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Common Conditions

ADHD

Definition

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for the child's age and development.

Alternative Names

ADD; ADHD; Childhood hyperkinesis

Causes

ADHD affects school performance and interpersonal relationships. Parents of children with ADHD are often exhausted and frustrated.
Neuroimaging studies suggest that the brains of children with ADHD are different from those of other children. These children handle neurotransmitters (including dopamine, serotonin, and adrenalin) differently from their peers.
ADHD is often genetic. Whatever the specific cause may be, it seems to be set in motion early in life as the brain is developing.
Depression, sleep deprivation, learning disabilities, tic disorders, and behavior problems may be confused with, or appear along with, ADHD. Every child suspected of having ADHD deserves a careful evaluation to sort out exactly what is contributing to the behaviors causing concern.
Attention Deficit Disorder (ADD) is the most commonly diagnosed behavioral disorder of childhood, affecting an estimated 3 - 5% of school aged children. It is diagnosed much more often in boys than in girls.
Most children with ADHD also have at least one other developmental or behavioral problem.

Symptoms

The Diagnostic and Statistical Manual (DSM-IV) divides the symptoms of ADHD into those of inattentiveness and those of hyperactivity and impulsivity.
To be diagnosed with ADHD, children should have at least 6 attention symptoms or 6 activity and impulsivity symptoms -- to a degree beyond what would be expected for children their age.
The symptoms must be present for at least 6 months, observable in 2 or more settings, and not caused by another problem. The symptoms must be severe enough to cause significant difficulties. Some symptoms must be present before age 7.
Older children have ADHD in partial remission when they still have symptoms but no longer meet the full definition of the disorder.
Some children with ADHD primarily have the Inattentive Type, some the Hyperactive-Impulsive Type, and some the Combined Type. Those with the Inattentive type are less disruptive and are easier to miss being diagnosed with ADHD.
Inattention symptoms:
1. Fails to give close attention to details or makes careless mistakes in schoolwork
2. Difficulty sustaining attention in tasks or play
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
5. Difficulty organizing tasks and activities
6. Avoids or dislikes tasks that require sustained mental effort (such as schoolwork)
7. Often loses toys, assignments, pencils, books, or tools needed for tasks or activities
8. Easily distracted
9. Often forgetful in daily activities
Hyperactivity symptoms:
1. Fidgets with hands or feet or squirms in seat
2. Leaves seat when remaining seated is expected
3. Runs about or climbs in inappropriate situations
4. Difficulty playing quietly
5. Often "on the go," acts as if "driven by a motor," talks excessively
Impulsivity symptoms:
1. Blurts out answers before questions have been completed
2. Difficulty awaiting turn
3. Interrupts or intrudes on others (butts into conversations or games)

 

Exams and Tests
Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue.
The diagnosis is based on very specific symptoms, which must be present in more than one setting. The child should have a clinical evaluation if ADHD is suspected.
Evaluation may include:
• Parent and teacher questionnaires (Connors, Burks)
• Psychological evaluation of the child AND family including IQ testing and psychological testing
• Complete developmental, mental, nutritional, physical, and psychosocial examination

 

Treatment
The American Academy of Pediatrics has guidelines for treating ADHD:
• Set specific, appropriate target goals to guide therapy.
• Medication and behavior therapy should be started.
• When treatment has not met the target goals, evaluate the original diagnosis, the possible presence of other conditions, and how well the treatment plan has been implemented.
• Systematic follow-up is important to regularly reassess target goals, results, and any side effects of medications. Information should be gathered from parents, teachers, and the child.
ADHD is a frustrating problem. Alternative remedies have become quite popular, including herbs, supplements, and chiropractic manipulation. However, there is little or no solid evidence for many remedies marketed to parents.
Children who receive both behavioral treatment and medication often do the best. Medications should not be used just to make life easier for the parents or the school. There are now several different classes of ADHD medications that may be used alone or in combination. Some ADHD medicines have been linked to sudden death in children with heart problems. Talk to your doctor about which drug is best for your child.
The following may also help:
• Limit distractions in the child's environment.
• Provide one-on-one instruction with teacher.
• Make sure the child gets enough sleep.
• Make sure the child gets a healthy, varied diet, with plenty of fiber and basic nutrients.

 

Outlook (Prognosis)
ADHD is a long-term, chronic condition. About half of the children with ADHD will continue to have troublesome symptoms of inattention or impulsivity as adults. However, adults are often more capable of controlling behavior and masking difficulties.
Statistics show that there is an increased incidence in juvenile delinquency and adult encounters with the law among individuals who had ADHD as a child.
Every effort should be made to manage symptoms and direct the child's energy to constructive and educational paths.

 

Possible Complications

Many adults with ADHD are in successful jobs. Possible complications, if ADHD is not adequately treated, could include failure in school or other similar problems.

When to Contact a Medical Professional

Call your health care provider if you or your child's school personnel suspect the possibility of attention deficit disorder.

Prevention

While there is no proven way to prevent ADHD itself, early identification and treatment can prevent many of the problems associated with ADHD.

References

American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000; 105(5). 1158-1170.
US Food and Drug Administration. FDA Directs ADHD Drug Manufacturers to Notify Patients about Cardiovascular Adverse Events and Psychiatric Adverse Events. Rockville, MD: National Press Office; February 21, 2007. Report P07-26.

Appendicitis

Definition

Appendicitis is inflammation of the appendix. The appendix is a small pouch attached to your large intestine.

Causes

Appendicitis is one of the most common causes of emergency abdominal surgery in the United States. Appendicitis usually occurs when the appendix becomes blocked by feces, a foreign object, or rarely, a tumor.

Symptoms

The symptoms of appendicitis vary. It can be hard to diagnosis appendicitis in young children, the elderly, and women of childbearing age.
Typically, the first symptom is pain around your navel. (See: abdominal pain.) The pain initially may be vague, but becomes increasingly sharp and severe. You may have reduced appetite, nausea, vomiting, and a low-grade fever.
As the inflammation in the appendix increases, the pain tends to move into your right lower abdomen and focuses directly above the appendix at a place called McBurney's point.
If the appendix ruptures, the pain may lessen briefly and you may feel better. However, once peritonitis sets in, the pain worsens and you become sicker.
Abdominal pain may be worse when walking or coughing. You may prefer to lie still because sudden movement causes pain.
Later symptoms include:
• Fever
• Loss of appetite
• Nausea
• Vomiting
• Constipation
• Diarrhea
• Chills and shaking

Exams and Tests

With appendicitis, pain increases when the abdomen is gently pressed and then the pressure is suddenly released. If peritonitis is present, touching the abdomen may cause a spasm of the abdominal muscles. A rectal examination may identify abdominal or pelvic pain on the right side of your body.
Doctors can usually diagnose appendicitis by your description of the symptoms, the physical exam, and laboratory tests alone. In some cases, additional tests may be needed. These may include:
• Abdominal ultrasound
• Abdominal CT scan
• Diagnostic laparoscopy
Note: In December 2005, the US Food and Drug Administration recalled a drug used during some imaging tests after reports of life-threatening side effects and two deaths. The drug, called NeutroSpec, is used to help diagnose appendicitis in patients ages 5 and older who may have the condition but do not show the usual signs and symptoms. 

Treatment

For uncomplicated cases, a surgical procedure called an appendectomy is performed to remove the appendix soon after the diagnosis. An appendectomy can be done as an "open" procedure, where fairly large surgical cuts are made in your abdomen. The surgery can also be done as a laparoscopic procedure, which uses a camera and small incisions.
If the operation reveals that the appendix is normal, the surgeon will remove the appendix and explore the rest of the abdomen for other causes of your pain.
If a CT scan reveals an abscess from a ruptured appendix, the patient may be treated and the appendix removed later, after the infection and inflammation have gone away.

Outlook (Prognosis)

If your appendix is treated before it ruptures, you will probably recover rapidly from surgery. If your appendix ruptures before surgery, you will probably recover more slowly, and are more likely to develop an abscess.
Possible Complications
• Peritonitis
• Abscess
• Fistulas
• Wound infection

When to Contact a Medical Professional

Call your health care provider if you develop abdominal pain in the lower right portion of your belly, or any other symptoms of appendicitis.

References

US Food and Drug Administration. FDA Issues Public Health Advisory on use of NeutroSpec, [Technetium (99m TC) Fanolesomab], Imaging Agent for Diagnosis of Appendicitis. Rockville, MD: National Press Office; December 19, 2005. Press Release P05-104.

Asthma

Definition

Asthma is an inflammatory disorder of the airways, which causes attacks of wheezing, shortness of breath, chest tightness, and coughing.

Alternative Names

Bronchial asthma; Exercise-induced asthma

Causes

Asthma is caused by inflammation in the airways. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swell. This reduces the amount of air that can pass by, and can lead to wheezing sounds.
Most people with asthma have wheezing attacks separated by symptom-free periods. Some patients have long-term shortness of breath with episodes of increased shortness of breath. Still, in others, a cough may be the main symptom. Asthma attacks can last minutes to days and can become dangerous if the airflow becomes severely restricted.
In sensitive individuals, asthma symptoms can be triggered by breathing in allergy-causing substances (called allergens or triggers). Triggers include pet dander, dust mites, cockroach allergens, molds, or pollens. Asthma symptoms can also be triggered by respiratory infections, exercise, cold air, tobacco smoke and other pollutants, stress, food, or drug allergies. Aspirin and other non-steroidal anti-inflammatory medications (NSAIDS) provoke asthma in some patients.
Approximately 20.5 million Americans currently have asthma. Many people with asthma have an individual or family history of allergies, such as hay fever (allergic rhinitis) or eczema. Others have no history of allergies.

Symptoms

• Wheezing
o Usually begins suddenly
o Comes in episodes
o May be worse at night or in early morning
o Gets worse with cold aira, exercise, and heartburn (reflux)
o May go away on its own
o Is relieved by bronchodilators (drugs that open the airways)
• Cough with or without sputum (phlegm) production
• Shortness of breath that gets worse with exercise or activity
• Intercostal retractions (pulling of the skin between the ribs when breathing)
Emergency symptoms:
• Extreme difficulty breathing
• Bluish color to the lips and face
• Severe anxiety due to shortness of breath
• Rapid pulse
• Sweating
• Decreased level of alertness, such as severe drowsiness or confusion, during an asthma attack
Additional symptoms that may be associated with this disease:
• Nasal flaring
• Chest pain
• Tightness in the chest
• Abnormal breathing pattern --breathing out takes more than twice as long as breathing in
• Breathing temporarily stops

Exams and Tests

Allergy testing may be helpful in identifying allergens in patients with persistent asthma. Common allergens include pet dander, dust mites, cockroach allergens, molds, and pollens. Common respiratory irritants include tobacco smoke, pollution, and fumes from burning wood or gas.
The doctor will use a stethoscope to listen to the lungs. Asthma-related sounds may be heard. However, lung sounds are usually normal between asthma episodes.
Tests may include:
• Lung function tests
• Peak flow measurements
• Chest x-ray
• Blood tests, including eosinophil count (a type of white blood cell)
• Arterial blood gas

Treatment

Treatment is aimed at avoiding known allergens and respiratory irritants and controlling symptoms and airway inflammation through medication.
There are two basic kinds of medication for the treatment of asthma:
Long-term control medications are used on a regular basis to prevent attacks, not for treatment during an attack. Types include:
• Inhaled steroids (such as Azmacort, Vanceril, AeroBid, Flovent) prevent inflammation
• Leukotriene inhibitors (such as Singulair and Accolate)
• Anti-IgE therapy (Xolair), a medicine given by injection to patients with more severe asthma
• Long-acting bronchodilators (such as Serevent) help open airways
• Cromolyn sodium (Intal) or nedocromil sodium
• Aminophylline or theophylline (not used as frequently as in the past)
Sometimes a combination of steroids and bronchodilators are used, using either separate inhalers or a single inhaler (such as Advair Diskus).
Quick relief, or rescue, medications are used to relieve symptoms during an attack. These include:
• Short-acting bronchodilators (inhalers), such as Proventil, Ventolin, Xopenex, and others.
• Corticosteroids, such as prednisone or methylprednisolone) given by mouth or into a vein
Persons with mild asthma (infrequent attacks) may use quick relief medication as needed. Those with persistent asthma should take control medications on a regular basis to prevent symptoms. A severe asthma attack requires a medical evaluation and may require a hospital stay, oxygen, and intravenous medications.
A peak flow meter, a simple device to measure lung volume, can be used at home to help you "see an attack coming" and take the appropriate action, sometimes even before any symptoms appear. If you are not monitoring asthma on a regular basis, an attack can take you by surprise.
Peak flow measurements can help show when medication is needed, or other action needs to be taken. Peak flow values of 50-80% of an individual’s personal best results indicate a moderate asthma attack, while values below 50% indicate a severe attack.

Support Groups

The stress caused by illness can often be helped by joining a support group, where members share common experiences and problems. See asthma and allergy - support group.

Outlook (Prognosis)

There is no cure for asthma, though symptoms sometimes decrease over time. With proper self management and medical treatment, most people with asthma can lead normal lives.

Possible Complications
• Respiratory fatigue
• Side effects of asthma medications
• Pneumothorax
• Death

When to Contact a Medical Professional

Call for an appointment with your health care provider if you or your child experience mild asthma symptoms (to discuss treatment options).
Call your health care provider (or go to the emergency room) for moderate shortness of breath (shortness of breath with talking, peak flow 50-80% of personal best), if symptoms worsen or do not improve with treatment, or an attack requires more medication than recommended in the prescription.
Go to the emergency room for severe shortness of breath (shortness of breath at rest, peak flow less than 50% of personal best), if drowsiness or confusion develops, or for severe chest pain.

Prevention

Asthma symptoms can be substantially reduced by avoiding known allergens and respiratory irritants. If someone with asthma is sensitive to dust mites, exposure can be reduced by encasing mattresses and pillows in allergen-impermeable covers, removing carpets from bedrooms, and by vacuuming regularly. Exposure to dust mites and mold can be reduced by lowering indoor humidity.
If a person is allergic to an animal that cannot be removed from the home, the animal should be kept out of the patient's bedroom. Filtering material can be placed over the heating outlets to trap animal dander. Exposure to cigarette smoke, air pollution, industrial dusts, and irritating fumes should also be avoided.
Allergy desensitization may be helpful in reducing asthma symptoms and medication use, but the size of the benefit compared with other treatments is not known.

References

Guidelines for the Diagnosis and Management of Asthma -- Update on Selected Topics 2002. Bethesda, MD. 2003 June. National Asthma Education and Prevention Program. NIH publications 02-5074.

Autism

Definition

Autism is a complex developmental disorder that appears in the first 3 years of life, although it is sometimes diagnosed much later. It affects the brain's normal development of social and communication skills.
Common features of autism include impaired social interactions, impaired verbal and nonverbal communication, problems processing information from the senses, and restricted and repetitive patterns of behavior.
The symptoms may vary from moderate to severe. Two related, milder conditions are Asperger syndrome and "pervasive development disorder not otherwise specified" (PDD-NOS).

Alternative Names

Pervasive developmental disorder - autism

Causes

Autism is a physical condition linked to abnormal biology and chemistry in the brain. The exact causes of these abnormalities remain unknown, but this is a very active area of research. There are probably a combination of factors that lead to autism.
Genetic factors seem to be important. For example, identical twins are much more likely than fraternal twins or siblings to both have autism. Similarly, language abnormalities are more common in relatives of autistic children. Chromosomal abnormalities and other neurological problems are also more common in families with autism.
A number of other possible causes have been suspected, but not proven. They involve digestive tract changes, diet, mercury poisoning, vaccine sensitivity, and the body's inefficient use of vitamins and minerals.
The exact number of children with autism is not known. A report released by the U.S. Centers for Disease Control and Prevention (CDC) suggests that autism and related disorders are more common than previously thought, although it is unclear if this is due to an increasing rate of the illness or an increased ability to diagnose the illness.
Autism affects boys 3 to 4 times more often than girls. Family income, education, and lifestyle do not seem to affect the risk of autism.
Some parents have heard that the MMR vaccine that children receive may cause autism. This theory was based, in part, on two facts. First, the incidence of autism has increased steadily since around the same time the MMR vaccine was introduced. Second, children with the regressive form of autism (a type of autism that develops after a period of normal development) tend to start to show symptoms around the time the MMR vaccine is given. This is likely a coincidence due to the age of children at the time they receive this vaccine.
Several major studies have found NO connection between the vaccine and autism, however. The American Academy of Pediatrics and the Center for Disease Control and Prevention report that there is no proven link between autism and the MMR vaccine.
Some doctors attribute the increased incidence in autism to newer definitions of autism. The term "autism" now includes a wider spectrum of children. For example, a child who is diagnosed with high-functioning autism today may have been thought to simply be odd or strange 30 years ago.

Symptoms

Most parents of autistic children suspect that something is wrong by the time the child is 18 months old and seek help by the time the child is 2. Children with autism typically have difficulties in verbal and nonverbal communication, social interactions, and pretend play. In some, aggression -- toward others or self -- may be present.
Some children with autism appear normal before age 1 or 2 and then suddenly "regress" and lose language or social skills they had previously gained. This is called the regressive type of autism.
People with autism may perform repeated body movements, show unusual attachments to objects or have unusual distress when routines are changed. Individuals may also experience sensitivities in the senses of sight, hearing, touch, smell, or taste. Such children, for example, will refuse to wear "itchy" clothes and become unduly distressed if forced because of the sensitivity of their skin. Some combination of the following areas may be affected in varying degrees.
Communication:
• Lack of pointing to direct others' attention to objects (occurs in the first 14 months of life)
• Does not adjust gaze to look at objects that others are looking at
• Cannot start or sustain a social conversation
• Develops language slowly or not at all
• Repeats words or memorized passages, such as commercials
• Does not refer to self correctly (for example, says "you want water" when the child means "I want water")
• Uses nonsense rhyming
• Communicates with gestures instead of words
Social interaction:
• Shows a lack of empathy
• Does not make friends
• Is withdrawn
• Prefers to spend time alone, rather than with others
• May not respond to eye contact or smiles
• May actually avoid eye contact
• May treat others as if they are objects
• Does not play interactive games
Response to sensory information:
• Has heightened or low senses of sight, hearing, touch, smell, or taste
• Seems to have a heightened or low response to pain
• May withdraw from physical contact because it is overstimulating or overwhelming
• Does not startle at loud noises
• May find normal noises painful and hold hands over ears
• Rubs surfaces, mouths or licks objects
Play:
• Shows little pretend or imaginative play
• Doesn't imitate the actions of others
• Prefers solitary or ritualistic play
Behaviors:
• Has a short attention span
• Uses repetitive body movements
• Shows a strong need for sameness
• "Acts up" with intense tantrums
• Has very narrow interests
• Demonstrates perseveration (gets stuck on a single topic or task)
• Shows aggression to others or self
• Is overactive or very passive

 

Exams and Tests

All children should have routine developmental exams by their pediatrician. Further testing may be needed if there is concern on the part of the clinician or the parents. This is particularly true whenever a child fails to meet any of the following language milestones:
• Babbling by 12 months
• Gesturing (pointing, waving bye-bye) by 12 months
• Single words by 16 months
• Two-word spontaneous phrases by 24 months (not just echoing)
• Loss of any language or social skills at any age.
These children might receive a hearing evaluation, a blood lead test, and a screening test for autism (such as the Checklist for Autism in Toddlers (CHAT) or the Autism Screening Questionnaire).
A health care provider experienced in the diagnosis and treatment of autism is usually necessary for the actual diagnosis. Because there is no biological test for autism, the diagnosis will often be based on very specific criteria laid out in a book called the Diagnostic and Statistical Manual IV.
The other pervasive developmental disorders include:
• Asperger syndrome (like autism, but with normal language development)
• Rett syndrome (very different from autism, and only occurs in females)
• Childhood disintegrative disorder (rare condition where a child acquires skills, then loses them by age 10)
• Pervasive developmental disorder - not otherwise specified (PDD-NOS), also called atypical autism.
An evaluation of autism will often include a complete physical and neurologic examination. It may also include a specific diagnostic screening tool, such as:
• Autism Diagnostic Interview  - Revised (ADI-R)
• Autism Diagnostic Observation Schedule (ADOS)
• Childhood Autism rating Scale (CARS)
• Gilliam Autism Rating Scale
• Pervasive Developmental Disorders Screening Test-Stage 3
Children with known or suspected autism will often have genetic testing (looking for chromosome abnormalities) and perhaps metabolic testing.
Autism encompasses a broad spectrum of symptoms. Therefore, a single, brief evaluation cannot predict a child's true abilities. Ideally, a team of different specialists will evaluate the child. They might evaluate speech, language, communication, thinking abilities, motor skills, success at school, and other factors.
Sometimes people are reluctant to have a child diagnosed because of concerns about labeling the child. However, failure to make a diagnosis can lead to failure to get the treatment and services the child needs.

Treatment

An early, intensive, appropriate treatment program will greatly improve the outlook for most young children with autism. Most programs will build on the interests of the child in a highly structured schedule of constructive activities. Visual aids are often helpful.
Treatment is most successful when geared toward the child's particular needs. An experienced specialist or team should design the individualized program. A variety of effective therapies are available, including applied behavior analysis (ABA), speech-language therapy, medications, occupational therapy, and physical therapy. Sensory integration and vision therapy are also common, but there is little research supporting their effectiveness. The best treatment plan may use a combination of techniques.
APPLIED BEHAVIORAL ANALYSIS (ABA)
This program is for younger children with an autism spectrum disorder. It highly effective in many cases. ABA uses a one-on-one teaching approach that relies on reinforced practice of various skills. The goal is to get the child close to typical developmental functioning.
ABA programs are usually conducted within a child’s home, under the supervision of a behavioral psychologist. Unfortunately, these programs can be very expensive and have not been widely adopted by school systems. Parents often must seek funding and staffing from other sources, which can be hard to find in many communities.
TEACCH
Another program is called the Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH). TEACCH, developed as a statewide program in North Carolina, uses picture schedules and other visual cues. These help the child work independently and to organize and structure their environments. Though TEACCH tries to enhance a child's adaptation and skills, there is also an acceptance of the deficits associated with autism spectrum disorders. In contrast to ABA programs, TEACCH programs do not anticipate that children will achieve typical developmental progress in response to the treatment.
MEDICINE
Medicines are often used to treat behavior or emotional problems that people with autism may have. These include hyperactivity, impulsiveness, attention problems, irritability, mood swings, outbursts, tantrums, aggression, extreme compulsions that the child finds it impossible to suppress, sleep difficulty, and anxiety. Currently, only risperidone is approved for treatment of children ages 5-16 with irritability and aggression associated with autism.
DIET
Some children with autism appear to respond to a gluten-free or a casein-free diet. Gluten is found in foods containing wheat, rye, and barley. Casein is found in milk, cheese, and other dairy products. Not all experts agree that dietary changes will make a difference, and not all reports studying this method have shown positive results.
If considering these or other dietary changes, seek guidance from both a gastroenterologist (doctor who specializes in the digestive system) and a registered dietitian. You want to be sure that the child is still receiving adequate calories, nutrients, and a balanced diet.
OTHER APPROACHES
Beware that there are widely publicized treatments for autism that do not have scientific support, and reports of "miracle cures" that do not live up to expectations. If your child has autism, it may be helpful to talk with other parents of children with autism, talk with autism specialists, and follow the progress of research in this area, which is rapidly developing.
At one time, there was enormous excitement about using secretin infusions. Now, after many studies have been conducted in many laboratories, it's possible that secretin is not effective after all, but research is ongoing.

Support Groups

For organizations that can provide additional information and help on autism, see autism resources.

Outlook (Prognosis)

Autism remains a challenging condition for individuals and their families, but the outlook today is much better than it was a generation ago. At that time, most people with autism were placed in institutions. Today, with appropriate therapy, many of the symptoms of autism can be improved, though most people will have some symptoms throughout their lives. Most people with autism are able to live with their families or in the community.
The outlook depends on the severity of the autism and the level of therapy the individual receives.

Possible Complications

Autism can be associated with other disorders that affect the brain, such as tuberous sclerosis, mental retardation, or fragile X syndrome. Some people with autism will develop seizures.
The stresses of dealing with autism can lead to social and emotional complications for family and caregivers, as well as the person with autism.

When to Contact a Medical Professional

Parents usually suspect that there is a developmental problem long before a diagnosis is made. Call your health care provider with any concerns about autism or if you are concerned that your child is not developing normally.

References

Autism and Developmental Disabilities Monitoring Network Surveillance Year 2002 Principal Investigators; Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders--autism and developmental disabilities monitoring network, 14 sites, United States, 2002. MMWR Surveill Summ. 2007 Feb 9;56(1):12-28.
Muhle R, Trentacoste V, Rapin I. The Genetics of Autism. Pediatrics. 2004;113;472-486.

Cerebral Palsy

Definition

Cerebral palsy refers to a group of disorders that involve loss of movement or loss of other nerve function.

Alternative Names

Spastic paralysis; Paralysis - spastic

Causes

Cerebral palsy is caused by injuries to the cerebrum (the largest part of the brain), which occur as the baby grows in the womb or near the time of birth.
Initially cerebral palsy was thought to be related to trauma and strangulation during birth (birth asphyxia), which leads to lack of oxygen to the brain), but in a study of 45,000 births it was shown that birth asphyxia is an uncommon cause of cerebral palsy.
In patients with cerebral palsy, parts of the brain areas receive lower levels of oxygen (hypoxia) at some point, but it is not known why this occurs.
Premature infants have a slightly higher rate of cerebral palsy. Cerebral palsy may also occur during early infancy as a result of illnesses (encephalitis, meningitis, herpes simplex infections, and so on), head injury that results in subdural hematoma, blood vessel injuries, and many others conditions.
Injury to the cerebrum can result in the loss of nerve functions in widely different areas. The classical finding of CP is increased muscle tone ( spasticity ). Spasticity may affect:
• One arm or leg
• One side of the body (spastic hemiplegia)
• Both legs (spastic diplegia)
• Both arms and legs (spastic quadriplegia)
In addition, the child may have a partial or full loss of movement (paralysis), problems hearing and vision, and sensation abnormalities. Speech problems are common. Seizures may occur.
Intellectual function may range from extremely bright normal to severe mental retardation. Symptoms are usually seen before age 2. In severe cases, they may appear as early as 3 months.
Classifications of cerebral palsy include spastic, dyskinetic, ataxic, and mixed.
• Spastic cerebral palsy is the most common type.
• Dyskinetic (athetoid) cerebral palsy involves development of abnormal movements (twisting, jerking, or other movements).
• Ataxic cerebral palsy involves tremors, unsteady gait, loss of coordination, and abnormal movements.
• Mixed cerebral palsy involves any combination of symptoms.

 

Symptoms

• Seizures
• Muscle contractions
• Difficulty sucking or feeding
• Irregular breathing
• Delayed development of motor skills, such as reaching, sitting, rolling, crawling, walking, and so on
• Motormental retardation
• Mental retardation
• Speech problems (dysarthria)
• Visual problems
• Hearing problems
• Spasticity
• Joint contractures that slowly get worse
• Limited range of motion
• Peg teeth

Exams and Tests

In many cases, a doctor's examination indicates delayed development of motor skills. Infantile reflexes (such as sucking and startle) may persist past the age where they usually disappear. Muscle tremor or spasticity may be evident, with a tendency of infants to tuck their arms in toward their sides, scissors movements of the legs, or other abnormal movements.
Various laboratory tests may be performed to eliminate nutritional or other causes of the symptoms.
• MRI of the head demonstrates structural or congenital abnormalities
• CT scan of the head demonstrates structural or congenital abnormalities
• Hearing screen (to determine auditory status)
• Visual testing (to determine visual status)
• EEG
• Blood tests to exclude metabolic or hereditary conditions

Treatment

There is no specific cure for cerebral palsy. The goal of treatment is to maximize independence. Treatment is guided by the symptoms exhibited and may include physical therapy, braces, appropriate glasses and hearing aids, medications, special education or appropriate schooling, and, in severe cases, institutionalization.
Mainstreaming in regular schools is advised unless physical disabilities or mental development makes this impossible. Glasses, hearing aids, or other equipment must be designed specifically for the particular disabilities and may assist with communication and learning. Physical therapy, occupational therapy, orthopedic intervention, or other treatments may be appropriate.
Medications may include muscle relaxants to reduce tremors and spasticity, and anticonvulsants to prevent or reduce the frequency of seizures.
Surgery may be needed in some cases to release joint contractures, a progressive problem associated with spasticity. Surgery may also be necessary for placement of feeding tubes and to control gastroesophageal reflux. Recently, the use of botulinum toxin injections has been show to reduce or delay the need for surgery.

Support Groups
For organizations that provide support and additional information, see cerebral palsy resources.
Outlook (Prognosis)

Cerebral palsy is a lifelong disorder. Long-term care may be required. The disorder does not affect expected length of life. The extent of disability varies.
Possible Complications
• Seizures
• Injuries from falls
• Reduced mobility
• Reduced communication skills (sometimes)
• Reduced intellect (sometimes)
• Social stigmatization

When to Contact a Medical Professional

Call your health care provider if symptoms of cerebral palsy develop, especially if you know that an injury occurred during birth or early infancy.

Prevention

Adequate prenatal care may reduce the risk of some rare causes of cerebral palsy. However, dramatic improvements over the last 15 years in obstetrical care at delivery have not reduced the rate of cerebral palsy. In most cases, the injury causing the disorder may not be preventable.
Pregnant mothers with various medical conditions may need to be followed in a high risk prenatal clinic.

Hernia

Definition

A hernia occurs when part of an organ (usually the intestines) sticks through a weak point or tear in the thin muscular wall that holds the abdominal organs in place.
There are several types of hernias, based on where it occurs:
• Inguinal hernia appears as a bulge in the groin or scrotum. This type is more common in men than women.
• Femoral hernia appears as a bulge in the upper thigh. This type is more common in women than in men.
• Incisional hernia can occur through a scar if you had abdominal surgery.
• Umbilical hernia appears as a bulge around the belly button. It occurs when the muscle around the navel doesn't close completely.

Alternative Names

Hernia - inguinal; Inguinal hernia

Causes

Usually, there is no obvious cause of a hernia, although they are sometimes associated with heavy lifting.
Hernias can be seen in infants and children. This can happen when the lining around the abdominal organs does not close properly before birth. About 5 out of 100 children have inguinal hernias (more boys than girls). Some may not have symptoms until adulthood.
If you have any of the following, you are more likely to develop a hernia:
• Family history of hernias
• Cystic fibrosis
• Undescended testicles
• Extra weight
• Chronic cough
• Chronic constipation, straining to have bowel movements
• Enlarged prostate, straining to urinate

Symptoms

• Groin discomfort or groin pain aggravated by bending or lifting
• A tender groin lump or scrotum lump
• A non-tender bulge or lump in children

Exams and Tests

A doctor can confirm the presence of a hernia during a physical exam. The mass may increase in size when coughing, bending, lifting, or straining. The hernia (bulge) may not be obvious in infants and children, except when the child is crying or coughing.

Treatment

Most hernias can be pushed back into the abdominal cavity. However, if it cannot be pushed back through the abdominal wall, this can lead to a strangulated loop of intestine. If left untreated, this portion of the intestine dies because of loss of blood supply.
Almost all hernias require surgery, preferably before complications occur, to reposition the herniated loop of intestine and secure the weakened muscles in the abdomen.
For information on such surgery, see: Hernia repair

Outlook (Prognosis)

The outcome is usually good with treatment. Recurrence is rare (1-3%).

Possible Complications

An incarcerated hernia can lead to a strangulated intestine, which can result in gangrene, a life-threatening condition requiring emergency surgery. In rare cases, inguinal hernia repair can damage structures involved in the function of a man's testicles.
Another risk of hernia surgery is nerve damage, which can lead to numbness in the groin area.

When to Contact a Medical Professional

Call your doctor right away if:
• You have a hernia and the contents cannot be pushed back into the abdomen using gentle pressure
• You develop nausea, vomiting, or a fever with your hernia
• The hernia becomes red, purple, dark, or discolored
Call your doctor if:
• You have groin pain, swelling, or a bulge
• An umbilical hernia fails to heal on its own by the time your child is 5 years old

Prevention

• Use proper lifting techniques.
• Lose weight if you are overweight.
• Relieve or avoid constipation by eating plenty of fiber, drinking lots of fluid, going to the bathroom as soon as you have the urge, and exercising regularly.

 

References

Patient Care Committee. Society for Surgery of the Alimentary Tract. Surgical repair of groin hernias. SSAT patient care guidelines. J of Gastrointestinal Surgery. 2004; 8(3): 365-6.
Hachisuka T. Femoral Hernia Repair. Surg Clin North Am. 2003; 83(5): 1189-1205.
Awad SS. Current approaches to inguinal hernia repair. Am J Surg. 2004; 188(6A Suppl): 9S-16S.

 

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