PEDS EXAM 3: Child with Special Needs and Sensory Alterations
asperger syndrome
- "high-functioning autism" - Used to be classified as high-functioning autism, but now is considered its own separate entity - Distinct category within the autism spectrum - Do not show the same level of disability as autism - High levels of intellectual and language development
hearing screening
- All infants and children should be assessed regularly at well visits for any communication delay or academic difficulty that may be related to decreased hearing - Many children have mild to moderate hearing loss, despite screening. - Hearing loss can affect both language development and school achievement
fragile x syndrome therapeutic management
- All managed through special educational and vocational programs, behavioral management classes, on medications to treat comorbidities such as anxiety and seizures - Speech and language evaluation and therapy generally prescribed during first year of life and made available on a continuing basis - Sensorimotor integration therapy may be offered - No medications used to treat this, but used to manage associated symptoms (depression or anxiety, hyperactivity, and seizures)
orbital cellulitis treatment
- An emergent condition that requires aggressive IV antibiotics - Child is treated with IV antibiotics designed to act on the major causative organisms → treatment is individualized once the culture results are available - If area is painful, analgesics may also be prescribed - May progress to meningitis if untreated ** Also blindness
fragile x syndrome - comorbid disorders
- Anxiety and depression - May have seizures - May have endocrine disorders as well - Girls can experience primary ovarian insufficiency, postpubertal testicular enlargement
down syndrome heart defects
- At risk for heart defects - Children with DS may have other serious abnormalities that affect their development, including congenital cardiac defects, vision and hearing difficulties, and childhood leukemia - When partaking in physical activity, could be at risk for some serious complications
autism spectrum disorders
- Atypical patterns of development - Range in severity from severe (autism) to a milder form (Asperger syndrome) - Clusters of developmental problems and deficits - No genetic cause - Difficulty developing and maintaining social relationships - Symptoms noticeable by 3 years of age
FAS developmental milestones
- Below the expected range for the child's age, physical or psychosocial circumstances in at least 3 of the following: cognitive function, executive function, attention, motor function, and social skills - Associated problems such as abnormal sensitivities to taste and touch or inability to appropriately respond to facial expression or parenting techniques
fragile x syndrome etiology & incidence
- Caused by a genetic defect on x chromosome - More common in males, and women are often carriers - Females protected by their double X chromosome - Known genetic cause of autism but can occur with or without autism
autism etiology
- Caused by range of prenatal, perinatal and postnatal conditions ** Including maternal rubella, untreated phenylketonuria, tuberous sclerosis, anoxia during birth, encephalitis, seizures, and FXS - No link to Immunizations!!!!! - Maternal metabolic influences during pregnancy - Research finding between obesity and diabetes during pregnancy and subsequent development of autism in the child - Genetic mutations that can result in autism - 1 in 59 children being diagnosed with autism
color deficiency
- Color blindness - Typically happens in colors with red, green, and blue - No cure - Occurs more often in boys than girls - safety is an issue - kids can struggle with color coordination for clothing
mixed hearing loss
- Combination of conductive and sensorineural loss
strabismus
- Cross eyed - Eyes are not aligned because of a lack of coordination of the extraocular muscles - Caused by a lack of coordination in extraocular muscles - Caused by muscle imbalance or paralysis of the extraocular muscles - Can also result from conditions such as a brain tumor, myasthenia gravis, or infection
fetal alcohol spectrum (FAS) diagnosis
- Diagnosed through examination and perinatal history - History is from the mom → most likely a lot of shame, especially if HCP is coming to the mom and telling her the diagnosis and asking how much alcohol she drank - Mom will most likely lie and underestimate the amount of alcohol she drank
Asperger syndrome symptoms - social and emotional
- Display an impaired ability to understand common social cues and an inability to behave according to social norms - Fluent in language, but the content of conversations is fixated on the topic of interest to the child, with no regard for the reaction of the listener - Might have difficulties with emotional relationships and connections - People who work with childrens with autism → a lot of therapy surrounds how to appropriately interact with another person, these are learned skills - When you talk to someone, look them in the eye - Based on their response you respond - Kids can develop and learn how to interact with other children
autism management - early identification
- Earlier diagnosed, earlier interventions can occur and behavioral therapy can begin - Treatment entails creating an environment that facilitates interaction and promotes replacement of stereotypical behaviors with more normal behaviors
nursing care of child with intellectual and developmental disability
- Early assessment of the specific cause and nature of the disorder or disability - Understanding when milestones occur and how a child should be developing normally is so critical to caring for families - Identification of possible co-morbidities and risk factors - Support of the family - A lot of families are eligible for full time nursing, a multitude of therapies through insurance → helping family connect to different specialists and services - Referral to support services - Requires multidisciplinary efforts and strong advocacy - Advocacy is key to caring for these kids → educationally as well ** Primary nursing responsibilities when caring for a child and child's family with an intellectual disability include facilitating initial grief, assistance with coping, and identifying resources to help meet the child's lifelong needs
caring for the child with a hearing loss
- Encourage hearing aid use. --> Make sure the hearing aid is in place before speaking to the child. - Have the child's complete attention before beginning to speak (to enhance lip reading) - Speak clearly but not loudly or slowly. - Eliminate background noise. - Use visual aids (includes pictures, hands, and written messages for older children) - If child uses American Sign Language to communicate, have a diagram of commonly used words readily available - Therapeutic management
failure to thrive management - family therapy
- Enhancing positive parenting - Effective parenting classes can assist the parent to identify psychological and physical factors that have contributed to the child's condition - If there is an inorganic cause at play, make sure there is something psychosocial, some type of therapy at play
Americans with Disabilities Act
- Equal rights and accessibility for all disabled individuals - Developmental disability must have the following components: - Severe and chronic with mental and/or physical impairment - Impairment must be present before child turns 22 y.o. - Impairment is likely to continue and require life-long services and support - Substantial functional limitations in 3 or more areas ** Areas include self care, receptive and expressive language, learning, mobility, self direction, capacity for independent living, and economic self sufficiency (ability to hold a job and support themselves financially)
sensory neonatal development
- Eyes begin to develop at 22 days. - Ears begin to develop during the 3rd week, with the critical period occurring at 4-6 weeks of gestation. - Fetus capable of hearing during 2nd trimester - Sensitive to teratogens ** Teratogens: include anything that the fetus is exposed to that could be harmful including drugs, alcohol, prescription medications, etc. - Any interference in development can result in later sensory alterations
fragile x syndrome - social and emotional relatedness
- Gaze aversion (can't look people in eye), difficulty with peer and social relationships - Often have disruptive behaviors and extreme agitation - This difficulty appears to be related to facial recognition → the ability to recognize a face that has been seen before (face encoding)
intellectual disability management - safety
- Huge concern because children may have impaired executive motor function, means injuries are more common - Children who are intellectually impaired are less capable of managing environmental challenges than their peers who are unimpaired - Children with intellectual disabilities may need prolonged teaching, more demonstration during teaching, frequent verbal and visual reminders, and more practice - Sites of concern: kitchen (burns, poisoning), bathroom (falls, burns, cuts), yard or playground (animal bites, poisoning, abduction), and vehicles (cuts, falls, serious injury)
cause of intellectual disability - neonatal alterations
- If born premature or very low birth weight - Perinatal insult or injury - Other conditions present at birth: hyperbilirubinemia, hypoglycemia, CNS hemorrhage, ABO incompatibilities
cause of intellectual disability - genetic
- Inborn errors of metabolism → phenylketonuria, tay sachs disease, galactosemia - Hereditary syndromes → muscular dystrophy, tuberous sclerosis, neurofibromatosis - Chromosomal alterations → down syndrome and fragile X
failure to thrive management - nutritional
- Increase caloric intake - Multivitamin supplement --> To ensure that specific nutritional deficiencies do not occur in the course of rapid growth - Goal: grow 2-3X average rate for age - Caloric enrichment of food - Formula may be concentrated in titrated amounts up to 24 cal/oz
orbital cellulitis
- Infection of soft tissue of eye orbit - Caused by sinus infection or trauma to the eye - Usual infecting organisms: staphylococcus aureus and S. pneumoniae
cause of intellectual disability - alteration occurring during pregnancy
- Intrauterine infection: herpes, HIV, toxoplasmosis, congenital rubella - Exposure to environmental toxins: alcohol (fetal alcohol spectrum) or drugs - Intrauterine growth restriction
autism management - behavior management
- Key in how we manage autism - Referred to special programs designed to offer stimulation, modify stereotypical behaviors or establish routines for teaching - Programs usually focus on safety precautions for self-injurious behaviors such as head banging and the promotion of communication
autism management - promotion of communication
- Key part to being a member of society - Teaching them how to communicate is a learned skill, can learn and adapt with how to do that - Facilitative communication through the use of picture boards or keyboards
autism spectrum disorders characteristics / indicators
- Lack of social ability (poor eye contact) - Lack of verbalization (lack interest and response) - Lack of smiling - Inability to use toys - Excessive preoccupation with creating order - Does not seek comfort or cuddling (parents express concerns that child does not appear to be attaching to them)
fragile x syndrome - distinct physical characteristics
- Large, prominent ears - Long and narrow face - Head circumference that may be disproportionate to child's height and weight - Flat feet, lax ankles - Hyperextensible fingers - Enlarged testicles - Soft, smooth skin - Mitral valve prolapse
fragile x syndrome - speech and language capability
- May have abnormal speech patterns - Echolalia: repeat back what they heard said to them - Often have language delays - Language and sensory impairments likely contribute to the social and behavioral dysfunctions associated with FXS → - includes disruptive behaviors such as temper tantrums, self injury, extreme agitation - Autism like behaviors such as gaze avoidance, hand flapping, echolalia, and abnormal speech patterns - Hyperkinetic behaviors including restlessness, agitation, and attention deficits - Hand biting - Sensory motor integration deficits such as poor coordination, motor planning deficits, and tactile defensiveness
intellectual disability management - comorbidities
- Medical strategies often geared toward preventing and treating infections, correcting structural deformities, treating associated behaviors such as aggressiveness - Corrective measures → include congenital heart surgery for malformations, inserting tympanostomy tubes, or placing splints on joints that are hypotonic and hyperextended - Treatment of behavioral difficulties and psychosocial disturbances may involve administration of medications
cause of intellectual disability - acquired childhood conditions or diseases
- Meningitis, encephalitis, pertussis, lead poisoning, head trauma, cardiac arrest - Neurologic insult (trauma hydrocephalus, tumors) - Conditions impairing cardiac or respiratory function (cardiorespiratory arrest, asphyxiation) - All could cause intellectual disability once a child recovers
nursing care of child with a visual impairment
- Orient the child to the hospital environment by emphasizing spatial relations. - Keep all things in the same location and order. - Emphasizing where things are in the room - Never touch the child without identifying yourself and explaining what you plan to do. - Remember that parents are often the best source for communication. - Identify noises for the child. - Abnormal noises like the monitor going off or the IV pump beeping - Allow as much control as possible
conductive hearing loss
- Outer or middle ear affected by damage, inflammation, or obstruction - May be the result of excessive cerumen (wax), foreign bodies, perforated tympanic membrane, or otitis media - Sound conduction is prevented from progressing from the outer ear to the inner ear - Managed by medical or surgical correction of underlying problem
fragile x syndrome - sensory impairment
- Poor coordination, touch sensitivities - Sensory motor integration deficits such as poor coordination, motor planning deficits, and tactile defensiveness - Child may have strengths in visual memory but weakness in auditory process abilities and abstract reasoning, improved performance with simultaneous rather than sequential processing, language delays, perseveration, tangential speech, and other communicative disorders
down syndrome therapeutic management
- Regular screening, early intervention, and active management of identified problems - Surgery to correct cardiac abnormalities, GI malformations, and craniofacial deviations used to prolong life, alleviate discomfort, and decrease the likelihood of further medical complications - Neck radiography should be performed before the child participates in any sports → children with DS are at risk for atlantoaxial instability
sensorineural hearing loss
- Result of damage or malformation of the inner ear and/or auditory nerve - May be the result of heredity or environmental factors such as infection, exposure to loud noise, ototoxic medications, or prematurity - Meningitis is a significant cause of acquired sensorineural hearing loss - Not reversible (usually permanent) - Hearing aids are used to manage this - In the ear hearing aids best for kids - Can be used as early as 2 months - Cochlear implants are also possible
central hearing loss
- Result of damage to the conduction system between the auditory nervous system and the cerebral cortex - Can be the result of trauma, neurovascular changes, or brain tumors - May cause difficulty in differentiation of sounds, auditory memory
orbital cellulitis manifestations
- See severe eyelid edema, redness (erythema) - An anteriorly displaced eye - Decreased or absent vision, increased intraocular pressure, and pain can complicate child's condition - Child is febrile and has elevated WBC count
refractive errors
- Shape of the eye doesn't bend light correctly resulting in blurred vision - Cause vision disturbances from alterations in the path of light rays through the eye - Usually result from an abnormally shaped orb → orb may be flattened or elongated - Includes myopia (nearsightedness) hyperopia (farsightedness) and a astigmatism
down syndrome distinct facial features
- Short head, flat profile, inner epicanthal folds, wide and flat nasal bridge, narrow and high-arched palate, protruding tongue, small and short ears - Brachycephaly: disproportionate shortness of the head
FAS CNS abnormalities
- Small head circumference - Brain abnormalities, motor defects - Seizures - Picked up upon when children are not meeting developmental milestones - Is a spectrum, can vary from child to child
FAS facial abnormalities
- Smooth philtrum → space in between the nose and the upper lips - Thin vermillion border → no indent in upper lip, just straight across - Small palpebral fissures → space between where the eyeballs are and space between inner and outer eyelid
pervasive developmental disorders
- Spectrum disorders - Can range from mild to severe impairment - Ex: rett syndrome, down syndrome, fragile X syndrome, ADD, ADHD, aspergers, autism
rett syndrome clinical signs
- Stereotypical hand and gait disturbances - Loss of fine motor control - Regression in speech - Seizures
intellectual disability diagnosis
- Tests to assess child's level of intellectual and adaptive functioning *** Paper and pencil tasks, motor tasks, sensory tasks, intellectual processing - Developmental screening at each well visit *** AAP recommends formal developmental screening at 9, 18, and 30 months - Most diagnoses not made until significant academic failure at school
intellectual disability management - prenatal care
- To ensure there is not any prenatal exposures - Genetic testing can occur to identify hereditary mutations - Happens very early on in pregnancy so that family can decide if they want to continue on with pregnancy → nurses have to put own values aside and be supportive
strabismus treatment
- Treated with corrective lenses or surgery if severe, or even botox because it would paralyze the eye muscles which would allow the opposite muscle to straighten the eye - Botox is injected into the eye muscle to produce temporary paralysis, allows muscles of opposite paralyzed muscle to straighten the eye - Treatment includes special corrective lenses, vision therapy, surgery, or pharmacologic therapy ** Goal is to initiate treatment as early as possible to preserve vision and reduce the risk for amblyopia
failure to thrive manifestations
- Weight below the 5th percentile - A sudden or rapid deceleration in the growth curve - Delay in reaching developmental milestones - Decreased muscle mass - Muscle hypotonia, abdominal distention, generalized weakness, and cachexia (general ill health and malnutrition) - Behavioral indicators: avoidance of eye contact, avoidance of physical touch, intense watchfulness, sleep disturbances - Lack of age-appropriate stranger anxiety, inappropriate lack of preference for one's own parents, and disturbed effect (apathy, extreme irritability, extreme compliance) - Repetitive self-stimulating behaviors → rocking, head banging, intense sucking, intense chewing on fingers or hands, and head rolling
autism manifestations - language
- abnormalities in production of speech (inappropriate volume, pitch, rate, rhythm, or intonation, such as a monotone voice or echolalia) - Markedly abnormal nonverbal communication (Child uses no gestures or behavioral cues) - Absence of imaginative play - Unable to have conversation (unable to have back-and-forth conversation) - Impaired interactive speech and communication
down syndrome diagnostics - prenatal testing
- amniocentesis or chorionic villus sampling - An abnormal triple maternal serum screen value (low a-fetoprotein, low unconjugated estriol, and increased human gonadotropin levels) may prompt additional testing
disorders of the eye
- blocked lacrimal duct - refractive errors - color deficiency - amblyopia - strabismus
types and etiology of hearing loss
- conductive - sensorineural - mixed - central
eye infections
- conjunctivitis - orbital cellulitis
autism management includes
- early identification - behavior management - safety - promotion of communication
Fetal alcohol spectrum diagnosis criteria
- facial abnormalities - growth deficit - CNS abnormalities - developmental milestones
causes of intellectual disability
- genetic - alterations occurring during pregnancy - neonatal alterations - acquired childhood conditions or diseases - unknown causes - psychosocial problems
hearing loss therapeutic management - sensorineural hearing loss
- hearing aids recommended as soon as possible to help facilitate language development - Cochlear implants: implant is a small electronic device surgically implanted into the cochlea - It delivers electrical stimulation to the inner ear, causing nerve impulses to travel to the brain, where they are interpreted as normal sound
down syndrome risk factors
- increased maternal age and genetic predisposition - As soon as woman is 35, risk goes up and increases with each age - Risk is also higher if parents already have one child with DS - Genetic predisposition can be screened early in pregnancy and then the family can decide whether or not to continue on with pregnancy
rett syndrome
- mutations on the X chromosome - almost exclusively linked to the female sex - Characterized as autism spectrum disorder however genetic cause is not known in terms of why this causes autism - initial period of normal development - symptoms emerge between 6 and 18 months - social and intellectual development stops
failure to thrive management includes
- nutritional - family therapy - goal is to gain weight
intellectual disability management
- prenatal care - increase the time spent in a regular school setting - multidisciplinary efforts - strong advocacy on the part of parents - comorbidities - safety
down syndrome diagnostics
- prenatal testing: amniocentesis or chorionic villus sampling - evident at birth - Chromosomal analysis is conducted to confirm the diagnosis - Other diagnostic tests are conducted to identify associated medical conditions, such as nasopharyngeal abnormalities or cardiac defects
autism manifestations - behavior
- repetitive body movements (very sensitive to overstimulation --> spinning around, head banging, "flapping," rocking) - abnormal attachment to objects - insistence on a routine - marked distress over a minor change in environment - marked restriction in range of interests
autism manifestations include
- social - language - behavior
asperger syndrome symptoms
- social and emotional - rigidity regarding schedules, motor clumsiness, trouble handwriting, and organizational problems
fetal alcohol spectrum (FAS) disorder
- the most severe form experienced by the infant exposed to alcohol in utero - No known safe alcohol consumption during pregnancy - FASD refers to the classic defects of persistent symmetric growth retardation, malformations of the face and skull, skeletal and cardiac malformation, and CNS deficits, including intellectual and developmental disabilities - Disorder that has a known environmental cause
autism manifestations - social
- unaware of others feelings - lack of or abnormal imitation of others' actions - abnormal social play (or none at all) - abnormal comfort seeking at times of distress - gross impairment in social peer relationships
FAS growth deficit
10th percentile or less for height, weight, or both - Infant with FASD exhibits prenatal and postnatal growth deficiency, microcephaly, joint anomalies, mild to moderate intellectual disability, tremulousness in the neonatal period, and irritability - Child experiences hyperactivity
rett syndrome - symptoms develop between ___ and ___ months
6 and 18 months
autism management - safety
Big concern especially if their repetitive behavior is them hitting their head against the wall → these children wear helmets to protect their head
blocked lacrimal duct
Blocked tear duct - Characterized by excessive tearing (epiphora) and crusting on the eyelids when child awakens - Parents may also note a small mass just below the inner aspect of the eye - If duct is infected would see drainage (green or yellow puss) indicative of infection - Would be treated with antibiotics eyedrops or ointment - Noninfected duct → drainage is usually white or clear
orbital cellulitis diagnosis
CT scan
conjunctivitis etiology
Caused by bacteria, could also be caused by virus (contagious in this instance) - Bacteria in infants: chlamydia - Bacteria in older children: haemophilus influenzae and streptococcus pneumoniae - Could also be caused by allergies or trauma to the eye or even an upper respiratory infection ** Itching and tearing often identifies the cause as an allergic response
failure to thrive
Children whose weight or rate of weight gain is below that of comparably aged children - Dramatically smaller than peers - Result of organic or inorganic causes
mental age
Considered the level of intellectual understanding - Ex: if nurse is caring for a 12-year-old (chronologically), if mental age is 5, nurse should interact with patient as if they are 5
strabismus diagnostics
Corneal light reflex test, simultaneous red reflex test, cover-uncover test, and alternate-cover test
conjunctivitis treatment
Depending on cause is how we treat - Allergic response → antihistamines - Bacterial → antibiotics - Viral → antiviral drops - Need to stay at home for at least 24 hours until antibiotics - Handwashing is key
autism spectrum disorders characteristic features
Difficulty developing and maintaining social relationships, disordered communication, and sterotyped interests and behaviors
refractive errors are discovered when
Discovered when a child squints, frowns, or moves objects so they are more easily seen
amblyopia
Lazy eye - Results from a variety of eye alterations seen in children whose visual acuity is impaired - Both eyes are unable to focus simultaneously - Brain suppresses the image from the deviating eye to avoid double vision (diplopia) - If untreated in kids under 4 years of age, can lead to permanent vision loss - Depth perception may also be impaired
rett syndrome diagnosis
Made by detecting mutations on the X chromosome, gene MECP2, combined with clinical evaluation for the characteristic clinical signs
fragile X syndrome
Most common inherited cause of cognitive impairment and genetic cause of autism - Intellectual functioning - Physical characteristics - social and emotional relatedness - speech and language capability - sensory impairment - comorbid disorders
cause of intellectual disability - unknown causes
Nearly half of cases have an unknown cause
conjunctivitis
Pink eye - Inflammation of the conjunctive (the clear, membraneous lining of the lid and sclera) - Very common, extremely contagious
cause of intellectual disability - psychosocial problems
Psychosocial deprivation, poverty and inadequate healthcare, parental neurosis, psychosis, character disorder; childhood psychosis, autism, other pervasive developmental disorders
intellectual and developmental disorders (IDD)
These children may have limitations in both intellectual and adaptive functioning. - Social interaction - Use of language for self-expression - Self-care abilities - Lifelong challenges that require assistance from health care and educational professionals for both the child and family
blocked lacrimal duct treatment
Treated by massaging tear duct in upward motion or by surgery in severe cases - If duct remains blocked despite massaging or remains blocked after 1 year of age, surgical opening of the duct is indicated - Lacrimal massage: wash hands thoroughly, place index finger over lacrimal duct, and "milking" or gently massaging the duct in an upward motion
amblyopia treatment
Treated with corrective lenses and placing a patch over the stronger eye to make the lazy eye work harder and become stronger
refractive errors treatment
Treated with corrective lenses or contact lenses when old enough
intellectual impairment / intellectual disability
When there is a significant limitation in both intellectual and functional capacity - Impairment manifests in measured intelligence (i.e., IQ) and also in adaptive behavior - Considered through assessment of language, cognition, academic ability, self-help skills, social behaviors, and motor performance - Intellectual disability has replaced the term mental retardation
down syndrome
aka trisomy 21 - Caused by the presence of all or part of a third copy of chromosome 21 - Nondisjunction: a failure of the chromosomes to separate normally during meiosis - moderate to severe intellectual impairment - distinct facial features - heart defects
FAS other abnormalities
altered palmar crease patterns, short distal phalanges, cervical vertebral malformations, ear anomalies, cleft lip and palate, severe cardiac defects, renal anomalies, strawberry hemangiomas, and genital anomalies
disorders with little understood genetic influence
autism spectrum disorders
developmental disability - umbrella term encompasses
children who have intellectual disability, sensory alteration (hearing, vision, and speech), orthopedic problems, and conditions such as cerebral palsy and autism spectrum disorder - Uniting these disorders under the term developmental disability has important legal and policy implications because it unites a number of people who have similar psychosocial and development disorders and similar needs from services
hearing test in the older child (>3)
done by play audiometry or conventional audiometry
disorders of intellectual impairment
down syndrome
americans with disabilities act result of bill
every disabled child must have a written individualized education plan (IEP) that outlines specialized instruction and services the public school system will provide
disorders related to environmental alterations
fetal alcohol syndrome (FAS) and failure to thrive
disorders of known genetic cause
fragile X and Rett syndrome
conjunctivitis S&S
itching, burning, light sensitivity (photophobia), "scratchy" feeling, redness, edema, and discharge
functional age
level of adaptive functioning
adaptive functioning
level of coping the child has developed to complete activities of daily functioning (ADLs), communication skills, and social skills - Possible for child with low mental age to function well beyond what is expected
hearing loss therapeutic management - conductive hearing loss
managed by medical or surgical correction of the underlying problem (otitis, cerumen) - Device successful → bone conduction hearing device
failure to thrive - organic causes
medical causes - Chromosomal abnormalities, defects in heart or lung, CNS damage, exposure to toxins
failure to thrive - inorganic causes
more based on behavioral aspects - Child's temperament, refusing to eat (behavioral), parenteral expectations, maternal emotional state, and sociodemographic factors - Has to do with relationship that child has with caregiver
down syndrome body features
short stature, short, broad hands, wide gap between first and second toes, short and broad neck, increased likelihood of umbilical hernia, dry skin with tendency to crack and fissure, hyperextensibility of joints with hypotonicity of muscles, and atlantoaxial instability (at the first and second cervical vertebrae)
infant hearing screening
the auditory brainstem response and the evoked otoacoustic emissions test