This study examined whether the mental rotation ability of infants was affected by their abilities to crawl and manually explore objects. There were 48, 9-month old infants recruited for this study with half of them having been crawling for an average of 9.3 weeks.
As children grow, they need healthy and appropriate sensory motor experiences to support vibrant brain development which ultimately forms who they are as human beings. The way our children develop their motor skills can give us an insight into how their brains are dynamically developing, as ‘mindness is the internalization of movement’ (Llinas 2001). The brain is the most underdeveloped organ at birth, with the most rapid growth occurring in the first two years of life. During this time the brain needs sensory motor experiences to stimulate healthy growth. We are able to promote this growth in our practices and at home from birth. When looking at a child’s movement it is important to assess whether the movement is appropriate for their age, whether it is coordinated and smooth, and if there are signs of good motor planning (Keating, G., & Keating, R. 2014). The recommended windows of motor milestones are wide, with each child developing uniquely. It is important to understand that children are supposed to reach each of these milestones; including rolling, crawling, sitting and of course, walking. Children with developmental challenges will have different time frames in which they will reach their milestones, however it is always important to encourage good sensory motor input to support dynamic brain growth in all children. When we question parents about their children’s motor development, common responses include that their child was either delayed in reaching a motor milestone or they skipped it, or it didn’t develop smoothly or typically. It doesn’t have to be this way.
The aim of this study was to determine the motor abilities in children with Down syndrome and examine which areas are significantly delayed. This study also assessed functional balance as a feature of quality of movement. A small sample size of 79 children were recruited and divided into groups according to:
- age: <3 years old, 3-6 years old, >6 years old and
- motor impairment rating scale: mild, moderate and severe.
All children attended physical therapy sessions once per week for 2 years. The aim of these sessions were to:
- develop psychomotor abilities
- assist with the development of quality motor function
- normalise muscle tone.
- train balance reaction and
- postural maintenance
Children were assessed using the Gross Motor Function Measure-88 (GMFM-88) and body balance was estimated by Pediatric Balance Scale (PBS). "There was no control as the original validation sample of GMFM-88 included children aged from 5 months to 16 years, so the score of GMFM-88 is the percentage of the score of the original validation group."
The results of the present study revealed none of the children with Down syndrome, in the group aged 3-6 years old developed 100% of the motor functions as evaluated by GMFM-88 (Typical development by 5 years is when all GMFM-88 functions are developed). The ability to stand upright was achieved in 95% of children in this study at 3 - 6 years, however only 10% of children <3 years were able to stand. The researchers discussed how standing position is achieved after acquiring postural alignment between the head, torso and hip and this may be difficult for children with Down Syndrome because it engages trunk flexors and extensors and these muscle synergies may often be hypotonic. Walking developed later in infants with Down Syndrome than typically developing infants. Most children included in this study began walking when they were 3 years and older. The authors suggested this delay may be a result of their poor balance (cerebellar hypoplasia), joint laxity and hypotonia.
The aim of care in children with Down syndrome should be to help improve functional balance, postural alignment, muscle tone and symmetry. This may assist with minimizing delays in motor abilities that are developed in childhood.
Written by Carla Vescio, Chiropractor
Today’s children are involved in many and varied types of sports and activities. There are children in swimming, dancing, ice skating, soccer, baseball, netball, footy, cricket, rugby and many more. Each of these sports have specific skills required for accurate execution of the game. If neurologic imbalances affecting parietal awareness, balance and comprehension are left unaddressed in the infant and toddler, we may see children in sport that are clumsy, lack eye hand coordination, don’t follow instruction or find certain postures and movements scary and/or uncomfortable. Clinical experience and case studies from chiropractic offices around the world tell a story of how chiropractic care in early childhood assists the function of nerve pathways necessary for motor skills of developmental milestones as well as language development. These skills are necessary when playing sport either with a team or as an individual.
What is Down syndrome?
Down syndrome is the most common genetic chromosomal disorder and cause of learning disabilities in children. Trisomy 21 is due to an extra chromosome 21 in all of the cells. This is caused by abnormal cell division during the development of the sperm cell or the egg cell. Mosaic Down syndrome is when not all the cells of the body have the exta chromosome 21. This mosaic of normal and abnormal cells is caused by abnormal cell division after fertilization and accounts for 2 to 4 percent of people diagnosed with Down syndrome. Translocation Down syndrome. This occurs when part of chromosome 21 becomes attached (translocated) onto another chromosome, before or at conception. These children have the usual two copies of chromosome 21, but they also have additional material from chromosome 21 attached to the translocated chromosome. Not all cells of the body will have the extra chromosome 21. This is the only form of Down syndrome that can be inherited. It only accounts for about 4 percent of children with Down syndrome.
Heart defects: About half the children with Down syndrome are born with some type of heart defect. These heart problems can be life-threatening and may require surgery in early infancy.
Dementia: People with Down syndrome have a greatly increased risk of dementia — signs and symptoms may begin around age 50. Those who have dementia also have a higher rate of seizures. Having Down syndrome also increases the risk of developing Alzheimer's disease.
Sleep apnea: Because of soft tissue and skeletal changes that lead to the obstruction of their airways, children and adults with Down syndrome are at greater risk of obstructive sleep apnea.
Other problems: Down syndrome may also be associated with Increased Risk of Leukemia, obesity and infections. Other health conditions, including gastrointestinal blockage, thyroid problems, early menopause, seizures, ear infections, hearing loss, skin problems such as psoriasis, skeletal problems and poor vision.
How We May Help
First and foremost, see the child first. Put the child before the syndrome and don’t refer to the syndrome first, for example we don’t want to say“ A Down’s child” . Please refer to a “ A child with Down syndrome”.
With increased risk of sleep apnea, infections and gastrointestinal issues, gentle cranial and dural techniques are ideal. Helping to decrease stress at the brainstem level where our sleep and wake centres, digestion, respiratory control, heart rate and sensory and motor pathways are found is ideal for these infants.
Low tone will be present in the majority of infants so core tone strengthening exercises are fantastic. Ball rocking and tummy time for babies. Superman and skydiver for older children. Plenty of daily repetition is essential. Exercises that help cross the midline are also very helpful.
Sensory stimulation for face and body. Massage of the trigeminal nerve to help give the brain more feedback. Encourage breast feeding as it works the facial muscles and tongue far more regularly and efficiently than oral motor/speech therapy. This helps with tongue position and speech.
Lots of sensory massage. TacPacis great and uses different textures to different music http://www.tacpac.co.uk/TP-order-online.htm.
Nutrition is very important as there may be malabsorption from the gut as a result of genetically-induced weaker digestion or subclinical gluten intolerance (Gale et al 1997). Low thyroid function my be linked to Zinc deficiency. Increased metabolism of Vitamin C which can lead to Vitamin C deficiency. A nutrient dense diet is recommended, including whole foods, green smoothies, low to no gluten or dairy due to common intolerances. Nutrients that have been found to be deficient in children with Down syndrome include:
- Zinc, Vitamin E, (Cengiz et al 2000)
- Vitamin A (Baer et al 1990)
- Vitamin B6 (Coburn 1983)
- Selenium (Neve et al 1983)
- Vitamin C (Hilty et al 1991; Colombo et al 1989)
- Folate (David et al 1996)
- Magnesium (Monterio 1997)
Try good quality whole food supplements or referral for co-management with a Naturopath/Nutritional consultant.
Lots of movement, dance, martial arts, gymnastics, yoga, sports and playgrounds to build good body awareness and tone by plasticising pathways.
Written by Lorene Dennis, Chiropractor
Auckland, New Zealand
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Twenty years ago I began the most challenging journey. When it began I had achieved a lot in my life. I was successful in so many ways and I thought this journey would be another of these. I was under no illusion that I would have to work and learn many things along the way. I understood that this was a long term scenario that would be challenging. But nothing had prepared me for the places this would take me and the degree to which this would challenge everything I knew.
This journey was the becoming of a parent
The Centre for Chiropractic Research at the New Zealand College of Chiropractic is working on many exciting projects at present. Two of these projects we are particularly enthusiastic about were part-funded by the CCNP. These projects are investigating the effects of chiropractic care on the brains ability to integrate sensorimotor information in those with Autistic Spectrum Disorder (ASD) and how it controls eye-tracking in children with ADHD.
This retrospective population study aimed to document the relationship between doula support, desire for doula support and cesarean section delivery. This study included 2400 women aged 18 to 45 years who participated in an online survey. The Listening to Mothers survey collected information about doula care alongside self reported clinical experiences, perceptions, and decisions about childbirth. In addition, the survey asked about awareness of and level of familiarity with doula care and whether women who knew about doula care would have wanted to have this type of care.
Babywearing, is it the latest fad, fuelled by our obsession with all things celebrity, or is it an instinctual practice that we (and our babies’) crave? “Babywearing is the practice of wearing or carrying a baby in a sling or in another form of carrier. Babywearing has been practiced for centuries around the world. In the industrialised world, babywearing has gained popularity in recent decades, partly under influence of advocates of attachment parenting. Babywearing is a form of baby transport (2)."
Many women today are turning to Doulas for support through their pregnancy and birth journeys. In a time where childbirth intervention rates are climbing and more women are suffering from postnatal depression, it's no wonder women are in need of support and searching for different options.
This article looked at the bracing methods as the primary mode of conservative treatment for AIS. This was a literature review which aimed to identify the most effective forms of conservative treatment for AIS. Interestingly, they identified cosmetic improvement as one of the main goals when treating AIS, as further physical or neurological impact in the literature (excluding severe cases) is yet to be firmly identified. “According to a consensus by Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) experts, esthetic improvement is one of the main goals of scoliosis treatment. In a recent study on the importance of physical deformity in patients with AIS, 'severity of deformity' consistently ranked as the most important clinical consideration when proposing surgical treatment.”
Adolescent idiopathic scoliosis (AIS) in the literature details many different approaches when trying to define an optimal treatment for the condition at what age and at varying severities. Below are 2 articles that have varying approaches to treatment. As chiropractors we can have a beneficial effect on the neurology in any patient with a biomechanical/neurophysiological distortion, however some cases may require further referral and co management. Something we all need to consider as practitioners wanting to give our patients the best health outcomes as possible.
When most of us think about scoliosis we don’t automatically think of a new born baby or infant. Although rarer than other forms of scoliosis, infantile scoliosis is a condition that does present to paediatric practices. Do you know the red flags, important testing procedures and treatment protocols for infantile scoliosis? When a child is less than 3 years of age the scoliosis is considered infantile. While idiopathic (meaning of unknown cause or not caused by pathology or syndrome) is the most common type, congenital, neuromuscular, syndrome-related, and spinal curvature due to secondary reasons such as trauma are also possible causes.
The objective of this prospective study was to compare gross and fine motor development among 4- and 6-month old infants routinely placed in either prone or supine position to sleep. At 15 months these infants were reassessed to determine if there were ant persisting differences in development. The Alberta Infant Motor Scale (AIMS), Battelle Developmental Inventory and the Peabody Developmental Motor Scales (PDMS) were used to evaluate motor development and awake practices were documented by parents or caregivers using a diary developed by R. Barr.
This cross-sectional population-based study of children examined the association between gestational age at birth and the risk of respiratory illness, hospital admissions and other health related outcomes in the first 10 years of life. Participants included 13,361 preterm-born children and 13,361 term-born matched control subjects. Respiratory and neurological health was measured via a parent-completed questionnaire and hospital database records. Gestational age at birth was used to categorize the children into early-term (37-38 weeks’ gestation) and full-term (39-42 weeks’ gestation) categories. The gestational age was based on maternal reporting of the last menstrual period and antenatal ultrasound scans.
The results of this particular study revealed early term-born children had a significantly higher rate of caesarean section (CS) delivery, particularly those delivered by means of elective CS, compared to the full term-born control subjects. Of the children less than 5 years of age, the prevalence of wheeze, use of inhaler medication and hospital admission in first year of life were higher in the early term-born children than the full-term born control. Of the children aged 5 years and older, there was a higher prevalence in the pre term-born than full term-born subjects in wheezing, recent wheeze, doctor’s diagnosis of asthma, exercise induced asthma, chest infection over the last year, admissions to the neonatal unit in the first 28 days of life and admissions to the hospital in the first year of life. There were no statistically significant findings relating to the difference between children delivered by means of CS compared with those delivered by means of vaginal delivery (VD) for respiratory symptoms throughout childhood. However, early term–born or full term–born infants delivered by means of CS were associated with greater admissions to the neonatal unit when compared with those born early term or full term and delivered by means of VD. The children born early term by means of CS or VD had higher rates of wheezing compared with children born full term by means of VD and marginally increased rates for children born early term by means of CS compared with children born full term by means of CS.
This paper suggests that respiratory symptoms continue into early school years for early term–born children when compared with full term–born children and that these children are receiving increased treatment. The data demonstrated that early term–born children have more wheezing than full term–born control subjects. The authors suggested the possible mechanisms underlying these recurrent respiratory symptoms in children born early term might be related to delivery at a marginally earlier stage of lung growth and development when surfactant production might not be optimal.
Edwards, M.O., Kotecha, S.J., Lowe, J., Richards, L., Watkins, W.J., & Kotecha, S. (2015). Early-term birth is a risk factor for wheezing in childhood: A cross-sectional population study. 136(3), 581-587. doi: 10.1016/j.jaci.2015.05.005.
Birth practises have changed markedly over the last 20 – 30 years and the research for the various medical interventions during pregnancy and birth is often contradictory. In my experience, as a previously registered midwife of over 25 years, the amount of information women are given today regarding pregnancy and birth is huge and can sometimes be conflicting as well as confusing. Making it difficult for women to make informed decisions.
Frenectomy for the correction of ankyloglossiaa: A review of clinical effectiveness and guidelines. Rapid Response Report, Canadian Agency for Drugs and Technologies in Health, June 15 2016.
First of all - what is a tongue tie, and why is it an issue?
Tongue tie, or ankyloglossia for those who love greek derivatives, is a congenital anomaly in which the child is born with an abnormally short and/or thick lingual frenulum that limits the movement of the tongue. Potential concerns are breastfeeding problems including difficulty latching, nipple pain, infection, poor milk supply, discontinuation of breastfeeding, inadequate weight gain, oral hygiene concerns, speech problems, and developmental and social consequences. A hereditary link is noted, but these don’t explain all cases, with prevalence being reported between 4-10% and more commonly males.
The Canadian Agency of Drugs and Technologies in Health (government funded, independent not-for-profit organisation https://www.cadth.ca) published a “Rapid Response Report” summary with critical appraisal of clinical effectiveness and guidelines of clipping of the frenulum (frenectomy) for the correction of tongue tie (ankylogossia) in June 2016. This is an extremely thorough review of the evidence, though they note they are not conducting a meta-analysis.
Their search turned up 150 articles, and after exclusion criteria, they were left with eight reports. This include two systematic reviews (one review published in two reports, but as they reported additional data in the second report, both were included), one randomised controlled trial (RCT), and four non-randomised studies. The ’n’ of total cases was around 6000. Data was obtained from studies in 11 countries. Included within the systematic reviews (SR) were RCTs, non randomised studies, and case series, and data from the primary clinical studies included two retrospective chart review and one prospective controlled before and after study.
The patient populations studied for one SR included children from 0-18 years, whereas the other SR focused on neonates and infants less than six months of age with ankyloglossia and breastfeeding problems. The interventions included various methods of tongue-tie division: simple release (frenotomy = simple horizontal cut), laser release, and frenulectomy/frenectomy (removal). The procedures were conducted by a range of health professionals including family, neonatal, and paediatric doctors, general, paediatric or speciality surgeons, and lactation or specialist consultants. The outcomes tracked were breastfeeding efficacy, feeding out comes, nipple pain, milk supply, weight gain, adverse events, speech outcomes, and parent satisfaction.
One SR rated the evidence as high to moderate quality for breastfeeding efficacy, and weak for the other outcome measures. The other SR reported mixed study quality (RCTs higher, non randomised studies and case series/reports being lower quality, with the overall strength of the evidence being low to insufficient for the majority of outcomes.
A multitude of confounding factors were noted with all the outcome measures, particularly with the difficulty separating the parents subjective report relative to results. Variations in diagnostic approach were noted, with differing levels of expertise and assessment tools utilised.
The majority of studies reported no significant harms or minimal harm. The most common harm reported was minor and/or limited bleeding, with other potential harms of re-operation, scarring, slowed healing time due to tissue slough and pain. Serious harms were observed in a single case series as a result of the procedure being conducted by untrained personnel.
No evidence based guidelines were identified regarding frenectomy for the correction of akyloglossia in newborns and infants. The results are likely not generalisable to the wider population due to the variation in assessment, age, correction technique, follow up time, comorbidities etc.
They conclude that the use of frenectomy to treat ankyloglosssia in neonates and infants with breastfeeding problems appears to be safe and may be confer benefit to the mother and baby. However, the results should be interpreted with consideration of the subjectivity of outcome measures; generalisability issues due to differences in patient populations, procedure, and outcome measure; lack of information on long term benefits and harms; unclear influence of potential co-founders; and questionable reliability of pooled and poor quality figures. Given the minimal harms they report, and probably benefit (albeit of uncertain magnitude), they state frenectomy may be a viable treatment option for infants of mothers who wish to breastfeed and are experiencing difficulty.
Tongue-tie, from embryology to treatment: a literature review. Dezoio, Piras, Gallottini, and Denotti. J Pediatric and Neonatal Individualised Medicine. March 2015.
This free access journal article provides an excellent overview of ankyloglossia (http://www.jpnim.com/index.php/jpnim/article/view/040101). It is written with numerous author opinions without strong references which weakens it’s level of evidence (particularly compared to the depth of the Canadian article reviewed), however it does provide a good review of tongue tie. The Italian authors nicely describe the embryology of the tongue in a way that doesn’t have you dozing off. They add commentary as to the importance of the tongue in the ‘'functional matrix hypothesis that states the origin, growth, and maintenance of all skeletal tissues and organs are always necessarily secondary phenomena and offset by other previous events that occur in not skeletal tissues, organs or functions areas (functional matrix) that specifically bound’’. They present a clear table describing the classification of ankyloglossia per Kotlow’s assessment (Class I-IV).
They consider factors related to the definition of the shape and lingual functionality, which relate to the posture of the cervical spine, the lip seal and breathing, the TMJ, and relations with the inter maxillary bone. They state ''when the frenum is short, it is impossible or really difficult to establish normal anatomical rapports, so the anatomical deficiency becomes also a functional problem; this issue generates other anatomical problems related to the short frenum’’.
The following three pages describe the embryology, physiology, and possible sequelae of a tongue tie in depth in an accessible format. They then discuss diagnosis (and selected measures used), age and treatment, techniques, and effects on the tissue by laser treatment. They conclude that ‘’tongue tie is a very important problem - if not treated well it can create problems not only relate to feeding and speech, but also involving growth and posture’'.
Reviewed and written by Matthew Doyle, Chiropractor