Clubfoot Clinic Check-in

It has been over a year since we saw our orthopedic team, and so we headed to the specialty clinic early Tuesday morning. Our routine is to get a hip x-ray as well as examine Verity's feet, which were clubbed at birth. (You can read about the early treatments when she was tiny here and see some photos of the progression here. And this is the boots-and-bar phase we were in for awhile. Goodness, she looks so teeny tiny in these early blog posts!)

So, we will give an update on her feet first. I don't have a photo handy of her AFOs, which she has had for nearly a year now, but she has definitely outgrown them. (AFOs = ankle/foot orthotics.) She got the best use out of them when she was weight bearing, so in a stander or gait trainer or the like. When sitting, unfortunately her right foot (the "problem" foot that won't flex all the way) would sometimes get red spots, even though we've always been careful to take them off regularly and check. We had noticed her right ankle seemed just a bit tighter, and the measurements from the PT at the clinic confirmed this.

The good news is that overall, there really isn't much change with her feet, other than growth, obviously! So we have a new prescription for a new set of AFOs. The last ones took at least 3 trips to Hanger Clinic to get "right," and they still maybe could have been adjusted even more, but they worked! And the frayed velcro straps and scuffed bottoms were definite proof that we used them daily!

The doctor does not feel he wants to do foot surgery anytime soon, as long as we can continue getting AFOs that fit properly and allow her to work on weight bearing. This wasn't a surprise, as he had said he felt he had done as much as he could with the last tenotomy surgery (tendon lengthening for the Achilles). 

So that leads to the hips. Dr. S has monitored her hips since we first moved to Colorado in 2017. Verity first saw him when she was about 8 months old. Hip dysplasia is common for our little ones, and while Verity's tendons did need a release in conjunction with the November 2018 tenotomy, her hips have looked pretty good her whole life. 

This x-ray, though, showed a bit of a possible concerning trend. Because Verity has not been able to bear weight, isn't crawling, standing, walking, etc., her hip socket hasn't quite developed right. So on her left side, the femur doesn't necessarily stay well in place! For now, we have the hip abduction brace, shown below, which really is not as uncomfortable as it looks. It's soft and easily adjustable.  In fact, we were all pleasantly surprised when Verity calmed down and almost seemed soothed when we put her in it! (We wondered if perhaps it feels almost like being swaddled feels to a baby?!) She took a nap yesterday afternoon while wearing it. However, since we did not have a nurse on duty at night, we are going to play it safe. As you can also see in the photo, Verity often sticks her fingers in her mouth (which, by the way, is a nice developmental step--she usually seems to be rubbing her gums where teeth are coming in). While she has come a loooong way from a year ago when the only reason she put her fingers in her mouth was to stimulate her gag reflex, she still on occasion does manage to gag herself. With her CPAP mask on at night, we don't want to chance this happening before we can fully wake up and realize what's happening! Since her preferred sleeping position is on her right side, we will utilize the brace as we can during the day and during the occasional night when we do have a night nurse.

While Dr. S has been a pretty good provider overall for us, the way he worded some things seemed to indicate (probably unintentionally) his opinion regarding surgery should Verity need it down the road. When talking about her hip issue, he said if the femur comes out of socket and isn't able to be put back in, OR if she starts showing signs of pain, then--for any other child--surgery would be a given. But his opinion of the surgery seemed to be based on expected outcomes for the patient. His example, cerebral palsy clients, referred to the fact that their expected life span is much longer than for Trisomy 18 patients. Because of my tendency to give people the benefit of the doubt, I'd LIKE to think that his seeming reluctance to consider surgery for Verity may be based on what happened during her last surgery with him. Perhaps her reaction to fentanyl (which is now listed as an allergy on all her medical records) has made him gun shy to put her under again.

But...if our girl gets to the point where she needs surgery, we will make sure she gets it! And if Dr. S is reluctant to do it, we will find someone else willing to go forward. However, I'm hoping it will be a non-issue!

Update: Spring Appointments

Recent posts have detailed the couple of respiratory illnesses that Verity had in March and April, so now it's time for a general update on the slew of other appointments we've had over the past few months! October was our busy month in the fall as the referrals finally went through and we started seeing her specialty providers, and April of course was the 6-month mark for follow-up. So here is the list of what all we've been up to!

March 22: Pulmonology
The pulmonology follow-up was scheduled even before Verity's first illness struck, but it was timed well as she had been out of the hospital about 10 days or so. At that time her lungs sounded amazingly good, and since we had never had any lung issues before, the doctor said she would leave it up to the Sleep Clinic doctor as to whether or not she would continue to follow Verity. Of course, little did we know that Verity would have pneumonia about a month later! Sleep clinic is scheduled for May 25...

April 2: Ophthalmology
We drove 45 minutes to get to Ft. Carson to spend a whopping 5 minutes with Dr. B, who assured us Verity's eyes are looking great and he doesn't need to dilate them again until our fall appointment. Okie dokie then.

April 17: Orthopedics
At this follow-up appointment we got another hip X-ray, which indicated her left hip is still stiff but not any worse than in the fall. Her feet are looking good and we are to continue using the bar (supposedly naps and nighttime but in reality more like 2-3 hour chunks a couple of times a day).

April 19: Pediatric Visit
We needed a doctor to look at Verity's umbilical hernia, which was repaired with her G-tube surgery May 2017 but has been flaring up again recently. She ordered an abdominal ultrasound. (This is the day we realized Verity was getting sick, and at 3am the next morning we took her to the hospital, where she was diagnosed with aspiration pneumonia.)

April 24: Renal ultrasound and barium enema
The ultrasound looked normal (per the follow-up the next day), and the barium enema did not reveal any particular reason for Verity's difficulty pooping, although it did show a "tortuous" pathway. (Once she gets started going she does pretty well, but we frequently have to give her a liquid suppository to start the process.)

April 25: BAHA fitting
Verity got her Bone-Assisted Hearing Aid, which fits on a headband! We learned lots of details about how to use this device and have a whole bag of STUFF to go along with it. She wears it in stints, as it is very overwhelming for her to have it on all the time at this point. Slowly we are working up to it! She isn't terribly responsive, although we know for sure when she is DONE!

April 30: Adaptive Stroller Shopping
We went to an equipment provider that we know of through The Resource Exchange (our home therapy program) to look at and take measurements for an adaptive stroller for Verity.

May 3: Echocardiogram
Our cardiologist is very optimistic about the way Verity's heart looks right now. Her large VSD has completely patched up! She still has a teeny tiny one that causes her heart murmur, but everything is balanced, and he does not think PH will be a problem. Whew! He feels comfortable waiting another year before we do another echo.

May 4: Post-hospital follow-up with PCM
Verity had been off oxygen for some time before we had this appointment, and she looked quite well. Her PCM was pleased.

May 7: Abdominal ultrasound
This was a pretty quick appointment, but we didn't hear anything about the results until I asked a week later. We have a referral to see a pediatric surgeon since clearly the hernia is there.

May 15: Dietitian assessment
Our Verity weighed in at 14 pounds, 14 ounces!! And she is 26 inches long now!! In less than 2 weeks, she will be 15 months old...15 pounds by 15 months!!! Clearly she is growing and thriving on the Nourish formula. Now that she is 100% on this whole-foods mixture (plus plenty of water), our next step is to meet with the GI doc and formulate a plan for compressing her feeds so that she can get on more of a bolus feeding schedule. Her vomiting can still be a problem, particularly when she is bearing down to poo or pass gas, but it is much less frequently to be sure. I'm not going to lie...I would LOVE for her to not be hooked to the feeding pump 24/7. But...counting my blessings. Our baby is growing and thriving and becoming SO much stronger and sturdier!

In between all the above listed appointments were nearly weekly visits to the chiropractor as well as nearly weekly occupational and physical therapy sessions in our home.

COMING UP:
May 25: GI follow-up and Sleep Clinic

May 31: Surgery consult

June 6: Speech evaluation

June 7: BAHA check

Whew. That's all for now, folks!!!

All Kinds of Check-ups

Here are the nitty-gritty after-visit summaries of Verity's recent appointments and a quick word about an upcoming visit.

GI, September 29, 2017
Stats:
BMI: 15.33 (14th percentile)
Weight: 11lbs, 13.5oz (< 1st percentile)
Height: 23.31" (< 1st percentile)

1. Swallow study ordered. [Scheduled for November 30--in the meantime, we need to work with Verity to help her swallow more than she currently is!! The study requires at least an ounce, and she only takes about 5ml on a good day.]
2. Zarbees multi-vitamin recommended [now using daily]
3. Trial of a powdered probiotic recommended [now using daily]
4. Follow-up in 2-3 months to check on weight, feeds, etc.
5. Call or message with weights every 2-3 weeks.
6. Work toward 105-110ml per feeding.

Since this appointment, Verity's reflux problems have resurfaced. Every time we try to bump up her feeding amounts, it seems we see an increase in vomiting and discomfort. We had gotten her up to 95ml, but we went back to 90 the last couple of days and she is still acting uncomfortable during her feedings and shortly after. We've slowed the rate down as well. I spoke with a nurse from the GI office and we are planning to do a pH scope to determine the level of reflux and use the information to help us decide the next course of action. Seemingly, there are two options: medication and a Nissen fundoplication. We do not yet have a date for this test.

ENT, October 16, 2017
Stats:
BMI: 15.80 (23rd percentile)
Weight: 12lbs, 3.9oz (< 1st percentile)
Height: 23.35" (< 1st percentile)

[This doctor was very thorough with his notes! I'm going to copy most of them here and simply link to definitions of the more unfamiliar terms and place explanations in brackets.]

"Verity is a 7-month-old female with a hx of Trisomy 18, hypotonia, aspiration with G-tube placement and bilateral hearing loss. Most feeds are happening through the G-tube. Family had a sleep ABR [Auditory Brainstem Response] back in May of this year that showed severe CHL [Conductive Hearing Loss] in the right ear. MOC feels that the hearing has improved over the last couple of months, no wearing hearing aids at this time. Family has not been evaluated by an ENT prior to today. There are concerns about sleep apnea based on her sleep patterns, retrognathia, hypotonia and her diagnosis of Trisomy 18.

Examination today showed poor tone, not able to hold her head up. Bilateral external auditory canal stenosis, unable to view the ear drums [her ear canals are abnormally narrow]. Some soft tissue narrowing of the nose at the vestibule, improved nasal airway on the mucosal side. Flexible laryngoscopy was performed and showed some mild nasal narrowing in the midportion of the nose, no adenoid obstruction, intermittent collapse of the pharynx when she was bearing down. The vocal cords were mobile with a good view of the larynx, no prolapse of the tongue.

I would like to repeat the ABR during sedation and obtain bone conduction for both sides. I would recommend hearing aids of some form sooner than later. We will order a sleep study to rule out sleep apnea. I would like to see the family back after the sleep study and the hearing test."

Currently the sleep study is scheduled for January 8, but we are on the waiting list in case something opens up sooner. If so, it would be a same-day deal, so we'd need to drop everything and make haste to the sleep lab!! I hope we can get some answers sooner rather than later...these awful nights are killing us!

Orthopedic, October 17, 2017

I don't have a lot of written notes on my paperwork, so I'll try to remember the main points...

1. Verity has responded very well to the boots and bar--we are cleared to use it for nights only and not concern ourselves with nap time since her sleeping habits leave much to be desired.

2. They did change the angle her boots were fixed to the bar so that her feet are not turned outward nearly as much. We hope this is making it more comfortable for nighttime sleeping! 

3. New boots will be fitted on Monday, as her toes are nearly hanging out of her old pair!

4. They took an X-ray of her hips, as there was concern about less movement in her left hip. Things look all right for now, but there is danger of her hip coming out of socket. We are to do certain stretches with her diaper changes to help with this issue.

5. They want a follow-up with the PT in 3 months and with the doctor in 6 months.

Coming up: 

Cardiology (Echocardiogram), October 26, 2017

This appointment is to give us a baseline echo of Verity's heart; when we last examined it in April, everything looked wonderful. The VSDs were all closing, everything was balanced, no heart murmur. However...at the ENT visit on Monday, the doctor heard a murmur, the first time this has happened. He said that if HE could hear it, then it definitely needs checked, since that isn't his specialty. :-/ So...I wasn't concerned about the echo appointment before, but now...I am...a bit...