1. Acute presentations

2. 2 teams who take in turn to ask a clinical question You can ask for 1 piece of information –History –Examination finding –Investigation Clinical management game

3. Points 1 point for every relevant question 1 point off for a poor question Can guess diagnosis after good question Bonus of 5 points for the correct diagnosis Bonus of 5 points for good management plan Lose 10 points for incorrect diagnosis

4. GP referral Please see Jimmy he is a 12 year old boy who has an underlying diagnosis of cerebral palsy and who has been unwell and feverish for 24 hours

5. A + E Come and see Josephine she is having a prolonged tonic seizure

6. GP Please see Danielle aged 6 years she has cerebral palsy and has been crying and screaming for the last 24 hours and her mother is beside herself

7. Neonatal follow up clinic Jessica was born at 25 weeks and is now 18 weeks old. Since discharge from the unit she has steadily lost weight and is now significantly below the 0.4 th percentile.

8. Community paediatrician Please, please admit Ruby who has cerebral palsy and whose mother says she has been crying and distraut for the last 24 hours, however when I look at them Ruby seems fine but her Mum is a complete wreck. Mothers partner has just been admitted to intensive care following a RTA in Manchester and she is desperate to be with him. There are no family members to care for Ruby and social care do not have a suitably trained foster carer

9. Secondary medical problems in children with cerebral palsy Epilepsy (20% CP) Feeding difficulties GOR Drooling Constipation

10. Feeding difficulties - why Difficulties with head control / poor seating Motor dysfunction – oral and pharyngeal Being fed rather than feeding yourself GOR Drugs Psychogenic – stress, boredom, anxiety

11. Feeding difficulties - assess Length of time to feed Distress during or after feeding Coughing, eyes watering during feed Weight gain and nutritional status Vomiting and regurgitation

12. Videofluroscopy Lateral Xray of different radio opaque food 3 stages of swallow –Oral, voluntary –Pharyngeal, involuntary –Oesophageal, involuntary See aspiration, failure to clear oral cavity or pharynx

13. Management of feeding difficulties SALT with experience in feeding difficulties Check seating Advice from SALT – thickened liquids / no lumps etc Does history suggest reflux? NG / gastrostomy feeding If inserting gastrostomy then ensure no reflux

14. Gastro-oesphageal reflux 70% of children with CP ?therapeutic trial vs IX Ix – Ba meal, gastroscopy, PH studies Rx –Drugs – antacids, thickeners, H2 antagonists, proton pump inhibitors, prokinetics –Surgery – Nissens

15. Drooling 33% children with CP drool No relationship to CP type Improves with age Treatment –Seating, check teeth, SALT –Drugs – hyoscine patches, Glycopyrollate –Intraglandular botulinum toxin –Reimplant ducts

16. Pain More than half the children with CP have pain on more than 4 days in a row. Useful markers of pain in children are: Cranky Seeking comfort Change in eyes Less active Gesture to part that hurts Tears Gasping

17. Child in pain think about: Ears Teeth – more difficult to go to dentist Bowels - constipation Hips – dislocation, pathological fracture Spasticity

18. Unwell child with CP Try to get old notes – the families hate retelling the history. Better still is to find someone who knows the child Look for clues in presenting compliant. If none then consider –Chest difficulties –Pain –VP shunt blockage –Seizures –Side effect of medication –Abuse

19. Chest Difficulties –Infection –Aspiration –Decreased respiratory reserve Scoliosis Underlying muscle disorder –Sleep apnoea

20. Pain –Ears –Teeth – more difficult to go to dentist –Bowels - constipation –Hips – dislocation, pathological fracture

21. Clinical approach Presenting compliant –Chest symptoms / aspiration symptoms –Symptoms suggesting pain –Bowel habit Ask the parents if their child has been unwell like this before and if so what was the problem!

22. Past History – hopefully from notes Underlying diagnosis and cause Comorbidities esp VP shunt or seizures Orthopaedic complications – hips / spine Drugs – check with family what currently taking Allergies Immunisations Feed regime – and any difficulties

23. Present function Mobility Hand function Vision Hearing Communicate –How know happy / sad –Communicate yes / no –Use symbols / words if so complexity

24. Examination Baseline observations, including –Respiratory rate and sats –Conscious level –BM Examine all systems esp –Any ostomies –ENT –Teeth –limbs

25. Management If find cause treat! If decreased conscious level+ shunt for urgent neurosurgical opinion If decreased conscious level no cause – I.e. no seizure then investigate including blood gases If stable try analgesia Low threshold for considering LRTI

26. Summary Secondary disabilities are common regardless of underlying cause In order to manage children with complex disability you need to consider the co morbidities and complications

27. When assessing a child with complex disabilities who is unwell Think broad Understand the underlying problems Understand the child’s current function Complete a thorough examination