SPECTRUM OF AUTISTIC DISORDERS
Apart from autism, there are four other neuropsychiatric disorders, which are characterized by problems with social interaction, verbal and non-verbal communication, and repetitive behavior of varying degree of severities. Autism disorder is the first in the list. As to the etiology, no known etiology can be found in 80% - 90% of cases, a genetic syndrome such as fragile X-syndrome or chromosome 15q duplication is found in 10% - 30% of cases. There is strong family component. There has been many claims regarding possible environmental triggering factors especially vaccines and in particular measles, mumps, and rubella. But so far, no link between the uses of MMR vaccine with autism has been found.
WHAT ARE THE 3 ESSENTIAL FEATURES OF AUTISM?
1. Impaired social interaction (extreme aloneness, failure to make contact)
2. Absent or abnormal speech and language development
3. Narrow range of interest and stereotype or repetitive responses to objects
WHAT BEHAVIORS OF CHILDREN SHOULD AROUSE SUSPICION OF POSSIBLE AUTISM?
1. Avoidance of eye contact during infancy
2. Relating to only part of his body (e.g. the lap) rather than to the whole person.
3. Failure to acquire speech or speech acquisition in an unusual manner (e.g. repeating another person’s speech)
4. Failure to respond to name when called
5. Spending long period of time in repetitive activities and fascination with movement (e.g. spinning records, dripping water)
6. Failure to look in the same direction when directed by an adult
7. Absence of pointing to show or request something
8. Excessive lining of toy or other objects
9. Limited pretend or symbolic play
WHEN SHOULD SCREENING BE DONE FOR AUTISM?
It is recommended that all children receive autism specific screening at 8- 12 months and whenever there’s a concern for autism. A younger sibling of children who has autism has 10-20 fold increased risk of autism. Problem with pre verbal gestural language and deficit in social skill is present in most children by 18 months of age. The 23 Autism M-CHAT (modified version of checklist for autism in toddler) is probably the most commonly use screening questionnaire. Positive result, warrant referral to more detailed testing.
DOES EARLY INTERVENTION AND/OR THERAPY IMPROVE THE OUTCOME IN CHILDREN WITH AUTISM?
In general, early diagnosis and involvement of therapies on children with autism does appear to improve outcomes such as decreased need for social education in later years and an increase in the chance for independence as an adult. Certain subsets of children with autism such as those with no co-existing cognitive deficits will fare better. Additionally, early recognition and intervention may assist families in understanding and coping with potentially challenging medical co morbidities and social and behavioral issues. When autism is suspected the child should be referred to specialist in this field, also, referred to speech and language pathologist to get therapy started as soon as possible. All autism needs audiology evaluation because of their language disorder.
- Asthma is the most common chronic inflammatory condition in Children characterized by reversible small airway obstruction, Smooth muscle contraction in the wall of airway; edema and mucous production are the contributing factors for the obstruction. The above change in airway usually follows a stimulating agent which originates from gene-environment interaction that may start in early life and even during pregnancy.
- The initiating or stimulating causes are usually allergens like cold air, perfumes, high humidity and most commonly viruses like viruses causing common cold or cigarette smoke and many others.
- Asthma comes in a form of attack and causes symptoms like persistent coughing, shortness of breath and a musical sound in the chest called wheezing which is because of airway narrowing.
- Breast feeding especially in first 4-6 months of life seems to be protective against later asthma.
- Early complimentary or solid feeding in infant may put the children at high risk for developing allergy (atopic dermatitis and asthma)
- Vitamin D intake through diet, sunlight or supplementation may be beneficial in the prevention of asthma.
- Antibiotic use has been shown to be associated with development of asthma in the later stage of life especially the use of broad spectrum antibiotic in 1st year of life.
- Maternal smoking both during pregnancy and after birth is associated with measurable harmful effect, including greater risk of developing asthma symptoms in early life.
- Respiratory viral illness during early life has been associated with as increase likelihood of asthma.
- The connection of asthma with psychological aspects seems logical because data showing a connection between stress and immune cells of the human being.
Compelling evidence shows that atheroscerotics process (building up of fatty plaque in arteries) begins in childhood and progresses slowly into adulthood. Then it often leads to Coronary Heart Disease, the leading cause of death in many countries. So, elevated cholesterol level early in life can play a role in development of Coronary Heart Disease. There are 3 major Lipoprotein groups which are classified by their density. Very Low Density Lipoprotein (VLDL), Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL).
WHAT ARE THE NORMAL CHOLESTEROL LEVEL OF CHILDREN AND ADOLESCENTS?
Total Cholesterol (mg/dL):
- Acceptable: <170
- Borderline: 170-199
- High: >200
- Accpetable: <110
- Borderline: 110-129
LDL Cholesterol (mg/dL)
WHICH CHILDREN SHOULD HAVE THE CHOLESTEROL MEASURED?
Currently recommendations developed by American Academy of Pediatrics recommended a screening of all children after 2yrs of age, but before 10years, if the following are presents:
1. Family history of parent or grandparents aged 55yrs or younger which documented myocardial Infarction, Atherosclerosis, Angina Pectoris, Peripheral Vascular Disease or Cerebrovascular Disease
2. History of parent with elevated Total Cholesterol more than 240mg/dl
3.Children who may have increase risk of Coronary Heart Disease irrespective of his family such as those who smoke cigarettes ,are overweight, Obese, Diabetic or have Hypertension.
WHAT ARE THE AMERICAN HEART ASSOCIATION DIETARY STARTEGIES FOR ALL CHILDREN OLDER THAN 2 YEARS?
1 .Balance Dietary calories with physical activity to maintain the normal growth
2. Engage in 60 minutes of moderate to vigorous play or physical activity
3. Eat vegetable and fruit daily and limit juice intake
4. Use vegetable oil and margarines low in saturated fats and Trans fatty acids instead of butter or most animal fat in the diet.
5. Eat whole grain breads and cereals rather than refined-grain products.
6. Reduce the intake of sugar sweetened beverages and foods.
7. Use non Fat (Skim) or low fat milk and dairy products daily.
Dr. Hossein Sardari-Zadeh
Armada Medical Centre
The most common anemia in children is Iron-Deficiency Anemia, which can influence physical and mental growth of the child
The blood in your vessels, consist of white blood cells, Red blood cells, platelets and the plasma in which these cells swim in it. Beside the above cells, there are also proteins, lipids, sugars, vitamins and many other little bitty materials. Each of the above has a special function like Red Blood cells (RBC) that contains hemoglobin and has the function of carrying oxygen to the body’s tissues and organs. The decrease of hemoglobin or Red Blood Cells is traditionally called anemia.
The following are the lower normal hemoglobin levels below which children are considered to be anemic:
- Newborn (full term) : 13gm/dl
- 3 months : 9.5gm/dl
- 1 – 3 years : 11.0gm/dl
- 4 – 8 years : 11.5gm/dl
- 8 – 12years : 11.5gm/dl
- 12 – 16years : 12gm/dl
Anemia are of different types and have different causes but the basic problem causing anemia includes:
1. Decrease Red blood cells production in the bone marrow, like leukemia.
2. Destruction of excessive Red Blood Cell (hemolysis) in the vessels as in thalassemia.
3. Blood loss like bleeding, the cause of which could be allergy to cow’s milk protein, parasitic infection or maybe trauma. The symptoms of anemia depend on the age of the child, the cause, and the speed of its development. Most children with anemia are asymptomatic and infrequently may have pallor, fatigue, tiredness, jaundice, and poor gain in weight. They may not be critically ill. In severe chronic cases there may be dyspnea, palpitation, edema, shock, enlargement of spleen and heart, and growth disturbances. History and clinical findings on physical examination with the help of a few simple laboratory tests can reveal the underlying cause of anemia. The pallor and irritability may not show up until hemoglobin is less than 7 – 8 mg/dl.
Among many causes of anemia in children:
The most common is iron deficiency anemia. Where the body is depleted of iron and the red blood cell gets small and pale in shape. This type of anemia can influence the physical, mental growth and the ability of learning in the child. It is usually caused by poor intake of iron, like using cow’s milk, which has low iron with low bioavailability in a child less than one year, bleeding which could be secondary to being sensitive to protein of the cow’s milk, prematurely born baby whish has low iron store, and secondary to different type of sickness. One of the most common causes of iron deficiency anemia in children is low cultural awareness of the quality of foods and feeding, making use of junk foods like chocolate, chips, chewing gum, different type of liquid beverages or taking huge amount of cow’s milk daily, in the second year.
1. Healthy term infants who are exclusively breastfed are at risk of iron deficiency after 5 to 6 months of age if they not use proper complimentary food besides the breast milk. This is more complicated in premature born infant, as their iron store is less.
2. Although breast milk and cow’s milk contain about the same amount of iron, non-heme iron is absorbed at 50% efficiency from breast milk but at only 10% from cow’s milk. In addition, cow’s milk may cause microscopic gastrointestinal bleeding in younger infant as a result of mucosal injury, possibly from sensitivity to bovine albumin. In older infants, cow’s milk may interfere with iron absorption from other sources, too.
3. Screening for iron deficiency anemia should be considered for all infants between 9 – 12 months of age specially if:
- Low birth weight
- Consumption of the whole cow’s milk before the age of one year.
- Use of formula not fortified with iron.
- Exclusive breastfeeding (without solid or formula supplementation) beyond the age of six months).
- Perinatal Blood loss
- Teenage female (if menstruation is heavy or if pregnant)
- Infant living in poverty
4. Iron depletion (with or without anemia) maybe associated with lassitude, and decrease concentration ability and mood swings.
5. Bioavailability of non-heme iron is decreased by phosphates, tennates, polyphenols and oxylates found in cereal, milk, cheese, tea, and complex carbohydrates. It is increase by fructose citrate and specially ascorbic acid found in red kidney beans, cauliflower and banana. In children with iron deficiency, besides the administration or replacement of iron, a Vitamin C fortified fruit juice 30 minutes before a meal makes physiologic sense.
6. Multiple studies have shown an association between iron deficiency in infants between nine and twenty four months old and lower motor and cognitive scores and increase behavioral problems compared with non anemic controls. Some long term studies suggest that the developmental impairments maybe long lasting. Debate remains about whether this relationship remains casual and, if so, whether the correction of anemia leads to reversal of the problems.
Dr. Hossein Sardari-Zadeh
Armada Medical Centre
Recurrent miscarriage is often due to genetic causes
Fertile couples with repeated miscarriages should be evaluated for the presence of a chromosomal abnormality.
Up to seventy percent of miscarriages are caused by chromosomal errors, Chromosome abnormalities occur in 1 of 160 live births, the most common being extra chromosomes 21, 18 and 13.
Chromosomal abnormalities are more common in women who are over thirty-five. Women (and men) older than 35 have a greater tendency to produce eggs or sperm with chromosomal abnormalities.
One or both partners may have a balanced translocation or other silent chromosomal abnormality like an aneuploid mosaic that gives the couple a statistically increased odds of miscarriage in each pregnancy.
The transmission of a chromosome abnormality to an embryo can result in a low implantation rate, miscarriage, or the birth of a baby with a genetic disorder.
Aneuploidy refers to an abnormal number of chromosomes. An extra or missing chromosome is a common cause of genetic birth defects. Aneuploidy occurs during cell division when the chromosomes do not separate properly between the two cells.
Is there help for recurrent miscarriage?
Preimplantation genetic diagnosis (PGD) is most frequently recommended for patients who are at risk for genetic disorders such as cystic fibrosis, Tay Sachs disease, or thalassemia.
PGD is also helpful for patients with unexplained infertility, a history of recurrent miscarriage, unsuccessful IVF cycles, advanced maternal age, or the birth of a child with a chromosome abnormality such as Down syndrome. or male factor infertility. In these cases, the most likely cause is a chromosome abnormality.
Male Factor Infertility
Approximately one-half of all infertility is caused by sperm abnormalities. Many sperm disorders are due to a chromosome abnormality such as aneuploidy or a structural chromosome abnormality.
Y chromosome deletions are found in approximately 5 to 20 percent of males with a very low sperm count. These deletions appear to impair normal sperm development. While these deletions do not appear to cause any genetic disease, they appear to decrease the chance of men with a low sperm count to successfully fertilize eggs in a normal condition .
Men who carry a balanced translocation chromosome are at risk of producing sperm with a structural chromosome abnormality. Studies have shown that approximately 3 to 8 percent of sperm from normal, fertile men are aneuploid and 27 to 74 percent of sperm from men with severe infertility are aneuploid.
Couples with infertility due to male factor should consider chromosome analysis of the male’s sperm prior to IVF.
Aneuploidy and Advanced Maternal Age
Women 35 and older are at a higher risk of producing aneuploid embryos, which results in implantation failure, Aneuploidy is believed to be a major reason for the decrease of fertility with age. Studies have shown that approximately 62 percent of embryos from women of advanced maternal age might be aneuploid.
Prior to attempting a pregnancy, women in this age group should talk with their physician or a medical geneticist about their chances of having a child with a genetic disease and if PGD should be considered.