-1 The child Hypotonic Hypotonia: A child with Decreased pitch Diagnostic Always is a challenge.

The interval should be Considered Age That Is Essentially The firs t year of life, if it Appears Later, Rather the focus will be direct to the stud y of paralysis Learned. His condition must be Malthus Approaches Depending on th e age at Which Is this hypotonia presented. The term is Used to denote hypotonia Lack of preparedness for action found in the muscles When There Are Changes in Certain areas of extrapyramidal area of the CNS. In this case, the Influence exe rted by the excitatory pyramidal system on groups of motor neurons and as a resu lt Decreases the Reduction of Its muscles show sensitivity to stretching. GLOBAL IMPACT OF DOWN SYNDROME approaches one in 700 births (15/10.000), but the risk varies with age of the mother. The incidence in mothers of 25 years is 1 p er 2000 live births, while mothers of 35 years is 1 in every 200 births and 1 in 40 women over 40 years. For this reason, prenatal diagnostic techniques recomme nded to all women from age 35. Etiology may be due to central nervous system dys function, muscle disorders or genetic Achondroplasia Aicardi Syndrome Canavan Di sease Congenital Hypothyroidism Congenital Cerebellar Ataxia Syndrome Kernicteru s (brain damage due to severe jaundice) Leukodystrophy Marfan Syndrome Muscular Dystrophy Myasthenia target color Grave Prader-Willi Syndrome Sepsis Rickets CHARACTERISTICS OF DOWN SYNDROME Although there are over 50 recog nized symptoms of Down syndrome is rare to find one person with all or even most of them. Some features include: Lack of muscle tone set eyes, with the skin fol ded on the corner of his eye; hyperflexibility (the ability to extend over the j oints), small hands and broad, with a single crease in the palm of one or both h ands; feet wide with short toes; The flat nose bridge, small ears, at the bottom of the head, short neck, small head, small oral cavity short, high-pitched crie s of children. Individuals with Down syndrome typically are smaller than their p eers, and their physical and intellectual development is slower. Apart from a di stinct physical appearance, children with Down syndrome often experience problem s related to health. Because of the low resistance, these children are more pron e to respiratory problems. Visual problems such as crossed eyes and myopia are c ommon in children with Down syndrome, as well as impairment of speech and hearin g. Approximately one third of babies who have Down syndrome also have heart defe cts, most of which can be corrected. Some individuals are born with gastro intes tinal problems can also be corrected through surgery. In many cases, children wi th Down syndrome are prone to gain weight over time. In addition to the negative social implications, this weight gain threatens the health and longevity of the se individuals. A supervised diet and exercise program may present a solution to this problem. PATHOPHYSIOLOGY excitatory influence exerted by the pyramid schem e on groups of motoneurons decreases and muscles as a result have reduced their sensitivity to stretch Neuropathology BRAIN AND LEARNING DISORDERS: The reception of information, further processing a nd the ability to connect and build new information systems required open and at tentive in the human brain. There are specialist areas and preferred circuits fo r which such information should move and organize. The most active in these proc esses are the hindbrain, the previous association areas, the prefrontal cortex a nd motor cortex These are large structures that are interconnected in an increas ingly complex role of CNS plasticity (CNS) and the child allotments made during its development. CLASSIFICATION 2. According to the presence or absence of movement: a. There are no paralytic hypotonia or adynamia movements. In these cases the hypotonia is u sually secondary to injury neuromuscular3. b. Hypotonia Hypotonia nonparalytic p revails as the main sign, child mortality is normal and the origin of the diseas e is a disturbance in the Central Nervous System (CNS) 3. 3. According to the le vel of the underlying lesion 1: a. Hypotonia neurological injury in the CNS. Thi

s lesion may be localized in suprasegmentaria or central€segmental or periphera l or mixed if it affects both. b. Hypotonia Impaired elastic connective tissues, muscles, tendons and cartilage involved in posture and joint movements. c. Mixe d hypotonia commits both the CNS and the connective tissue. 3. a. From the Heart Disorders Malnutrition not agree Hypothyroidism 2,4,5,6 neurological etiology p rotein-calorie Environmental congenital connective tissue defects b. c. d. Central nervous system hypoxic-ischemic encephalopathy bilirubin encephalopathy congenital cerebellar disease Genetic diseases and chromosomal abnormalities in Prader-Willi Syndrome Spinal cord degeneration spinal muscular atrophy infantile neuronal Polio Nerve, nerve root sensory motor neuropathy e. Neuromuscular junction transient neonatal myasthenia Myasthenia gravis congen ital Infant Botulism f. Myotonic dystrophy myopathy myotubular myopathy central core disease congenital muscular dystrophy by glycogen storage disease Duchenne muscular dystrophy mitochondrial encephalomyopathy. g. Other benign congenital h ypotonia. CLASSIFICATION OF UNKNOWN ORIGIN hypotonic DURING THE PERIOD OF NEWBORN AND NURS ING 1. Suprasegmentarias: a. Hypoxic ischemic encephalopathy Disorders Sepsis Ac ute Bacterial Meningitis intracerebral hemorrhage - b. Inborn Errors of Metaboli sm Chronic disorders of intrauterine growth retardation intrauterine infection w ith cytomegalovirus disease Congenital Toxoplasmosis Congenital anomalies cerebr al tuberous sclerosis Aicardi Syndrome Joubert Syndrome Miller-Dieker syndrome chromosome abnormalitie s Trisomy 21 Loss of the short arm of chromosome 4 loss of the short arm of chro mosome 5 genetic syndromes Prader-Willi Syndrome Zellweger Syndrome Lowe 2. Segm ental a. Progressive spinal muscular atrophy neuropathies Atrogriposis neurogeni c - Mobius syndrome b. Hipomielinizante congenital neuropathy Neuropathy - Guill ain-Barre Syndrome c. Disorders of neuromuscular transmission transient neonatal myasthenia gravis congenital Myasthenia gravis Myasthenic Syndrome Child - Infa nt botulism d. Myotubular myopathy myopathy myopathy myotonic dystrophy congenit al muscular dystrophy Polymyositis centronuclear child Carnitine deficiency - de ficiency of cytochrome-c oxidase 2. A. Mixed Riley-Day syndrome b. Krabbe diseas e most frequent pathologies HEART Between 40 and 50% of newborns with DS have co ngenital heart disease, ie, a disorder of the heart present at birth, this being the main cause of mortality in children with SD. Some of these diseases only re quire monitoring to ensure that their development is adequate, while others may need urgent surgical treatment. Almost half of them correspond to defects of the atrio-ventricular septum (no more or less complete closure of the wall between atria and ventricles). One-third (in around 30% according to sources) are defects of closure of the ventricular septu m (wall separating the ventricles from each other). In general most of these def ects cause inappropriate way of blood from the left chambers of the heart to the right, increasing the pulmonary circulation. Tetralogy of Fallot, in turn, caus es a short circuit reverse, thereby decreasing pulmonary blood flow and appears cyanosis (bluish color because of poor oxygenation of the blood), particularly i n crisis cries or strains. This is a serious disease that requires surgery, usua lly in the first year of life, to repair the defects. Often the clinical examina tion of newborn suspicion can not provide so they can be undiagnosed in the neon atal period up to 50% of newborns with congenital heart disease. For this reason it is recommended to conduct an ultrasound of the heart to all newborns with DS . In the stage of adolescence or young adult may appear defective heart valves ( most often, mitral valve prolapse). Adults with DS have, however, reduced risk o f atherosclerosis and a blood pressure levels lower than in the general populati on, as a population group are considered protected against coronary heart diseas

e (angina, myocardial infarction ...) . Gastrointestinal disorders The frequency of digestive abnormalities or malformations associated with SD is much higher t han expected in general population: about 10% of people with DS have any of thes e disorders. The list of anomalies and their clinical expression (severity with which they are presented) is very wide and variable€but those that are have a h igher incidence of esophageal atresia, duodenal atresia or stenosis and anorecta l malformations. Esophageal atresia is the interruption of the lumen of the esop hagus (this is "blocked" by an incomplete development). The risk of children wit h DS is almost 30 times higher than the general population, and requires early s urgical treatment to prevent aspiration of saliva and food to the airway and all ow adequate transit of food into the stomach. A similar picture is shown in duod enal atresia or stenosis (atresia: total occlusion, stenosis, partial obstructio n), but in this case in the section of intestine located immediately behind the stomach. May be due to mechanical compression of the pancreas by a developmental anomaly called "annular pancreas." This malformation (duodenal atresia) occurs in up to 8% of newborn children with DS. Imperforate anus is the most common ano rectal malformation in children with DS: described an incidence of 2-3% (ie, two or three gives every hundred newborn children with DS have it), while its appea rance in the population generally estimated at around one in 5,000. The diagnosi s is clinical and surgical treatment. Other disorders are relatively common megacolon, or excessiv e dilation of the distal gastrointestinal tract by a defect in relaxation and ce liac disease (digestive intolerance to gluten), which also appear with higher fr equency than that seen in newborns without the syndrome. ENDOCRINE DISORDERS Peo ple of any age with DS have a higher than average risk of developing thyroid dis orders. Almost half have some type of thyroid disease during their lifetime. Thi s is usually mild acquired or autoimmune hypothyroidism in many cases require no treatment, even when the severity required to be initiated as early as possible to see not committed intellectual development potential. Vision Disorders More than half (60%) of people with DS have a lifetime disorder treatable vision or s peech. Astigmatism, the congenital or myopia are the most common diseases. Given the enormous importance of the visual field is for children to learn these peri odic checks are recommended to correct any shortfall in its early stages at this level. Hearing Disorders The particular anatomical arrangement of the faces of people with DS determines the frequent occurrence of transmission hearing loss ( auditory deficits by poor sound wave transmission to the brain receptors). This is due to the presence of trivial but very common diseases such as cerumen impac tion, serous otitis, cholesteatoma or canal stenosis, causing decreased hearing acuity in up to 80% of these individuals. Odontostomatological DISORDERS People with DS have a lower incidence of caries, but often present morphological disord ers often by poorly positioned teeth, agenesis (absence of the formation of teet h), or delay in tooth eruption. Periodic reviews are necessary for a prompt corr ection of major or disorders involving the masticatory and phonatory function. D elayed psychomotor development during infancy children are able, according to pr edictable patterns, physical abilities, cognitive, language, personal and social. Most children achieve these goals in an apparently spontane ous, with more successes than failures. However, children with Down syndrome may face some difficulties in certain areas of development and are achieving these milestones at their own pace, which is generally slower than other children. To assist in this process is important to assist a program of adequate stimulation, that a systematic program of physical therapy, exercise and activities designed to prevent or remediate developmental delays. The program should be individuali zed to meet the specific needs of each child. An intervention program should tak e into account the four major areas of development: gross motor skills and fine motor, language, social and personal development (autonomy). The sooner you star t, the better, though, it's never too late to start. In Cognitive Development ac tivities are smaller in scale Brazelton behavioral responses with lower than exp ected for chronological age. One that is reflected in the early months is eye co

ntact. It is usually given at 4-5 months when it begins to explore the environme nt extramaterno,€being the maximum frequency to 6-7 months. In children with Do wn syndrome this exploratory eye contact and reference may be absent, for exampl e not to look at the mother or the people as they talk, even this problem may pe rsist until 12 or 23 months. Regarding attention, at 9-10 months of development, normal children show more exploratory behavior, while those affected by Down sy ndrome look more toys without going to explore the medium. Even around 12 to 18 months, are focusing more on toys as a minor interactions with her mother and wi th the environment. At 28 months still show repetitive behaviors and less contac t with her mother. Children with Down syndrome have a deficit of short-term memo ry. Being their biggest obstacle to recall the information received aurally. The refore show better results in tests in visual and auditory and visual learn bett er aurally. Involvement in the concept of number is remarkable, but getting bett er with age. Nevertheless, the influence of socio-family environment is crucial in the cognitive development of Down children. Therefore, the sensory-motor beha vior and cognitive, will improve and perfect, according to the efforts and resul ts of rehabilitation of affected functions and academic performance can improve with appropriate cognitive stimulation program. Language development in general and specifically of the vocabulary is slow and difficult. Thus, the first word w ith referential meaning often appears to 20-24 months and the first words are ac hieved around 3 or 4 years. The cause we look at the hypotonia of the muscles of articulation and delayed neuromotor m aturation. Comprehensive Language evolves better, parents should know this and e ncourage interaction where the child has the opportunity to use sign language. R egarding the evolutionary pattern of the game, also follows a slower pace, the c hild is difficult especially when it comes to games and symbolic chains (sets of rules, house, doctor, etc). Children with Down syndrome tend to isolate themsel ves from peers, interacting more with adults. Of course, there are notable indiv idual differences in this aspect, which can not be generalized. The degree of re tardation varies greatly and can be mild, moderate or severe. Most, however, has a mild to moderate retardation, and studies suggest that, with proper intervent ion, fewer than 10 percent of them have severe mental retardation. The child's a cademic performance can be improved with the cognitive stimulation and adequate escorts. It is important to be vigilant to detect hearing or vision problems as there is an increased risk of congenital hearing impairment (50%), hearing loss (75%), diseases of the eyes (60%), including cataracts (15% ) and severe refract ive errors (50%) therefore becomes necessary to revise the annual re-birth and a review of audiological and vision care professionals with experience in caring for these children. Cognitive Performance monitoring should continue during adol escence and adulthood because a considerable number of adults with Down syndrome (15-20 percent) developed Alzheimer's disease when it reaches maturity. DIAGNOS IS Because Down syndrome is made up of such a unique group of characteristics, p hysicians can sometimes determine the existence of the syndrome in a child only with a physical examination. To confirm the physical findings, you can take a sm all blood sample and analyze the chromosomes to determine the presence of extra chromosome 21 material. This information is important in determining the risk in future pregnancies. (Down syndrome Translocation Down syndrome and mosaic impai red have different recurrence risks). Chromosomal abnormalities such as Down syn drome can often be diagnosed before birth by analyzing cells from amniotic fluid or the placenta. Fetal ultrasound during pregnancy can also give information ab out the possibility of Down syndrome, but ultrasound is not 100 percent accurate , since many Babies with Down syndrome on ultrasound that looks like a baby without Down synd rome. A chromosome analysis, whether a blood sample or cells from amniotic fluid or placenta, is greater accuracy than 999 p Other features Some birth defects a ssociated with Down syndrome can cause serious health problems. Babies with Down syndrome often have poor muscle tone or heart problems, stomach or eyes. Intell igence ranges from low normal to very retarded, ie learning is very slow. TREATM

ENT improved treatments for diseases associated with SD has increased life expec tancy of these people, from age 14 a few decades ago, almost to normal (60 years , in developed countries) today. Over the past 150 years have been postulated em pirical treatments (thyroid hormone, growth hormone, glutamic acid, dimethyl sul foxide, vitamin and mineral complex, 5-hydroxytryptophan or piracetam) without a ny longitudinal studies have shown double-blind administration cause any signifi cant positive effect on motor development, social, intellectual or verbal expres sion of people with DS. There is to date no effective pharmacological treatment for SD, although studies launched the human genome sequencing augur a possible a ction (enzymatic or genetic), however, in a still somewhat distant future. The o nly treatments that have shown a significant influence on the development of chi ldren with DS are the Early Childhood programs, aimed at stimulating the central nervous system early in the first six years of life. Especially during the firs t two years the CNS has a very high degree of plasticity which is useful to enha nce mechanisms of learning and adaptive behavior. Individuals with major learnin g difficulties have often been placed in institutions, but it has been found to be living at home, where they develop more fully their potential. Curricular ada ptation in many cases allows a standard integration routine in schools, but must take into account their special needs. The mental age that they can achieve is still to be discovered, and reports directly to the educational and social envir onment in which they thrive. When this is too protective, boys and girls tend (as would happen in a person without SD) to go along, barely discovering th eir potential. Stimulating contexts generated help overcome behaviors that drive the development of intelligence. Consequently, it is impossible to determine th e work and performance they can get in adult life. Enhancing their efforts and b reak the static approaches which they have historically pursued are unavoidable social obligations that companies must address current. THERAPEUTIC APPROACH Thi s is the first link in the therapeutic chain: the baby must be a child who has a n illness and not a set of pathology spreads in the body of a child. With this a pproach the concept of a family group therapy anxious to know, anxiety about the future uncertain and afraid to fight what is not known The first thing you need is to "know" what they are facing. So it is transcendent communication code tha t parents have with their therapist. Early intervention is essential in these ca ses, because no cure, but because more is done early, we better enable this pati ent, working on the basis of the plasticity of the CNS to succeed in getting par ents to make them more operational and strengthening the link with her new baby, you can gradually take its place within the family group that is given from hea lth and not from the disease. In therapy it is important: Management in coordina tion with the physiotherapist. and parents to build a network of support and con tainment of the baby. § Provide parents with space and time to ask and to the e xtent that the mother and father learn to hold, watch and talk "with" your baby and not just "the baby." So we avoid that parents become dependent on the therap ist and therapy. § The therapeutic consultation should be a resource for questi ons and guidance to achieve shared objectives in the short, medium and long term . § The frequency of consultation will depend on the need and possibility for p arents, their commitment to your child and the parent-therapist relationship has been established during the sessions. Therapy should aim to improve the quality of life of the family group, which everyone should participate baby gradually i ncorporating all daily activities€trying not to alter the rules of family life family dynamics but adapting to the entry of a new member. The stimulation shoul d be interpreted as an ongoing activity which takes place in the natural moments (food, hygiene, walking) and not as a g ym to perform three times daily or twice a week. By providing parents knowledge and freedom, we increase their self-esteem, enhance their parenting role and est ablish a method of education, parenting and child empowerment is personal, uniqu e and unrepeatable. If this is achieved at all levels mentioned (family, medical and therapeutic), we will be ensuring the integration of the child, but from wh at adults in their social context and so come to learn what children need to gra

sp. FIRST STEPS THERAPEUTIC PHASE: The family receives an expected child but wit h an unexpected illness. This results in a logical and healthy crisis. To accomm odate the new member is needed spontaneous rearrangement, which fluctuates betwe en rejection and hope to get to reality, which culminates in the acceptance. Thi s will ultimately be resolved feelings of guilt that can generate overprotection of the child and the abandonment of healthy family members. The therapist acts as a chaperone, allowing time and space for their anxieties, fears, anger and qu estions. This is very important to the transmission of disease diagnosis, it doe s not take precedence over the child's image and to establish such a relationshi p in which the child can not be constituted as a person. The diagnosis can thus become a constraint on the prognosis. This is important for the therapist to obt ain a family profile as the need arise, the breeding projects, strengthening sel f-esteem, the establishment of affective bonds. All this will be improving the o peration of the parents. SECOND PHASE: It starts when parents are perceived to h ave been fairly calm their anxieties have been rearranged because they can start listening to suggestions. Early interventions aim to correct the deviations tha t appear in all developmental areas affected. The alterations may involve sensor y areas, motor, intellectual and psycho. You can include extramural activities a s swimming matronatación in common or playground activities with the mother and therapist's systematic These spaces stimulate areas psychomotor, affective, social and neurolinguistic using physicality and its relationship as an essential tool. The frequency of th erapy is established in consultation with parents and according to availability, the severity of the disease and the needs they arise. There will be a joint pro gram of empowerment, with short and medium term to improve the quality of life o f children and their families. THIRD PHASE: Inclusion of specific therapies aime d at Orthodox most affected area (speech therapy, psychology, psychology, kinesi ology). The new professionals who will be added will be linked to the initial th erapist until it is deemed necessary according to the safety of the patient and his family. The moments of change and time duration of each stage is determined according to the maturity of each family group and the evolution of development aspects of the patient. Adapting therapy to life of every family and not to make this life in therapy. CONCLUSIONS For the implementation of a treatment program requires: CUN high degree of commitment from each of the individuals linked to child development. A clear code management to achieve fluency in the communicati on circuit. Transdisciplinary approach. REFERENCES 1. Aicardi J. Pediatric Neuro logy. 2nd edition. 1998 2. à lvarez Fernández Colomer and "The hypotonic infant" in Pediatric Neurology, and Fernández à lvarez Fejerman Eds. 2nd edition. Editori al Panamericana. 1997. 3. Dubowitz V: The Floppy Infant. Physiotherapy and Rehab ilitation eFisioterapia.net MEMBERS Carolina Alvear. Rosibel Caballero. Elena P. Castano. Paola A. Castro. Wilber A. Restrepo.