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Spina Bifida
OverviewSpina bifida refers to a group of conditions involving improper development of the spine during embryonic development, leading to protrusion of the spine and/or its coverings, the meninges, from the vertebral canal. This defect occurs about the end of the first month of gestation. "Neural tube defect" (NTD) is used somewhat interchangeably with "spina bifida" but also includes anencephaly, which is when the brain fails to develop from the neural tube, and encephalocele, which is when the brain and the meninges protrude from the developing skull. Defects above the level of the spinal cord will not be discussed further.
The entire human nervous system develops from a plate of specialized cells that form along the back of the embryo. The edges of this elongated plate curl toward each other, joining in as many as four places to form a tube and then proceeding caudally (tailward), where the end of the spinal cord will form, and cephalad (toward the head), where further specialization will lead to brain development. Spina bifida results from problems during this amazingly complex process in which genetic and environmental factors are involved. [Kaufman: 2004] [Finnell: 2003]. Defects can be classified as open (spina bifida) or closed (spina bifida occulta, diastematomyelia). Types of spina bifida include:
- Myelomeningocele: The most common symptomatic form of NTD and the most severe. The spinal cord and the meninges protrude through the posterior openings in the vertebrae. See the Myelomeningocele Illustration (MedlinePlus).
- Meningocele: The meninges protrude through the posterior openings in the vertebrae, but the spinal cord is not involved.
- Encephalocele: The meninges or brain tissue protrude through the skull.
- Anencephaly: The cephalic end of the neural tube fails to close, resulting in the absence of a major portion of the brain, skull, and scalp. Anencephaly is not compatible with life; infants born with anencephaly, on average, live only a few hours.
- Spina bifida occulta: There is an opening or defect in one or more vertebrae with no pathology in the spinal cord. This is generally asymptomatic.
- Closed neural tube defects: This comprises a diverse group of defects where the spinal cord is malformed, but the vertebral column is intact. These include lumbosacral lipomas and diastematomyelia. These defects may have clinical presentations ranging from mild to very severe. Infants with these defects may be asymptomatic at birth and then develop symptoms over time. Midline sacral skin tags, hairy patches, hemangiomata and other cutaneous markers may signal the presence of a closed neural tube defect and should be looked for in all newborns. [Brand: 2007]
- Abnormal spinal cord development results in some degree of paralysis, or muscle weakness, and sensory loss below the level of the defect. The neurologic lesions are complicated and unique for each child. The paralysis is most likely to be a flaccid paralysis, although tethered cord and other accompanying defects may lead to lower extremity spasticity. Mobility is usually affected.
- Hydrocephalus and abnormal brain development - Most children with myelomeningocele also have hydrocephalus (70-90%) and may need a shunt or other procedure to relieve the fluid pressure in the brain. Children with myelomeningocele may also have abnormal brain development (Chiari II, thinning of the corpus callosum, with decreased neuron content in the posterior region of the brain, heterotopic grey matter, other).
- Bowel and bladder dysfunction are almost universal, even in low sacral lesions, and greatly affect morbidity, mortality, and quality of life.
- Neurogenic bladder - Because the bladders of children with myelomeningocele are paralyzed (neurogenic), reflux of urine up the ureters and into the kidneys (vesico-ureteral reflux) can occur. This can lead to kidney failure, particularly in the setting of frequent urinary tract infections.
- Lack of skin sensation, including feelings of pain, pressure, friction, heat, and cold that may contribute to skin problems.
- Constipation and other gastrointestinal problems
- Latex allergy
- Skin breakdown
- Orthopedic problems
- Learning and mood problems
While 90% of neural tube defects occur without a personal or family history of NTDs, the CDC has identified some risk factors:
- a previous NTD-affected pregnancy
- maternal folic acid deficiency (see Folic Acid Supplementation in NTD)
- maternal insulin-dependent diabetes
- use of certain anti-seizure/mood stabilizing medications (valproic acid and carbamazepine) during pregnancy
- medically diagnosed obesity in the mother
- exposure to high temperature in early pregnancy (prolonged fever or hot tub use)
- maternal race/ethnicity (more common among white women than black and more common in Hispanic women than non- Hispanic women)
- lower maternal socio-economic status
Other Names & Coding
Neural tube defect (NTD)
Q05.x, Spina bifida
The "x" above indicates the need for additional specificity (defect position and with/without hydrocephalus); for details, see ICD-10 for Spina Bifida.
PrevalenceNeural tube defects occur in 1 per 1,365 births in Utah, with myelomeningocele comprising 96% compared to only approximately 4% for meningocele. The incidence is higher in females than in males for unknown reasons. [Juriloff: 2012] The incidence is higher for families that already have one child with NTD (5%), two children with NTD (10%), or one parent with NTD (10%). Spina bifida occulta is very common in the general population, with some estimates as high as 40%, although most people with this form are unaware of it.
GeneticsFamilies who have a child with a NTD should be referred for genetic counseling if they are considering having another child. [Deak: 2008] Environmental influences, especially maternal folic acid ingestion and valproic acid exposure are also important. [Yerby: 2008]
PrognosisIn the U.S., infants with myelomeningocele typically undergo fetal surgery or surgery to close the lesion soon after birth. After post-natal repair, more than 75% of children born with myelomeningocele survive to early adulthood, although late complications are common. [Bowman: 2001] [Wong: 2001] The survival rate of children born with spina bifida at one year of age continues to rise, but is higher in whites than in Hispanics or blacks. [Shin: 2012] Greater morbidity and mortality are associated with higher lesions, including the presence and difficulty of managing hydrocephalus and the presence of vesico-ureteral reflux and/or frequent urinary tract infections. [Wong: 2001] An alternative to shunting, third ventriculostomy with choroid plexus cauterization, holds promise for improved outcomes. [Warf: 2008]
Practice Guidelines
Cheschier N.
ACOG practice bulletin. Neural tube defects. Number 44, July 2003. (Replaces committee opinion number 252, March 2001).
Int J Gynaecol Obstet. 2003;83(1):123-33. PubMed abstract
Roles of the Medical HomeSince neural tube defects (NTD) are often identified prenatally, the pediatrician may be involved in assisting the parents prior to the child's birth. After birth, routine health maintenance, preventive services (including all recommended immunizations), developmental and other screening, and guidance are at least as important for children with an NTD as for other children. Additional "chronic condition management visits" help ensure that time for routine care is not taken up by monitoring for, and responding to, problems related to spina bifida.
Clinical Assessment
OverviewThe initial diagnosis of open neural tube defects (NTD) is most commonly made during routine prenatal ultrasound exams, which allows for deliberate preparation by and for the family and health care providers. At this point, some families will choose to either terminate the pregnancy, be evaluated for prenatal surgery - although this is not an option for all families, or go on to have surgery postnatally. A randomized control trial, the MOMs Trial, showed that prenatal surgery led to a decreased need for shunting, improved motor and mental development scores at 30 months postgestational age, improved ambulation scores, and decreased hindbrain herniation; however, it was associated with significant risks for both the mom and the baby, including preterm labor and uterine dehiscence at delivery. [Adzick: 2011]
Although this section will focus on the initial evaluation and management of children with an open NTD, infants born after fetal surgery will still need to be followed for many of the same problems such as lower urinary tract dysfunction, which does not improve with fetal surgery, [Lee: 2012] hydrocephalus, and other issues.
Infants with open myelomeningocele commonly undergo surgery soon after birth to repair the defect and the accompanying hydrocephalus, if present. During their initial (birth) hospitalization, a protocol including echocardiogram, head CT, and renal ultrasound, and initiation of a latex-free environment is followed.
If hydrocephalus is present, there are now two alternatives for surgery, the standard ventriculo-peritoneal (VP) shunt, and endoscopic third ventriculostomy with choroid plexus catheterization (ETV-CPP). [Sufianov: 2010]
Pearls & Alerts for AssessmentThird ventriculostomy and choroid plexus cauterization
A new technique for control of hydrocephalus for infants/children with hydrocephalus after fetal or postnatal surgery, third ventriculostomy and concomitant choroid plexus cauterization may improve hydrocephalus outcomes compared to shunt surgeries while avoiding the risks of prenatal surgery. This technique may be particularly helpful in developing countries. [Sufianov: 2010]
For the ConditionNeural tube defects (NTDs) are often identified prenatally by ultrasound or following screening tests (triple or quadruple screen, α-fetoprotein or AFP), so the pediatrician may be involved in assisting the parents prior to the child's birth. [Bradley: 2005] Note that the sensitivity of the entire NTD screening process is estimated to be 86% for anencephaly and 78% for open spina bifida, while the specificity is 99.99%. If the screen is abnormal, a specialized ultrasound examination will usually be done to look for NTD (other conditions may also cause elevated AFP). Diagnostic testing is also usually performed during any pregnancy at high risk for NTD, including moms with a previous history of a NTD. [Jallo: 2005] See triple, quad, and penta prenatal screening description. Women who have had a previous child with a NTD should see a genetic counselor for discussion of diagnostic testing.
Diagnostic CriteriaDiagnosis is by anatomical characterization of the neural tube defect either by fetal ultrasound or postnatal imaging.
Comorbid & Secondary ConditionsAs most infants with myelomeningocele have surgery to close the spinal cord defect, most morbidity and mortality comes from co-morbid conditions, including hydrocephalus, problems with urination and defecation, orthopedic problems, and problems with development and learning.
History & Examination
Current & Past Medical HistoryWith the first visit to the Medical Home after myelomeningocele repair or after birth following fetal surgery, review the child's problem list and their medical history. For children just released from the hospital after initial management, a myelomeningocele protocol would have been followed that includes screening of likely affected organ systems (for an example, see Pre-op Myelomeningocele Protocol (Intermountain Primary Children's Medical Center) ( 200 KB) and Post-op Care of the Child with Myelomeningocele (Primary Children's Medical Center) ( 16 KB). Key information for the Medical Home to gather for optimum understanding of the newborn's condition on discharge includes:
- level of the spinal lesion; surgical repair and results; movement and sensation below lesion
- bladder and bowel function
- urinary tract screening (usually ultrasound and voiding cystourethrogram) results
- brain involvement – Chiari II malformation, hydrocephalus, shunted, third ventriculostomy?
- presence or absence of seizures
- family adjustments and acceptance
Pregnancy/Perinatal HistoryKnowing the timing of diagnosis and the counseling received to date will help you understand how well the family is prepared.
Developmental & Educational ProgressFollowing developmental progress and taking advantage of early intervention and subsequent therapies are crucial. Any regression in motor abilities may signal a complication such as a tethered cord, hydrocephalus, or shunt malfunction.
Maturational ProgressInquire about signs of puberty as precocious puberty is more common in children with a neural tube defect.
Social & Family FunctioningKnowledge of others in the extended family with spina bifida, or related problems, may alert you to sources of support or anxiety. Ask how the child with spina bifida and the family are coping emotionally, financially, and in the community. Consider screening adolescents for mood disorders.
Physical Exam
Vital SignsVital signs should include blood pressure at all visits, and at least twice a year, because of the risk of renal involvement from neurogenic bladder and reflux. For normative values at different ages, please see Vital signs at different ages (Emedicine).
Growth ParametersLength/height | weight | BMI | OFC: Follow weight and length for adequate growth; follow OFC for increasing percentiles that may signal hydrocephalus. Head circumference should be followed until there is no further growth, particularly in children with a history of hydrocephalus and shunting. For a child who is unable to stand, you may need to follow length (as opposed to height), understanding that translation to a height growth chart may be initially misleading. For many reasons, obesity is common in children with spina bifida and should be managed early.
SkinEvaluate surgical repair wound; some infants will need evaluation and care by plastic surgery. In older children who are not ambulatory, evaluate skin integrity, looking particularly for pressure sores.
AbdomenFeel for kidneys (hydronephrosis), and for masses that suggest constipation. Check anal sphincter tone initially and as clinically indicated afterwards. In male infants, observe urinary stream if possible.
Extremities/MusculoskeletalLook for spinal deformity such as kyphosis, scoliosis, etc. Check hips for clicks and dislocation. Club feet may be present.
Neurologic ExamIn infants, check for gag and suck reflexes. Perform a baseline exam to determine reflexes and confirm level of lesion. A baseline is important if there is a question of deterioration (e.g. due to tethered cord, increased intracranial pressure). In subsequent visits, perform a motor exam, including observation of muscle bulk and tone and the presence of spontaneous and responsive movement Perform sensory exam of the extremities and trunk - usually the level of sensory dysfunction is slighter higher than the dysfunction detected on motor exam.
Sensory TestingCheck results of newborn hearing screening. Routine screening for hearing and vision may be adequate. However, if cognitive skills are impaired, screening may not be as effective as needed.
Laboratory TestingRoutine testing is not indicated, but consider urinalysis and culture with any concern of infection.
ImagingAt birth, ultrasound or CT scans may be used to visualize bony defects and surrounding anatomy, as well as presence or absence of hydrocephalus and/or other cranial anomalies; MRI is the best study to identify contents of the lesion. Shunt series, head CT, MRI may be indicated for concerns regarding hydrocephalus and/or shunt malfunction; generally done in collaboration with neurosurgical colleagues.
Other TestingUrinary tract/kidney evaluation:
- The evaluation starts in the newborn period with a renal ultrasound to look for anatomical abnormalities, such as absent kidney or horseshoe kidney, the frequencies of which are greater in children with myelomeningocele. [Liptak: 2003]
- Cystometrograms are then performed as needed to evaluate the function of the bladder sphincter and the bladder detrusor muscle; if bladder pressure is high and/or reflux present, clean intermittent catherization should be started.
Specialty Collaborations & Other Services
In many locations, specialized clinics are available to provide multi-disciplinary evaluation and care for children with spina bifida. If this is not available, the Medical Home should collaborate with subspecialists and make appropriate referrals based on the child's needs. These might include neurosurgery, neurology, physiatry, orthopedics, nutrition, developmental pediatrics, neuropsychology or psychology, ophthalmology, urology, and gastoenterology. Baseline evaluations with recommendations for follow-up care should be recommended by the Medical Home. Most or all of the subspecialists listed below are likely available in a multidisciplinary Spina Bifida Clinic but, if not, they should be consulted initially and participate in ongoing evaluation and management.
Spina Bifida Clinics (see ID providers [2])
When available, specialty care at a Spina Bifida Clinic is preferred.
Pediatric Urology (see ID providers [1])
Evaluates and manages neurogenic bladder and consequent problems. Because difficulties with voiding occur in infancy and may lead to kidney damage, urological assessment begins in the newborn period.
Pediatric Neurosurgery (see ID providers [2])
Neurosurgical care is needed on an ongoing basis to evaluate and manage hydrocephalus and to screen and treat spinal cord re-tethering.
Pediatric Orthopedics (see ID providers [4])
Evaluates for and treats orthopedic complications, including scoliosis, kyphosis, hip dislocation, etc. Pediatric orthopedics should be involved at an early stage and assessments scheduled regularly.
Pediatric Physical Medicine & Rehabilitation (see ID providers [1])
PMR Team - assessment and treatment of the child with disabilities should begin soon after birth with PT, OT, and speech therapy added when appropriate. This team will also order and manage positioning and mobility needs, such as feeding chairs and wheelchairs, and can help in the management of issues like constipation.
Developmental - Behavioral Pediatrics (see ID providers [3])
May be helpful with development, behavior, nutrition, constipation, and school issues.
Pediatric Neurology (see ID providers [2])
Pediatric neurology should be involved early to monitor development and the neurological exam, as well as to diagnose and treat of seizures if they occur.
Neuropsychiatry/Neuropsychology (see ID providers [3])
To evaluate achievement and IQ to guide development of educational programs based on the child's strengths and weaknesses.
Educational Advocacy (see ID providers [3])
Educational and vocational specialists can help guide academic and vocational plans, particularly for those patients with learning disabilities.
Treatment & Management
OverviewSeveral decades ago, children with spina bifida often didn't live to adulthood. [Pruitt: 2012] Now, individuals with spina bifida have near-typical life expectancies, but will live with chronic health care needs. Some of these needs are acute and obvious, such as expanding head size and hydrocephalus. Other needs, including urinary tract health, continence, and avoidance of constipation, can be misinterpreted as less urgent, even though they affect quality of life, health, and life expectancy. Acute urinary tract infections may be life-threatening; even children who have not suffered acute infections have ended up in renal failure, requiring a transplant after years of sub-optimal care. Best care practices for the urinary tract and the gastro-intestinal system require consistency and surveillance on a day-to-day basis, a difficult thing for many families with multiple demands on time and resources. Children who have received prenatal and postnatal surgery will need multi-disciplinary care in a Spina Bifida Multi-Disciplinary Clinic when available.
It is important to think about life transitions for a child with spina bifida, from hospital to home, to preschool, elementary school, high school, and independent living as an adult. An important part of the transition to independent living is bladder and bowel continence, which makes jobs, marriage, sex, and every day interactions easier for individuals with spina bifida.
Pearls & Alerts for Treatment & ManagementMobility in children with myelomeningocele
Although individual myelomeningocele lesions are unique and often complicated, some generalizations on future mobility can be made based on the level of the lesion. Children with sacral lesions will often be able to walk, with or without braces, though usually later than typical children. Children with lower to mid-lumbar lesions will require more support to walk, including crutches, walkers, and/or bracing. These children will often become wheelchair-dependent as they move into adolescence. Children with high lumbar or thoracic lesions will usually be wheelchair dependent. Children with higher lesions that involve the upper extremities may need motorized wheelchairs for mobility. Note that power chairs can be used at developmental levels as young as two to three years.Fractures due to osteoporosis
Fractures due to osteoporosis are common in nonambulatory children, especially if additional risk factors are present (e.g. the child is taking valproic acid or a proton pump inhibitor). Children with myelomeningocele should be maintained on a diet with adequate calcium and vitamin D and weight-bearing with braces or a standing apparatus should be encouraged. Bisphosphonates should be considered if fractures occur in the setting of low bone density. Referral should be made to pediatric endocrinology if this is being considered. See Services, below.
If families have decided to continue pregnancy after an in utero diagnosis of spina bifida, they are given information about fetal surgery and postnatal myelomeningocele surgery. If prenatal surgery is chosen, and mother and fetus are appropriate candidates, the family will be referred to centers in the US that perform fetal myelomeningocele surgery (e.g. University of California San Francisco, Children's Hospital of Pennsylvania, Vanderbilt University, and others.) Proximity, family input, and insurance requirements usually dictate choice of program. As there are still a limited number of centers performing this surgery, moms will sometimes need to travel to, and stay near, a center away from their home. When prenatal surgery is performed, the uterus is opened, the myelomeningocele is repaired, and then the uterus is closed between 19 - 25.9 weeks of the pregnancy. Delivery is planned for 37 weeks estimated gestational age.
If the mother and/or the fetus are not candidates for prenatal surgery, or the family has decided on post-natal surgery, babies with a NTD are generally followed by both a high risk pregnancy program and their local obstetrician with delivery planned at a tertiary care center. A person with expertise in neonatal care, such as a neonatologist will generally provide parent education regarding expectations at and immediately following birth. A person from the Spina Bifida Clinic usually provides counseling about problems that may arise during pregnancy and throughout life. The type of delivery is decided by the obstetrician, but large head circumference, breech presentation, and any fetal distress are indications for C-section. A person with expertise in neonatal care, such as a neonatologist, will generally provide parent education regarding expectations at and immediately following birth.
Postnatal and ongoing care
Following birth, a protocol for newborns with spina bifida is activated. Pediatric neurosurgeons will repair the lesion usually within the first 24-72 hours and multiple evaluations are obtained to assess future management needs. Although there may be minor differences among programs, the protocol is fairly generic. Upon discharge, referrals to early intervention, a Spina Bifida Clinic, and other appropriate specialists should be in place, along with a first visit to the Medical Home. Infants who have fetal surgery are also evaluated according to protocol and will return to their home with records from the institution where they received care. Children with both pre- and post-natal surgeries will benefit from care in a Spina Bifida Clinic.
Evaluation and Treatment/ManagementBasic considerations/evaluations after birth include:
- neurosurgical - present/extent of hydrocephalus and need for treatment
- ensure healing of surgical repair wound
- urinary - evaluation for anatomy and function
- universal latex precautions
- begin urinary and bowel care
In hydrocephalus excess cerebrospinal fluid (CSF) accumulates in and around the brain and spinal cord causing potentially harmful pressure on those tissues. Many children with spina bifida will require treatment and ongoing management of hydrocephalus including children who have had fetal or post-natal surgery. Pediatric neurosurgeons are critical to the spina bifida team.
Signs and Symptoms
Initial signs of hydrocephalus in infants, which may be subtle, include sleepiness, irritability, vomiting, sunsetting eyes, a bulging or full fontanelle, splayed sutures, and seizures, as well as a large and/or rapidly increasing head circumference. In children whose skull bones have already fused, nausea, headache, sunsetting eyes, balance problems, irritability, seizures, and visual disturbances, such as diplopia and blurred vision, may develop. Hydrocephalus that is slowly developing may cause more subtle changes, and may be more difficult to recognize as changes occur slowly, such as a plateau or regression in developmental milestones, new learning problems, such as memory loss and difficulty concentrating, and personality changes.
If hydrocephalus is present, the child will require either a shunt placed by a neurosurgeon or in some cases, a third ventriculostomy with choroid plexus cauterization (ETV+CPC). The decision on timing of the first shunt placement or ETV+CPC must balance the risks of surgery and related complications with potential brain damage from hydrocephalus. Nobody knows if a child with small ventricles and a shunt will do better than a child with stable, large ventricles. Although a pre-surgery MRI is helpful, the decision on which operation to do will ultimately be made during surgery.
The most typical arrangement for a shunt is a ventriculo-peritoneal shunt. If a VP shunt is inserted, risks of the shunt include:
- shunt malfunction, which may result from obstruction by biologic debris or mechanical failure
- obstruction or under drainage, which includes continued increased intracranial pressure with symptoms of hydrocephalus
- overdrainage, which may lead to subdural hematomas or slit ventricle syndrome and cause intermittent symptoms
- abdominal complications
- infections, which are more common in the first few months after shunt placement and are most often due to Staphylococcus species.
Families and providers for children with shunts should be alert to the primary signs of shunt obstruction and infection, including headaches, vomiting, and drowsiness. Slowly progressing shunt malfunctions may present with progressively worsening headaches, loss of developmental milestones, falling asleep in school, personality changes, and new learning problems. These signs should prompt evaluation by the neurosurgeon or local emergency room. X-rays of the shunt (commonly called a "shunt series") and a CT scan or fast MRI of the head may be indicated, along with, if infection is a concern, a shunt tap to examine the cerebro-spinal fluid (CSF).
A third ventriculostomy is an alternative procedure to a shunt in which a small hole is made in the floor of the third ventricle to allow the CSF to escape the ventricular system to the space surrounding the brain, thus bypassing the obstruction. The choroid plexus is the structure within the ventricles which make 80% of the CSF. Coagulation of the choroid plexus is done through a single burrhole in the skull from which the neurosurgeon can coagulate the choroid plexus on both sides of the brain. If an ETV+CPC is successful, the problems of shunts such as obstruction and failure are eliminated. Risks of an ETV+CPC include:
- procedure abandonment due to hemorrhage or dangerous anatomy
- meningitis
- seizures
- CSF leak
- major arterial injury (rare)
Hydrocephalus is extremely common in children born with myelomeningocele; approximately 60-80% will end up needing either a shunt or an ETV+CPC, which are performed anywhere from 5 days to 6 months after myelomeningocele closure. Although early shunting in the first few weeks of life may improve neurodevelopmental outcome [Sgouros: 2006], many other factors, including the degree of brain malformation, affect ultimate intellectual and functional outcomes. It is possible that ETV-CPC instead of shunting will improve outcomes; data is not yet available comparing these two treatments although appears that children with ETV-CPC will need fewer additional procedures compared to those with a VP shunt.
Children with myelomeningocele without shunts are followed closely with clinical exam, including neurodevelopmental assessment and imaging, usually with a pediatric neurosurgeon involved in care.
- Refers to displacement of cerebellar tonsils and inferior vermis, and possibly the fourth ventricle, choroid plexus, and medulla, into the spinal canal.
- Chiari II malformation is present in virtually all patients with myelomeningocele but requires treatment in only a small minority.
- Infants may present with difficulty breathing, increased high crying, apneic episodes, aspiration, and arching (the latter is similar to that seen in infants with reflux), or if syringomyelia is present, individuals may present with spasticity and/or progressive weakness.
- Older children present less dramatically, but may have headache, swallowing difficulties, and passing out episodes.
- Symptoms of Chiari II malformation may be difficult to separate from the symptoms of shunt malfunction and/or increasing hydrocephalus
in unshunted individuals.
- The spinal cord in most children is able to move with the child, but with a tethered cord, the spinal cord is stretched, eventually leading to damage to nerves that control the bowel, bladder and legs.
- The cord is also sometimes tethered in children with spina bifida occulta, and in children with other closed neural tube defects such as diastematomyelia. Certain skin findings over the lower part of the back, including fat deposition, a hairy or discolored patch of skin, skin tags and dimples may signal the presence of a tethered cord.
- Symptoms may include back and associated leg pain, worsening ambulation and/or stamina, bowel or bladder problems and/or orthopedic problems including back pain, scoliosis, or new, changing joint contractures, and weakness and loss of sensation in the legs. Increased tightness or spasticity in the legs leading to decreased range of motion may also be noted.
- Symptoms of tethered cord might be subtle, especially in a child who is in a wheelchair where gait problems will not be noted; back and leg pain may be the presenting symptoms; in younger children these might manifest as a decrease in activity, failure of toilet training, or wet diapers between catheterizations in children with neurogenic bladder.
- Tethered spinal cord syndrome is principally diagnosed clinically along with an MRI of the spine looking for a worsening tethered appearance or a synrinx. In some cases, if tethered cord is confirmed, surgery is needed to release the spinal cord so that it can move freely within the spinal canal.
- Controversy exists regarding the threshold of signs and symptoms at which treatment of tethered cord in children with myelomeningocele is necessary.
- Surgery may be helpful in preventing further deterioration and in preventing irreversible damage; however, only about half of the patients return to their pre-tethering baseline state with surgery.
- Tethered cord can recur in about 1/4 of children who have had release surgery; routine follow-up visits with neurosurgery
are important.
- Syringomyelia involves fluid or a cyst within the spinal cord. Many children with myelomeningocele have syringomyelia, yet it causes symptoms in only a small percentage (2-5% [Liptak: 2003]). It can be difficult to distinguish symptoms of myelomeningocele, tethered cord, Chiari II malformation.
- Seizures and epilepsy in children with myelomeningocele are common, occurring in 10-25% of affected children. [Talwar: 1995] [Noetzel: 1991] [Bartoshesky: 1985] [Yoshida: 2006]
- Most studies have found epilepsy to be more prevalent in myelomeningocele patients with hydrocephalus than in those without. ([Noetzel: 1991])
- The presence of shunts and shunt revisions is not correlated with epilepsy. [Klepper: 1998]
- Children with myelomeningocele and epilepsy tend to have other brain abnormalities, such as polymicrogyria or agenesis of the corpus callosum. [Talwar: 1995] [Yoshida: 2006]
- Children with myelomeningocele and epilepsy may be more likely to have intellectual disability than those without epilepsy. [Noetzel: 1991]
- If seizures occur in myelomeningocele patients, they are treated similarly to seizures in the general population (see Seizures/Epilepsy).
- Unless the child has confounding factors of intellectual disability and/or hydrocephalus, the prognosis is generally good for seizure control. [Noetzel: 1991]
Specialty Collaborations & Other Services
Pediatric Neurosurgery (see ID providers [2])
Neurosurgery follow-up will be required in most children with myelomeningocele.
Pediatric Neurology (see ID providers [2])
Referral to neurology for seizures may be helpful. Neurology will generally be part of a multidisciplinary spina bifida clinic.
Urinary management includes the use of diapers, typical toileting with or without medications, intermittent catheterization, and surgical diversion to help an individual with spina bifida achieve urinary continence. In addition to the achievement of continence, management aims to avoid infection and damage to the kidneys.
Many infants will leave the hospital after birth with a regimen of clean intermittent catheterization due to high bladder pressure or reflux of urine which can cause kidney damage. Anticholinergic medications (e.g. ditropan) are sometimes used to lower bladder pressure. Constipation contributes to urinary tract problems and should be managed carefully. See Constipation.) Bladder and kidney function are then monitored over time and antibiotics prescribed (for infection or prophylaxis) as needed. If these more conservative measures fail, various surgeries are sometimes required.
Urinary Tract Infections – From birth, children with myelomeningocele should be monitored for urinary tract infections and treatment provided as needed. Frequent urinary tract infections in this population hasten kidney damage. Signs and symptoms of urinary tract infections include chills/fever, foul-smelling, cloudy, or dark urine, blood in urine, nausea/vomiting, pain in the lower back or abdomen, discomfort with catheterizations, general signs of illness. It is sometimes difficult to determine if an individual who performs clean intermittent catheterization has an infection or benign bacteruria. In a study performed in 2005, no consensus was found to exist among Spina Bifida Clinics in the United States regarding the management of bacteriuria.[Elliott: 2005]
Kidney Dysfunction – Neurogenic bladder and subsequent kidney dysfunction are major sources of morbidity and mortality in children with spina bifida. Although only about 10% will have kidney dysfunction at birth, about 50% will go on to have deterioration in kidney function, sometimes requiring dialysis or renal transplant. [Liptak: 2003]
Urologic tests that may be needed:
- renal ultrasound to assess kidney size, anatomy
- voiding cystourethrogram (VCUG) primarily to look for reflux of urine back into the kidneys and to determine if voiding leads to appropriate emptying of the bladder.
- cystometrogram (CMG) to assess bladder pressure and capacity. This test looks for high pressure in the bladder that may cause reflux into the kidneys and leakage of urine at high pressures.
- a vesicostomy where an opening is created between the bladder and the abdomen allowing leaking into a diaper to keep urine levels in the bladder low. This procedure is used when the bladder is not emptying sufficiently, leading to reflux of urine into the kidneys. Usually this opening is closed after infancy.
- injections into the ureter to make the opening between ureter and bladder smaller, decreasing reflux of urine into the kidneys
- a catheterizable urinary stoma (also called a mitrafanoff, a MIC, or continent vesicostomy) where an opening is created from the abdomen into the bladder. Immediately after surgery, a tube is left in the opening to allow the wound to heal, and then removed. The opening can then be catheterized using clean intermittent catheterization.
- re-implantation of ureters where the position of the ureters is changed to lessen reflux. This is performed when clean intermittent catheterization and medications aren't successful. Often the child has been subject to frequent urinary tract infections.
- bladder augmentation to increase the amount of urine the bladder can hold, decreasing reflux back into the kidneys. This procedure is often done with a mitrafanoff procedure.
- bladder muscle augmentation to strengthen the sphincter that holds urine in the bladder until it is voluntarily released, allowing urination. In some children, the sphincter is not strong enough to prevent leaking in between urination.
Specialty Collaborations & Other Services
Pediatric Urology (see ID providers [1])
Careful attention to the urinary tract issues, along with evaluations every few months in infants and less frequently as the child gets older have prevented morbidity and mortality in many children with myelomeningocele. Most children will require periodic visits with pediatric urology for kidney damage prevention, the achievement of continence, and urinary tract infection prevention.
Gastro-Intestinal & Bowel Function
Voluntary control of both sphincters, the internal anal sphincter and external anal sphincter, are affected in individuals with spina bifida. Nerves that control these sphincters are the lowest on the spinal cord; therefore, an opening anywhere along the spinal cord can interrupt communication with the brain. Therefore individuals with spina bifida need a regular elimination program to prevent accidents.
Individuals with spina bifida are particularly prone to constipation. It occurs because the movement of stool through the colon has slowed. Slowing of movement occurs due to:
- diet low in fiber
- inactivity
- inadequate fluid intake
- irregular and incomplete emptying
- anesthesia-surgery
- pain medications
When constipation is an ongoing problem, fecal impaction can occur. As more stool accumulates, the colon enlarges, muscle tone is lost, and the urge to empty decreases. Seepage of liquid around clumps of stool causes diarrhea-like bowel movements. Impaction requires a complete clean out of the colon with enemas before a regular emptying program can be started.
Prevention of constipation starts at the first visit and continues with every visit to the Spina Bifida Clinic and the Medical Home. Knowledge of the child's bowel habits should guide initial interventions. What time of day does the patient have a bowel movement? How long after eating? What is the consistency of the stool? Does the patient need an enema, a suppository, or just time on the toilet before stooling? Full details of managment for constipation can be found in the Portal's Constipation. Common considerations include:
- Interventions, including dietary manipulations, should aim for 1-2 mushy, easy-to-pass stools per day.
- Diets should be high in fiber.
- PEG 3350 (Miralax or Glycolax) should be added to give bulk to stools if a high fiber diet isn't helping.
- For softer stools, water and prune juice should be added. Stool softeners, such as docusate, can also be added when needed.
- Greasy foods should be avoided.
- Meals and predictable time periods after eating for sitting on the toilet should be scheduled to utilize the gastrocolic reflex.
- If timing bowel movements after meals is not successful, suppositories should be added (glycerin or biscodyl) to initiate bowel movements. Stimulants such as senokot, or osmotic agents such as milk of magnesia, are also sometimes helpful.
- Bowel "clean-outs" are sometimes necessary when constipation has been an issue for a long period. Bowel clean-outs are usually followed by PEG 3350 daily until the colon adjusts to normal bowel movements. For details.
- Consider a referral to gastroenterology if interventions are not successful.
Specialty Collaborations & Other Services
Pediatric Gastroenterology (see ID providers [3])
If children are not responding to standard treatment and/or if an ACE procedure is being considered, a referral to gastroenterology may be helpful.
For children: Although nutrition is important for everyone, it is especially important for children with spina bifida. Poor eating habits and reduced activity compared to typical children may lead to obesity, constipation, pressure sores, osteoporosis, anemia, and other problems. By the age of six, at least 50% of children with myelomeningocele are overweight, making movement more difficult and leading to further weight gain and deconditioning. Obesity also increases the risk of decubitus ulcers, makes continence of bladder and bowel more difficult to manage, and may lower self-esteem. Weight management should start in the early years – prevention is easier than losing weight once obesity is present. See the Childhood Obesity Screening & Prevention and Let's Talk About... Spina Bifida and Nutrition (Spanish & English). The Portal's Childhood Obesity Screening & Prevention discusses screening for risk factors, screening for the conditon, and role of the medical home in preventing obesity.
Children who have decreased mobility and are on certain medications are more susceptible to fractures. Calcium and vitamin D intake should be monitored and supplemented as needed.. See Calcium and Vitamin D.
Specialty Collaborations & Other Services
Nutrition Assessment Services (see ID providers [103])
Children should be monitored by a dietician for weight and height changes over time for different stages of life.
Although the IQ of children with spina bifida averages less than the general population, lower scores are generally found in children with hydrocephalus and higher spinal cord lesions, as well as in those with a history of central nervous system infection. [Lollar: 1995] Children with myelomeningocele have difficulty with perceptual motor skills and this tends to bring the full scale IQ down, whereas verbal intelligence scores are closer to the normal range. Children with myelomeningocele will generally do better in reading and writing classes than in math.
Specific learning problems
Even with normal intelligence, children with myelomeningocele will often have difficulties with perceptual motor skills, organization, memory, sequencing and problem solving, as well as with attention problems. These issues need to be looked for and addressed in the classroom and in the individualized education program.
Self care and independence
Even with normal intelligence, children with myelomeningocele will score poorly on measures of self-care, such as the WeeFim (Functional Independence Measure for Children) and the PEDI (Pediatric Evaluation of Disability Inventory). The reasons for this are not well understood, but may reflect specific learning problems (such as organization, sequencing and attention deficits), as well as personal mental health and family functioning problems. One report of neuropsychological functioning in teens with myelomeningocele found deficits in fine motor coordination, information processing speed and a slower learning curve compared to the typical population. [West: 1995]
Neuropsychological Testing
Children with neural tube defects should be assessed with a full neuropsychological profile, examining intelligence, achievement, attention, etc. to best identify strengths and weaknesses and teaching methods aimed at maximizing the potential of the child. Funding for a full profile can be hard to obtain; school districts and/or the patient's insurance may be helpful but often require letters requesting the testing from the Medical Home.
Helping with school issues involves tracking progress, accommodations for learning problems, accessibility to all areas of the school, and a school health plan. An Individualized Education Plan (IEP) and a "504 Plan" should be developed and implemented for every child with spina bifida – details on these can be found in Education & Schools under For Physicians & Professionals.
Skin & Appearance
- These areas are insensitive to pain.
- These areas are stationary in spina bifida children in wheelchairs, unless efforts are made to increase movement voluntarily (for example, with sitting push-ups).
- The spinal defect involves autonomic nerves that control the vascular supply to these areas, thus increasing the chances of getting decubitus ulcers and delaying healing when sores develop.
- Constipation and diarrhea - passing hard large stools can tear the skin around the anus and liquid stool causes rashes and breakdown of the skin around the opening to the rectum.
Treatment – The family should participate in ongoing education and prevention that includes pressure releases while in a wheelchair (10 second lifts every 15 minutes); frequent changes in positioning (for example, from a wheelchair to a mat every hour or two while at school); and, position changes every two hours while lying in bed. The first step in treating a pressure sore is to remove the pressure causing it. Consider new wheelchair cushions, a change in orthotics, or, if it is exacerbated by a contracture, antispasticity agents and a referral to surgery to release the contracture. If the decubitus is mild, thorough cleansing and possibly an occlusive dressing to keep the area moist may be sufficient. More advanced sores may require various other types of dressings (wet to dry dressings, Carrington gel), intravenous antibiotics, whirlpool treatments, and surgical debridement/skin grafting.
Latex Allergy – All children with spina bifida and their families should be taught to avoid latex in their environment. Newborns with myelomeningocele are usually put on latex precautions at birth. A large percentage of children with spina bifida have latex sensitivity and allergy, with symptoms ranging from itchy watery eyes to hives to fatal anaphylactic reactions. Although there are correlations between previous latex exposure history, number of previous surgeries, and the presence of other allergies, the intricacies of this allergy are not well understood. Because latex exposure to mucus membranes seems to correlate with increasing difficulty with latex allergy, sexually active adolescents and adults with spina bifida should use latex-free condoms. Specific recommendations for avoidance and lists of products that contain latex can be found at the Spina Bifida Association Website. See Latex Information (Spina Bifida Association).
Common orthopedic problems associated with spina bifida include:
- scoliosis
- kyphosis
- hip dislocations
- foot and knee deformities
Kyphosis, curvature of the spine in an anterior posterior plane, can cause progressive problems with seating, positioning, and pressure sores on the skin overlying the convex side. It can also lead to compression of abdominal contents and secondary interference with the function of the diaphragm and breathing. Kyphosis can be very difficult to manage, often requiring major spinal surgery to correct the deformity. Fortunately, kyphosis is less common than scoliosis in children with meningomyelocele, accounting for about 10 % of spine defects. It is more common when the myelomeningocele lesion is above T12. [Foster: 2007]
Hip dislocations are common in children with myelomeningocele, increasing in incidence with higher lesions. Muscle release surgeries may decrease the forces dislocating the hips. Bone surgery can correct the deformities resulting from the muscle imbalance, improve the range of motion of the hips and knees and facilitate bracing and standing. The decision to surgically treat hip dislocation is often based on the child's potential to walk, which is correlated with a lower lesion level (L3 level) and whether it is unilateral or bilateral.
Foot deformities are common in young children with myelomeningocele. They may require bracing if the deformity is flexible. If the deformity is rigid, corrective surgery can relax the foot so that bracing can be effective.
When a family first hears they will have a child with spina bifida, they often have questions about fertility. Teens with myelomeningocele also have questions about sexuality and the usual sources of reliable information often do not address issues specific to those with physical or intellectual disabilities, leaving adolescents to feel that they are not given enough practical information. [Sawin: 2002] [Sawyer: 1999]
Although many adolescents with spina bifida are involved in intimate relationships, [Verhoef: 2005] poor body image and fear of bowel and bladder incontinence can cause some people to limit intimate connections. Adolescents with myelomeningocele should be taught that, like other adolescents, they may be fertile and are subject to sexually transmitted disease. Because of the risk of latex allergy, sexually active patients should be taught to use latex-free condoms. Because the effectiveness of latex-free condoms in preventing pregnancy and sexually transmitted diseases is still being studied, males with neural tube defects (NTDs) should use a latex-free condom inside a regular condom, and females with spina bifida should have their male partner use a latex-free condom over a regular condom. See Latex-free condoms (About.com) for more information. Both males and females with NTDs may have decreased sensation in their perineal and genital regions and must watch for skin breakdown that may occur with sexual activity. Many women with myelomeningocele are able to become pregnant, although fertility rates aren't known. A small percentage of women with small pelvises might have difficulty carrying a child to full term. See [Jackson: 2005] for a discussion of reproductive issues in women with spina bifida. There is little information available about the sexual response in women with myelomeningocele. Adolescent females with myelomeningocele should take folic acid because of the risk of spina bifida in their children, which is greater for mothers with spina bifida than it is in the general population. See Folic Acid Supplementation in NTD and [Toriello: 2005].
As many as 1 in 4 males with NTDs will have undescended testicles. [Meyer: 1984] Approximately 3/4 of males with myelomeningocele will be able to have erections, although most will experience them only from local physical stimulation rather than psychogenically. The ability to have and sustain an erection is related to the level of lesion; the lower the level, the more likely the male will be able to have an erection. Even with the ability to have an erection, many men with spina bifida will be unable to sustain it long enough for sexual intercourse. Erectile dysfunction drugs have been very helpful. If those medications fail, various surgical interventions are possible. It is unknown how many men with myelomeningocele are infertile, and whether they are infertile because they experience retrograde ejaculation or because of decreased sperm count or motility. Artificial insemination may be an option, using their own sperm. Fertility specialists should be consulted if these questions arise. [Sawin: 2002]
Precocious Puberty
For unknown reasons, children with spina bifida and hydrocephalus often exhibit precocious puberty. Although precocious puberty is more frequent in girls (possibly as high as 50%, [Proos: 1996]), it also occurs in boys. Precocious puberty causes a number of physical and emotional problems in children who may already feel socially isolated and different. These problems include:
- an early pubertal growth spurt, followed by a change to adult bone structure and cessation of growth. Adults with spina bifida are shorter than the general population; this problem is more pronounced if they experienced precocious puberty, starting their growth spurt earlier and stopping growth earlier.
- changes that sometimes occur with adolescence, such as moodiness, increased aggressiveness in boys, and sexual readiness are experienced earlier than in children without spina bifida and at a time when families, friends, and schools may not be anticipating them. [Liptak: 2003]
Signs of early changes include testicular enlargement and the development of pubic hair and acne in boys, and breast development in girls. If noted, the child should be seen by a pediatric endocrinologist to consider treatment. Testing may include bone age, ultrasound examination for uterine size, blood testing for elevated levels of sex hormones and pituitary hormones, and determination of the child's rate of growth.
Some patients, families, and their doctors choose medication, usually leuprolide (lupron), to slow the maturation process. In addition to preventing precocious puberty, treatment delays the puberty-related growth spurt, allowing the child greater adult height. Gonadotropin-releasing hormone analogs can also help attain greater adult heights in children with spina bifida and precocious puberty. If precocious puberty is already well underway, treatment may not be possible. [Trollmann: 1998]
Specialty Collaborations & Other Services
Pediatric Endocrinology (see ID providers [2])
Boys or girls with precocious puberty can be referred to pediatric endocrinology.
Specialty Collaborations & Other Services
Social Workers (see ID providers [0])
Social workers are able to help with transition planning in many ways from the fully practical to the emotional response of the individual and/or the family.
Issues Related to Spina Bifida
Nutrition/Growth/BoneFolic Acid Supplementation in NTD
Ask the Specialist
Why isn't my child doing better in school? He has spina bifida at a low level and I've been told his IQ is normal.
This is a complicated question. Children with spina bifida have been noted to perform less well in school and achieve less than other individuals of the same intelligence (as measured by IQ). There are many reasons to think that the brains of children with spina bifida, even those with low lesions, may also be affected by the same early developmental process that caused the spina bifida. Children with spina bifida, even those with few complicating problems, like hydrocephalus and seizures, are noted to have higher verbal IQs than performance IQs, giving them a different learning and achievement profile than individuals without spina bifida. Although not specifically proven for the population of children with spina bifida, we believe that early intervention and school intervention is helpful for children for special needs. Continue to be an advocate for your child at school to help him achieve the best possible outcome in his life. See Educational Advocacy (see ID providers [3]).
Resources for Clinicians
On the Web
Helpful Articles
PubMed search for Spina Bifida in children and adolescents, last 2 years
Frey L, Hauser WA.
Epidemiology of neural tube defects.
Epilepsia. 2003;44 Suppl 3:4-13. PubMed abstract
Rossi A, Biancheri R, Cama A, Piatelli G, Ravegnani M, Tortori-Donati P.
Imaging in spine and spinal cord malformations.
Eur J Radiol. 2004;50(2):177-200. PubMed abstract
Clinical Tools
Patient Education & Instructions
Let's Talk About... Hydrocephalus and Shunts (Spanish & English)
Printable handout regarding hydrocephalus and shunts; Intermountain Healthcare.
Let's Talk About... Spina Bifida (Spanish & English)
This page contains basic information for parents about spina bifida and includes pictures; Intermountain Healthcare.
Let's Talk About... Spina Bifida and Nutrition (Spanish & English)
Printable handout on spina bifida and nutrition; Intermountain Healthcare.
Let's Talk About... Spina Bifida and Urologic Management (Spanish & English)
Printable handout on spina bifida and urologic management; Intermountain Healthcare.
Let's Talk About... Clean Intermittent Catheterization for Boys (Spanish & English)
Three-page, printable handout explaining how to clean and care for intermittent catheterization; Intermountain Healthcare.
Let's Talk About... Clean Intermittent Catheterization for Girls (Spanish & English)
Printable handout explaining how to clean Intermittent Catheterization; Intermountain Healthcare.
Let's Talk About... Self-Catheterization (Spanish & English)
Spina Bifida and self-catheterization printout; Intermountain Healthcare.
Let's Talk About... Spina Bifida Urologic Surgeries (Spanish & English)
Printable handout on Spina Bifida Urologic Surgeries; Intermountain Healthcare.
Resources for Patients & Families
Information on the Web
March of Dimes Spina Bifida Information
Easy-to-read information from the March of Dimes on neural tube defects.
Spina Bifida (KidsHealth)
Family-focused information about spina bifida, from the Nemours Foundation.
Let's Talk About... Spina Bifida (Spanish & English)
This page contains basic information for parents about spina bifida and includes pictures; Intermountain Healthcare.
Spina Bifida (MedlinePlus)
From the National Library of Medicine; basic information and numerous links to other reliable sources.
Spina Bifida Handout ( 961 KB)
This 24-page document for teens and young adults explains spina bifida, medical terms, diagnosis, symptoms, management, latex precautions, and more, from the Southwest Institute for Families and Children with Special Needs.
National & Local Support
Children and adults with spina bifida website
Excellent site including basic medical, surgical, and educational information with patient and family discussion lists
Hydrocephalus Association
An excellent resource that offers education, research, advocacy and support to eliminate the challenges of hydrocephalus.
Services for Patients & Families in Idaho (ID)
|Service Categories
|# of providers* in:
|Other states (5) (show)
|Developmental - Behavioral Pediatrics
|Educational Advocacy
|Nutrition Assessment Services
|Pediatric Endocrinology
|Pediatric Gastroenterology
|Pediatric Neurology
|Pediatric Neurosurgery
|Pediatric Orthopedics
|Pediatric Physical Medicine & Rehabilitation
|Pediatric Urology
|Social Workers
|Spina Bifida Clinics
|Vocational Education
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Adzick NS, Thom EA, Spong CY, Brock JW 3rd, Burrows PK, Johnson MP, Howell LJ, Farrell JA, Dabrowiak ME, Sutton LN, Gupta
N, Tulipan NB, D'Alton ME, Farmer DL.
A randomized trial of prenatal versus postnatal repair of myelomeningocele.
N Engl J Med. 2011;364(11):993-1004. PubMed abstract
Bartoshesky LE, Haller J, Scott RM, Wojick C.
Seizures in children with meningomyelocele.
Am J Dis Child. 1985;139(4):400-2. PubMed abstract
Bowman RM, McLone DG, Grant JA, Tomita T, Ito JA.
Spina bifida outcome: a 25-year prospective.
Pediatr Neurosurg. 2001;34(3):114-20. PubMed abstract
Bradley LA, Palomaki GE, McDowell GA.
Technical standards and guidelines: prenatal screening for open neural tube defects.
Genet Med. 2005;7(5):355-69. PubMed abstract
Brand MC.
Part 3: examination of the newborn with closed spinal dysraphism.
Adv Neonatal Care. 2007;7(1):30-40; quiz 41-2. PubMed abstract
An excellent discussion of the types of and significance of cutaneous markers for closed neural tube defects in babies.
Cheschier N.
ACOG practice bulletin. Neural tube defects. Number 44, July 2003. (Replaces committee opinion number 252, March 2001).
Int J Gynaecol Obstet. 2003;83(1):123-33. PubMed abstract
Deak KL, Siegel DG, George TM, Gregory S, Ashley-Koch A, Speer MC.
Further evidence for a maternal genetic effect and a sex-influenced effect contributing to risk for human neural tube defects.
Birth Defects Res A Clin Mol Teratol. 2008;82(10):662-9. PubMed abstract
Edwards M, Borzyskowski M, Cox A, Badcock J.
Neuropathic bladder and intermittent catheterization: social and psychological impact on children and adolescents.
Dev Med Child Neurol. 2004;46(3):168-77. PubMed abstract
This article describes the use of intermittent catheterization from the perspective of the individuals with myelomeningocele and their families.
Elliott SP, Villar R, Duncan B.
Bacteriuria management and urological evaluation of patients with spina bifida and neurogenic bladder: a multicenter survey.
J Urol. 2005;173(1):217-20. PubMed abstract
Foster, Mark M.D., Ph.D.
Spina bifida outcome: a 25-year prospective.
(2007) http://www.emedicine.com/orthoped/topic557.htm .
Frey L, Hauser WA.
Epidemiology of neural tube defects.
Epilepsia. 2003;44 Suppl 3:4-13. PubMed abstract
Jackson AB, Sipski ML.
Reproductive issues for women with spina bifida.
J Spinal Cord Med. 2005;28(2):81-91. PubMed abstract
Jallo G, Becske T .
Neural Tube Defects.
emedicine; (2005) http://www.emedicine.com/neuro/topic244.htm.
Juriloff DM, Harris MJ.
Hypothesis: the female excess in cranial neural tube defects reflects an epigenetic drag of the inactivating X chromosome on the molecular mechanisms of neural fold elevation.
Birth Defects Res A Clin Mol Teratol. 2012;94(10):849-55. PubMed abstract
King JC, Currie DM, Wright E.
Bowel training in spina bifida: importance of education, patient compliance, age, and anal reflexes.
Arch Phys Med Rehabil. 1994;75(3):243-7. PubMed abstract
A description of some toileting interventions for individuals with spina bifida.
Klepper J, Busse M, Strassburg HM, Sorensen N.
Epilepsy in shunt-treated hydrocephalus.
Dev Med Child Neurol. 1998;40(11):731-6. PubMed abstract
Lee NG, Gomez P, Uberoi V, Kokorowski PJ, Khoshbin S, Bauer SB, Estrada CR.
In utero closure of myelomeningocele does not improve lower urinary tract function.
J Urol. 2012;188(4 Suppl):1567-71. PubMed abstract
Liptak, G.S.
Evidence-based Practice in Spina Bifida: Developing A Research Agenda.
Evidence-based Practice in Spina Bifida, 2003; Washington D.C.. / http://web.archive.org/web/20040701175406/http://www.sbaa.org/site/Doc...
Lollar, D.J.
Learning Among Children with Spina Bifida.
Spina Bifida Spotlight. 1995; https://spinabifidaassociation.org/wp-content/uploads/2015/07/Learning...
This article describes learning problems and possible interventions in children with myelomeningocele.
Meyer S, Landau H.
Precocious puberty in myelomeningocele patients.
J Pediatr Orthop. 1984;4(1):28-31. PubMed abstract
Noetzel MJ, Blake JN.
Prognosis for seizure control and remission in children with myelomeningocele.
Dev Med Child Neurol. 1991;33(9):803-10. PubMed abstract
Proos LA, Dahl M, Ahlsten G, Tuvemo T, Gustafsson J.
Increased perinatal intracranial pressure and prediction of early puberty in girls with myelomeningocele.
Arch Dis Child. 1996;75(1):42-5. PubMed abstract / Full Text
Pruitt LJ.
Living with spina bifida: a historical perspective.
Pediatrics. 2012;130(2):181-3. PubMed abstract / Full Text
Rossi A, Biancheri R, Cama A, Piatelli G, Ravegnani M, Tortori-Donati P.
Imaging in spine and spinal cord malformations.
Eur J Radiol. 2004;50(2):177-200. PubMed abstract
Sawin KJ, Brei TJ, Buran CF, Fastenau PS.
Factors associated with quality of life in adolescents with spina bifida.
J Holist Nurs. 2002;20(3):279-304. PubMed abstract
Sawin, K.J., Buran, C.F., Brei, T.J., and Fastenau, P.S.
Sexuality Issues in Adolescents with A Chronic Neurological Condition.
J. Perinat. Educ. 2002;11(1):22-34.
Sawyer SM, Roberts KV.
Sexual and reproductive health in young people with spina bifida.
Dev Med Child Neurol. 1999;41(10):671-5. PubMed abstract
Sgouros S, Kulkharni AV, Constantini S.
The international infant hydrocephalus study: concept and rational.
Childs Nerv Syst. 2006;22(4):338-345. PubMed abstract
Shin M, Kucik JE, Siffel C, Lu C, Shaw GM, Canfield MA, Correa A.
Improved survival among children with spina bifida in the United States.
J Pediatr. 2012;161(6):1132-7. PubMed abstract
Sufianov AA, Sufianova GZ, Iakimov IA.
Endoscopic third ventriculostomy in patients younger than 2 years: outcome analysis of 41 hydrocephalus cases.
J Neurosurg Pediatr. 2010;5(4):392-401. PubMed abstract
Talwar D, Baldwin MA, Horbatt CI.
Epilepsy in children with meningomyelocele.
Pediatr Neurol. 1995;13(1):29-32. PubMed abstract
Toriello HV.
Folic acid and neural tube defects.
Genet Med. 2005;7(4):283-4. PubMed abstract
Trivedi J, Thomson JD, Slakey JB, Banta JV, Jones PW.
Clinical and radiographic predictors of scoliosis in patients with myelomeningocele.
J Bone Joint Surg Am. 2002;84-A(8):1389-94. PubMed abstract
Trollmann R, Strehl E, Dorr HG.
Precocious puberty in children with myelomeningocele: treatment with gonadotropin-releasing hormone analogues.
Dev Med Child Neurol. 1998;40(1):38-43. PubMed abstract
Verhoef M, Barf HA, Vroege JA, Post MW, Van Asbeck FW, Gooskens RH, Prevo AJ.
Sex education, relationships, and sexuality in young adults with spina bifida.
Arch Phys Med Rehabil. 2005;86(5):979-87. PubMed abstract
Vogel TW, Bahuleyan B, Robinson S, Cohen AR.
The role of endoscopic third ventriculostomy in the treatment of hydrocephalus.
J Neurosurg Pediatr. 2013;12(1):54-61. PubMed abstract
Warf BC, Campbell JW.
Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment of hydrocephalus for infants with myelomeningocele: long-term results of a prospective intent-to-treat study in 115 East African infants.
J Neurosurg Pediatr. 2008;2(5):310-6. PubMed abstract
Webb HW, Barraza MA, Stevens PS, Crump JM, Erhard M.
Bowel dysfunction in spina bifida--an American experience with the ACE procedure.
Eur J Pediatr Surg. 1998;8 Suppl 1:37-8. PubMed abstract
West M, Fjeldvik L, Rand-Hendriksen S.
Helping to solve problems associated with spina bifida: 1. Presentation of the TRS Project: organizing services for low frequency diagnostic groups and 2. Cognitive deficits often seen in young adults with spina bifida: effects in the school and work place.
Eur J Pediatr Surg. 1995;5 Suppl 1:12-5. PubMed abstract
Wong LY, Paulozzi LJ.
Survival of infants with spina bifida: a population study, 1979-94.
Paediatr Perinat Epidemiol. 2001;15(4):374-8. PubMed abstract
Yerby MS.
Teratogenicity and antiepileptic drugs: potential mechanisms.
Int Rev Neurobiol. 2008;83:181-204. PubMed abstract
Yoshida F, Morioka T, Hashiguchi K, Kawamura T, Miyagi Y, Nagata S, Mihara F, Ohshio M, Sasaki T.
Epilepsy in patients with spina bifida in the lumbosacral region.
Neurosurg Rev. 2006;29(4):327-32; discussion 332. PubMed abstract


text:
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Reinstatement requirements vary depending on the type of suspension and the circumstances of the conviction(s).
This information is provided as a general reference for six common driver's license suspension types.
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Points are accumulated on a person's driving record as a result of certain convictions. Georgia driver's licenses are suspended for any person who accumulates 15 or more points within 24 months; anyone under age 18 who accumulated 4 points within twelve months; and for any person under the age of 21 who is convicted of a 4 point violation.
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Reinstatement FAQs – Third Points Violations (Age 21 & over)
Super Speeder
If the DDS receives notification of your conviction for speeding at 75 mph or more on a two-lane road or highway, or at 85 mph and above on any road or highway in the State of Georgia, the offender will be notified by first class mail of the $200 Super Speeder fee.
The offender will have 120 days from the date of the notice to pay the fee to DDS. Failure to pay the fee in the time allotted will result in the suspension of the driver's license and the offender will be required to pay a reinstatement fee, select Reinstatement Fees and Payment Options for details.
Additionally, select for Super Speeders FAQs.
Additional Reinstatement Information
Select for Reinstatement FAQs - General Information.
Driver's License Suspensions and Revocations

subset: commoncrawl


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Hi HG, I'm a huge cookie dough fanatic... I just can't get enough! But I don't like all of the calories and fat grams that come along with it. Got any guilt-free alternatives? Cookie Dough Craver
Hi Cookie Dough Craver,
You're definitely not alone on this one -- people LOVE cookie dough. But you're right -- it can get you into trouble. Luckily, there's some stuff out there that'll satisfy your cookie dough cravings without derailing your diet. Check 'em out... Freezer-aisle finds - While most cookie dough ice cream is a fatty free-for-all, there are a few brands that you should get to know. Dreyer's/Edy's Slow Churned Light is my favorite guilt-free ice cream, hands down. It has half the fat and a third less calories than regular ice cream, but there's nothing diety-tasting about it. And there's a Cookie Dough flavor -- 130 calories and 3.5g fat per 1/2-cup serving (PointsPlus® value 4*)! I also love Breyers Blasts! Mrs. Fields Chocolate Chunk Cookie Dough ice cream. It's not billed as "light" on the packaging, but it has pretty reasonable stats -- 140 calories and 4.5g fat for a half cup (PointsPlus® value 4*). That's why you always have to read those nutrition labels -- sometimes there are GOOD surprises! Can't be trusted to stick to one serving? Check out Smooth & Dreamy Chocolate Chip Cookie Dough Sandwiches, also from Breyers. They're slightly higher in calories (160 per treat, PointsPlus® value 4*), but since they're portion controlled, you don't have to worry about finishing an entire pint of ice cream. Cookie-dough-flavored snack bars - There are a lot of 'em out there that'll fill you up and satisfy that cookie dough craving... Luna and Larabar both make bars that taste great and have pretty good stats -- 170 - 210 calories and 6 - 11g fat (PointsPlus® value 5 - 6*), plus the Luna bar has a whopping 12g protein. If you just want a little something, Balance Bar mini energy bars come in a Cookie Dough flavor, with 100 calories and 3.5g fat each (PointsPlus® value 3*). Can't find a bar that's specifically cookie dough flavor? Any soft, chewy bar in a basic chocolate chip flavor should do the trick. Example: Clif Kid ZBar in Chocolate Chip, which has 120 calories and 3g fat (PointsPlus® value 3*). DIY ideas - Use Torani Sugar Free Chocolate Chip Cookie Dough Syrup to infuse anything with cookie dough flavor, guilt-free -- everything from coffee to oatmeal to HG-style French toast. And don't forget about our softies, which are soft and chewy (especially when consumed straight out of the oven). Totally cookie-dough-like, especially the chocolate chip ones. There you have it -- lots of cookie-dough-ish products to buy and recipes to try... YAY!
Hey, Lisa! I'm looking at gift baskets for the holidays, and they're all full of fattening foods like cheese, fatty meats, chocolate, cookies, etc. Do you have any better-for-you gift basket ideas? Guilt-Free Gift Giver
Hi Gift Giver,
Oooh, great Q! I've got ideas for everyone on your list. And you'll be happy to know there's nothing naughty here, in case you want to treat yourself... For HG fans... This Vitalicious gift set is a no-brainer. Gift-wrapped chocolatey treats with 100 calories each = the best! Here's another idea for lovers of guilt-free chocolate... Check out this beautifully wrapped bag of 30-calorie truffles from Gayle's Miracles. (They're essential for making these TV-famous Fudgy Truffle Bites!) For anyone... Lucero makes the most amazing balsamic vinegars infused with fruity flavors like peach, wild cherry, and blueberry. And just 25 calories per tablespoon. We recently got our hands on the new white balsamic vinegars, and they're fantastic. This sampler pack would be perfect for any foodie. For those who like it hot, this Salsa of the Month Club rocks. We were gifted with a subscription a few years ago (thanks, Jen!), and we've been obsessed ever since. Rather go mainstream? Edible Arrangements are always good picks, and there are options for every budget. Make your own baskets... Get creative! If your friend enjoys guilt-free cocktails, pair a copy of Hungry Girl Happy Hour with a bottle of Torani Sugar Free Syrup. (That zero-calorie mixer is essential for decadent cocktails sans guilt.) Is your pal a coffee enthusiast? Grab a bag of Starbucks Christmas Blend Blonde Roast coffee beans (so good!) and some of the seasonal Peppermint Mocha VIA. Add a cute mug, and you've got a great gift. And last but not least, lovers of our famous Lord of the Onion Rings will flip for jars of Vivi's Original Carnival Mustard Sauce and Sir Kensington's Gourmet Scooping Ketchup -- the perfect guilt-free dipping accompaniments. (Even if they're not onion ring enthusiasts, they'll likely enjoy these yummy condiments!) Happy gifting, and happy holidays!
HG News You Can Use! Vitamin Angels helps children worldwide get the nourishment they need, and you can help too. Click now to see how!
Today, December 12th, is National Gingerbread House Day. We LOVE Jet-Puffed Gingerbread Mallows -- just 100 calories per 11-piece serving! Add a few to low-cal cocoa... YUM!!!
Have a question for Hungry Girl? Send it in! She answers new Qs each week (but cannot respond to emails personally).
SmartPoints® value not what you expected? Click here for more info on how the values are calculated, plus more FAQs about PointsPlus® and SmartPoints® values on our website.


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Domenico Gilardoni
Stage director: Radim Vizváry
Sets: Lucia Škandíková
Costumes: Petra Vlachynská
Light design: Karel Šimek
Chorus master: Martin Buchta
Motion cooperation: Miřenka Čechová
An opera about opera - thus can be briefly characterised Donizetti's dramma giocoso Le convenienze ed inconvenienze teatrali (Conventions and Inconveniences of the Stage), also known as Viva la Mamma. The action takes place during the preparations and rehearsals for a new opera production, featuring singers, artists, theatre-makers and staff both on stage and backstage. Perhaps the most distinct character is that of Mamma Agata, the mother of the second donna, portrayed by a man. The application of travesty highlights the comicality of both the personage and the whole farce, thus linking up to the centuries-old tradition of comic theatre. The conduct of the other protagonists is funny, annoying, yet moving too. And just as funny, annoying and moving, and in the final analysis, admirable, is the behaviour of today's descendants of Donizetti's characters. The very timelessness of the operatic farce is actually that which makes it so enthralling. In addition to an amusing plot, the audiences can also savour Donizetti's brilliant bel canto music at its peak. By and large, the opera is a sort of quintessence of 19th–century musical comedy, which also has the indisputable potential of enchanting present-day consumers.
The opera is staged in Italian original version. Czech and English subtitles are used in the performance.
Approximate running time, including intermission:
2 hours, 20 minutes, one 20-minute intermission.


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2013 Series Recap
The 2013 screening series commemorating the first anniversary of Superstorm Sandy was a huge success, with 36 films and media projects screening over four nights at three terrific venues.
Brooklyn Arts Council's film program showcases the tremendous and diverse film talent based in Brooklyn as well as the best films from emerging filmmakers around the world principally shot in the borough. Our fall 2013 series (October 25 - 29) commemorates the 1st Anniversary of Superstorm Sandy.
Scene: Brooklyn includes a yearly screening and discussion series; special screenings, parties and discussions in partnership with local film and media organizations throughout the year; professional development seminars for filmmakers and film & media organizations; and filmmaker meet ups and social gatherings.
Brooklyn Arts Council supports the creation of film and media art by awarding grants to over 15 Brooklyn film and media artists each year, promoting film and media artists and organizations though its online registry and directory, and providing artists with fiscal sponsorship.
The 2013 screening series commemorating the first anniversary of Superstorm Sandy was a huge success, with 36 films and media projects screening over four nights at three terrific venues.
Partnering with Scene: Brooklyn will align your brand with an independent film program reaching an enthusiastic audience of curious, culturally aware Brooklyn taste makers.
Scene: Brooklyn is made possible, in part, by support from the Henry Nias Foundation and the William Talbott Hillman Foundation.
Major corporate, foundation and in-kind support is provided by:
Astoria Federal Savings; Bay and Paul Foundations; Booth Ferris Foundation; Brooklyn Community Foundation; CME Group Community Foundation; Con Edison; Concert Foods; Concord Baptist Christfund; Dennis Shipping Company; Henry Nias Foundation; JPMorgan Chase Foundation; Lily Auchincloss Foundation, Inc.; Mary Duke Biddle Foundation; MetLife Foundation Creative Aging Program, administered by the National Guild for Community Arts Education; Milton and Sally Avery Arts Foundation; New York Council for the Humanities; Rose M. Badgeley Residuary Charitable Trust; Smart Family Foundation; TD Charitable Foundation; William Talbott Hillman Foundation; The H.W. Wilson Foundation; The Emma A. Sheafer Charitable Trust; The Laura B. Vogler Foundation, Inc.; The New York Community Trust; Toyota; and Two Trees Management Co., LLC.
Official Media Partner: WNYC


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I have been using Awstats for many years to process my log files. But I am missing many possibilities (like cross-domain reports) and I hate being stuck with extra fields I created years ago. Anyway, I am not going to continue to use this script.
Is there a modern apache logs analytics solution based on modern storage technologies like NoSQL or at least somehow ready to cope with large datasets efficiently?
I am primarily looking for something that generates nice sortable and searchable outputs with the focus on web analytics, before having to write my own frontends. (so graylog2 is not an option)
This question is purely about log file based solutions.


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- About the Onyx Pillars Test Print
- Run the Onyx Pillars Test Print
- Use the Test Print as a Diagnostic Tool
About the Onyx Pillars Test Print
The Onyx Pillars Test Print can be used to diagnose printing issues on the Mark Two. This test print is significantly more effective at diagnosing wet Onyx than the Wet Plastic Purge routine. In addition, the Onyx Pillars Test Print can help diagnose under-extrusion or several other printing issues.
The Onyx Pillars Test Routine will run for about 15 minutes and then will pause to allow you to inspect it. Wet plastic or under extrusion issues may be visible at this time. As with any paused print, after inspecting the part, you will have the option to stop the print or to resume it. Resuming the print will allow it to run for another hour or so and may provide more definitive results as to the quality of your plastic and prints.
Running the Onyx Pillars Test Print
The Onyx Pillars Test Print is a utility that can be run directly from your printer.
To run the Onyx Pillars Test Print:
- Apply glue to your print bed as shown in the picture below and place your print bed into your printer.
- Press the menu button in the upper right corner of your printer's LCD touchscreen.
- Select the "Utilities" tile from the available options.
- Select the "Test Prints" tile from the available options.
- Select the "Onyx Pillars Test Print" tile.
Using the Test Print as a Diagnostic Tool
The Onyx Pillars Test Print can be used as a diagnostic for several issues on the Mark Two. See below for pictures and descriptions of potential failure modes for this part and what they mean. If you experience a failure mode that is not shown here, please Contact Support for additional assistance.
- Good Test Pillars: Walls and floors are well-formed, lacking gaps or stringing. Plastic is uniformly distributed and all shapes are dimensionally accurate.
- Pillars with Wet Plastic: Stringing between pillars or off of walls.
Solution: Pull several feet of filament off of the spool and discard it. Reload the plastic and run the Onyx Pillars Test Print again. If the test print still shows signs of wet plastic, discard the spool and try a new one.
- Pillars with Under-Extrusion: Gaps in walls or floors.
Solution: Change the nozzle and check for any jams in the drybox, extruder, or print head.
- Pillars with Dimensional Inaccuracy: Looking from the top-down, circles are wider than tall, or vice versa. Square pillars look like rectangles. Plastic is not evenly distributed.
Solution: Check the belt tension and the bearings in your pulleys. Dimensional inaccuracy on this print can be a sign that the motion system on your printer needs to be calibrated.


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How to upgrade
With features like Dark Mode, Stacks, and two new built-in apps, macOS Mojave helps you get more out of every click. Before you upgrade your Mac, make sure your Mac is ready.
Check compatibility
Most Mac models introduced in 2012 or later are compatible with macOS Mojave, and you can upgrade directly from OS X Mountain Lion or later.See compatible Mac models
Make a backup
Before installing any upgrade, it's important to back up your Mac. Time Machine makes it simple, and other backup methods are also available.Learn how to back up
Free up space
To install macOS Mojave, your Mac needs at least 2GB of memory and 12.5GB of available storage space to upgrade—or up to 18.5GB of storage space when upgrading from OS X Yosemite or earlier.Learn how to free up space
Download macOS Mojave
Visit the macOS Mojave page on the App Store, then click the Get button. After downloading, the installer opens automatically.
Keep macOS Mojave up to date
To automatically install macOS updates in the future, including apps downloaded from the App Store, select "Automatically keep my Mac up to date" from Software Update in System Preferences. Your Mac will notify you when updates require your Mac to restart, so you can always choose to install those later.
What's new in macOS Mojave
Get an overview of features such as Dark Mode, Stacks, and Continuity Camera, as well as the the new apps in macOS Mojave: Home, and Voice Memos.
macOS Support
Get help using macOS, moving content to a new Mac, and more.
Update to iOS 12
iOS 12 makes your iPhone and iPad more powerful, personal and intelligent than ever.Update your device
Update to watchOS 5
With watchOS 5, you can do even more with your Apple Watch — from your morning workout to bedtime.Update your Apple Watch


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Hey all.
Im 14, living in the UK. For my age, I do well in Maths, and have basic computer skills.
To me, programming looks really interesting. Both the maths, logic, and creativity look really appealing. Like alot of maths, programming looks to be like a "perfect logic," like a chess game that must be won!
However, I have NO programming experience, and do not know where to start. I will definatly want to go to university when I'm 18, possibly for a mathmatics or software development course.
But like I said, i don't know where to start! When did you guys start programming, and how? What advice would you give? I know its looking alot into the future, but I was thinking of programming as a career, how would i begin?
Any advice would be appreciated.
Thanks alot, Ric


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1981 Learned Societies Conference fonds
- Fonds
- 1979-1981
Fonds consists of conference reports, press clippings, information on individual and society participants, and administration and planning documents.
Learned Societies Conference.
1981 Learned Societies Conference fonds
Fonds consists of conference reports, press clippings, information on individual and society participants, and administration and planning documents.
Learned Societies Conference.
Fonds contains textual records relating to the history of the activities of the Dalhousie University English Department and to Bevan's academic activities. The fonds consist of research notes generated during Bevan's study of Dryden'...
Bevan, Allan, Dr., 1913-1981
Fonds contain materials relating to the work and teaching of Brian Hall. Items include awards and notices of awards received by Hall, correspondence regarding his work and achievements, lecture and class notes from courses Hall taught, information...
Byron Ulric Hatfield Photograph Collection
Collection contains seventy-seven glass plate lantern slides created by Byron Ulric Hatfield in Nova Scotia during the early twentieth century. Hatfield took photographs of coastal landscapes, churches and other buildings, and people working and i...
Hatfield, Byron Ulric
Canadian Union of Public Employees Local 1725 fonds
Fonds includes circulars issued by Dalhousie University to recruit members for the Canadian Union of Public Employees as well as circulars issued by the Canadian Union of Public Employees to the existing Dalhousie University members. Also included...
Canadian Union of Public Employees. Local 1725.
Fonds consists of handwritten and printed sermons and lectures and an open letter to the Chancellor of the University of Halifax (1877). It also includes a convocation address (1870) and the order of service for Macdonald's funeral (1901).
Macdonald, Charles
Correspondence of Daniel C. Harvey
File consists of correspondence to Harvey from Dr. A. MacMechan and his wife, a recommendation letter from MacMechan to Edwin Laftus, and a letter from George W. Robinson to Dr. MacMechan.
Harvey, Daniel Cobb, Dr.
Dalhousie Alumni Association fonds
The fonds consists of records relating to the administration and governance of the association; correspondence carried out on behalf of the Association; events such as the amalgamation of Dalhousie University and the Technical University of Nova S...
Dalhousie Alumni Association
Fonds consists of administrative records related to the operation of the Dalhousie Arts Centre which includes correspondence, personnel files, reports, and memos; audio-visual materials; minutes, correspondence, and reports related to the Dalhousi...
Dalhousie University. Arts Centre.
Dalhousie Student Union and other student organizations
This collection contains the minutes and reports of the Student Council and its related committee and administrative correspondence.
Dalhousie Student Union
Dalhousie University Libraries fonds
Dalhousie University. University Libraries.
Dalhousie University Photograph Collection
Collection contains thousands of photographs depicting events at Dalhousie University from the late 1800s to the present day.
Dalhousie-King's Reading Club fonds
Fonds consists primarily of meeting minutes, membership and attendance lists, programmes, a copy of the club's sixty-fifth anniversary cookbook, correspondence, and miscellaneous papers which include photos and records related to the club's annive...
Dalhousie-King's Reading Club
Fonds contains music and lyrics as well as a letter from Donald Murray.
Murray, Donald
Drawings of the Dalhousie University mace
File contains nine drawings of the Dalhousie University mace created by R.L. de C.H. Saunders, a Dalhousie University Professor of Anatomy who designed the mace in 1949. The drawings illustrate details of various parts of the mace. The mace was ca...
Fonds consists of a printed copy of Ritchie's thesis, completed in 1889 at Cornell University; two essay offprints from The Dalhousie Review; and a hand-bound catalogue of Ritchie's book collection, with her personal bookplate on the end...
Ritchie, Eliza
Emily Bevan Harrington's university lecture and essay notes
Essay and/or lecture notes primarily on topics of literature and the Bible, and a two-part essay on Beowulf.
Harrington, Emily Bevan
Fonds consists of a draft typescript of Baird's "Doctor Archibald MacMechan: An Estimate and an Appreciation," commissioned by The Halifax Chronicle for their 1923 New Year's edition and withdrawn at Archibald MacMechan's ...
Baird, Frank, Rev. Dr., 1870-1951
This fonds consists primarily of records related to the Board of Governors collected by Farquhar during his time on the board, including minutes; the report A Survey and Plan of Fund-raising for Dalhousie University; and a file of correspondence, ...
Farquhar, George
Fonds comprises a letter from Ernest Rutherford and correspondence regarding a proposal to apply for the presidency of the University of New Brunswick. There is also a letter of appointment from the Ministry of National Defence, a list of Henderso...
Henderson, George Hugh
Fonds consists of records primarily originating from Herbert L. Stewart's work as a philosopher, professor, and political commentator. Records include manuscripts and typescripts, notes, scrapbooks, diaries, offprints, reports, and correspond...
Stewart, Herbert Leslie
Fonds consists of notes of lectures on logic delivered by James Ross at the Theological Seminary in Truro, Nova Scotia (1860-1861) and on Moral Philosophy at Dalhousie College (1863-1864), as well as certificates of attendance from the 1860s and a...
Baxter, James, 1844
James W. Clark's "Freud and Dalhousie: The Symons Affair of 1929"
The manuscript was for a presentation Clark delivered at a Dalhousie History Seminar in March 1985. The text discusses Norman Jellings Symons, a professor of psychology at Dalhousie during the 1920s who studied, taught, and published articles rela...
Clark, James, W.
Collection contains original records, and reproductions or altered forms of materials created by Jerome H. Barkow. Items include course materials taught by Barkow, on subjects like anthropology. biology, and sociology; drafts of his published pape...
Barkow, Jerome H.
Jewish Endowment Fund for Dalhousie fonds
Fonds consists of correspondence to and from donors (1936-1945), student lists, and miscellaneous papers and receipts. Most of the donor correspondence relates to requests for donations, in particular for the Cape Breton Regional Scholarship and t...
The Jewish Endowment for Dalhousie.
Cummings, Joan Elizabeth
Fonds consists of material created and collected by John F. Graham during his career as a professor at Dalhousie University, as well as some material prior to this time. Types of records include correspondence, meeting minutes, notes, manuscripts ...
Graham, John F.
Note from John J. MacKenzie regarding a class cancellation
Item is a note from J.J. MacKenzie to an unnamed colleague regarding his class cancellation due to illness and making reference to an impending guest lecture by Sir W. Young.
Mackenzie, John James, 1847-1879
Notebooks of Bertha and Minna Liechti
File consists of three notebooks (ca. 1887-1894) of lecture notes on geography, advanced German, literature, and psychology. It also includes Mima Liechti's notebook (1866-1869) recording visits made and/or received and lists of members and a...
Liechti, Bertha E. Susanna, b. 1871
Personal archives of Ian McAllister
Accession contains research material, articles, book reviews and books written by Ian McAllister between 1967 and 2010. Subjects include regional and international development, universities, peacebuilding, the Red Cross, and humanitarian aid. Acce...
McAllister, Ian, 1937-
Personal archives of Murray G. Brown
This fonds contains primarily research- and teaching-related materials, including notes, annotated drafts of papers, presentations and reports, abstracts, correspondence, funding applications and reports, as well as some administrative papers and ...
Brown, Murray
Personal archives of Theodore Ross
Accession consists of incoming and outgoing correspondence of Theodore Ross. Materials primarily concern agricultural and personal matters, Dalhousie's anniversary, capital campaign, and student residents at Pine Hill.
Ross, Theodore
This fonds consists of photographs; audiovisual materials; newspaper clippings; pamphlets and posters; Dalhousie publications and other printed material; student and personnel files; correspondence; manuscripts; reports created by or reviewed by s...
Dalhousie University. Office of the President.
Fonds consists of Phi Delta Theta records, including programs, budgets, reviews, newspaper clippings and materials related to the fraternity's fiftieth reunion in 1980. There is also Morton's history of the fraternity, miscellaneous corr...
Morton, Ralph S. , 1908-
Fonds contains records produced by the Dalhousie University Registrar's Office, including student registration cards, registration books, exam books, matriculation registers, student directories, and correspondence.
Fonds comprises primarily Dawson's research materials, including newspaper clippings, assorted print materials, notes and correspondence, manuscript drafts, proofs and offprints. There is a smaller volume of personal and family papers, person...
Dawson, Robert MacGregor
Song lyrics written for the 50th reunion dinner of Dalhousie's Class of 1915
Lyrics written for the Class of 1915's fiftieth reunion dinner.
MacKenzie, Charles Guy, Reverend, 1895-19??
Technical University of Nova Scotia fonds
Fonds consists of the records of the Technical University of Nova Scotia, predominanty from its first 40 years as the Nova Scotia Technical College and from its final decade before amalgamation with Dalhousie University.College governance is well ...
Technical University of Nova Scotia.
Technical drawings of Dalhousie University buildings
Accession contains architectural sketches and textual documents related to Eliza Ritchie Hall; Storage Facility; Shirreff Hall; Howe Hall; Studley House; Old Management Building (Coburg); Marion McCain Building; Dalplex; Computer Science; Central ...
Collection contains both original records and reproductions of materials related to Reverend Thomas McCulloch. Items include a glass plate etching of McCulloch, microfilm copies of his books, a sample of his shorthand, a ticket to a lecture given ...
McCulloch, Thomas, 1776-1843
Fonds consists of Thomas McCulloch Jr.'s correspondence with various persons and organizations, manuscripts, and documents from McCulloch's visit(s) to France.
McCulloch, Thomas, Jr.
University of the air was a distance learning initiative started by CTV's regional television affiliates, to offer degree-related video courses, taught by University professors around the country. Production of University of the Air started i...
Dalhousie University. Board of Governors.
Fonds consists of law publications and print materials relating primarily to government, the Canadian Constitution, or to Newfoundland joining confederation; copies of speeches; correspondence with family, friends, and professional associates, inc...
MacDonald, Vincent Christopher
Fonds consists primarily of correspondence and records pertaining to the Dalhousie Class of 1926 and William Jarvis McCurdy. Financial records include class contributions and invoice payments; correspondence includes letters exchanged between McCu...
McCurdy, William Jarvis


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- The Inductees
- Induction Ceremony
- Educational Resources
- Exhibits
- Get Involved
- About Us
- Calendar
- Contact Us
We welcome your nominations for future CWHF Inductees! Nominations are accepted on an ongoing basis and are reviewed by our Consulting Scholars Committee. Each year, the Consulting Scholars select a theme for the Induction Ceremony and create a slate of nominees for approval by the Board of Trustees. Qualified candidates may or may not be inducted in the year in which they are nominated, but all nominations are kept on file for future consideration.
To be considered for induction to the Connecticut Women's Hall of fame, a nominee must:
You may use the form below to submit your nomination or use the printable form. Please address additional materials to our office. All materials sent in support of a nomination become the property of the CWHF.