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History: Review parental concerns; current level of functioning; review current programming (early intervention, preschool, school); ear problems; sleep problems (snoring or restless sleep might indicate obstructive sleep apnea); constipation; review audiologic and thyroid function tests; review ophthalmologic and dental care. Monitor for behavior problems.

Exam: General pediatric and neurological exam including evaluation for signs of spinal cord compression: deep tendon reflexes, gait, Babinski sign. Include a brief vulvar exam for girls. Use Down syndrome growth charts, as well as growth charts for typically developing children. Be sure to plot height for weight on the latter chart.

Lab and Consults: Echocardiogram by a pediatric cardiologist if not done previously; Thyroid function test (TSH and T4) yearly; behavioral auditory testing every 6 months until 3 years of age, then yearly. Continue regular eye exams every year if normal, or more frequently as indicated. Between 3 years and 5 years of age, lateral cervical spine x-rays (neutral view, flexion and extension) to rule out atlanto-axial instability: have the radiologist measure the atlanto-dens distance and the neural canal width. X-rays should be performed at an institution accustomed to taking and reading these x-rays. Initial dental evaluation at two years of age with follow-ups every six months. At 2-3 years of age, screen for celiac disease with IgA antiendomysium antibodies, as well as total IgA. Administer Pneumococcal vaccine at 2 years of age.

Developmental: Enrollment in appropriate developmental or educational program; complete educational assessment yearly, as part of Individualized Family Service Plan (IFSP) for children from birth to 3 years of age, or Individualized Educational Plan (IEP) from age four until the end of formal schooling. Evaluation by a speech and language pathologist is strongly recommended to maximize language development and verbal communication. An individual with significant communication deficits may be a candidate for an augmentive communication device.

Recommendations: Twice daily teeth brushing. Total caloric intake should be below recommended daily allowance (RDA) for children of similar height and age. Monitor for well-balanced, high fiber diet. Regular exercise and recreational programs should be established early. Continue speech therapy and physical therapy as needed. Continue SBE prophylaxis for children with cardiac defects. Monitor the familyÕs need for respite care, supportive counseling and behavior management techniques. Reinforce the importance of good self-care skills (grooming, dressing, and money handling skills).