Fasd Diagnostic Supplement

(MUSIC PLAYING) Dr. Wargowski: So this series of videos serves as a supplement to the podcast on screening diagnosis and assessment of fetal alcohol spectrum disorders. So usually this portion of the evaluation comes in after the initial recognition of a concern about the possibility of a FASD. After information has been gathered about alcohol exposure, the growth history of the child, and the child's developmental and behavioral histories, then comes the physical assessment. So the physical assessment basically has two parts. The first is to look for the three cardinal features, physical features of prenatal alcohol exposure, which are the short palpebral fissures, the smooth philtrum and the thin upper lip. The assessment can go further though and also include evaluation for other characteristics that occur at lower frequency but are easy to assess and can support a diagnosis and in some cases have medical implications for the individual being assessed, and these are things such as cervical spine abnormalities that can limit mobility, radiohumeral synostosis that can limit pronation and supination at the elbows and short distal phalanges of the fingers. The only tool that you really need for this part of the assessment in addition to your usual diagnostic equipment is a ruler, ideally a transparent ruler, and even more ideally to have a few rulers with different colors to provide contrast against a range of skin tones. Some tips are to stablize the ruler against the face by holding your hand against a portion of the face to try to hold the ruler parallel in three dimensions to the palpebral fissure and to get as close as possible to the eye to get an accurate measurement. Also ideal is a neutral facial expression on the patient, this can be a little bit of a challenge in infants at times, so we will see sample exams initially of a child, a school age child to kind of give an overview of the exam and then of an infant and then also an adolescent to highlight some of the challenges that the assessment presents in each of those age groups. The physical assessment portion of the diagnostic evaluation is actually fairly straight forward, and I think simple enough once learned to be incorporated into a well child evaluation. After typical measurements, recumbent length in children less than two years old or standing height, in older children, weight and head circumference, and actually the head circumference needs to be done in children of all ages for this purpose and having all of those plotted on standard charts we can then move into the portion of the examination that's specific to looking for manifestations of prenatal alcohol exposure. So Evan is doing a great job keeping a neutral facial expression, which is ideal, but obviously not always possible. We'll start by measuring his eyes. Evan I'm going to use this ruler just to measure across your eyes just like that. In measuring the palpebral fissures it's best to keep the ruler in an angle parallel with the eye. Really in three dimensions, so if the eye is slanted one way or another, you adjust the ruler this way. If the orbit is cated in or out, you can adjust the ruler this way to get the most accurate measurement. But really you just want to measure from the inner margin of this eye, the inner corner to the outer corner where the skin portions of the eye lids come together. And for children with epicampic folds or folds of skin over the inner margin, sometimes you have to account for that a little bit and add a couple of millimeters to what you can see. So for Evan, I'll put the ruler just like this, and then align my eye sight so that I get a good straight on view of the palpebral fissure, and his right palpebral fissure measures 26 millimeters and then I do the same thing on the left side. Then I'd like to take a look in your mouth if you could tip your head back a little bit and open your mouth wide, very good. So I can look at the rough of your mouth or pallet and then say, ah, okay, and I can see his uvula which has a nice normal formation. Good. Close your mouth. Now what I'm going to have do you is I want to see how your neck moves if you can tuck your chin down to touch your chest. Very good. Okay, now bring your face back up and then tip your head back as far as you can. Good. Bring it back up. And then I want you to tip your head sideways so your ear goes to your shoulder. Very good. Okay, now try on the other side. So Even has nice normal neck mobility. And then the final part is to look at the hands and the elbows. Evan if you would show me your fingers like this, let me look at the palmar creases. There is, in the literature, what's called a hockey stick palmer crease where the distal crease angles up into the space between the first and second fingers, but this is a very nonspecific finding. More important is to look at the distal digits and see how long they are. Shortening or hypoplasia of the distal digits is another characteristic finding, Evan doesn't have that either. Then while we're looking at the hands, keeping the elbow bent, we just pronate and supinate at the elbow to check for any signs of radioulnar synostosis, and Evan doesn't have that either. So as we would expect, Evan has no signs of prenatal alcohol exposure. And that's really the exam, looking for the features that are characteristic of prenatal alcoholism. Not too bad, huh? Speaker: Next we'll seen a assessment of an 8 month old infant. Dr. Wargowski: So Lucy has had her length measured and her weight and her head circumference and now we're going to look at Lucy's eyes (crying) and Lucy's not happy. So obviously, anything we can do to engage her is very good and helpful. And we're going to measure right across her inner campal distance there (crying). Here, look. And get a good look at her right palpebral fissure using the ruler and aligning it with the plain of her eye. You did a very good job, 24 millimeters. And now this is getting in the way here. And now we'll try the left one (crying). And Lucy is cooperating very nicely (rattle shaking). Lucy? You like that card, don't you. And again, aligning the ruler to 24 millimeters on the left side. Your eyes match. Now can we trade? What do you think? You like this better? This has a picture. And what we want to do, again, is compare the lip and philtrum to the lip philtrum guide, and ideally you want to observe Lucy when she's not making a face, which is a challenge in an infant, and I found also that it can be successful to do this part of the exam during the history when the child's actually not engaged. Her lip and philturm are certainly normal. She's got the lip tucked in a little bit at the moment (crying). Now, look, what do we have here? There, now can you can see her lip and philtrum a little bit better. Obviously, a infants neck mobility is a more passive observation, and she has shown a fairly normal range of motion of her neck. We can still do the hand exam. Look for the shortening of the distal phalanges of the fingers and pronation and supination. Let's see on this side. I don't want you to plop over backwards. There, very good job. Finally, an assessment of an adolescent. So in older children, who are either going through or have been through puberty, there are some changes in the face that sometimes throw off the initial impression of the physical characteristics that we're looking for, but the cardinal features are still present, so the evaluation really isn't much different, but I'd ask you to do now, McKenzie, is take your glasses off now please. What I want to do now first is measure across your eyes. So using the ruler, I'll measure from the inner corner of your left eye to the inner corner of your right eye, which is 3 centimeters. And then again angling the ruler to the plain of the eye, measure across your right eye, which has a palpebral fissure length of 29 millimeters, and then on the left do the same thing, and the measurement again is 29 millimeters. Then I'd like to take a look at your ears, if you could turn your head that way for a minute so we can show for the camera, tuck your hair back here, maybe not, there we go. Just to look at the ridges again. And she has nice normal ear ridges, and then back this way, and again on this side, ear ridges look nice and normal. Let's look at your philtrum first, so again she has a nice neutral facial expression, and a very normally formed philtrum and upper lip, somewhere between a 2 and 3 . Okay. Now I'll have you open your mouth and tip your head back just a little bit. Very good. Okay, and then say ah. Okay. Good. Nice normal pallet and uvula, and you had your head half way there, tip your head back as far as you can reach, okay, good. Then bring it back down, now touch your chin to your chest. Very good. Bring your chin back up and then tip your head to your side put your ear on your shoulder and then on the other side. Very good. Nice normal neck mobility. Let's take a look at your hands. Again, nice normal distal phalanges, and then we'll check pronation and supination and that seems fine. Very good. Okay. For more information contact the FASD regional training center nearest you. (music playing)