromosome or they are missing part of one X chromosome. The effects of the condition vary widely among girls with Turner syndrome. It all depends on how many of the body’s cells are affected by the changes to the X chromosome.
Girls with Turner syndrome are usually short in height. Girls with Turner syndrome who aren’t treated for short stature reach an average height of about 4 feet 7 inches (1.4 meters). The good news is that when Turner syndrome is diagnosed while a girl is still growing, she can be treated with growth hormones to help her grow taller.
In addition to growth problems, Turner syndrome prevents the ovaries from developing properly, which affects a girl’s sexual development and the ability to have children. Because the ovaries are responsible for making the hormones that control breast growth and menstruation, most girls with Turner syndrome will not go through all of the changes associated with puberty unless they get treatment for the condition. Nearly all girls with Turner syndrome will be infertile, or unable to become pregnant on their own.

Other Effects Turner Syndrome Can Have

A number of other health problems occur more often in girls with Turner syndrome, including kidney problems, high blood pressure, heart problems, overweight, hearing difficulties, diabetes, and thyroid problems. Some girls with the condition may experience learning difficulties, particularly in math. Many have a difficult time with tasks that require skills such as map reading or visual organization.
In addition to short stature and lack of sexual development, some of the other physical features commonly seen in girls with Turner syndrome are:

  • A “webbed” neck (extra folds of skin extending from the tops of the shoulders to the sides of the neck)
  • A low hairline at the back of the neck
  • Drooping of the eyelids
  • Differently shaped ears that are set lower on the sides of the head than usual
  • Abnormal bone development (especially the bones of the hands and elbows)
  • A larger than usual number of moles on the skin
  • Edema or extra fluid in the hands and feet

Because Turner syndrome can affect how a girl looks and develops, some girls may have problems with body image or self-esteem.
People with TS are all different. Some may have many physical differences and symptoms, whereas others experience only a few medical problems. With early and appropriate medical care and ongoing support, most people with TS can lead normal, healthy, and productive lives.

Diagnosing Turner Syndrome

Girls with Turner syndrome are usually diagnosed either at birth or around the time they might be expected to go through puberty. If a baby girl has some of the signs of Turner syndrome, a doctor will usually order a special blood test called a karyotype. The test counts the number of chromosomes and can identify any that are abnormally shaped or have missing pieces. In some cases, there are no recognizable signs that a girl has the condition until she reaches the age at which she would normally go through puberty.
If the karyotype blood test reveals that a girl has Turner syndrome, her doctor may order additional tests to check for problems with the kidneys, heart, hearing, and other problems that are often associated with Turner syndrome.

Treating Turner Syndrome

Because Turner syndrome is a condition that is caused by a chromosomal abnormality, there’s no specific cure. However, scientists have developed a number of treatments that can help correct some of the problems associated with the condition such as growth problems and researchers are constantly looking into new forms of treatment.
Growth hormone treatment can improve growth and influence a girl’s final adult height. In fact, in many cases, the treatment can help many girls with Turner syndrome reach a final height in the average range, especially if treatment is started early enough in childhood.

Another treatment for Turner syndrome is estrogen replacement, which helps the girl develop the physical changes of puberty, including breast development and menstrual periods. This treatment is often started when a girl reaches about age 12 or 13.

And a technique called in vitro fertilization can make it possible for some women with Turner syndrome to become pregnant. A donor egg can be used to create an embryo, which is then put into the uterus (womb) of the woman with Turner syndrome. With proper supportive care, the woman can carry the pregnancy to term and deliver a baby through the normal birth process.

Living With Turner Syndrome

Although people with Turner syndrome may have certain learning difficulties, the majority are able to attend regular school and classes and are generally able to:

  • Write well
  • Learn well by hearing
  • Memorize information as well as others
  • Develop good language skills

Welcome to The Medically Fragile Child

Posted by on Sunday, 4 April, 2010

Welcome to our newly designed website, we would like to thank all of our members for sharing their interest in wanting an easier site to navigate through and the ability to subscribe to our blog and read and post comments. Returning members and new visitors, you’re welcome to comments on any topic. We are still working on a next Newsletter that we have scheduled for next month.

For those of you just arriving here for the very first time I’ll start be giving you  brief history about myself and why I decided to write a book on caring for medically fragile children. After being a registered nurse and licensed for 25 years with the state of California as a small family home for medically fragile children. In my continuing work in this area, I saw a growing need for a Medically Fragile Training Manual for foster, adoptive parents and other child-care professionals.

This manual is directed to the basic level of care that is needed for the medically fragile child. A few examples of what this manual contains are common medical diagnosis with signs and symptoms, paperwork required, medications, procedures explained, definitions and sample forms. The Medically Fragile Training Manual is available for purchase and soon will be available in an down loadable e-book format. I hope you find our site useful as well as informative towards your medically fragile child care needs. Please browse our site and don’t hesitate to send us comments on what we could do to improve your viewing experience and any topics you feel may help yourself and others caring for medically fragile children.


Helpful Interventions

Posted by on Saturday, 3 April, 2010

Interventions to decrease stress in the drug exposed medically fragile infant

  • Decrease lights and noise in room, including TV/radio.
  • Wrap the baby snugly with hands mid-line.  This helps to overcome extensor tone.
  • Always place baby on back or side to sleep—never on tummy.
  • Hold the baby’s hands mid-line over the baby’s chest with one of your hands, exerting a secure feeling.
  • Try rocking with baby held vertically. This is often more successful than horizontal rocking.
  • Frequent warm water baths help calm them.
  • If baby is gaze averting seemingly over stimulated by simple eye contact with you, sit the baby on your lap, snugly wrapped, facing away from you.
  • Do not use walkers with these infants. Walkers increase predisposition to weight bear on toes.
  • Protect the baby’s knees from irritation during periods of frantic fussiness.
  • Use a pacifier to help with their non-nutritive sucking needs.

Gastrostomy Feedings

Posted by on Saturday, 3 April, 2010

Children who are unable to take nourishment by mouth because of conditions such as anomalies of the throat, esophagus, or bowel, impaired swallowing capacity, severe debilitation, respiratory distress, or unconsciousness are frequently fed by way of a tube. This tube is inserted directly into the stomach (gastrostomy) or jejunum (jejunostomy) or nasally to the stomach (gastric gavage). Such feedings may be intermittent or by continuous drip. Placement of a gastrostomy tube is performed under general anesthesia and the tube is held in place by a balloon filled with fluid. Postoperative care of the wound site is directed toward prevention of infection and irritation. The area is cleansed and covered with a sterile dressing daily or as often as needed to keep the area dry. After healing takes place meticulous care is needed to keep the area surrounding the tube clean and dry to prevent excoriation and infection. Daily applications of antibiotic ointment or other preparations may be prescribed to aid in healing and prevention of irritation. Care is exercised to prevent excessive pull on the tube that might cause widening of the opening and subsequent leakage of highly irritating gastric juices.

Bolus feeding using a syringe. The feeding syringe is connected to the extension tubing.
Infants and children can be fed simply and safely by a tube passed into the stomach through either the nares or the mouth. The tube can be inserted and removed with each feeding (short-term only) or taped securely in place between feedings (also, short-term only). When this alternative is used, the tube should be removed and replaced with a new tube according to specific orders, and the type of tube used. Meticulous hand washing should be practiced during the procedure to prevent bacterial contamination of the feeding, especially during continuous drip feedings.

GI tube

The schedule of tube feedings is planned to meet the infant’s/child’s nutritional, fluid and electrolyte needs. A Physician must order tube feedings. The order should include formula, rate, route, and frequency. Some tube feedings are ordered as continuous drip over 24 hours while others are ordered for a specified amount given at intermittent intervals.

Preparation for gavage/gastrostomy feedings:

  • A suitable tube selected according to the size of the child/infant and the viscosity of the solution being fed.
  • A receptacle for the fluid; gavage bag, syringe barrel or asepto syringe are satisfactory.
  • A syringe to aspirate stomach contents and/or to inject air after the tube has been placed (gavage).
  • Water or water-soluble lubricate to lubricate the tube; sterile water is used for infants (gavage).
  • Tape to mark the tube and to attach the tube to the infants neck (gavage).
  • A stethoscope to determine the correct placement in the stomach (gavage).
  • The solution for feeding.
  • Infusion pump for continuous feedings.

Procedure for gastrostomy feedings: bolus method

  1. Check placement or gastric tube (gavage feedings only), always prior to feeding via oral GT.
  2. Elevate head of bed to 30 degree during the feeding and one hour after to help prevent aspiration.
  3. You will need a syringe to aspirate stomach contents. This is done when the infant is first started on feedings. The residual is the contents of the last feeding remaining in the stomach just before the next feeding is to be given. If more than ½ of the last feeding remains in the stomach as residual, hold feeding for 1 hour, then check residual again. If the infant continues to have large amounts of residual, hold feedings and contact the doctor.
  4. Record gastric residual if ordered and return the residual into the stomach.
  5. Slowly pour the formula into the syringe and unclamp the tubing. Keep the syringe filled to prevent air from entering the stomach. Adjust the flow rate by raising or lowering the syringe. The feeding should finish in 5-10 minutes for bolus feedings.
  6. When the syringe is nearly empty, add the prescribed amount of water to the syringe. Administration of water with gastric feedings also maintains fluid and electrolyte balance.

Continuous drip method:

  1. Hang gavage bag on IV pole.
  2. Connect administration set to end of gastrostomy or nasogastric tube.
  3. Connect to infusion pump and set pump.
  4. Advance tube feedings (as ordered). Should be advanced gradually to prevent diarrhea and gastric intolerance of formula.
  5. Provide free water as ordered.

Complications

Tube feedings provide an excellent environment for bacterial growth, which may lead to gastrointestinal infection. The tubing and the feeding bag should be changed every 24 hours. The infant/child must receive adequate fluid in order for the waste products or protein metabolism to be excreted in the urine. Fluid intake/output must be recorded carefully. The tube should be flushed regularly with water to prevent clogging of the tube. A guidewire or stylet is never used to unclog feeding tubes.

Gastrointestinal problems are the most common problem associated with tube feedings. Delayed emptying of the stomach is common. Medication that speeds movement in the stomach may be prescribed. Diarrhea is another common complication. The treatment depends on the cause. In many cases, the diarrheas can be treated by changes in the tube feeding, such as diluting the formula or changing the type of formula. Aspiration is a serious complication. Pneumonia can develop if some of the stomach contents enter the lungs. Elevation of the head of the bed to 30 degrees, and periodically measuring gastric residual (so that excessive amounts do not accumulate) are ways of preventing aspiration.

Metabolic complications such as fluid and electrolyte imbalance are easily corrected if the infant/child is carefully monitored. Mechanical problems can result from irritation of the gastrointestinal tract by the tube itself or from clogging of the tube.

A nutrition support team in collaboration with the physician will monitor the infant/child carefully to see that nutritional goals are being met and to treat complications, if they develop. The infant will be weighted regularly. Fluid and electrolytes are checked, as are other indicators of nutritional status such as serum albumin and transferrin levels, total lymphocyte count, skinfold thickness, and normal rate of growth in children.

Records should be maintained to record amount and type of feeding, the infant’s response to tube feeding, patency of tube, and any adverse effects.


Who is who?

Posted by on Saturday, 3 April, 2010

There are many specialist in the medical field that you are important for you and your baby to become acquainted with. I have prepared a list of the most common health-care professionals that I have had the opportunity to become more familiar with their practices for the continued well being of the medically fragile infants I have cared for over the years.

Audiologist: a medical professional who is specially trained to detect, diagnose, and treat individuals with impaired hearing. Cardiac surgeon: who specializes in performing surgery on the heart.

Cardiologist  and Cardiac surgeon: A doctor who specializes in the heart and circulation of blood and also performs surgery on the heart.

Gastroenterologist: A doctor who specializes in the treatment of stomach and intestinal disorders.

Geneticist: A Specialist who studies birth defects and their causes.

Hematologist: who specializes in diagnosis and treatment of blood problems.

Occupational Therapist (OT): person who treats problems involving the use of muscles, also may work with babies who have trouble eating.

Ophthalmologist: A doctor who specializes in eye problems

Orthopedist: A doctor who specializes in bone problems.

Physical Therapist (PT): person who treats feeding problems and problems of the muscles.

Neonatal Nurse Practitioner (NNP): a RN who has special training in the care of critically ill babies.

Neonatologist: A baby doctor (pediatrician) who has specialized training in the care of premature infants or critically ill newborns

Neurologist: A doctor who specializes in diagnosis and treatment of brain and nervous system disorders.

Neurosurgeon: A doctor who specializes in surgery on the brain and nervous system.

Pediatric cardiologist: A doctor who specializes in diagnosis and treatment of heart problems in children.

Pediatric surgeon: A doctor who specializes in performing surgery on newborns and children.

Pulmonologist: A doctor who specializes in diagnosis and treatment of certain lung conditions.

Resident: A doctor in training after medical school, frequently used in medical school hospitals.

Respiratory therapists: Medical professionals who are trained, certified, and registered to set up, calibrate, monitor, and supervise the use of respiratory equipment.

Urologist: A doctor who specializes in diagnosis and treatment of urinary tract infections.