1. Dr. Pradeep Dubey - Consultant Pediatrician Dr. Pradeep Dubey MD (Ped.), DCH. Cons. Developmental Ped. Dr. Pradeep Dubey MD (Ped.), DCH. Cons. Developmental Ped. EARLY INTERVENTION IN CEREBRAL PALSY HOW EARLY CAN WE INTERVENE ? “DEVCHHAYA” Early Intervention Centre Prem Mandir Chowk, Wright Town

2. Dr. Pradeep Dubey - Consultant Pediatrician

4. 400 mcg. Start before conception Birth defects  by 30% Mandatory food fortification in US & Chile F O L I C A C I D

5. Dr. Pradeep Dubey - Consultant Pediatrician Mother – Rh negative Precautions for Rh incompatibility MATERNAL BLOOD GROUP

6. Dr. Pradeep Dubey - Consultant Pediatrician DYSKINETIC - C.P.

7. Dr. Pradeep Dubey - Consultant Pediatrician STAGES OF BRAIN DEVELOPMENT Formation of Medula, pones & fore brain Differentiation of Neurons in to various nuclie Hypothalamus, Thalamus etc. Neo cortical layer & formation of Gyrie & Sulcie. Establishment of synapses & Myelination of brain stem. Functional development of mid brain & fore brain.

8. Dr. Pradeep Dubey - Consultant Pediatrician Pre Term Babies  Periventricular infarction  Periventricular Hem.  Subcortical Necrosis MATURITY vs NEUROLOGICAL OUTCOME NEURO. INSULT (Hypoxia / Infection / Hypothermia) nNOS + Free Radicals Neuronal Necrosis Term Babies  Cortical Necrosis  Status marmoratum  Focal & Parasag. Necrosis  eNOS – ER2 receptors

9. Dr. Pradeep Dubey - Consultant Pediatrician Anatomical Peculiarities Intracranial Hemorrhage & periventricular Leukomalacia. NEURO. DEFICIT : Birth wt. 800 – 1000 gms. 6 – 8% Birth wt. 800 gms. & less 20 – 40% PREMATURITY & LBW US spending 26 billion $ (120,000 Crores Rs.) annually on Preterm babies and their related problems

10. Dr. Pradeep Dubey - Consultant Pediatrician Normal population 1-5 – 2/1000 L.B. Asphyxia 50 – 100/1000 L.B. Mild Asphyxia all are normal. Mod. Asphyxia – about 1/5 develop CP. Severe asphyxia – most of the survivors develop CP. OUTCOME OF H. I. E.

11. Dr. Pradeep Dubey - Consultant Pediatrician Low birth weight babies. Severe H.I.E. Severe neonatal jaundice Persistence of Abn. Neuro signs after 2 wks. Hypodensisties in Ct. even after 4 wks. Oliguria (<1ml./kg./ hr.) for 24 hrs. associated with H.I.E. Low apgar (0-3) after 20 mts. Late seizures in a depressed NB Background abnormalities in interictal EEG. HIGH RISK CONDITIONS

12. Dr. Pradeep Dubey - Consultant Pediatrician  Responsiveness / Alertness  Spontaneous motility Persistant hyper excitability Feeding difficulty Constant fisting Abnormal movements / convulsions. Abnormal postures Abnormal Head circumerence  Responsiveness / Alertness  Spontaneous motility Persistant hyper excitability Feeding difficulty Constant fisting Abnormal movements / convulsions. Abnormal postures Abnormal Head circumerence ALARMING SIGNS Abnormalities of tone Ocular abnormalities Lack of response to sound. Abnormalities of tone Ocular abnormalities Lack of response to sound.

13. Dr. Pradeep Dubey - Consultant Pediatrician NEUROPLASTICITYNEUROPLASTICITY Brain tissues are plastic and responsive. Adequate and repeated stimuli can modify brain physiology as well as morphology Brain port in patient with Vestibular damage – Secondary pathways unmasked. Grey matter mass of Med. Students brain increase in months of exam. “DO WE MAKE THE ROAD BY WALKING.”

14. Dr. Pradeep Dubey - Consultant Pediatrician CRITICAL PERIOD IN BRAIN MATURATION Kitten blind folded after birth for 3 months developed acquired amblyopia, Visual Cortex start processing auditory information. Strabismus in infants leads to acquired amblyopia Congenital deafness – auditory area process visual information. “WE USE IT OR WE LOSE IT”

15. Dr. Pradeep Dubey - Consultant Pediatrician STRABISMUS IN C.P.

16. Dr. Pradeep Dubey - Consultant Pediatrician HEMIPLEGIC C.P.

17. Dr. Pradeep Dubey - Consultant Pediatrician FOLLOWUP OF HIGH RISK INFANTS Cerebral Palsy -4% Mental Retardation-5% Seizure Disorder-3.9% Hearing Impairment-1.5% Learning Problems-14% ROP in VLBW babies -24% NICU SURVIVORS – LONG TERM FOLLOWUP Majority of these babies were LBW & Preterm.

18. Dr. Pradeep Dubey - Consultant Pediatrician 1. Early identification of neuro developmental disorders. 2. Minimisation of persistant abnormalities & detection of transient neurological abnormalities 3. Prevention of asymmetries & abnormalities of development. 4. Stimulation along channel of normal development EARLY INTERVENTION - AIMS THE PRINCIPLE OF NEUROPLASTICITY FORMS THE BASIS OF EARLY INTERVENTION

19. Dr. Pradeep Dubey - Consultant Pediatrician PRIORITIES OF MANAGEMENT Communication Socioemotional Development Maximal independence in ADL As near normal appearance as possible Mobility

20. Dr. Pradeep Dubey - Consultant Pediatrician AMIEL TISON - 2 MTHS, 7 MTHS, 12 MTHS AMIEL TISON - 2 MTHS, 7 MTHS, 12 MTHS P.G. I. CHANDIGRAH – 9 MTHS. P.G. I. CHANDIGRAH – 9 MTHS. OTHERS - 8 MONTHS OTHERS - 8 MONTHS AGE FOR ASSESSMENT

21. Dr. Pradeep Dubey - Consultant Pediatrician AMEIL TISON’S METHOD VOJTA’S TECHNIQUE CAPUTE AND ASSOCIATES INFANT NEUROLOGICAL INTERNATION BATTERY (INFANIB) NEURO DEVELOPMENTAL EXAMINATION METHODS

22. Dr. Pradeep Dubey - Consultant Pediatrician Head – size shape, fontanell sutures Eyes – Setting sun, Strabismus, nystagmus Skin abnormalities – Cafeaulet, Nevi etc. Skin abnormalities – Cafeaulet, Nevi etc. Cranial nerves Altered mental status Spine AMIEL TISON’S METHOD A. GENERAL DISCRIPTION

23. Dr. Pradeep Dubey - Consultant Pediatrician 1. Tone - Scarf sign heel to ear leg abduction, Popliteal angel leg abduction, Popliteal angel - dorsoflexion of foot Pull to sit. - dorsoflexion of foot Pull to sit. prone, sitting position prone, sitting position - atnr, - atnr, 2. Vestibular - Side ways sparachute, backward & Functionforward parachute, body rotative Function forward parachute, body rotative 3. Lethargy/Hyper excitability 4. Vision & Hearing 5. Developmental delay AMIEL TISON’S METHOD

24. Dr. Pradeep Dubey - Consultant Pediatrician PROGNOSIS FOR WALKING IN CP Hemiplegia 100% Diplegia (Paraplegic) 90% Ataxia/ Dyskinesia 80% Quadriplegia18%

25. Dr. Pradeep Dubey - Consultant Pediatrician Vestibulo Kinesthetic stimulation Tactile stimulation Auditory & Visual stimulation Cognitive stimulation Management of associated medical, neurological & behavioral problems neurological & behavioral problems INTERVENTION - MODALITIES

26. Dr. Pradeep Dubey - Consultant Pediatrician WE ARE GUILTY OF MANY ERRORS AND FAULTS, BUT OUR WORST CRIME IS ABANDONING OUR CHILDREN, NEGLECTING FOUNTAIN OF LIFE. ABANDONING OUR CHILDREN, NEGLECTING FOUNTAIN OF LIFE. MANY THINGS WE NEED IN LIFE CAN WAIT, THE CHILD CAN NOT. RIGHT NOW IS THE TIME – HIS BRAIN IS GROWING, HIS BLOOD IS BEING MADE. HIS SENSES ARE BEING DEVELOPED. TO HIM WE CAN NOT ANSWER TOMORROW TO HIM WE CAN NOT ANSWER TOMORROW HIS NAME IS “TODAY ” GABRIELA MISTRAL (NOBEL LAURIET FROM CHILE)

27. Dr. Pradeep Dubey - Consultant Pediatrician www.healthychildindia.com “DEVCHHAYA” Early Intervention Centre Prem Mandir Chowk, Wright Town “DEVCHHAYA” Early Intervention Centre Prem Mandir Chowk, Wright Town