Strokes in Children: What Parents Should Know

Many might picture a stroke patient as middle aged or elderly, but the reality is that the ailment occurs in people of all ages, a CHOC Children’s neurologist says.

A stroke happens when blood flow to the brain stops, and many types exist, Dr. Sharief Taraman says.

Dr. Sharief Taraman

  • Ischemic strokes, most common in children, prevent oxygen and nutrients from reaching the brain. This causes brain cells to die, and can result in permanent damage to the brain and body’s functioning.
  • In hemorrhagic strokes, which are uncommon in children, the blood vessel breaks, which floods the brain with blood and damages brain cells.
  • Perinatal strokes occur in babies near their time of birth, usually during delivery or right after birth because the infant lacked oxygen during delivery.

Stroke causes

Each year, between six and 13 of every 100,000 children will experience a stroke, and they are most likely to happen between a woman’s 28th week of pregnancy and one month after birth.

In older children, strokes are often caused by another condition that can affect blood flow to the brain, Dr. Taraman says. The largest risk factors for stroke in children include heart disease (19 percent), blood clotting disorders (14 percent) and dehydration (11 percent).  About a quarter of young stroke patients have a combination of risk factors.

Further, children with some, few or no vaccinations are more than seven times more likely than fully vaccinated children to have a stroke, Dr. Taraman says. This is likely because many vaccine-preventable illnesses, such as chicken pox, can injure the brain’s blood vessels.

Girls who have migraine headaches that show symptoms before pain begins – a type called “migraine with aura” – are also at a higher risk of stroke. Clinicians are still working to understand the connection fully. There is evidence, however, that some types of oral contraception can exacerbated the migraine-stroke risk. Patients should discuss the risks with their physician when selecting a medication, Dr. Taraman says.

What to look for

Signs of stroke vary widely in children, depending on their age and the resulting brain cell damage. Symptoms include slurred speech, blurred vision, memory loss or sudden weakness.

Children who have experienced a perinatal stroke sometimes tend to favor one hand more than the other. They may also grow normally, but development may occur at a much slower pace than other children. Those whose strokes caused more substantive brain damage may also experience seizures. Often, signs of perinatal stroke don’t materialize until months or years later.

It’s important that children who have experienced a stroke get medical treatment as quickly as possible. Parents who suspect their child has had a stroke should see a doctor immediately or call 911.

Stroke diagnosis, treatment

Strokes can be difficult to diagnose because their symptoms can be subtle and patients who have strokes often have another illness, Dr. Taraman says. To diagnose strokes, physicians rely on blood tests and a variety of imaging techniques.

Treatment varies among patients. Those who are diagnosed during the episode can receive medication that can off-set potential damage. Others may receive treatment for the underlying condition, such as a heart problem, or a resulting condition, such as seizure.

Regardless, children also require extensive rehabilitation that includes neuropsychology; developmental monitoring; educational intervention; and physical, occupational, and speech therapies. Most of the functional recovery occurs in the first two to three months after the stroke.

CHOC has a collaborative team to treat pediatric stroke aggressively. Learn more about the CHOC Children’s Neuroscience Institute.

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Keeping Kids Safe Around Water

It’s usually a lapse in supervision that results in drownings – not a lack of supervision, a CHOC Children’s community educator tells CHOC Radio.

In this podcast, Amy Frias explains that grownups need to designate one person as a “water watcher” while children are swimming, and make changes in water watcher shifts clear.

In this podcast, Amy also discusses several other aspects of water safety:

  • Physical barriers around bodies of water
  • Floatation devices and pool toys
  • What drowning looks like

Learn more about the Kohl’s Water Safety and Education Program and download printable tip sheets with information to help keep children safe in the water.

Families can call the CHOC community education department at 714-509-8887 to request a “water watcher” tag that can be worn as a necklace to clearly identify who is responsible for watching swimmers.

CHOC Radio theme music by Pat Jacobs.

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The HPV Vaccine: A Pediatrician’s Perspective

By Dr. Shruti Vora, pediatric resident at CHOC Children’s

What is HPV?

Human papilloma virus affects nearly all sexually active men and women at some point in their lives according to the Centers for Disease Control and Prevention (CDC). Many people “clear” or fight off their infections within one to two years, never knowing that they ever had an infection at all. A percentage of people with the virus do not clear their infections and may develop genital warts, cervical cancer, head and neck cancers, and penile cancers.

What is the vaccine made of?

Scientists use a “virus-like particle” to make the HPV vaccine. It cannot cause HPV because it is not a portion of the actual virus. The serotypes (specific strains) responsible for the majority of cancers are HPV 16 and 18.  Ninety percent of genital warts are caused by HPV 6 and 11. All four serotypes are contained in the quadrivalent (four type) Gardasil vaccine. Gardasil 9, which covers nine additional strains, will soon be replacing the quadrivalent Gardasil, offering even better protection.

If HPV is transmitted sexually, and my child is not having sex, why do they need to get the vaccine?

The HPV vaccine is a preventative vaccine. Studies have shown that in patients who never had HPV, the effectiveness of preventing pre-cancerous changes to the cervix was 97-100 percent . This is why the vaccine is recommended in all girls before they begin to be sexually active. The vaccine is also known to be more effective when given at a younger age. It is recommended in girls 9-26 years of age.

My son is not at risk for cervical cancer, why should he get the vaccine?

The vaccine is recommended in all boys ages 9-21 years due to the fact that many head and neck, penile and anal cancers are directly linked to HPV serotypes 16 and 18. Vaccinating males can also help prevent cervical cancer in their female partners by reducing the rate of transmission.

I am concerned that my child will become sexually active at an earlier age because they received the HPV vaccine.

This is a common concern and actually has been studied multiple times. In the journal Pediatrics in 2012, doctors looked at the medical records of 493 girls who received the HPV vaccine and 905 who did not. There was no difference between the number of pregnancies, rates of sexually transmitted disease testing, or discussions regarding birth control between the two groups.

How do we know that giving the vaccine will not have any side effects?

The most common side effect has been pain and redness at the site of the shot. Fainting has also been reported as the second most common side effect, but the CDC has recommended some years ago for all patients to stay seated or lying flat for 15 minutes after the injection is given. This has greatly reduced the number of fainting spells and subsequent falls.

The HPV vaccine is a rare opportunity for you to make an investment in your child’s future and potentially prevent cancer in our young ones.  Ask your pediatrician about it.

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Cheerleading Safety Tips

Cheerleading is a physically demanding sport, much like ballet or gymnastics. Sports medicine specialists at CHOC Children’s regularly treat common sports injuries like ankle sprains and tendinitis, but say athletes may be overlooking some of the more serious injuries, and ways to avoid them, according to Dr. Jonathan Minor.

Dr. Jonathon Minor

Stress fractures in the feet, shins and back, herniated discs, spinal cord and vertebral injuries, elbow and shoulder dislocations, concussions and major fractures, are some of the other potential injuries athletes, parents and  coaches should be aware of and monitor for, says Minor.

Since each member of a cheer squad plays a unique role, they’re exposed to different potentials for injury. Flyers, bases and spotters rely on one another in teamwork to safely perform stunts and poses. One slip up could mean foot coming into contact with a teammate’s head leading to a concussion, or a fall to the ground with a major injury.

Like many other sports, youth cheerleaders spend many hours each week working together and developing teamwork that depends on a sense of trust and communication in order to perform with perfection. But this can often lead to overuse injuries, says Minor. Overuse injuries are becoming more common in youth sports because increasing pressure to compete at a higher level leads athletes to specialize in one sport at a younger age, as opposed to trying other activities in their off season. Learn how to prevent overuse injuries.

Much like gymnastics, running, diving, figure skating and dance, among other sports, there is an aesthetic look that the sport cultivates, such as low body weight and a slim build. The pressure of appearance and the rewards of recognition, says Minor, can promote unhealthy eating behaviors and disorders. This can lead to broken bones, stress fractures and muscle strains because bones and muscles don’t properly recover from stress and demands. Learn more about the warning signs of eating disorders.

Although cheerleaders can suffer serious sports injuries due to the physical demands they meet that are unparalleled in other sports, safety and proper education when performing stunts, as well as communication with teammates, is paramount to preventing these injuries.

Learn more about CHOC’s sports medicine program.

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In the News: CHOC’s Feeding Program

Dr. Mitchell Katz, a CHOC Children’s pediatric gastroenterologist, recently appeared on the radio program “Good Food” on KCRW to offer insight into the challenges parents face when their child can’t or won’t eat.

Dr. Katz is the director of CHOC’s Multidisciplinary Feeding Program and pediatric GI lab services.

CHOC’s multidisciplinary feeding program is one of only a handful of specialty feeding programs in the United States to offer comprehensive outpatient consultation and inpatient programs.

Children under evaluation and treatment for feeding disorders at CHOC have typically failed outpatient feeding therapy and have either a feeding tube or at risk for a feeding tube. Patients  can have a range of medical problems, or difficult behaviors that make meal times a struggle. The program receives referrals from throughout the country.

Listen to Dr. Katz’s insight below:

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Autism awareness and safety

By Kelly McKinnon-Bermingham, director of behavior intervention and Anna Laakman, director of education and training, at The Center for Autism and Neurodevelopmental Disorders

April is Autism Awareness Month. According to the Center for Disease Control, one in 68 children has been identified with autism spectrum disorder (ASD). The Center for Autism & Neurodevelopmental Disorders has made safety one of our priorities for our families.  That means that there are over 45,000 people living in Orange County with autism. As our temperatures start to warm up, there are a few things we should be thinking about when it comes to safety and kids with ASD.

Individuals with ASD often present a unique set of skills as well as challenges. One of those challenges is safety. There are so many important safety considerations that parents, caregivers, providers and schools need to be aware of when interacting with or helping an individual with ASD.  Nearly half of all children with ASD will wander away from a safe environment at some point during their lives. Of those, roughly a third are non-verbal. We also know that individuals with ASD are often drawn to roadways, trains, and water. In past years, accidental drowning accounted for 91 percent of deaths reported in children with ASD age 14 and younger who went missing.  There are resources available to help prevent wandering and related accidents. Autism Speaks has several tools and tips for parents, schools and communities to help support individuals with autism.

To help prevent wandering, you can:

Secure your home

  • Make sure you secure entries and exits to your home in a way that an individual with ASD cannot easily leave on their own. Motion detection systems are also an option so family members are alerted if someone is leaving a safe space.
  • Place STOP signs at exits and doorways. Practice stopping and waiting to hear “Go”.

Consider tracking devices

  • There are many GPS devices that families can purchase and utilize with individuals with ASD who may be at a higher risk for wandering. Many devices can be synced with your cell phone or tablets so that you can easily locate an individual and you are alerted if they leave an expected location.

Consider ID bracelets

  • If an individual wanders from a safe space, it is helpful to have some basic identifying information so that people know who to contact.
  • Label or write name and phone numbers into your child’s clothing.

Teach your child to swim

  • We know that many individuals on the spectrum are drawn to water and it is crucial that they be able to swim.
  • Most cities offer swimming lessons or aquatics programs that can be found on the city’s website.
  • Use social stories with your child to explain when and where they can and cannot swim.

Alert your neighbors

  • Informing close and familiar neighbors regarding your child’s safety concerns can help set up phone trees and provide other families that may be on the look out for your child with necessary information.

Alert first responders

  • Your local police department or fire department may have additional resources and tips that you can use to help support your child with ASD. You may also alert your local police department of your address and your child’s unique needs, especially wandering. Police departments will want to know places your child may like to frequent, their interests and any other unique communication concerns your child may have.

Together, we can help prevent wandering. Learn more about additional safety resources.

CHOC Children’s is a member of The Center for Autism and Neurodevelopmental Disorders, in collaboration with UC Irvine.

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Depression and Anxiety in Cystic Fibrosis Patients and Parents

A recent study of over 6,000 cystic fibrosis patients, ages 12 years through adulthood, and over 4,000 parents, found that depression and anxiety were two to three times more elevated in patients with cystic fibrosis (CF) and in parents of children with CF compared to the general population.[1] Although depression and anxiety are common in CF, the stigma associated with mental health issues often make people less likely to talk about them.  When left untreated, depression and anxiety can affect a patient’s ability to effectively manage his treatment plan.  CF patients with untreated depression, anxiety or both tend to have worse lung function and lower body mass index, in addition to experiencing more hospitalizations.

To address this issue, the Cystic Fibrosis Foundation (CF Foundation) announced newly developed guidelines for screening and treating depression and anxiety.  CHOC Children’s  —  one of only a few affiliated care centers of the CF Foundation in Southern California and the only CF treatment center in Orange County — is one of the first care centers to adopt the recommended guidelines.

“The psychology component of our cystic fibrosis program really makes CHOC stand out,” said Dr. Amy Harrison, pulmonologist and CF specialist at CHOC. “Our multidisciplinary approach allows our care team to manage all aspects of CF from diagnosis to physical and mental health.”

Dr. Amy Harrison

The program is a recent recipient of the CF Foundation’s grant, Implementation of the Depression and Anxiety Guidelines: Award for a Mental Health Coordinator. The grant provides CHOC the opportunity to have a psychologist at every CF clinic to help patients and families, and extends the CF social worker’s availability. They will provide annual screenings, evidence-based interventions and follow-up care for depression and anxiety, as well as develop a community referral network of mental health providers.

Guideline Recommendations

The guidelines propose that screening and treating depression and anxiety should become a routine part of CF care. The voluntary screening consists of completing a couple of short questionnaires.

Recommendations include:

  • All patients 12 years and older should receive annual screening for depression and anxiety.
  • Parents and caregivers of patients 17 years and younger should be offered annual screening for depression and anxiety.
  • A stepped process for prevention, screening, assessment and intervention. This can include talk therapy, medication or a combination of the two.

Staying Well

Patients and caregivers who recognize the beginning signs of depression or anxiety should speak to their CF care team.  In partnership with the patient and/or family, CHOC’s team will recommend the appropriate interventions.

“CHOC wants to help patients and parents break their goals into manageable pieces and focus their energy where they would get the most ‘bang for their buck.’  Patients and caregivers are experts on their own lives, so this is truly a partnership to help families continue the strategies that work for them and make changes to those that don’t,” explains Adrianne Alpern, Ph.D., a postdoctoral fellow in CHOC’s pediatric psychology department and a member of the CF team.

The CF Foundation offers the following general guidelines to help mitigate the impact of depression and anxiety:

  • Talk with someone, preferably in person.
  • Spend time with people who lift your spirits.
  • Avoid alcohol and drugs.
  • Continue with your CF treatment plan.
  • Practice good sleep habits.
  • Spent 30 minutes outside each day.
  • Make time for things you enjoy.
  • Be physically active.
  • Practice relaxation techniques.
  • Avoid caffeine and cigarettes.

Referral to the CHOC Cystic Fibrosis Center

When a child is diagnosed or is suspected to have CF, a referral to an accredited CF care center can ensure that the child gets diagnosed properly, lives a long and healthy life, and receives treatment based on the most advanced research available. With access to a full range of CHOC pediatric subspecialists, the CHOC Cystic Fibrosis Center offers a number of life-enhancing technologies and treatments.

CHOC’s multidisciplinary CF clinic includes a board-certified pulmonologist and gastroenterologist, respiratory and physical therapist, nutritionist, nurse specialists, social worker and a psychologist. An endocrinologist and other specialists are available to attend the appointment, if needed. Genetic testing and counseling can also be provided.

For appointments, please call the Patient Access Center at 888-770-2462 (888-770-CHOC).

[1] Quittner AL, Goldbeck L, Abbott J, Duff A, Lambrecht P, Solé A, Tiboshc MM, Brucefors AB, Yüksel H, Catastini P, Blackwell L, Barker D. Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of The International Depression Epidemiological Study across nine countries. Thorax. 2014;69:1090-1097. doi:10.1136/thoraxjnl-2014-205983

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Choosing the Right Milk for Your Family

By Rima Kandalaft, MS, RD, CSP, clinical dietitian at CHOC Children’s

Milk is the white liquid that comes out of the udder of cows and other mammals, right? Well mooooove over cows, several plants are being “milked” too. Plant-based milk alternatives have been gaining in popularity recently. Consumers can choose from soy milk, almond milk, rice milk and many others.

A quick stop at the supermarket to grab some milk is not so quick anymore. You walk down the dairy section and you are confronted with endless choices:  cow’s milk with three to four varieties of fat content, with or without lactose, plain or flavored. Not to be outdone, plant-based milk alternatives are also available in several flavors, and with varying fat contents.

Let’s take a look at the nutritional benefits of cow’s milk.

It is packed with good-for-you nutrients like protein, calcium and phosphorous. An 8-ounce cup of whole milk has about 150 calories, 8 grams of protein, 8 grams of fat, and 12 grams of carbohydrates (mostly the milk sugar known as lactose). Skim milk has all the goodness of whole milk, but no fat and only 90 calories. It is an option for those trying to cut back on calories and/or saturated fat and cholesterol.

People who are lactose intolerant don’t have enough lactase, an enzyme necessary for digesting the lactose in milk. Lactose-free milk is processed to break down lactose.

So what about the non-dairy milk beverages available?

Plant-based milk alternatives, such as soy, almond, cashew, rice and coconut milk, are good choices for vegans and vegetarians, or for those with allergy concerns. They are typically fortified with calcium, vitamin D and other nutrients. They are lower in calories than dairy milk, unless they are sweetened. With the exception of soy milk, they are quite low in protein.

You may have heard about a new product on the US market called A2 milk™. It’s produced and marketed by a company based in New Zealand, where A2 milk was introduced about 15 years ago.

Let’s look at basic dairy science. Milk proteins are 80 percent casein and 20 percent whey. Beta-casein is the second major casein protein. The two major genetic variants are A1 and A2 beta-casein. They differ by one amino acid at position 67 in the protein chain.

Regular cows’ milk contains both A1 and A2 beta-casein. The A2 milk™ brandcontains only A2 beta-casein. This is achieved through selective breeding of the dairy herd.

A few studies correlate A1 beta-casein with various adverse health effects, and suggest that for certain individuals, A2 beta-casein may be a better choice.

A pilot study published in 2014 in the European Journal of Clinical Nutrition compared the gastrointestinal effects of A1 versus A2 beta-casein, in 41 males and females. Consumption of A1 beta-casein milk was associated with looser stools than A2 milk™. Fecal calprotectin, a marker of gastrointestinal inflammation, correlated highly with subjective measures of digestive discomfort on the A1 diet but less on the A2 diet.

While the “A1 versus A2” debate continues, we will have to wait for more robust studies to validate the health claims.

In conclusion, the next time you go shopping for milk, arm yourself with a few milk facts to help you pick the right milk for you and your family-one that meets your nutritional needs and taste preference.

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Music to a Little Girl’s Ears

Penelope Grand had normal hearing from the day she was born. She loved to dance to music and she was easily woken by noises. Her parents, Luci and Paul, anxiously awaited her first word. Then, when she was about 10 months old, something changed.

“We really knew there was something wrong when I went to get her out of her crib after her nap one day,” mom Luci says. “She was calling out and fussing, she wanted out of there, and I came into the room but she wasn’t facing the door. I stood right in front of her crib and I called out her name, I clapped, but I got no response from her.”

Genetics are the cause of roughly half the cases of prelingual deafness, even when symptoms don’t appear at birth, as in Penelope’s case. Hearing tests and an auditory brainstem response (ABR) test revealed that Penelope had developed profound hearing loss in both ears. She had become essentially deaf.

“We were devastated,” Luci says. “I was preparing to hear ‘mild to moderate,’ not ‘profound.’ The air sucked out of my lungs. I wondered why. She is so sweet and loving, why did she have to lose her hearing?”

cochlear implant

Penelope’s audiologist prescribed hearing aids, but she had no benefit from them. That made her an ideal candidate for a cochlear implant, a new treatment offered at CHOC Children’s in close partnership with Providence Speech and Hearing Center. A cochlear implant is a small electronic device that is surgically implanted under the skin behind the ear, and has an electrode that extends into the cochlea in the inner ear. The implant’s electrode directly stimulates the cochlear nerves that perceive sound.

Dr. Nguyen Pham, CHOC pediatric otolaryngologist and head and neck surgeon, performed two outpatient surgeries on Penelope to place a cochlear implant on each of her ears.

“A cochlear implant can be life-changing for a child,” Dr. Pham says. “Children who would have been in the deaf community are now joining the hearing community because of cochlear implants. It is essentially restoring nearly normal hearing in these children.”

A Sense of Sound Restored

Oct. 13, 2015, was a memorable day for the Grands. That’s the day Penelope’s cochlear implant was activated, amidst her family and a crowd of supporters from CHOC and Providence.

Penelope begins to hear at 0:06.

“The first moment we knew she could hear was, well, it’s hard to describe what that felt like: joy, pride, happiness, excitement,” Luci says. “The look on her face was beautiful. We must have rewatched that video a hundred times.”

A cochlear implant does not translate sound perfectly. Those who wear an implant hear sounds with a robotic, mechanical quality. Following the implant’s activation, Penelope’s team of audiologists at Providence fine-tuned the frequencies of the electrodes—a process called mapping—until they produced the optimal sounds for her ears.

Now, she is undergoing comprehensive speech and language therapy, a crucial step in helping her interpret the sounds she hears and learn to communicate. She also uses American Sign Language.

“We are in awe of her, how much she’s already progressed,” Luci says. “She responds to her name now when we call out to her. She finally said her first word, bye bye, and she can now say mom. She has begun to dance again. She also has started singing in the car with me along to the music. We realized that she is so smart and so very happy, and her potential is endless. We are happy and grateful every day that she had this opportunity.”

Learn more about the CHOC Children’s Cochlear Implant Program.

 The Cochlear Implant Program is generously supported by Wildcard Army, in memory of Nixon Wildcard Hunter. 

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April is Occupational Therapy Month

The occupational therapy program at CHOC helps children develop or improve important skills for daily life. In honor of National Occupational Therapy Month, we spoke to Chelsey Kaufman, an occupational therapist at CHOC Children’s. Kaufman works with acute hospitalized patients on building or re-building fine and gross motor skills and developmental milestones, as well as feeding and swallowing disorders.

Q: Why did you want to become an occupational therapist?

A: I always knew that I wanted to work with kids in the medical field, but I wasn’t sure in what capacity. I first discovered occupational therapy when I was in high school. I used to babysit a child with a medical condition, and I would accompany him to occupational therapy. I found it so amazing to watch a young child regain the strength and independence needed to do all the activities that just getting to be a kid encompasses. It was so special to observe his parents watch him have experiences that are innate and natural for most children. In watching and observing sessions, I realized occupational therapy was what I wanted to do with the rest of my life. Now, as an occupational therapist, I get to help children rebuild foundational skills they need for functional tasks, and help them maximize their independence during these activities.

Q: What part of being an occupational therapist are you most passionate about?

A: I am most passionate about the families and children I am lucky enough to work with. Working in acute care, I meet families and children at what may be one of the most stressful and vulnerable times in their lives. To be let into that time and to help give a child the tools to grow and develop and regain independence with daily activities, or to help a baby learn to feed and swallow safely is a privilege. I feel so lucky and fortunate to get to do that every day.

Q: What advice would you offer someone considering pursuing a career in occupational therapy?

A: I think it is such a special, unique and rewarding profession no matter what area you practice in. Because there are so many different areas and settings, it is important to research all the different opportunities as well as volunteer or get an internship in specific areas of interest.

Q: What attracted you to CHOC?

A: I had always wanted to work in a pediatric hospital setting. I was specifically attracted to CHOC because of the multi-disciplinary inpatient feeding program as well as the incredible opportunities to enhance and expand my career.

Q: What else should people know about occupational therapy?

A: A lot of people are unfamiliar with occupational therapy. I think one of the most important things to know is that there is so much diversity and variety within the profession in terms of populations, settings, and specialties. The profession is also expanding rapidly due to the large amount of growing research and evidenced-based practice. There are so many opportunities for professional growth and the ability to expand knowledge.

Occupational therapy may be recommended if a child has delayed developmental skills, abnormal muscle tone, limited movement, swallowing or feeding issues, or is not able to do age-appropriate self-care activities. Learn more about CHOC’s occupational therapy program.