Pediatrics Flashcards
1
Q
what develops first, the vestibular system or auditory system?
A
vestibular system
2
Q
when are the semicircular canals developed by
A
7 weeks gestation
3
Q
when are the cristae and maculae developed by
A
12-14 weeks gestation
4
Q
when is the cochlea developed
A
mid term of gestation
5
Q
when does the vestibular system myelinate
A
around 16 weeks gestation
6
Q
when is the auditory system myelinated
A
around 20-24 weeks gestation
7
Q
when is the vestibulo-ocular reflex present
A
24 weeks gestation
8
Q
when is the peripheral vestibular system anatomically developed fully
A
at birth
9
Q
VOR as an infant
A
physiologically is similar to that of an adult, but does have maturational effects
—VOR can be evaluated by rotary chair at birth
10
Q
when do saccades and smooth pursuit develop
A
4-6 months
11
Q
when do OPK/ONK fully develop
A
age 4
12
Q
incidence of vestibular problems in children
A
- limited data on incidence as it is thought to be rare
- data often found in retrospective reviews of data
- review of records of 724 kids:
- –27.82% migraine
- –15.68% BPPV
- –9.81% vestibular neuritis
- –14% head trauma
13
Q
development of the vestibular system (when is it fully developed)
A
*anatomically the vestibular system is fully developed at birth, however, maturation is needed for balance to be consistently maintained. this will occur around 12-15 years of age
14
Q
the VOR purpose and maturation
A
- purpose= to maintain a steady vision during head movement and to keep the visual target on the fovea
- will reach full maturity by 6-12 months of age
15
Q
vestibulo-colic reflex purpose (VCR)
A
- stabilize the head during body movement
- –same reflex that is used in cVEMP testing
- a baby with inability to hold their head up may be indicative of a significant vestibular pathology
16
Q
vestibulo-spinal reflex (VSR) purpose and age of development
A
- goal is to stabilize the body for postural control
- this system is not fully developed until 12-15 years of age
- the sensory organization test (SOT) with CDP will evaluate this reflex
17
Q
gross motor in kids with HL
A
- higher incidence of gross motor delay
- incidence increased when cognitive delay is noted as well
- compared to peers will show delays in:
- –holding up upright
- –sitting
- –standing
- –walking
- –crawling
18
Q
typical norms for gross motor
A
- sititng= 6-8 months
- standing= 10-11 months
- walking=10-12 months
- while each child is different this is a guide to appropriate gross motor development
19
Q
gross motor norms for children with vestibular loss
A
- sitting= 8-18 months
- standing= 9-20 months
- walking= 12-33 months
- –huge range in milestones for these kids because it depends on onset and severity of the vestibular loss
20
Q
strategy changes with development
A
- strategy for integrating visual, proprioceptive, and vestibular info changes as we mature
- children tend to be more dominant on vision in their early years
- –because vestib system isnt fully developed yet
- by age 14-15 the utilization of vision is more adult like but the vestibular system is still maturing
- the use of all 3 systems starts to be utilized around 10-15 yrs, but around 7-8 children begin the process
21
Q
vestibular eval of children
A
- under age 5 need to plan the eval because the next test you acquire may be your last
- older children can often be tested like adults
- do not be afraid to take longer tan 1 session to test
- may even want to let parents know they can expect to take longer than one visit
- **do not let them leave on a bad note
22
Q
things to ask during history and see during clinical presentation
A
- are symptoms episodic or persistent?
- do symptoms seem to represent a sensation of movement of the child’s environment or of the child within the environment?
- if episodic how long are the episodes?
- history of childhood diseases since birth, prenatal disorders, postpartum disorders?
- any know or suspected hearing loss?
- often ask parent but let pt tell you stuff too, because they may have told the parent something but the parent brushed it off
- –also helps rapport
23
Q
direct office exam of an infant at the start of independent walking
A
- head thrust
- -sticker on forehead or nose and baby on parents lap
- pursuit tracking
- –large sticker on finger
- –younger than 4 months may not be able to perform
- saccade testing
- –use 2 finger puppets or 2 different stickers
- –have 1 pop up and disappear, alternating between the 2
- –parents may need to gently hold the head/chin
- optokinetic testing
- –under 4 months may not be able to perform
- –use cloth with repeating stickers that can be drawn across the visual field
- –lack of OPK is not necessarily indicative of problem, may be developmental
- rotary chair (non-diagnostic)
- –oscillating office chair back and forth with child on parent’s lap
- –child needs to look at examiner and not environment
24
Q
direct office exam of a child walking independently (18 months+)
A
- all methods used with younger children can still be used, however variations would be used
- –smaller objects to focus on
- –rotary chair would be performed on diagnostic piece of equipment
- children over 6 should be testing similar to adults, however adult norms cannot be used
- add office exam of SOT utilizing 4 conditions
- –standing on firm surface with and without vision
- –standing on a compliant surface with and without vision
- —-if a child will not keep their eyes closed use a blindfold
25
Q
what is the purpose of laboratory testing children?
A
- determine the pathophysiology of dizziness complaints
- the etiology of hearing loss
- the underlying cause of gross motor developmental delay
26
Q
rotary chair with children
A
- only tests horizontal canal
- does not provide ear specific info
- is a good test of the horizontal canal when unable to achieve accurate caloric responses due to tubes, atresia, middle ear fluid, etc
- tolerated well y children, can sit by themselves or on parents’ lap, usually 4 months of age or older
- taking can be done with conversation, counting, spelling, singing nursery rhymes, etc
- rotary chair outcomes are similar to adults, in the normal population a high gain result may be seen and should not be considered abnormal
- if abnormal findings are found in a kid <6 months, it is recommended they are repeated when they are older to evaluate of a true disorder
27
Q
postural control assessment of children
A
- sensory organization test (SOT)
- children must weigh 30 lbs to put enough weight on the platform to record sway
- normative data for 3+ years is available
- composite scores improve with age
- conditions 1-3 can mimic adults
- remaining conditions 4-6 will see greater sway util 12-15 yrs of age
- can be used to detect balance dysfunction but also to monitor various disorders
28
Q
pursuit testing with children
A
- can be tested as young as 2 months of age
- however, smooth pursuit gains are significantly lower and more variable with children as compared to adults
- normal smooth pursuit should be present by 5 year of age
29
Q
random saccade testing of children
A
- saccade latency decreases with age while velocity remains stable
- maturation of saccades is thought to be complete by age 12
30
Q
OKN up to age 7
A
- the target should take up to 90% of the visual field
- OKN is thought to reach maturity by age 7
- those kids under age 7 will have low gain values
- some equipment has the ability to switch to cartoon characters
- –if not you cant just tell them to watch and tell me when you see ____
- –similar to telling adult to look for the pink light
- –let the eyes natural reflex work without too much instruction
31
Q
hallpike and roll tests children
A
- BPPV is rare in children but it can occur especially after head trauma
- BPPV has been reported in children as young as 3
- testing and treatment of BPPV is the same as adults
32
Q
gaze and postural testing children
A
- test as you would with adults with the exception of your target, again using stickers or cartoon characters
- findings are interpreted the same for adults and children
33
Q
VEMPS: cervical and ocular in children
A
- cVEMP:
- –evaluated the saccule and inferior vestibular nerve
- –ipsilateral ressponse
- –has been measured in infants as young as 1-4 weeks at 95-100dBHL
- –morphology is similar to adult but latencies are shorter in younger children and prolong with age
- –greater variability in peak to peak amplitude
- oVEMP:
- –evaluated the utricle and superior portion of the vestibular nerve
- –contra respose
- –do not appear to be reliable until 4 yrs of age
- –no significant difference in latency or amplitude to date; more research is needed
34
Q
pros of VEMPS in children
A
- quick to administer
* great to use in peds because dizzy symptoms to no have to be induced to get results unlike calorics
35
Q
cons of VEMPS in children
A
- difficult to get children to hold muscle contraction or eye position for very long
- stimulation rates that induce a response can be harmful to a small pediatric ear when considered safe in the adult ear canal
36
Q
caloric irrigation in children
A
- interpretation of calorics is identical to adult standards
- caloric responses have been reported in children as young as 2 months of age with complete maturation by 6-12 months
- calibration may be a concern if you cant tell them to look at the dot
- children may be fearful of the stimulation
- –they are already concerned about otoscopy, now add air or water
- if you do get a stimulation they become dizzy and may refuse further irrigations
- consider monothermal (warm because stronger responses)
- praise and encourage (and bribe)
37
Q
Video head impulse testing in children (vHIT)
A
- just as with adults, looking for overall gain, and corrective saccades (overt and covert)
- no reports on vHIT in children as of right now
- getting child to fixate on target is difficult
38
Q
disorders in utero (CMV)
A
- cytomegalovirus (CMV)
- congenital infection which is the leading cause of hearing loss in children, resulting in progressive and fluctuation sensorineural HL
- 40,000 children with CMV born each year
- vestib loss is common in CMV, SSCs and saccule may be affected
- –dont have research about utricle yet
- –60% children with CMV have abnormal calorics (33% have absent cVEMPs)
39
Q
more in utero disorders
A
- rubella
- –variable vestib loss, HL also associated
- usher syndrome
- –autosomal recessive genetic condition
- –SNHL and retinitus pigmentosa
- waardenburg
- –HL, while forelock, and heterochromia iridium
- –1 in 40000 affected
- –77% of these kids have vestib loss
- auditory neuropathy
- –breakdown of vestib info transmission
- –cVEMP absent often and caloric responses are variable
- GJB2 connexin 26 mutations
- –absent cVEMP and variable calorics, unilateral to bilateral
40
Q
acquired disorders in children
A
- meningitis
- –doesnt always cause vestib loss but can and can also be variable
- –known to delay motor milestones
- –expect poor balance
- ototoxicity
- –when vestib system is affected it is often widespread, otolith and SCCs
- measles and mumps
- –both are virus that is highly contagious
- –vaccination has greatly reduced the concern
- what is the concern most recently? anti-vaccers
