Disparities in Health Supervision for Children With Down Syndrome

Ophthalmologic and neuro-ophthalmologic findings in children with Down syndrome

Down syndrome, also known as Trisomy 21, is a genetic disorder associated with mild-to-moderate intellectual disability, delays in growth, and characteristic facial features. A wide range of ocular complications are seen in children with Down syndrome, including strabismus, nystagmus, refractive errors, congenital cataracts, the presence of keratoconus, and decreased visual acuity. Early ophthalmic examination is needed for early diagnosis and treatment in patients. This narrative review examines ocular manifestations in children with Down syndrome and the importance of prompt ophthalmic interventions for treatment.

Ophthalmic manifestations in children with Down Syndrome in Bogotá, Colombia

BACKGROUND

To describe the ocular features of a cohort of children with Down Syndrome (DS) in Bogotá, Colombia.

METHODS

We performed a cross-sectional study, evaluating 67 children with DS. A pediatric ophthalmologist performed a complete optometric and ophthalmological evaluation of each child, including visual acuity, ocular alignment, external eye examination, biomicroscopy, auto-refractometry, retinoscope in cycloplegia, and fundus examination. Results were reported as frequency distribution tables with percentages for categorical variables and means and standard deviation or median and interquartile ranges for continuous variables, according to their distribution. We used the Chi-square test or Fisher's exact test for categorical variables and ANOVA or Kruskal-Wallis for continuous variables when indicated.

RESULTS

A total of 134 eyes from 67 children were evaluated. Males represented 50.7%. The children's age ranged from 8-16 years, with a mean of 12.3 (SD 2.30). The most frequent refractive diagnosis per eye was hyperopia (47%), followed by myopia (32.1%) and mixed astigmatism (18.7%). The most frequent ocular manifestations were oblique fissure (89.6%), followed by amblyopia (54.5%) and lens opacity (39.4%). Female sex was associated with strabismus (P = 0.009) and amblyopia (P = 0.048).

CONCLUSION

Our cohort had a high prevalence of disregarded ophthalmological manifestations. Some of these manifestations, such as amblyopia, can be irreversible and severely affect the neurodevelopment of DS children. Therefore, ophthalmologists and optometrists should be aware of the visual and ocular affection of children with DS to assess and provide appropriate management. This awareness could improve rehabilitation outcomes for these children.

A Mixed Methods Analysis of Care Coordination Needs and Desirable Features of an M-Health Application to Support Caregivers of Children With Down Syndrome

INTRODUCTION

Care coordination is critical for the management of health care needs of children with Down syndrome by encompassing management of health information and linking of providers. This study was designed to identify caregiver and health care provider experiences of care coordination to inform the development of an m-health application.

METHOD

In this mixed methods study, caregivers completed survey materials addressing the child's health care needs, m-health use, and care coordination experiences. A sample of caregivers and health care providers were interviewed to further understanding.

RESULTS

Most caregivers reported having a primary health care provider but wanted increased communication and help with care coordination. Interview data identified themes related to care coordination challenges, including information management, information sharing, use of health care guidelines, tracking health data, resources, technology use, previous application use, and coordination of schedules.

DISCUSSION

Qualitative themes were linked to desired features of an m-health application to aid in development.

Health Surveillance in a Down Syndrome Specialty Clinic: Implementation of EHR-integrations during the COVID pandemic

Objective

To address gaps in routine recommended care for children with Down syndrome, through quality improvement during the COVID-19 pandemic.

Study design

A retrospective chart review of patients with Down syndrome was conducted. Records of visits to the Massachusetts General Hospital Down Syndrome Program were assessed for adherence to five components of the 2011 American Academy of Pediatrics (AAP) Clinical Report, “Health Supervision for Children with Down Syndrome.” The impact of two major changes was analyzed using statistical process control charts: a planned intervention of integrations to the electronic health record (EHR) for routine health maintenance with age-based logic based on a diagnosis of Down syndrome, created and implemented in July 2020; and a natural disruption in care due to the COVID-19 pandemic, starting in March 2020.

Results

From December 2018 to March 2022, 433 patients with Down syndrome had 940 visits. During the COVID-19 pandemic, adherence to the audiology component decreased (58% to 45%, p <0.001); composite adherence decreased but later improved. Ophthalmology evaluation remained stable. Improvement in adherence to three components (TSH, hemoglobin, sleep study ever) in July 2020 coincided with EHR-integrations. Total adherence to the 5 AAP guideline components was higher for follow-up visits compared with new patient visits (69% and 61%, respectively; p < 0.01).

Conclusion

The COVID-19 pandemic influenced adherence to components of the AAP Health supervision for children with Down syndrome but improvements in adherence coincided with implementation of our intervention, and re-opening after the COVID-19 pandemic.

As each primary care pediatrician cares for 1–2 patients with Down syndrome (1), for many children the current care model involves a primary care physician providing health supervision for children with Down syndrome following the American Academy of Pediatrics’ (AAP) Clinical Report.(2–4)

Dental health care for children with Down syndrome: Parents' description of their children's needs in dental health care settings

A visit to the dental clinic may be challenging for a child with Down syndrome due to medical and oral health problems as well as communication problems. The aim of the present study was to explore how parents of children with Down syndrome describe their child's needs in the dental health care setting. In a survey concerning parental experiences with dental health care in Sweden, free comments were analysed with content analysis and resulted in five categories: “Need for continuity of care in dental health care”; “Need for dental health care professionals to have knowledge and expertise in caring for children with Down syndrome and other disabilities”; “Need for dental health care professionals to use a caring approach with children with Down syndrome”; “Need for the child with Down syndrome to be prepared to participate in their dental health care visit” and “Need for the child with Down syndrome to be given the same rights as typically developing children”. To support children with Down syndrome in an optimal way, dental health care needs to be tailored to meet the child's unique needs. In addition, dental health care professionals need knowledge of and expertise in the care of children with Down syndrome.

Care Coordination Needs of Families of Children with Down Syndrome: A Scoping Review to Inform Development of mHealth Applications for Families

Care coordination is a critical component of health management aimed at linking care providers and health-information-involved care management. Our intent in this scoping review was to identify care coordination needs of families of children with Down syndrome (DS) and the strategies they used to meet those needs, with the goal of contributing to the evidence base for developing interventions by using an mHealth application (mHealth apps) for these families. Using established guidelines for scoping reviews, we searched five databases, yielding 2149 articles. Following abstract and full-text review, we identified 38 articles meeting our inclusion criteria. Studies incorporated varied in regard to research designs, samples, measures, and analytic approaches, with only one testing an intervention by using mHealth apps. Across studies, data came from 4882 families. Common aspects of families' care coordination needs included communication and information needs and utilization of healthcare resources. Additional themes were identified related to individual, family, and healthcare contextual factors. Authors also reported families' recommendations for desirable characteristics of an mHealth apps that addressed the design of a personal health record, meeting age-specific information needs, and ensuring access to up-to-date information. These results will further the development of mHealth apps that are tailored to the needs of families with a child with DS.

Analysing Touchscreen Gestures: A Study Based on Individuals with Down Syndrome Centred on Design for All

There has been a conscious shift towards developing increasingly inclusive applications. However, despite this fact, most research has focused on supporting those with visual or hearing impairments and less attention has been paid to cognitive impairments. The purpose of this study is to analyse touch gestures used for touchscreens and identify which gestures are suitable for individuals living with Down syndrome (DS) or other forms of physical or cognitive impairments. With this information, app developers can satisfy Design for All (DfA) requirements by selecting adequate gestures from existing lists of gesture sets. Twenty touch gestures were defined for this study and a sample group containing eighteen individuals with Down syndrome was used. A tool was developed to measure the performance of touch gestures and participants were asked to perform simple tasks that involved the repeated use of these twenty gestures. Three variables are analysed to establish whether they influence the success rates or completion times of gestures, as they could have a collateral effect on the skill with which gestures are performed. These variables are Gender, Type of Down syndrome, and Socioeconomic Status. Analysis reveals that significant difference is present when a pairwise comparison is performed, meaning individuals with DS cannot perform all gestures with the same ease. The variables Gender and Socioeconomic Status do not influence success rates or completion times, but Type of DS does.

Demographic and Clinical Characteristics Associated With Adherence to Guideline-Based Polysomnography in Children With Down Syndrome

OBJECTIVES

To compare the demographic and clinical characteristics of children with Down syndrome who did and did not receive polysomnography to evaluate for obstructive sleep apnea after publication of the American Academy of Pediatrics' guidelines recommending universal screening by age 4 years.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary pediatric hospital.

METHODS

Review was conducted of children with Down syndrome born between 2007 and 2012. Children who obtained polysomnography were compared with children who did not, regarding demographic data, socioeconomic status, and comorbidities.

RESULTS

We included 460 children with Down syndrome; 273 (59.3%) received at least 1 polysomnogram, with a median age of 3.6 years (range, 0.1-8.9 years). There was no difference in the distribution of sex, insurance status, or socioeconomic status between children who received polysomnography and those who did not. There was a significant difference in race distribution (P = .0004) and distance from home to the medical center (P < .0001) between groups. Among multiple medical comorbidities, only children with a history of hypothyroidism (P = .003) or pulmonary aspiration (P = .01) were significantly more likely to have obtained polysomnography.

CONCLUSIONS

Overall, 60% of children with Down syndrome obtained a polysomnogram. There was no difference between groups by payer status or socioeconomic status. A significant difference in race distribution was noted. Proximity to the medical center and increased medical need appear to be associated with increased likelihood of obtaining a polysomnogram. This study illustrates the need for improvement initiatives to increase the proportion of patients receiving guideline-based screening.

Otolaryngologic management of Down syndrome patients: what is new?

PURPOSE OF REVIEW

The management of children with Down syndrome as it pertains to the otolaryngologist continues to evolve. Obstructive sleep apnea (OSA) has dominated the recent literature, but other topics including hearing loss, swallowing, and perioperative considerations are also reported.

RECENT FINDINGS

The prevalence of OSA in children with Down syndrome ranges from 57 to 73% in certain cohorts, and, whereas adentonsillectomy can decrease Apnea-Hypopnea Index, up to 80% may have persistent OSA. Surgical techniques involving reduction of the base of tongue are effective for those who fail adenotonsillectomy, and it is expected that drug-induced sleep endoscopy may improve outcomes. New technology is also on the horizon that can assist with diagnosis and treatment including computational modelling and upper airway stimulation. Children with Down syndrome may not respond to medical management of eustachian tube dysfunction as well as normally developing children. In addition, there is a high prevalence of inner ear anomalies, increasing the risk for sensorineural hearing loss.

SUMMARY

Questions remain pertinent to the otolaryngologist regarding the ideal management of children with Down syndrome. Additional studies are necessary, to optimize understanding and treatment of this complex population, in particular as opportunities develop with technological advances.