Care of the Down Syndrome Patient
for the Primary Care Physician
Jennifer Gibson, M.D.
Assistant Professor, ETSU Pediatrics
SW VA Pediatrics Conference, August 3, 2013
Disclosure Statement
I DO NOT have a financial interest/arrangement or
affiliation with one or more organizations that could
be perceived as a real or apparent conflict of
interest in the context of the subject of this
presentation. I DO NOT anticipate discussing the
unapproved/investigative use of a commercial
product/device during this activity or presentation.
Overview
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Down Syndrome: History, Epidemiology, & Genetics
Down Syndrome Physical Features
Diagnosis—How to Diagnose Prenatally and How to
Break the News
Effect of Down Syndrome on the Family
Review of Systems—What Can Go Wrong
AAP Health Maintenance Recommendations
References and Image Sources
Down Syndrome: History,
Epidemiology, & Genetics
History of Down Syndrome
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Initially described in 1856 by John
Langdon Down, an English physician
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Described people with distinctive
physical features & decreased intellectual
ability as grouped into one syndrome
Used the term “mongoloid” because the
facial features of these patients were
similar to those of the Mongolian people
Syndrome linked to a chromosomal
abnormality in 1959 by Dr. Jerome
Lejeune, a French physician
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Discovered that “mongoloids” had 47
chromosomes whereas people without
the syndrome had 46 chromosomes
Shortly thereafter, he performed a
karyotype showing Trisomy 21
Image of Dr. Down from DownSyndrome.com, image of Dr. Lejeune from Wikipedia.org
Down Syndrome Demographics
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Most common chromosomal malformation in newborns
Incidence is usually described as ~1 in 700 livebirths
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Average life expectancy is 49 years (as of 1997)
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Increased from 25 years in 1983
Most common causes of death are congenital heart
disease and respiratory infections
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Classically has been associated with advanced maternal age
Improved life expectancy due to early surgical repair of heart
defects and anomalies of GI tract
Total population of individuals with Down Syndrome is
growing and will continue to grow!
Down Syndrome Demographics
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There is no national registry for prenatal diagnoses of
Down Syndrome or number of livebirths per year.
Review of the National Center for Health Statistics data
on Down Syndrome from 1989-2006:
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Overall, there has been an 11% decrease in Down Syndrome
births from 1989-2006; however, there was a major decline
from 1989-1997 with increasing numbers from 1997-2006
Most Down Syndrome deliveries occur to mothers ages 15-34
years (also population with greatest number of deliveries)
Highest number of Down Syndrome births occur in the South;
fewest births occur in the Northeast
Non-Hispanic whites deliver the most infants with Down
Syndome; African-Americans deliver the fewest
Number of births is fairly equal regardless of educational level
Down Syndrome Genetics
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Sporadic Trisomy 21
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95% of diagnoses
Non-familial
47 chromosomes (one
extra chromosome 21)
Image from Zitelli Atlas of Pediatric Physical Diagnosis
Down Syndrome Genetics
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Unbalanced Translocation
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3-4% of diagnoses
Excess chromosome 21
material attached to
another acrocentric
chromosome, usually
chromosome 14
¾ are new mutations but
must rule out a balanced
translocation in the parents
Mosaicism
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1-2% of diagnoses
Mix of 2 cells lines—one
with Trisomy 21, one
normal
Image from Zitelli Atlas of Pediatric Physical Diagnosis
Down Syndrome Phenotype
Physical Findings in Down Syndrome
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Facial
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Small ears
Upward slant of eyes
Epicanthal folds
Brushfield spots
Flattened nasal bridge
Small mouth
Protruding tongue
Brachycephaly
Neck and Chest
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Nuchal skin fold
Small internipple
distance
Images from Zitelli Atlas of Pediatric Physical Diagnosis
Physical Findings in Down Syndrome
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Extremities
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Single transverse palmar
crease
Clinodactyly of fifth digit
Wide space between 1st
and 2nd toes
Neurologic
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Hypotonia
Extremity Images from Zitelli Atlas of Pediatric Physical Diagnosis; Hypotonia
Image from Living With Cerebral Palsy Website
Prenatal Diagnosis
Prenatal Diagnosis
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Earliest screening methods—maternal age and/or
history of previous infant with Down Syndrome
Amniocentesis and chorionic villus sampling both
provide a means to screen but present a small chance
of pregnancy loss—not ideal!
Multiple screening methods in use today as well as
various combinations of screens
American Congress of Obstetrics and Gynecology
recommends offering all pregnant women in the US
prenatal screening and diagnosis of Down Syndrome
Prenatal Diagnosis Techniques
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Fetal nuchal translucency
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Done via ultrasound at 11-14 weeks’ gestation
Review of 34 studies revealed 76.8% sensitivity in
detecting Down syndrome with false positive rate 4.7%
Results dependent on sonographer experience
Rosen T, D’Alton M. Down syndrome screening in the first and second
trimesters: What do the data show? Seminars in Perinatology. 2005:29:367-375.
Prenatal Diagnosis Techniques
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Second Trimester Screen
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Triple Screen—serum test for decreased maternal
alpha-fetoprotein (AFP), decreased human chorionic
gonadotropin (hCG), and decreased estriol (E3)
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Quadruple Screen—Triple Screen plus serum test for
elevated maternal inhibin-A
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Detection rate of 60% with false-positive rate of 4%
Detection rate of 67-76% with false-positive rate of 5%
First Trimester Screen
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Serum test for decreased pregnancy-associated plasma
protein A (PAPP-A) and elevated free beta-human
chorionic gonadotropin (β-hCG)
Detection rate of 60-74% with false-positive rate of 5%
How to Tell the Family
How to Break the News
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2009 Pediatrics review of 19 articles addressing the best
way to deliver a post-natal diagnosis
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Total of 3359 parental responses evaluated
Parents prefer to hear the news from the obstetrician and
the pediatrician together and to be informed as soon as
the diagnosis is suspected.
Parents prefer to have the discussion in a private place,
to be together, and to have the infant present.
Parents prefer that the conversation begin with positive
words and that language conveying pity, personal
tragedy, or extreme sorrow be avoided.
How to Break the News
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In the initial conversation, parents want 3 questions
answered:
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What is Down Syndrome?
What causes Down Syndrome?
What does it mean to live with Down Syndrome?
In the initial conversation, parents prefer to discuss only
those complicating medical conditions which the infant is
suspected of having or developing in the first year.
Parents want contact information for local support groups
and community resources as well as a list of information
resources (National Down Syndrome Society).
How Does Down Syndrome Affect
the Patient’s Family?
Down Syndrome Disease Burden and
Family Impact
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2011 study examined the results of the 2005-2006 National
Survey of Children with Special Health Care Needs to
profile the families of children with Down Syndrome
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Telephone survey conducted by the CDC
Survey of parents who reported a child with “Special Health
Care Needs” (SHCN)—Down syndrome, asthma, ADHD,
autism, cardiovascular, epilepsy, CP, cystic fibrosis, etc.
Questions included use of a medical home, presence of
unmet needs for care, lack of family support services
Found that 70% of parents of Down syndrome children
reported having no medical home; parents were 2x as
likely to report unmet needs and lack of support than
parents of children with other SHCN
Review Of Systems
Cognitive Effects
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All patients have some degree of cognitive impairment.
Mental development decelerates between 6 months and 2
years of life with a persistent plateau during adolescence
Most patients will have mild or moderate cognitive
impairment; severe impairment is rare
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Language production is often very impaired
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Mild—IQ 50-70
Moderate—IQ 35-50
Severe—IQ 20-35
Also with delayed verbal short-term memory
Early intervention education systems can be initiated
within the first months of life and help to stimulate
development—goal is adult social independence
Cardiovascular
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Most common structural defects in Down Syndrome
Prevalence of congenital heart defects in Down
Syndrome neonates is 44-58% worldwide
Atrioventricular septal defects (aka endocardial
cushion defects) & VSDs are the most common
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Other defects: ASD, PDA, & Tetralogy of Fallot
Higher incidence of persistent pulmonary hypertension
If Down Syndrome was diagnosed prenatally, fetal
echocardiogram may detect some defects
Atrioventricular Septal Defect
Diagram from MyKentuckyHeart.com Website
Cardiovascular
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Physical examination poorly predicts the presence of
congenital heart defects in Down Syndrome infants
Echocardiography is recommended for ALL patients
with Down Syndrome within the first month of life
Goal of early detection is to prevent complications
where possible (i.e. congestive heart failure with
left-to-right shunting, cyanosis in ToF)
Surgical repair of significant defects is usually done
at 2-4 months if possible
Gastrointestinal
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2nd most common structural defect
after cardiac
Duodenal Atresia and/or Stenosis
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Most common GI structural defect
in Down Syndrome
Incidence rates 1-5%
Presents as bilious vomiting on DOL#1
Appears as “double-bubble” on
abdominal x-ray
Requires nasogastric decompression
and surgical correction
Image from Zitelli Atlas of Pediatric Physical Diagnosis
Gastrointestinal
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Hirschsprung Disease
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Found in 1-3% of Down
Syndrome infants
More frequent in males
Symptoms include delayed
passage of meconium, chronic
constipation, failure to thrive
May see transition zone on
barium enema; diagnosed
with suction rectal biopsy
Requires surgical correction
(may include temporary
colostomy)
X-ray image from VCU’s Pedsradiology.com Website; Surgical
image from Zitelli Atlas of Pediatric Physical Diagnosis
Gastrointestinal
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Other structural defects:
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Celiac Disease
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Seen in 5-7% of children with Down Syndrome (10x higher
than the prevalence rate in the general population)
Can monitor with IgA anti-tissue transglutaminase antibodies
beginning at age 3 years
Gastroesophageal reflux
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anal atresia/stenosis
esophageal atresia with or without tracheoesophageal fistula
Rule out aspiration in recurrent lung infections
Constipation
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Serious problem resulting from hypotonia
Ophthalmologic
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More than half of patients with Down Syndrome will
have an occular abnormality
Brushfield spots
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Congenital cataracts
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White-brown spots in the periphery of the iris
Produced by collections of connective tissue
Seen in 38-85% of children with Down Syndrome
Seen in 4-7% of Down Syndrome infants (10-fold higher
prevalence than the general population)
Refractive Errors
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Seen in 43-70% of children with Down Syndrome
Examination is usually difficult
Does not improve as the child ages
Ophthalmologic
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Strabismus
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Misalignment of the eyes
If uncorrected, can result in loss
of vision
Treat with occlusion, correction
of refractive error, surgery
Seen in 20-45% of children with
Down Syndrome
Nystagmus
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Fine, rapid horizontal nystagmus
Occurs in 15-30% of children
with Down Syndrome
Does not require intervention
Image from Reecesrainbow Website
Otolaryngology
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Stenotic external ear canals
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Seen in 40-50% of infants with Down Syndrome
Often result in cerumen impaction and limited visibility
Likely will require visualization by ENT specialist
Canals should grow as the child ages; by age 3-4 years, no
special equipment is required for cerumen removal or for
tympanic membrane visualization
Chronic otitis media
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Increased risk for many reasons (increased frequency of URI,
midface hypoplasia with abnormal eustachian tube insertion,
hypotonia of palatal muscles create negative pressure)
Will take longer to resolve than in unaffected children
May require multiple sets of PE tubes
Otolaryngology
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Hearing loss
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Historically, ~75% of patients with Down Syndrome
developed some hearing loss
Most hearing loss is conductive, but sensorineural and mixed
type hearing losses are also seen
ABR hearing screens should be done in Down Syndrome
patients, as OAE is inaccurate if middle ear fluid is present
Puretone audiometry can detect differences between ears;
however, only 40% of 4-year-olds with Down Syndrome can
cooperate to accurate perform the testing
Even mild hearing loss should be corrected to maximize the
patient’s potential for language and education
Otolaryngology
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Chronic rhinorrhea/sinusitis
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Due to midface hypoplasia and small respiratory passages
Abnormal development of the frontal, maxillary, and
sphenoid sinuses
Usually will resolve with growth
Consider testing immunoglobulin levels, referral for
allergy testing, avoidance of environmental smoke
Utilize nasal saline rinses, nasal steroids, oral
antihistamines
May need adenoidectomy; if already performed, consider
imaging with CT to look for re-growth of adenoid tissue
Otolaryngology
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Obstructive Sleep Apnea
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Predisposing factors—midface hypoplasia, large adenoids
and tongue, small respiratory passages, obesity
Contributes to failure to thrive and pulmonary
hypertension; poor sleep also worsens neurodevelopment
and behavior
Seen in over 60% of patients with Down Syndrome
Evaluate with thorough history and physical exam, formal
sleep study in a sleep lab
Consider treatment with nasal saline washes, CPAP (may
not be well-tolerated), T&A (effective in only 50%)
Dental Abnormalities
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Down Syndrome patients may
demonstrate delayed dental eruption
or eruption out of sequence
Dental anomalies are 5x more
common in Down Syndrome patients
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Teeth are often malformed (sharp, pegshaped), small, and malaligned
Congenital absence of teeth (particularly
the lateral incisors) is also seen
Roots are conical which leads to an
increased risk for periodontal disease
Increased risk for dental caries—poor
oral hygiene, decreased immune
response to oral pathogens
Image from IntellectualDisability.info
Respiratory
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Respiratory infections are responsible for the majority of
the morbidity and hospital admissions in patients with
Down Syndrome
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Down Syndrome is an independent risk factor for developing
bronchiolitis with RSV infection
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Pneumonia commonly precedes admission to the PICU
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Increased risk for hospitalization and for prolonged stay
Higher incidence of acute lung injury than the general population
Increased risk of progression to ARDS
Higher risk for difficult intubation and subglottic stenosis
Recurrent wheeze is very common (up to 36%)
Other anomalies—tracheolaryngomalacia, pulmonary
hypoplasia
Immunology
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Increased susceptibility to infections is linked to abnormal
immune system parameters
Down Syndrome is the most common recognizable genetic
syndrome associated with immune effects
 Adaptive Immunity:
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Innate Immunity
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Decreased T cell and B cell counts
Lack of normal early T cell expansion of infancy
Smaller thymus
Decreased IgA in saliva
Decreased antibody response to immunizations
Decreased chemotaxis of neutrophils
Allergies are not highly-prevalent in Down Syndrome
children (despite chronic rhinorrhea)
Endocrinology
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Thyroid Abnormalities
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Reported in 28-40% of children with Down
Syndrome with increasing frequency as children age
Congenital hypothyroidism—2-3%
 Autoimmune (Hashimoto) thyroiditis—1%
 Compensated hypothyroidism—25-33% (isolated
elevated TSH)
 Graves’ Disease—0-2%
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Diabetes Mellitus—1% of children with Down
Syndrome
Musculoskeletal
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Most problems are due to ligamentous laxity
Occipitoatlantal Hypermobility
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Seen in up to 60% of patients with Down Syndrome
Lower risk of neurologic compromise
Atlantoaxial Instability
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Seen in 15-40% of patients with Down Syndrome (most
frequently-occurring orthopedic problem)
Occurs due to laxity of the transverse ligaments and can
develop during periods of growth
Defined as a distance of >4.5 mm from the odontoid process
of the axis to the anterior arch of the atlas
Usually 12-15% of patients with instability will go on to
develop neurologic sequelae from spinal cord compression
Consider fusion of vertebrae if distance is >10 mm and
neurologic compromise if felt to be imminent
Atlantoaxial Instability/Subluxation
Diagram of vertebrae from Atlas of Chiropractic, Rehabilitation, and Massage Therapy Website,
Diagram of instability from Judo and Down Syndrome Website; X-ray from Learning Radiology.com
Atlantoaxial Instability
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Basic guidance:
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Obtain lateral neck x-rays in neutral, flexion, & extension
positions at 3-5 years & later if symptoms present
If instability is present, avoid tumbling/diving/football
Obtain films prior to any operations or therapies which
involve neck positioning
Review symptoms of cord compression with the family
Musculoskeletal
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Aquired Hip Instability
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Seen in 5% of patients with Down Syndrome
Usually presents at 2-3 years of age
Progresses from acute to chronic to fixed dislocations
May be painful
Likely will require surgical correction
Patellofemoral Dislocation
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Occurs in 4-8% of Down Syndrome patients
Often presents around 2-3 years of age
Usually well-tolerated but may produce some pain
Conservative management with patellar sleeves,
medication, and activity restriction
Surgery may become necessary to preserve ambulation
Musculoskeletal
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Foot Abnormalities
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Include pes plano-valgus, metatarsus primus varus, and
bunions
Usually well-tolerated and treated with supportive shoes
Diagram of dislocation from UMMC website, image
of pes plano-valgus from Medical Observer website
Hematology/Oncology
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Transient neonatal neutropenia and thrombocytopenia with
increased nucleated red cells (no increased blasts!)
Transient Abnormal Myelopoiesis (TAM)
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aka Transient Myeloproliferative Disorder,Transient Leukemia
Seen in 10% of babies with Down Syndrome
Potential to transform into Myeloid Leukemia of Down
Syndrome (ML-DS)
Presents in fetal or neonatal period
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Fetal period—hydrops or anemia; worse prognosis
Neonatal—circulating blasts with/without leukocytosis, bruising,
exudative effusions, respiratory distress, hepatomegaly
Labs: normal hemoglobin and neutrophil count with
thrombocytopenia or thrombocytosis, nucleated RBCs,
immature blasts
Usually resolves within 3 months spontaneously; symptomatic
patients may be treated with low-dose cytosine arabinoside
Hematology/Oncology
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Myeloid Leukemia of Down Syndrome
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Usually presents between 1 and 4 years of age
20-30% of cases developed either as a progression from
TAM or after an apparent remission
70% of cases have preceding myelodysplastic phase—
progressive anemia and thrombocytopenia with dysplastic
changes to the erythroid cells and megakaryocytes as well as
hypercellularity of the marrow
Labs: reduced number of normal cells with dysplastic
changes in all myeloid lines and circulating blasts
Treatment with cytarabine
5-year survival rate of 80%
Hematology/Oncology
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Acute Lymphoblastic Leukemia of Down Syndrome
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1.7x more frequent than ML-DS
Clinical features are similar to ALL patients without Down
Syndrome
>90% have pre-cursor B-cell immunophenotype
More likely to have a less favorable prognostic karyotype
60-70% of children are cured (less than cure rates for ALL
without Down Syndrome) because of increased treatmentrelated toxicity events (infection and mucositis)
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Do not want to alter treatment because of high relapse rates
Genitourinary Abnormalities
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Urinary Tract Abnormalities
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Seen in ~3% of children with Down Syndrome
Hydronephrosis, hydroureter, renal agenesis, hypospadius
No recommendations for routine screening with renal
ultrasound, but clinical threshold to perform test is low
Sexual Development
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Similar to other adolescents for both females and males
Males have decreased ability to reproduce
Education to prevent pregnancy
Be aware of increased risk for sexual abuse in females
Neurology
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Epilepsy—more common in Down Syndrome patients
(0-13%) than in the general population
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Two age peaks—one in the infant period (40%), one in
the 3rd decade (40%)
Infant type—most likely infantile spasms or tonic-clonic
seizures with myoclonus
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Onset at 6-8 months of age
Male predominance; prematurity, congenital heart
disease, and family history of epilepsy increase the risk
Three EEG features: symmetrical hypsarrhythmia, no
focus revealed with IV diazepam administration, single
rather than clustered spasms on ictal EEG
Difficult to treat—no true drug of choice (ACTH,
vigabatrin, sodium valproate, phenytoin, diazepam)
Probable worsening of neurodevelopmental outcome
Early-onset adulthood—usually GTC or complex partial
Behavior
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Very pronounced neurobehavioral and psychiatric
problems—18-38% of Down Syndrome patients
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Most frequent in childhood are the “disruptive
behavioral disorders”
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ADHD—6%
Conduct Disorder/Oppositional Defiant Disorder—5%
Aggressive Behavior—6.5%
Obsessive-Compulsive Disorder
Autism Spectrum Disorder—6%
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More difficult to diagnose and to treat
Difficult diagnosis—overlap in behaviors
Psychiatric Disorders (more common in adults)
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Major Depressive Disorder—6%
Growth and Nutrition
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Children with Down Syndrome tend to grow more
slowly than children without the syndrome
Special Down Syndrome growth curves were created to
help account for this decreased growth rate (congenital
heart disease, thyroid disorders, hypothalamic
dysfunction, nutritional deficiencies, etc)
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Growth curves are more than 25 years old
Current recommendation from AAP is to plot Down
Syndrome children on the regular WHO/CDC growth curves
Currently, CHOP is working on the production of new growth
curves for Down Syndrome patients
Growth and Nutrition
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Obesity
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Up to 50% of children with Down Syndrome can be
classified as obese (higher than general population)
Also at increased risk of developing type 2 diabetes
Multiple factors:
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Physiology—slowed metabolic rate (burn fewer calories),
increased rates of hypothyroidism (slows metabolic rate),
increased leptin (stimulates satiety, too much = decreased
sensitivity), poor mastication (choice of softer foods)
Behavior—less vigorous physical activity, ADHD, oppositional
Management—encourage (safe) physical activity—family
events, Special Olympics involvement
Growth and Nutrition
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Nutrition
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Balanced diet with vitamin and mineral supplementation
Caloric restriction to prevent obesity or promote weight loss
Limits on portion sizes, reducing foods with hidden sugar
(cereals, beverages)
Encourage consumption of healthy softer foods (yogurts,
steamed vegetables, purees) if chewing difficulties
Discourage use of food as rewards or punishments
Referral to nutritionist if necessary
AAP Health Supervision
Recommendations
(2011)
At All Health Supervision Visits
(regardless of age)
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Monitor growth (height, weight, BMI) on standard WHO
growth curves
Evaluate for signs of neurologic compromise secondary to
atlantoaxial instability
Screen hearing every 6 months until normal hearing levels
are established with ear-specific testing, then screen yearly
Evaluate for symptoms of celiac disease
Evaluate for evidence of seizures
Evaluate for symptoms of sleep apnea
Evaluate for behavioral issues
Immunize appropriately, including 23-valent pneumococcal
vaccine or Synagis as applicable
Screening Labs and Referrals
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Echocardiogram at birth
TSH at birth, 6 months, 12 months, and then annually
CBC at birth; hemoglobin at 12 months and then annually
with reticulocyte count and ferritin levels added if iron
deficiency is a concern
Ophthalmology referral prior to 6 months; follow-up yearly
from 1-5 years, every 2 years from 5-13 years, and every 3
years from 13-21 years
Sleep study referral prior to 4 years
Neutral-position neck x-rays if neurologic signs present
with flexion/extension x-rays only if neutral x-rays show no
significant findings
Anticipatory Guidance
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Discuss avoidance of excessive extension or flexion of the
neck, contact sports and trampolines, and the need for
asymptomatic patients to have x-rays prior to sports or
Special Olympic participation
Encourage optimal nutrition and exercise for the family
Discuss available resources such as Early Intervention
programs, in-school therapy services or education programs
for vocational training, and local support groups; provide
literature or websites for more information
Prior to adolescence, discuss pubertal changes and need for
female gynecological care
Help with transition to adult medical care when appropriate
References
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Arya R, Kabra M, Gulati S. Epilepsy in children with Down Syndrome. Epileptic Disorders
2011;13:1-7.
Barksdale E. 2007. Surgery. In B Zitelli, H Davis (Eds) Atlas of Physical Diagnosis.
Philadelphia:Mosby, p 637-639.
Bay C, Steele M, Davis H. 2007. Genetic Disorders and Dysmorphic Conditions. In B Zitelli, H
Davis (Eds) Atlas of Physical Diagnosis. Philadelphia:Mosby, p 9-10.
Bull, M and Committee on Genetics. Clinical Report—Health supervision for children with Down
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Image References
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Title Slide Image—MyChildWithoutLimits.org Website, http://www.mychildwithoutlimits.org/?page=laptop-computers
Dr. John Down Image—DownSyndrome.com Website, http://downsyndrome.com/history-of-down-syndrome/
Dr. Jerome Lejeune Image—Wikipedia.org Website, http://en.wikipedia.org/wiki/J%C3%A9r%C3%B4me_Lejeune
Karyotypes and Physical Feature Images-- In B Zitelli, H Davis (Eds) Atlas of Physical Diagnosis. Philadelphia:Mosby, p 9-10.
Fetal Nuchal Translucency Image, Rosen T, D’Alton M. Down syndrome screening in the first and second trimesters: What
do the data show? Seminars in Perinatology. 2005;29:367-375.
Atrioventricular Septal Defect Diagram—MyKentuckyHeart.com Website, http://mykentuckyheart.com/information/AVCanal.htm
Strabismus Image—Reece’s Rainbow Down Syndrome Adoption Ministry Website,
http://reecesrainbow.org/category/waitingbycountry/russia/3region
Dental Image—IntellectualDisability.info, http://www.intellectualdisability.info/physical-health/dental-problems-in-peoplewith-downs-syndrome
Atlas and Axis Diagram—Atlas of Chiropractic, Rehabilitation, and Massage Therapy Website,
http://www.atlascnr.com/faqs.htm
Atlanto-Axial Instability Diagram—Judo and Down Syndrome Website, http://www.specialneedsjudo.eu/dis/5073/
Atlanto-Axial Instability X-ray—LearningRadiology.com Website,
http://www.learningradiology.com/archives06/COW%20214-Atlantoaxial%20subluxation/atlantoaxialcorrect.htm
Patellofemoral Dislocation Diagram—University of Maryland Medical Center Website,
http://www.umm.edu/imagepages/9721.htm
Pes Plano-Valgus Image—Medical Observer Medical Education Website,
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%20children%20-%205%20Oct%202007/Flat%20feet/Flat%20feet.html
CDC Regular Growth Curve, http://www.cdc.gov/growthcharts/data/set1clinical/cj41l018.pdf
Down Syndrome Growth Curve—Magic Foundation Website,
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