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Almost every baby born with T21 will face several common issues. The most critical are oxygen deprivation due to sleep apnea, and hypotonia (low muscle tone). Early and aggressive intervention maximizes a child’s potential by combatting the challenges presented by the condition. Designed as a day-one document, formula21 helps families first understand what are the basic issues they need to overcome, and how to tackle them. Each of the identified issues and their related therapies can be woven into daily routines, playtime and normal loving time spent as with any baby.

Sleep apnea is not common in typical children but has an alarmingly high rate of occurrence in babies with T21. Studies conducted by Professor Sally Shott, MD report a 50-100% incidence of this problem in overall age ranges and detection as early as within the first few months of life. Parents and carers absolutely must ask their pediatricians for early testing and continue throughout childhood and adulthood. It is extremely difficult if at all possible for parents to detect obstructive sleep apnea at home. Snoring may or may not present as a symptom due to a variety of predisposed factors from anatomic variances, and smaller airway sizes are a predominant contributor overall. The good news is once detected, the source of the sleep obstruction can be addressed, the most common being tonsil or adenoid adjustment. To reduce contributing factors directly due to global low tone, oral motor, occupational and physical therapies early are definitely pivotal. In summary early detection through an overnight sleep apnea test and continued testing is key.

Hypotonia manifests in several ways ranging from sensory deficit, to gross motor and fine motor control. The body's most heavily concentrated zone for fine motor skills is in the mouth, therefore addressing oral motor skills development early is equally important. Sensory deficiency is addressed through proprioceptor stimulation, massage and skin surface wake-up. Occupational and physical therapists can provide parents and carers with integrated exercises and techniques with sleeping eating bathing and play routines, that can be easy and fun.

formula21 lists five basic components, very common in almost every baby born with T21.

formula21 includes five components:

1. Oxygen Loss
2. Hypotonia
3. Oral Motors Skills
4. Sensory Wake Up
5. Nutrition

1. Oxygen Loss
2. Hypotonia
3. Oral Motors Skills
4. Sensory Wake Up
5. Nutrition

A sleep study is needed early in the life of a child with T21.

Sleep apnea has an effect on a child’s cognitive ability, behavior, growth rate, and heart issues. Since children with T21 are more likely to have heart problems from birth and are more likely to have sleep apnea, this combination can lead to severe complications. Unfortunately, it is very difficult for parents to accurately determine sleep abnormalities in their children with T21. Professor Sally Shot, MD conducted clinical studies which successfully led to the American Academy of Pediatrics to lower recommendations for earlier testing for sleep apnea to age three. Although a huge achievement, it has been proven to appear in as early as the first few months of life. This, coupled with the critical brain development which occurs in the first three years Families and cares are strongly urged to begin testing and to continue testing and overnight sleep studies from six months onward. A parent should have a short checklist with them when asking their pediatrician to prescribe sleep studies:

Issue 1

Over 80% + of Children with T21 test positive for sleep apnea over all. Included in this statistic is an alarming percentage of infants and toddlers.

Issue 2

Brain development between birth and three years of age is unanimously agreed as the most crucial in a human life. If a child suffers sleep apnea during this critical time, their brain is starved of oxygen hundreds of times during a regular night’s sleep, hence hindering normal healthy brain development.

Issue 3

Most families place their faith in the advice of their pediatrician. The country’s pediatrics governing body has not yet advised testing to begin early enough. Therefore families are usually told that the test is probably not necessary.

Issue 4

A large percentage of small children with T21 are unable to snore. And without audible snoring, tossing and turning, or other extremely restless symptoms sleep apnea is virtually undetectable without a fully excluded sleep study in a sleep clinic. With or without symptoms the condition can exist and accelerate cognitive delay.

During the earliest days of life, and continuing throughout a healthy adulthood, individuals with T21 can reduce the difficulties of hypotonia through physical therapy, movement and exercise. Hypotonia (low muscle tone) ligamentous laxity (looseness of the ligaments that cause overly flexible joints) challenge us globally: our gross motors, our fine motors, and our oral motors.

From birth, babies have a natural urge to move. With low muscle tone, it is a serious struggle. But engaging in a combination of occupational therapy sensory wake up techniques and physical therapy gross motors strengthening, a lifetime of healthy movement is entirely possible.

Without early intervention, children with T21 will surely find compensatory techniques and feel a natural tendency to avoid normal development. Movement begins in a small way and should quickly advance to reaching, then crossing the midline. Crossing the midline movements strengthens ultra important cross-brain patterning. Without attacking these cornerstone milestones early, babies will find otherwise simple activities challenging and tiring. From the midline work, rolling over develops more easily. Rolling over then evolves into pushing up, stepping up and eventually walking and running. A physical therapist can teach parents creative fun tactics to provoke a newborn’s urges to engage these movements, thereby creating therapy disguised as play. Our ultimate goal is a normal and independent life, and it begins with the simplest interventions.

TILT - Tongue In, Lips Together

Coupling oral motor skills to address issues with introductions to words and communication

The fundamental goal in building or a motor skills is to correct and instruct the tongue. Simply put, the tongue must reside inside the mouth and the lips must remain together, even during sleep. When basic oral motor skills exercises begin early and aggressively, babies born with T21 grow to eat to breathe and to speak with clarity and control.



Within the first critical 10 months of life, the shape of the mouth and hence positioning of the tongue can be changed, profoundly changing a baby’s future communication abilities, social interactions, and digestive health, not to mention healthy breathing. A baby born with T21 has an abnormally high arch in the roof of the mouth. Most commonly they also have an obstructive tongue (which also has a detrimental flacid quality due to low tone). Curiously the tongue size is usually normal in measurement, but cannot fit comfortably within the overly arched cavity of the mouth causing the obstructive characteristic. But by engaging early and aggressively in a grouping of oral motor skills and techniques involving stimulation, tongue-reflex building, and mouth massaging, this can be greatly improved or near totally corrected. A qualified speech and language pathologist can work in concert with aggressive oral motor skills to help to encourage the beginning formations of speech centric sounds. But specific to the critical oral motor skills needs therapy involves daily massaging of the roof of the mouth, tongue stimulation techniques, and mouth/sensory wake up of both the interior and exterior of the babies mouth. A qualified therapist must guide parents to teach them the proper techniques to be done daily during those first critical months.

Although this may appear to be overwhelming, interactions with a baby are 24 hours per day and can easily incorporate these ultra important exercises, into feedings or otherwise playful periods in a day.

Strengthen the entire respiratory system

With the help of physical therapy and building core strength, a child is able to sit up straight. It sounds overly simple, but sitting up straight is integral to proper oral motor skills development. Conversely with slouching comes a dropped, open mouth. Mouth breathing is the enemy to healthy air intake by preventimg the body from breathing through the nose (to clean and warm the air that goes into our bodies). Building upon the earliest skills will lead to higher levels of strength and endurance for continued exercise and greater respiratory stamina throughout a lifetime. Physical therapy is therefore integral to mouth control.

Reduction in chronic chest infection

Breathing through the nose warms and cleanses air intake, affording the body to be much less vulnerable to chronic chest and sinus infections. The three components of the respiratory system (being the airways, the lungs, and respiratory muscles) work in concert for efficient air and oxygen intake. With improved posture, tongue position and ultimately nose breathing the sinus cavity engages and is much more likely to develop and grow versus remain in a sinking position (which further prevents healthy air passage).

Myofunctional Inst.’s

Sensory deficiency is a fact of T21

Human beings need touch. And one of several negative effects of hypotonia is a lack of awareness of it.

In order for a baby to be able to feel touch at normal levels, families and carers have to wake up the surface of the skin, and it is achievable through techniques easily woven into regular routine and play.

There are endless methods of therapies available to enable proper breathing, swallowing and articulate speech. The Institute of Myofunctional Studies website provides a clear overview for how to begin to interpret the symptoms and solutions.

Left to the natural state of hypotonia an individual has a lower urge to move, roll over, or walk and talk.

Through sensory integration, external stimuli sends information that can be processed and create appropriate reactions. Without stimulation, the brain produces hyporesponsive (brain failing to register inputs) or hyperresponsive (brain registers input too intensely) reactions. It is possible for a child with T21 to be hyporesonsive for one type of input and hyper responsive for another. Occupational therapy provides techniques from the earliest days of life that begins to regulate sources of input and enable normal sensory interpretation. The same issue and treatments within the mouth are addressed with Oral Motor Skills therapies, also easily absorbed into daily routines.

Life shouldn’t be toxic. Our babies are born with known nutritional deficiencies, many of them learning enablers.

Countless and uncontested proof states the merits of a strong nutritional foundation for any child. Research is able to directly link certain nutrients to the strengthening of brain and eye health as well as cognition in general. A challenge that T21 presents is lower than normal levels of Zinc, selenium, copper, vitamin E to name just a few. Parents requesting a simple blood test can determine the severity of their child’s potential deficiencies, and how to supplement them. Advice from nutritionists ranges from dietary supplements to designing a diet to reduce inflammation, congestion and toxins.

We look forward to a day when conventional medicine addresses this very important challenge for our community. Until then contacting a nutritionist with this type of expertise is great risk-free step in raising our children’s global health.

A great reference for understanding the many different approaches to nutritional excellence is

How Nutrition Affects Muscle Tone & Cognition

A Powerful Tool for Learning Disabilities and Dyspraxia

Improving Cognitive Functioning with Nutrient Therapy

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