How Common is Tongue-Tie?

Patient Presentation
A pediatrician asked her partner if she had also been seeing an increase in parents being told their newborn had a lingual tongue-tie. “This is the third family today,” she said, “They can’t all have one.” Her partner replied that she had noted the increase too, and was concerned about unnecessary procedures being performed, their potential complications and their cost. “I agree that some babies and Moms would benefit from cutting the tongue-tie, but probably not at this rate,” she remarked.

Discussion
The anterior 2/3s of the tongue is formed from the 2 lateral lingual swellings fusing with the tuberculum impar and then separating from the mouth’s floor to form the lingual sulcus. Separation failure can result in anchoring of the tongue to varying degrees. Frenula are soft tissue structures which attach and support other oral structures. The lingual frenula attaches the tongue to base of mouth. Labial frenula are located centrally and attach the lips to the alveolar ridges. Often less prominent are the buccal frenula which are on the labial side and are smaller and more lateral to the labial frenula, usually being located around the canine and premolar areas.

Ankyloglossia or “tongue tie” is a “…condition of limited tongue mobility caused by a restrictive lingual frenulum.” The term “anterior” ankyloglossia refers “…to a lingual frenulum that extends to the tip of the tongue or near the tip of the tongue and restrict tongue mobility.” Posterior ankyloglossia for some professionals refers to the frenulum inserting into a posterior position on the tongue, with some people meaning it to insert submucosally. Other professionals do not feel it exists. In a recent consensus statement, the group could not reach actual consensus on this term. Buccal ankyloglossia “…has been used to describe a perceived tightness in the maxillary and/or mandibular buccal frenula.” Tight labial frenula are sometimes referred to as “lip ties.” While there are some classifications for lingual ankyloglossia, the professionals writing a recent consensus article could not recommend a preferred system.

Learning Point
The incidence of tongue-tie ranges from 2.8-10.7% depending on the study, and even up to 59% in healthy newborns in another. “There has been an increase in diagnosis of tongue-tie by 834% from 1997-2012 with a similar increase in the number of frenotomy procedures performed over the same time period.”

Tongue-ties are a hot topic that is very controversial. Consensus on the terminology and how to apply it to studies is lacking and makes it difficult to perform higher quality studies. Usually severe ankyloglossia is easily agreed upon, but moderate or mild causes more problems among professionals and in studies. Therefore studies may show associative effects but data for causal effects and treatment outcomes are often lacking.

Tongue-ties can have effects depending on the age and pattern. It is important to note that ankyloglossia may be present but does not cause any problems at all, and also if ankyloglossia is treated with frenotomy, it also may not fix the problem, as many of the problems listed below are multi-factorial.

  • Breastfeeding – this is probably the most common potential clinical problem and also a very common indication for potential frenotomy. Breastfeeding is a serious issue for the maternal-child dyad as well as for public health.Breastfeeding success or lack of is multifactorial with both maternal, infant and society playing multiple roles. Breastfeeding support along with time usually improves most breastfeeding problems. Positioning is one of the most important as significant percentages (70-90% in some studies) of maternal-child dyads with breastfeeding problems are found to have positioning problems. Frenotomy treatment is not a quick fix to breastfeeding problems.
    In a consensus statement, professionals said: “Breastfeeding difficulty can often improve with time and nonsurgical intervention by a lactation consultant or speech pathologist who specializes in breastfeeding issues.”
    Treatment with standardized clinical pathways for supporting breastfeeding and avoiding unnecessary surgery have shown a decrease from 11.3% to 3.5% without decreasing breastfeeding success.

  • Speech articulation – “…the quality of the evidence regarding speech outcomes is low and definite conclusions cannot be drawn.” Frenotomy in infancy is generally not considered an indication for this potential future risk but older aged children are sometimes considered for it.
  • Oral hygiene and caries prevention – as the tongue helps to clean the oral cavity, but many people even with ankyloglossia do not have any problems.
  • Dental occlusion and craniofacial development – data for causal effects is lacking
  • Functional/social – difficulties with daily activities such as kissing, licking foods, wearing dental appliance and playing an instrument are often not listed in the literature but can be concerns for older children, teens and families. These potentially can be reasons for frenotomy

Frenotomy or cutting of the frenulum is the most common procedure, being commonly performed in the outpatient setting. Frenuloplasty or cutting and re-alignment or tissues, or frenectomy or cutting and removal or tissues are other frenular procedures. Frenotomy complications commonly include pain, minor site bleeding, with risks to damaging the salivary ducts located near the lingual frenulum. Other potential complications include scaring, oral aversion, substantial bleeding including hypovolemia, hematoma, infection, oral edema, respiratory difficulty and problems handling oral secretions. Patients with underlying facial or genetic problems should be evaluated carefully before frenotomy is performed as it could cause additional problems. For example with Pierre Robin sequence, freeing the tongue may cause worsening glossoptosis.

Lingual frenula ties have been purported to be associated with “midline diastema between the teeth, increased caries and periodontal disease, gingival regression, difficulty in wearing denture or retainers, difficulty with lip mobility, and possible esthetic or psychological consequences.” Data on lingual frenula ties for breastfeeding is also controversial.

Questions for Further Discussion
1. What are your personal indications for frenotomy?
2. How do you support breastfeeding?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tongue Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. Otolaryngol Head Neck Surg. 2017;156(4):735-740. doi:10.1177/0194599817690135

Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020;162(5):597-611. doi:10.1177/0194599820915457

Colombari GC, Mariusso MR, Ercolin LT, Mazzoleni S, Stellini E, Ludovichetti FS. Relationship between Breastfeeding Difficulties, Ankyloglossia, and Frenotomy: A Literature Review. The Journal of Contemporary Dental Practice. 2021;22(4):452-461. doi:10.5005/jp-journals-10024-3073

Walsh J, McKenna Benoit M. Ankyloglossia and Other Oral Ties. Otolaryngol Clin North Am. 2019;52(5):795-811. doi:10.1016/j.otc.2019.06.008

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Caused This Summer Birthday Party Rash?

Patient Presentation
A 2-year-old female came to clinic with a “rash” on their cheeks and chin. This appeared after attending a birthday party the day before. The mother said she had no new foods, nor was exposed to any new sunscreen, insect spray, soaps, detergents, etc. She also was unaware of any lawncare being done in the area such as pesticides, or plant exposures such as poison ivy, and denied that the child “… got into anything else” at the party. “I really didn’t notice anything until the end of the party when her cheeks were red and she was complaining that her mouth hurt. I saw that her mouth and face were red but she had been eating lots of popsicles and birthday cake and I thought it was the food dye but it didn’t go away. There’s even one area that is a little purple now,” the mother pointed out. The mother reported that she was just a bit fussier and didn’t eat as much for breakfast. She had given the child some acetaminophen for pain.

The past medical history showed no relevant dental history. The review of systems was negative including any problems with oral intake, drooling, respiratory distress or pruritis or urticaria.

The pertinent physical exam showed a smiley toddler, who was cooperative except for the oral examination. Her skin showed redness and some swelling of the cheeks and chin particularly around the mouth. There was a 5 mm area with a purplish hue on the left side that also was more tender and harder on palpitation. Her oral examination showed good dentitia and some mild erythema of the tissues matching the red and purple areas of the cheeks.

The diagnosis of popsicle panniculitis was made. The pediatrician educated the parent about the problem and recommended to continue the acetaminophen for the discomfort. The pediatrician also counseled the parent about the risks of popsicle sticks and similar items being used by young children.

Discussion
Panniculitides are a diverse group of problems involving inflammation of subcutaneous fat. Subcutaneous fat has limited ability to show different patterns of disease and therefore the clinical appearance is the same but has different etiologies. The skin appears red or purple, swollen, may have discrete nodule(s) or plaque(s) and the affected area can be painful or pruritic. If necessary skin biopsy can help determine the etiology. Overall panniculitides are not very common but some presentations are expected because of particular exposure (i.e. cold) or inflammatory disease processes.

Types of panniculitides include:

  • Pediatric specific
    • Cold panniculitis – see below
    • Poststeroid pannicuitis – very rare and occurs with infants and children on prolonged systemic corticosteroid treatment after abrupt withdrawal.
    • Subcutaneous fat necrosis of the newborn – occurs in well newborns with an unknown etiology which usually resolves without problems
    • Sclerema neonatorum – rare and occurs in very ill newborns. Many die within a few days and etiology is unknown.
  • Adult-type appearing in children
    • Erythema nodosum – overall the most common panniculitis in children. Seen in boys and children, generally over the age of 2. Causes are the same as adults with Streptococcus and gastrointestinal infections as main causes. Up to 40% may be idiopathic.
    • Connective tissue disorders – Lupus erythematosus, dermatomyositis, polyarteritis nodosa and other similar etiologies
    • Enzymatic panniculitis – rare, associated with alpha-1 antitrypsin deficiency or pancreatic disease
    • Infectious – may be due to bacteria, fungi and Mycobacterium species
    • Malignancy – rare, associated with T-cell lymphomas and other malignancies
    • Physical panniculitis – due to trauma such as blunt trauma, injections, extravasation
    • Idiopathic lipoatrophic panniculitis in childhood – rare, presents clinically with childhood onset of fever and lipoatrophy that progresses over time with inflammation as an end process.

Learning Point
Cold panniculitis (CP) is relatively common in cold environments and in the right setting. It is sometimes called Haxthausen’s disease, adiposecrosis e frigore, popsicle panniculitis or equestrian cold panniculitis. CP is more common in infants and children than adults likely due to the difference in fat composition. Infants and young children have more saturated fat oils which have a higher solidification point. Therefore when they are subjected to cold, the fat oils can crystalize within the subcutaneous fat. As the child ages, there is less saturated fat. A 1928 study found 100% of newborns, 40% of 6 month olds and few 9 month olds to have subcutaneous nodule induction by holding an ice cube on the skin for 50 seconds. Body areas commonly affected are face and chin. In youth and adults it is associated with females, obesity and activities such as horseback riding, cycling or motorcycling. Areas affected especially are the thighs which may be subjected to wind and humidity with little protective clothing.

The differential diagnosis of CP includes chilblains and frostbite in addition to the other panniculitides above. The diagnosis can be made easily if the history of cold exposure is given which may include eating popsicles, sucking on ice cubes, using ice packs after trauma or for treatment of supraventricular tachycardia. Treatment is practical with rewarming the area and decreasing exposures. Most cases resolve in a couple of weeks without treatment.

Questions for Further Discussion
1. How is chilblains different from cold panniculitis? A review can be found here
2. How is frostbite different from cold panniculitis? A review can be found here
3. What anticipatory guidance do you provide to families about summer safety?

Related Cases

    Symptom/Presentation: Rash

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Rashes

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Torrelo A, Hernandez A. Panniculitis in children. Dermatol Clin. 2008;26(4):491-500, vii. doi:10.1016/j.det.2008.05.010

Quesada-Cortes A, Campos-Munoz L, Diaz-Diaz RM, Casado-Jimenez M. Cold Panniculitis. Dermatologic Clinics. 2008;26(4):485-489. doi:10.1016/j.det.2008.05.015

Delgado-Jimenez Y, Fraga J, García-Diez A. Infective Panniculitis. Dermatologic Clinics. 2008;26(4):471-480. doi:10.1016/j.det.2008.05.005

Aguirre-Martinez IL, Torrelo A. Lipoatrophic panniculitis of children. Clinics in Dermatology. 2021;39(2):220-228. doi:10.1016/j.clindermatol.2020.10.010

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What is Ondine’s Curse?

Patient Presentation
A 5-year-old female came to clinic for her pre-kindergarten health maintenance examination. She had moved to the area in the past month. She had congenital central hypoventilation syndrome (CCHS) and had received around the clock ventilatory support. “Before we even moved, we had meetings with the pulmonary specialists at the children’s hospital, along with the gastroenterologists. We are seeing you today and will see ophthalmology, endocrinology, and cardiology next week. School is still a few months away but again we are meeting with all the staff to update her IEP and plan for her medical needs at school,” the mother stated. She continued, “We’re going to need you to help us with her general pediatric problems like vaccinations and someone to help evaluate her when she gets sick. We’ve been fortunate that she had gotten some normal stuff like colds and ear infections, but she hadn’t been hospitalized for that, and only once for bad pneumonia.”

The past medical history revealed that the patient was diagnosed after she had respiratory distress after a 35 week gestation. She was not able to wean off her endotracheal tube which led to additional evaluation and eventually her diagnosis. She had some failure to thrive as an infant as well because of emesis. The family history was negative for genetic conditions, but was positive for obstructive sleep apnea in the paternal grandfather diagnosed in his 70s. The review of systems showed that she had some feeding difficulties with decreased intake, and her development was being monitored closely.

The pertinent physical exam showed a smiley, interactive female with normal vital signs. Her weight was at the 5th percentile and her height was 25%. HEENT showed a tracheostomy and trach cuff in place. Her lungs had some coarse breath sounds and her heart had no arrhythmias. The rest of her examination was normal.

The diagnosis of a kindergartener with CCHS was confirmed. The pediatrician and mother discussed her ongoing needs including updating her vaccinations, forms for school, and referrals for dental care, developmental monitoring and also recreational services in the community. Home health and nursing had already been well established for the family. “This town is very fortunate to have an active recreation program for all of its people including special programs for people with different needs. I know she can do most things, but they may also have ideas for other programs and also there may be a discount in the cost. I know you will also qualify for reduced or free public transportation as well. Do you need an updated handicapped parking sticker too?”, the pediatrician inquired.

Discussion
Congenital central hypoventilation syndrome (CCHS) is an autosomal dominant with variable inheritance genetic disease caused by mutation in the Paired Like Homeobox B2 (PHOX2B) gene on chromosome 4. There are two other genes which may also cause CCHS. CCHS affects the chemoreceptor afferent ventilation pathways and is a neural crest migration problem of the autonomic nervous system. The incidence is unknown but a prevalence of 1 in 200,000 live births has been reported. Obviously it is a rarer phenomenon because of the general lethality of the syndrome.

Patients usually present at birth or soon afterwards, but older children and adolescents have been diagnosed. They can have apnea and cyanosis often right after birth. Frank respiratory arrest can occur also. Patients usually have a normal physical examination and often will not show tachypnea or nasal flaring even during times of abnormal gas exchange such as illnesses. Other presentations may include failure to wean from a ventilator, delayed anesthesia recovery, and near drowning. CCHS should be considered when there is “…evidence of hypoventilation without underlying cardiopulmonary, metabolic, neuromuscular or brainstem dysfunction….Signs of cor pulmonale or failure to thrive may be seen and are indicative of the chronicity and severity of the disease.”

Patients may or may not have adequate ventilation while awake, but have alveolar hypoventilation (decreased rate and/or tidal volume) while asleep or at other times when increased ventilation is expected such as during illnesses. “Central alveolar hypoventilation is diagnosed when the arterial PCO2 is > 45 mm Hg during wakefulness, due to decreased central ventilatory drive.”

Treatment for patients centers on maintaining adequate ventilation. This is usually done by tracheostomy, face mask or phrenic nerve stimulation. Currently central nervous system stimulant medication does not produce the necessary affects needed for adequate ventilation. This is a life-long condition and therefore the overall need for ventilatory support may change with time and the methods of providing it, but CCHS will always need to be treated.

Long term prognosis is better with earlier diagnosis and treatments for patients of all ages. Mortality still remains high (in the 30% range) in up to 3 month olds. “The main causes of death include cor pulmonale, pneumonia and aspiration.” Patients can and do have happy and fulfilling lives and can live to adulthood and have children themselves.

The potential concomitant problems are usually due to autonomic nervous system issues due to neural crest migration abnormalities. These include:

  • Gastrointestinal problems – Hirschsprung disease occurs in up to 50% of patients and it tends to affect the colon extensively. Patients may also have failure to thrive or upper gastrointestinal problems.
  • Eye disorders – anisocoria, abnormal pupillary light reflexes, ptosis and strabismus
  • Congenital hyperinsulinism and related hypoglycemia
  • Cardiac arrhythmias – bradycardia, sinus pauses, postural hypotension
  • Tumors related to neural crest cells – gangioneuroma, ganglionneuroblastoma, neuroblastoma
  • Central nervous system problems – Seizures are thought to be due to hypoxia, hypoglycemia and arrhythmias. Slight cognitive impairment also seen in some patients is also believed to be due to some of the same problems.
  • Other autonomic features including profuse sweating and temperature instability/regulation

Learning Point
CCHS is the most commonly associated respiratory problem given the appellation of Undine’s or Ondine’s curse.
In mythology, the immortal nymph Ondine becomes human after falling in love with her husband who she later finds to have committed adultery. She curses him to be able to breath only while awake but not if he sleeps.
This poignant story is portrayed in many artistic forms in the written, visual and performing arts.

Other respiratory problems associated with Ondine’s curse include bulbar poliomyelitis, multiple sclerosis, other central nervous system degenerative diseases, and trauma, tumor and stroke occurring in loci that control ventilation are also causes of Ondine’s curse.

Questions for Further Discussion
1. What are some of the problems associated with chronic ventilatory support?
2. How does hypoventilation due to a congenital myopathy differ from CCHS?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Autonomic Nervous System Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Healy F, Marcus CL. Congenital central hypoventilation syndrome in children. Paediatr Respir Rev. 2011;12(4):253-263. doi:10.1016/j.prrv.2010.10.001

Demartini Z, Maranha Gatto LA, Koppe GL, Francisco AN, Guerios EE. Ondine’s curse: myth meets reality. Sleep Med X. 2020;2:100012. doi:10.1016/j.sleepx.2020.100012

Trang H, Samuels M, Ceccherini I, et al. Guidelines for diagnosis and management of congenital central hypoventilation syndrome. Orphanet J Rare Dis. 2020;15(1):252. doi:10.1186/s13023-020-01460-2

Ditmer M, Turkiewicz S, Gabryelska A, Sochal M, Bialasiewicz P. Adolescent Congenital Central Hypoventilation Syndrome: An Easily Overlooked Diagnosis. Int J Environ Res Public Health. 2021;18(24):13402. doi:10.3390/ijerph182413402

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Causes Kyphosis?

Patient Presentation
A 10-year-old male came to clinic as his aunt had noticed that he seemed to have a more prominent spine around his shoulders when he was swimming and mentioned it to his mother. He and his mother denied any mobility problems and neurological issues. His mother had noticed it before, but he “looks just like his father’s family,” she said. She denied any significant progression of it. The family history was positive for a grandfather with prominent kyphosis but without any functional problems. The review of systems was negative for any systemic problems.

The pertinent physical exam showed normal vital signs including blood pressure. He was obese with a muscular build. His physical examination was negative including no significant skin changes. He was pre-pubertal. His spine was straight in all positions including with flexion. He had full range of motion without any pain, numbness or tingling. There was a more noticeable rounded kyphosis in the thoracic area that did not appear to change much with position. He had well-developed trapezius muscles that appeared to accentuate the kyphosis on inspection. There was no specific mass or increased tissue in the area noted. Neurological examination was normal.

The diagnosis of kyphosis was made. The patient was referred to orthopaedics who felt this was a developmental kyphosis but was not significant enough at this time to warrant additional treatment. Monitoring at intervals was planned.

Discussion
There are 3 planes to view and describe spinal deformities from:

  • Coronal or frontal plane – the view is from front or back of the patient
  • Sagittal plane – is the view from the side of the patient
  • Transverse or horizontal plane – is the view from the top or bottom of the patient

Normally the spine is straight when viewed from the frontal or coronal plane. Normally the spine also has a small kyphosis in the thoracic region (20-45%) and lordosis in the sacral region when viewed laterally in the sagittal plane.

Scoliosis or abnormal deviation of the spinal laterally is the most common spinal deformity. It is best viewed from the frontal or coronal plane.
A review can be found here

Kyphosis is the second most common spinal deformity. It is an abnormal deviation of the spine posteriorly and is best viewed from the sagittal plane. Kyphosis is located in the thoracic or thoracolumbar spinal area and defined as having more than a 40 degree Cobb angle deviation as determined on radiographs. In a study of normally development children (ages 5-16 years) serial measurements were made and found that kyphosis increased for both males and females as they aged. Kyphosis usually does not cause significant functional issues, but is associated with a modest risk of back pain and may have an increased risk for negative body image.

There are two major kyphosis groupings: round and angular. Round is a smooth, large radius curve to the back that usually involves a large number of vertebrae. It is usually more stable, flexible and reducible in childhood, but can become rigid. Angular kyphosis has a sharp angle to the curve as fewer vertebrae are involved. It can be stable but is more likely to be unstable than round kyphosis.

Evaluation includes inspection and palpation of the spine in all angles and Adam’s forward bend test should also be performed. Flexibility, changing curvature, pain and provocation of neurological symptoms should be noted. Patients are often evaluated with radiographs as it can be more difficult to ascertain the extent of kyphosis.
Treatment is usually monitoring and physical therapy and bracing, plus potentially surgical correction.

Learning Point
Causes of kyphosis include:

  • Postural – most common, this improves with patient in proper posture, usually round
  • Developmental kyphosis <ul
  • Scheuermann’s disease is the most common form affecting 4-8% of patients especially boys. Usually round. Usually presents in late childhood with wedged vertebral bodies and cause is unknown but possibly genetic.
  • Congenital malformations usually due to vertebral segmentation and formation problem, often angular
  • Vertebral dysplasia – round or angular
    • Bone fragility problems such as osteogenesis imperfecta, osteoporosis, metabolic diseases, degenerative
    • Soft tissue diseases – Ehler-Danlos syndrome
    • Bone dystrophy
  • Iatrogenic including radiation
  • Infection – tuberculosis is the classic example
  • Paralysis or muscular problems
  • Trauma – often angular
  • TumorQuestions for Further Discussion
    1. How do you perform the Adams Forward Bend Test? A review can be found here
    2. What causes lordosis?
    3. How common is idiopathic scoliosis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Spine Injuries and Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Campos MA, Weinstein SL. Pediatric scoliosis and kyphosis. Neurosurg Clin N Am. 2007;18(3):515-529. doi:10.1016/j.nec.2007.04.007

    Oskouian RJ, Sansur CA, Shaffrey CI. Congenital abnormalities of the thoracic and lumbar spine. Neurosurg Clin N Am. 2007;18(3):479-498. doi:10.1016/j.nec.2007.04.004

    Miladi L. Round and angular kyphosis in paediatric patients. Orthop Traumatol Surg Res. 2013;99(1 Suppl):S140-149. doi:10.1016/j.otsr.2012.12.004

    Gardner A, Berryman F, Pynsent P. The Development of Kyphosis and Lordosis in the Growing Spine. Spine (Phila Pa 1976). 2018;43(19):E1109-E1115. doi:10.1097/BRS.0000000000002654

    Sheehan DD, Grayhack J. Pediatric Scoliosis and Kyphosis: An Overview of Diagnosis, Management, and Surgical Treatment. Pediatr Ann. 2017;46(12):e472-e480. doi:10.3928/19382359-20171113-01

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa