CP for ESI Final year clinics with voice over.pdf.pptx

#peds #cp

1. Approach to cerebral Palsy Dr. Shobhana

2. Definition of CP CP is a disorder of posture, movement and tone due to a static encephalopathy acquired during brain growth in foetal life, infancy or early childhood So evaluation must include Proving it is non progressive M otor handicap Associated abnormalities

3. Presenting complaints Directly related to CP History of delay in achieving physical milestones Abnormal movements Seizures Presentation of complication/co morbidities Indirectly related to CP Cough Fever Aspiration pneumonia Failure to gain weight

4. History of presenting illness Description in short of cough, fever etc for which the child is presently admitted If the child has no non specific complaint and is primarily admitted for delayed milestones, then start the description of achieved milestones age wise, ie development history

5. When to start the present history from? Start from the time the child was became symptomatic-If you start the history from 9 months of age, we should be very sure the child was absolutely well before that So if the abnormality started early in infancy, better to start from birth or antenatal history but if the child’s problem started at 1.5 years following meningitis, we should not start the history from birth but only from 1.5 yrs with the description of meningitis

6. Course of illness Every complaint how it started, improved or worsened and its present condition-course of every complaint(onset, duration, progress) For eg - In a child with spasticity of lower limbs initially had scissoring, progressed to more deformities with the presence of contractures and scoliosis and finally became bed ridden Or a child with spasticity, with good physiotherapy and care is able to walk now

7. Points to keep in mind while taking history Make sure history brings out the static nature of CP ie non progressive illness If the child has not attained sitting at the normal age of 8 months, CP child will ultimately achieve it even if it is at 1 year unlike neuro regression.

8. CNS history Higher functions-, schooling, Intellect, speech, communication Cranial nerves Swallowing difficulty, nasal regurgitation,(commonest in CP due to pseudobulbar involvement of IX &X nerves) Squint visual impairment

9. Motor system history- type of CP Has the mother noticed paucity of movements D oes the child remain in frog like position /shoulder slips under the held hand– hypotonic/Floppiness Difficulty in changing diapers/ scissoring on lifting-Adductor spasm indicating spasticity If stiff the distribution of stiffness will give us the type All four limbs affected equally- Quadriplegia L ower limbs affected much more than upper limb- Diplegia Upper and lower limb of one side affected with upper limb more involved than lower limb- Hemiplegia

10. Development history Age of attaining different milestones in all 4 domains Gross motor -head holding, rolling over, sitting, standing, walking, running ,climbing stairs up and down Fine Motor - Reaching for objects uni /bi dextrous approach, hand mouth coordination, self feeding buttoning and un buttoning shirts, wearing chappals Social and adaptive - Social smile , stranger anxiety, playing with peers, bladder and bowel control Language -Cooing, to monosyllables, to bi syllables, word and sentence formation, story and rhyme

11. Other history Seizures-their type course and control Abnormal movements – dystonia,chorea (indicating more extensive cortical involvement) Visual impairment Hearing impairment History of other co morbidities

12. C omplication/co morbidities Microcephaly Squint(strabismus) Recurrent LRTI –Aspiration due to pseudobulbar , GE reflux Dental caries Constipation Bed sores Malnutrition Vit Deficiencies Contractures Scoliosis/ kyphosis Behaviour disturbance Intellectual impairment Sleep disturbances

13. Gross motor functional grading Depending on the way a CP child carries our activities of daily living –like Eating, Dressing, Toilet use, Ambulation (EDTA-Pneumonic) and their degree of communication of their needs. It is graded as levels I-V

14. Search for etiology

15. Prenatal causes Condition Chromosomal abnormality-Down syndrome Microcephaly & IU Infection-TORCHES CNS malformation Cretinism (hypothyroidism) Relevant history Maternal age, consanguineous marriage Recurrent abortions Iron, Folic Acid intake ,IDDM Maternal hypo/hyperthyroidism

16. Perinatal causes Condition Prematurity Birth asphyxia Hypoglycemia Hypocalcemia Kernicterus Sepsis/neonatal meningitis ICH/IVH Inborn Errors of metabolism Relevant history Preterm/term/Type of delivery, Birth weight Cried immediately/ feeding NICU admissions-IVF, seizure, Jaundice, phototherapy/exchange transfusion, IV antibiotics Repeated vomiting after starting feeds

17. How to know if the insult is pre or perinatal ? Normal development at 3 months rules out pre and perinatal causes of developmental delay At 3 months, a normal child would Start head holding Recognises mother Social smile Follows objects full arc Vocalises when talked to Puts finger to mouth

18. Other sub headings of history Treatment history Diet history Immunisation history Socio economic history Family history

19. Always rule out treatable causes Hypothyroidism-So always do TFT in all developmental delays Certain IEM- Urine metabolic screening a must Karyotyping - for genetic counselling for next pregnancy

20. General examination Describe consciousness, orientation, posture Vitals- HR/PR, RR, BP, Temp,Spo2 Anthropometry and its plotting in charts with interpretation Feeding difficulties, a part of CP leads to malnutrition Microcephaly may be cause for CP Pallor, icterus, cyanosis, clubbing, lymphadenopathy

21. Development assessment At present whatever the child does description of that in all four domains and compare it with the history given Sometimes mothers may say the child doesn’t hold head but rolls over. Since by rule development is always cephalo caudal, whether it is normal or delayed, after checking it , we can ignore such wrong histories If a 3 year old has just started walking, then describe as what the child should have achieved at 1 year in gross motor milestones, it has achieved now

22. Head to foot examination Head size-micro/macrocephaly-IU infections/CNS malformations/ post meningitic sequelae AF/PF- hypothyroidism B and of loss of hair at the back because of chronic lying down Dysmorphism -chromosomal anomalies

23. Examination Eye Ptosis Squint Cataract& chorioretinitis - IU infection Roving nystagmus -blindness Vit A deficiency Optic atrophy Mouth Drooling of saliva Halitosis Poor dental hygiene Dental caries Glossitis Angular stomatitis

24. Squint Drooling Cataract Caries

25. Trunk & Limbs Rachitic rosary Windswept deformity Scissoring Callosities Bedsores. Contractures-hip adductors, tendo achillis Hip subluxation Kyphoscoliosis Gait –if walks

26. Scissoring Windswept deformity Rosary Contracture

27. CNS Higher functions Speech Gait Cranial nerves Motor system Sensory system-Involved only in extensive involvement of cortex Extrapyramidal

28. Motor Examination Bulk- Make sure there is no wasting, no need to measure bulk on the 2 sides if there is no obvious difference Tone-by feeling, soft muscles indicate hypotonia , by resistance to passive touch, by assessing the range of movement as hypotonia is accompanied by greater range of movement In infants-180 degree flip test

29. Motor contd . Power- Rough estimate in smaller children and severely retarded children.If the child can lift limbs above the bed power is roughly 3/5 Reflexes- Usually brisk biceps, triceps knee jerk ankle jerk in quadriplegic.In hemiplegic one sides brisk DTR Plantar – Upgoing Presence of abnormal movements like choreoathetosis,dystonia

30. CNS examination of young child https://www.youtube.com/watch?v=0f4B9vgTdIk

31. Diagnosis Static encephalopathy and classify based on findings Physiology as spastic/ hypotonia / choreoathetoid / mixed M otor type as quadriplegia/ diplegia / hemiplegia Functional grade as 1-5 Associated problems as squint/visual defect/ hearing impairment/Seizures Co m orbidities as PEM/LRTI/Contractures/bed sore

32. Investigations MRI P eriventricular leucomalacia in Diplegia Neuronal migration in quadriplegia Basal ganglia involvement in choreathetoid or mixed CP EEG BERA Karyotyping Metabolic screening IU infection screening

33. Hemiplegic CP and rehabilitation https://www.youtube.com/watch?v=MDO6bijBRHs

34. Treatment First step is to explain to the parents/ caregiver the nature of the disease and counsel them regarding the global delay in milestones expected. Appreciate the parents for taking good care of child Treatment goals is to treat associated defects and provide better quality of life to the child Appropriate medications for seizures Physiotherapy should be done continuously to prevent further worsening of spasticity and to prevent contractures Frequent change in position (to prevent bedsores) To prepare a model diet chart to address PEM. Increase calories by adding MCT oil to the feeds to make it calorie dense P rotein rich feeds can be encouraged Stool softeners in case of constipation

35. Babinski sign

36. Triceps jerk Knee jerk

37. biceps scissoring

38. Flat occiput Bed sores and café aulait spots

39. Assignment Common Causes of Developmental delay in children What are the relevant antenatal history in a child presenting with developmental delay? What is the grading of power? How will you clinically differentiate UMN from LMN lesions?

40. Thank You