Is there a better time of year than fall? Some would say the first snowfall is their favorite; and while there is something romantic about the first snowfall, it just isn’t as renewing as a bright, brisk fall day. I love every season, but fall is my favorite. I love watching the first sign of flurries but am always sad to see the beautiful leaves hidden by a blanket of snow.
After a hot summer, I welcome the relief of humidity and find comfort again during outdoor runs that seemed harder just weeks prior. For me, there is that urge to train more often because snow impedes outdoor running and cycling.
As a mom and a nurse, fall reminds me of the illnesses associated with the upcoming months. RSV, parainfluenza, influenza, croup…it’s coming. I’m starting to see youngsters affected by respiratory illnesses at work. It’s a reminder that we all need to do a better job at preventing the spread of respiratory illnesses by washing hands, covering coughs, staying home when feeling ill, and vaccinating if possible.
Here’s the thing: For our most vulnerable population, less kisses! No kisses to the hands, or face during flu season. Doesn’t that make sense?! It’s so hard to old back a kiss when you’re grandma or grandpa or adoring Aunties. Everyone loves to kiss babies and toddlers. It’s a trap! Keep your precious loved ones safe and kiss them in the spring.
Remember, you’re contagious and spreading some viruses before you realize you have one!
It has been ten weeks since we started Baricitinib and we had another follow-up appointment at CHOP this week. We started the day with lab work, then met with the neurologist to review his labs and discuss how Will has been doing since our last visit.
Since Will started Baricitinib we have noticed the following changes:
*He can hold his head up longer than he could before starting the drug.
*His trunk strength has improved, and he can maintain an upright posture when straddling our legs for longer periods of time.
*He has become more vocal: think tiny dinosaur…he is not babbling yet, maybe someday. The neurologist says that vocalizing is the precursor to babbling. We all wonder what his voice would sound like.
*He is easier to console, less irritable, and generally happier.
*We think he is bringing his hands to his mouth more often, which has been tough because he bites himself.
*He is chewing and swallowing better than he was, with a noticeable decrease in gagging on fluids and medicines.
*He is demonstrating reciprocal movements in his legs when assisted to standing and also on his hands and knees. The neurologists and research team is so excited to see this too.
Our team at CHOP recommended custom orthoses and a TLSO braces to use for therapy sessions. In addition to this, we have tried some medications to address the dystonia in Will’s arms and legs. Botox was given on two different occasions but did not seem to make a difference in Will’s tone. We moved onto baclofen, an oral medication but he did not tolerate it at all. He lost his spark and wasn’t eating meals because he couldn’t hold his head up. We have moved onto gabapentin. Gabapentin, like baclofen, has been a drug we are titrating to get to the desired dose. So far, the gabapentin has not made any difference in Will’s tone.
Sleeping (or lack thereof):
Will hasn’t slept through the night in about six weeks. We are a mess, exhausted. No sleep, no energy for exercise, less patience, etc. It’s ugly. We aren’t sure why he isn’t sleeping, but I know that swimming made a huge difference in Will’s sleep cycles. Six weeks ago when we were regularly crashing our friend’s pool, he was sleeping through the night. Could that be all it is, does he just need to move his body? Good grief! Our deck is near completion, and the hot tub is going to be placed in the next week or two. We need to have an electrician do his thing so we can be up and running.
We couldn’t afford to add the pool this summer and have big dreams about what that might be like for Will and the other kids, but it’s expensive and may take another year or more to save. Glamour Pools has an above ground pool with a sunbathers bench option that would be great for Will’s physical disabilities. To sit him in a chair in a shallow area before moving to the deeper water would be more advantageous. We have the sweetest friends’ who give us the open invitation to their beautiful pools; we are very fortunate to have such amazing support.
Many of our friends know that we lost our beloved dog Baxter to lymphoma. A huge presence is lost in our home. Every day one of my children say, ‘I miss Baxter.’ Hunter sleeps with the blanket we covered him with while he was sick. My children will never forget the love they have for Baxter. I miss walking into the kitchen and seeing him sprawled out on the floor, watching me with his big brown eyes. I also miss seeing Mia on the floor with him. She always took Will to him and played. Will loved his long-haired friend.
Daddy works during our trips to Philadelphia. He isn’t used to being away from his construction work as often as we have been, the stress wears on him but he tries to juggle it all as best as he can. Will offers a smile as we wait for dad to finish his phone call.
Our next trip to CHOP is January 8th. We will be there for two days and then fly home. At this visit, we will have labs drawn, see the doctor, and then have research visits with PT, OT, and neurobehavioral psychologists to track Will’s progress on the medication.
We appreciate the GoFundMe gifts, cards, help with the pets and kids so much. PALS pilots fly us to Philadelphia and that makes such a difference for us; we couldn’t afford to go to PA as often as we do without them. Not only does PALS give us the gift of transportation, but it helps Will stay healthy. The germs Will would encounter by flying commercially would undoubtedly impact his health. The monies received from our fundraising helped us with the hotel fees, meals, and Uber rides while we were in Philadelphia. We used all of the donated money for the trip in July, August, and this week. That’s a lot of money in a short amount of time. Having a child with special medical needs is very costly. I just remembered a nice gesture: the night we arrived in Philadelphia we went to the restaurant in our hotel. Our waiter asked what brought us to the city. When we said we were visiting for a medical appointment at CHOP, he apologized and wished us well. At the end of our meal, he brought us a paper bag and said he wanted to send us on our way with some fresh baked cookies. Things like that make me sad and happy all at the same time. Justin ate all the cookies (ok, maybe all but a bite). I ate the lonely chocolate cupcake.
“When I die, I want to know that I helped all the people I could with the time that I had.” J.P.
Arguably the most beautiful person I have met during my life.
We have seen Will move his legs forward, at times bending his knees at the proper time in the gait sequence. This is progress! He wasn’t able to do this until recently. If you look at the video closely, you can see he needs to be held up and also needs supportive ankle orthotics.
We are headed back to Philadelphia next week and I have asked to meet with our beloved physical therapist. We will have his legs casted and orthotics will be made for him. Also, I’d like to pick her brain about assistive devices that we can use at home to challenge Will (gait trainers or gait trainer/standers). He has shown us some new tricks, let’s see what we can do with some more practice. We are upping the ante on PT…if we need to go to Philadelphia to get what we need to help Will, we will. I’m not taking ‘you won’t be able to get that here’ for an answer again.
Click on the underlined links to see some videos of Will.
4 weeks of Baricitinib and what did we discover last evening? A walking William!!👣
This means we have a lot more work to do, but more importantly, we have progress. I have only seen Will walk in my dreams…it was once and it was perfect. I didn’t think I’d see the day he’d take steps on his own (or even with support). 👣
We are headed back to Philadelphia next week and will get some help with orthotics to support Will’s ankles. In the meantime, more swimming, therapies, and practice. I’m also interested in getting Will a gait trainer. This equipment will support Will’s body while we practice ‘walking.’ I’m going to find out what will be best for Will and ask the therapists to write the letter to the insurance company. We’re ready for more walking! 👣
We hit the ground running after being in Philadelphia for ten days, but wanted to write a quick update about Will. We have had a few questions about the drug, so I thought I’d include some information in this update.
Will takes Baricitinb twice a day. It’s a pill that partially dissolves in water; it doesn’t dissolve but breaks down into little particulates. We mix the particulates with other medicines Will takes and orally administer by syringe; he isn’t bothered by the taste or texture when we administer the medication in this way.
Within a couple of days, we noticed that Will had little ‘bursts’ of energy shortly after his afternoon dose; he would become more wiggly and vocal. So cool! He has been more engaging, less irritable, and his appetite is much better. To our surprise, he took some sips from my straw the other day, something he hasn’t been able to do until now. We have been offering him water in a sippy cup throughout the day for the past year but are routinely offering him a cup of milk or water because he enjoys the challenge of drinking from a cup so much. Small steps in the right direction.
We will be going back to CHOP 8/21-8/23 for lab work and a clinic visit. More updates to come!
We headed to CHOP this morning to visit a physical therapist and try out a beanbag chair. She had shown us some things to try with Will, so we asked her to demonstrate for us.
While there we met with one of the techs who casts kids for custom orthotics. We are waiting to hear if insurance will cooperate with them and if so, we will have some important pieces of equipment made for William. He will have some splints for nighttime, and a supportive vest (dragonfly TLSO) to wear during therapies and feeding. We have been hoping to schedule this visit for a while and it seems like it might come together for us. She told us to keep Will swimming and add equine therapy whenever we can.
Tomorrow will be one of our more difficult days. Our day starts at 6:50am. An IV will be placed and Will’s blood will be drawn over the course of the day to see how he is metabolizing the drug. The samples are sent to an outside lab and then once analyzed, we will adjust the medication accordingly.
We haven’t noticed any changes in Will since starting Baricitinib. The goal of the medication is to slow the progression of the illness and allow his brain to further develop. The interferon that Will has in his brain creates a hostile environment and makes him feel lousy. Click the underlined word above to read about JAK1/2 inhibition with baricitinib in the treatment of autoinflammatory interferonopathies. Our best description of what Will has is an ‘interferonopathy.’
Last year we learned that we could not have access to the experimental drug that was being given to the children in the Compassionate Use Program (now known as ‘expanded access’) at CHOP. We were excluded from the program because Will’s genetic results did not show the syndrome that the trial was intended to treat. It was incredibly painful to see our boy lose his milestone achievements over the course of 3-4 months and not understand why it was happening.
Finally, after looking for a treatable cause and not finding an answer, we have been granted access to the drug. A ‘single patient IND’ was requested and we will begin the drug that should help Will feel better. More specifically, it works by blocking the action of enzymes known as Janus kinases. These enzymes play an important role in the process of inflammation and cellular damage. By blocking the enzymes, baricitinib reduces inflammation. He will still battle the inflammatory condition that affects his brain, but we will be reducing the way his cells respond to this ongoing attack, which should help him feel better.
He will have a full medical exam, including a cardiology consult, EKG, echocardiogram, and lab work. Once the results are available and reviewed by his team, he will be given the drug. We will monitor Will and probably repeat labs once the medication has been initiated and then return to Maine 10 days later.
We met with six specialists during our visit to the Leukodystrophy Center of Excellence (LCE). First, we met with Dr. Goldstein, program director of the Metabolic Program. We reviewed Will’s genetics, including his mitochondrial tests and extensively reviewed Justin and my medical family history. Will and I share some mitochondrial similarities (mutations), but it has been decided that these findings are not likely to be causing Will’s symptoms.
Next, we met with Dr. Katz. She is the LCE rehab doctor, and we meet with her every time we visit CHOP for an appointment. We discussed Will’s tone management (dystonia and central hypotonia) as well as his sleep habits, and much more. She is the doctor who would inject Botox into Will’s muscles if we were to have that done at CHOP. For now, we will have Will’s Botox administered locally. We discussed some medicines for Will’s dystonia if the Botox wasn’t as helpful as we hope it will be. We will wait and see…
Dr. Katz works closely with PT and OT, and they usually come in at the end of her time with Will. They are a very enthusiastic bunch and win the kiddo over within moments. What we have noticed is that the entire team is energetic, motivated, and full of ideas. We showed them photographs of what we currently use for seating at home, and they made recommendations for equipment that might be helpful in the future. Will had Botox injected on Friday and the team gave recommendations about PT and OT sessions once he had the treatment. They were adamant about Will receiving intensive therapy twice a week for six weeks, on top of his currently scheduled visit from home health. We were excited to hear that they recommended intensive treatment because we have felt that Will needs more skilled therapy, especially once we get those muscles more relaxed. We also felt dread because it has been surprisingly difficult to find pediatric therapies close to home. We had a brief ‘couple’ moment after these three specialists left the room and Justin looked at me and said, ‘this seems like a lot to take on.’ Maybe it was the day, but I quickly responded, ‘it’s a lot, but if we take one thing at a time and put the pieces in place, it is manageable.’ We need to do this for Will, and I thought, ‘iWill find someone to help me.’
The fifth visit was Dr. Jaffe, a developmental pediatrician. I thought that I had seen it all, but then I was exposed to a developmental pediatrian…these humans are super cool. She is a breath of fresh air, and the little man digs her. She is the one who talks to us about growing, eating, pooping, skin, and everything in between. Everyone wants to see Will in a different place on the growth chart. I have felt that Will’s height and weight, though small, is close to where he would be if he were neurotypical. That said, we will follow her recommendations and try to feed him high-calorie shakes and keep offering him the foods we know are packed full of healthy calories and fats.
Dr. Vanderver, the director of the Leukodystrophy program, examined Will next. We travel to CHOP specifically to see her, but again, the rest of the team is excellent. Initially, I didn’t realize that when you go to CHOP to be seen by Dr. V, you see the whole team. It makes a lot of sense, and I am so grateful for this approach. They treat the whole child and give their opinions as a team. Dr. V reviewed everyone’s notes, she examined Will, and then we talked about where we are: undiagnosed. Her advice is to come back to CHOP for an MRI and another lumbar puncture under the supervision of a neuroradiologist who is an expert in neuro-inflammatory conditions. We will travel to CHOP in a few weeks; Will is planning to see Dr. Banwell for an initial office visit, then the next day have his MRI and LP under sedation. The third day we will be seen by the team again and review the imaging. The other specialists will see Will, and we will follow up on how the recommendations are going in Maine.
My ongoing concern about Will’s condition has always been about the inflammation in his brain. It seems that his symptoms wax and wane and there is no thought to treat this while we sort things out. We have used steroids twice for worsening encephalopathy, but CHOP recommended that we hold off on using steroids a little longer while we do more testing. What keeps me awake is that this inflammatory response is permanently affecting Will’s brain, and these effects seem to be the cause of Will’s global regression. He has lost almost everything at this point: purposeful movement, coordination, typical emotional responses, motor planning, etc. Will he eventually lose the ability to breathe on his own? I want to see someone offer to treat his inflammation, realizing that what is lost may never return. The devil tells me I should have driven him to Boston exactly one year ago when his symptoms began to peak; perhaps we would have gotten ahead of the disastrous effects of the inflammation in his brain. Would they have done the testing we waited months for? Would they have tried a steroid burst or IVIG in the setting of acute encephalopathy? I know these thoughts aren’t productive, but as a grieving mother, they are mine, and profoundly haunting. What’s done is done, and I know that Will’s treatment in Philadelphia is exactly what he needs. Will the next tests give us more information and enough evidence to try medications? We will find out in May.
What’s happening right now?
Will has had Botox and I am looking for someone to do PT and OT with him. He needs to be worked hard (it’s relative) and often by therapists. I can’t drive to Saco, but I’m looking for some help finding a therapist to assist us with Will, working his opposing muscle groups now that Botox has been administered.
We couldn’t do all of this without the support from PALS and their mission angels. The friends and family who care for our kids and pets while we are away gives us peace of mind. We all want to hear that there is some way to help Will get better, but what we have is a plan to give him the best care going forward. With all of the love and support you give us, you are part of Will’s expert team too. #WeWill
The basal ganglia (or basal nuclei) is a group of subcortical nuclei, of varied origin, in the brains of vertebrates including humans, which are situated at the base of the forebrain. Basal ganglia are strongly interconnected with the cerebral cortex, thalamus, and brainstem, as well as several other brain areas.
The “basal ganglia” refers to a group of subcortical nuclei responsible primarily for motor control, as well as other roles such as motor learning, executive functions and behaviors, and emotions. Disruption of the basal ganglia network forms the basis for several movement disorders. We have seen an increased amount of calcification in Will’s basal ganglia since his first MRI at nine months old. For more information about functional neuroanatomy you can find it here: Functional Neuroanatomy of the Basal Ganglia.
Spasticity is caused by damage to parts of the brain that send the messages for GABA to be released. The damage may occur anywhere along the pathway, from the brain to the brainstem to the spinal cord. The end result is the same: deficiency of GABA and a relative excess of excitatory impulses. The cause of dystonia is not understood nearly as well as the cause of spasticity. It is thought to be due to damage to the basal ganglia, deep structures in the brain that adjust the amount of movement that occurs when people tell a muscle to move. The cause of athetosis (writhing movements) is probably similar. The dystonias are a group of disorders characterized by excessive involuntary muscle contractions leading to abnormal postures and/or repetitive movements. Chorea (nonrhythmic, jerky, rapid, nonsuppressible involuntary movements) is due to damage to a different region of the basal ganglia, so that output from a structure called the internal globus pallidus is less than normal.
It isn’t clear to me if Will has dystonia or spasticity; he could be experiencing both. We see that his tone inhibits him from being able to tolerate his AFOs and because he can’t use those, isn’t able to stand in his stander. I have not seen athetosis or chorea, but Will’s strong tone inhibits him from being able to weight-bear. We have had pediatric rehab doctors, and neurologists suggest anticholinergic medications, baclofen, and gabapentin. The problem with using these medications on Will is that he has severe central hypotonia. Anticholinergics and medications like gabapentin are sedating; these side effects will worsen Will’s central tone, and he would be at a higher risk for aspirating. Given the risk potential of worsening Will’s central tone, we felt that targeting and treating the overexcited muscles is advantageous. We consulted with a local pediatric neurologist who treats patients with similar symptoms with Botox injections.
Botulinum toxin (BoNT) is a potent neurotoxin produced by Clostridium botulinum that causes regional muscle weakness through its action as a zinc endopeptidase cleaving specific proteins involved in vesicular fusion. Disruption of these fusion proteins interferes with the release of acetylcholine at the neuromuscular junction, resulting in localized muscle weakness. It is also viewed as the treatment of choice for spasmodic dysphonia (i.e., laryngeal dystonia), limb dystonia, and oromandibular dystonia.
Why use Botox for spasticity?
Botox helps relax the muscles by blocking messages from the brain that tell muscles to contract (tighten). Botox injections can help increase mobility, relieve pain, maximize comfort, facilitate muscle growth and ease caregiving. We are hoping that with the use of Botox, he will be able to tolerate his AFO’s and participate in weight-bearing activities.
How are Botox injections done?
The interventional radiologist uses an ultrasound and muscle stimulator to locate the targeted muscles for injection. Once the muscle is located, a tiny needle is used to inject a small amount of Botox into the muscle. This procedure is repeated for each of the desired muscles. Will’s neurologist will not use ultrasound or an interventional radiologist to target his muscles, his muscles are easy to locate and can be done safely without ultrasound.
We look forward to updating you on Will’s Botox treatment!
We can all agree that this has been a really tough flu season. As an ER nurse I have swabbed multiple patients and not many have been negative. That’s a lot of flu. I am a big fan of bleach, but when it comes to my children’s personal items, I choose to use a more gentle approach.
Breastmilk can leave an oily residue inside bottles and pump parts. Again, I don’t use products like regular dish soap because they are full of chemicals and leave a soapy odor. In our home, we use Dapple for our bottles, toys, pump parts, and plastic wear. The sanitizing wipes are great for that quick clean at the end of the day.
Our son has a rare neurological condition, but he has been the healthiest person in the house. We attribute this to consistent hand washing, keeping those with cold symptoms at a distance, and vaccines. A respiratory illness like the flu can be deadly for a person with severe neurological symptoms like central hypotonia.
Give Dapple a try, they are affordable and if you’re running low, Amazon Prime will have you stocked and ready for business in the next two days.