Treatments

• Pediatric Neurology is a very wide sub specialty and includes diseases Involving Brain, Spinal Cord, Nerves and Muscles.
• Some of these entities are disorders and not diseases in true sense.
• Following are broad categories of diseases/disorders that I manage in children :
  • autism
  • Epilepsy
  • Neuropathies
  • Neuroregression
  • Muscular dystrophy
  • Headache/Migraine
  • Developmental Delay
• Critically Sick Child - Guillian Barre Syndrome, FIRES ( Fever Induced Refractory Status Epilepticus), Acute Febrile Encephalopathy, ADEM ( Acute Disseminated Encephalomyelitis)

• The epilepsies are a spectrum of brain disorders ranging from severe, life - threatening and disabling, to ones that are much more benign.
• In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior or sometimes convulsions, muscle spasms, and loss of consciousness.
• The epilepsies have many possible causes and there are several types of seizures. Anything that disturbs the normal pattern of neuron activity - from illness to brain damage to abnormal brain development - can lead to seizures.
• Having a single seizure as the result of a high fever (called febrile seizure) or head injury does not necessarily mean that a person has epilepsy. Only when a person has had two or more seizures is he or she considered to have epilepsy.
• EEG and brain scans such as magnetic resonance imaging or computed tomography are common diagnostic tests for epilepsy.
• Once epilepsy is diagnosed, it is important to begin treatment as soon as possible.
• Seizures can be controlled with modern medicines and surgical techniques. Some drugs are more effective for specific types of seizures.

• Epilepsy refractory to or not responding to drug treatment may need other therapies.
• These include - Special Diet - Ketogenic Diet or Modified Atkin's Diet, Epilepsy Surgery - Palliative or Lesionectomy, Surgical Procedure - VNS
• The most common type of surgery for epilepsy is removal of a seizure focus, or small area of the brain where seizures originate. This type of surgery is appropriate only for focal seizures that originate in just one area of the brain.
• In general, people have a better chance of becoming seizure - free after surgery if they have a small, well - defined seizure focus.

• Developmental Delay is when a child does not reach his / her developmental milestones at the expected times. It is an ongoing major or minor delay in the process of development. Delay can occur in one or many areas - for example, gross or fine motor, language and / or social skills.
• Developmental Delay can have many different causes, such as genetic causes (like Down syndrome), or complications of pregnancy and birth (like prematurity or infections). Often, however, the specific cause is unknown. Some causes can be easily reversed if caught early.

• The term cerebral palsy refers to any one of a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination but don't worsen over time.
• Even though cerebral palsy affects muscle movement, it isn't caused by problems in the muscles or nerves. It is caused by abnormalities in parts of the brain that control muscle movements.
• Patients may have
  • Dystonia / Spasticity
  • Small Head Size
  • With / Without other Morbidities - Epilepsy, Visual Problems, Hearing Deficit
• Children with cerebral palsy require - comprehensive care.
• The earlier treatment begins the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them.
• Treatment may include physical and occupational therapy, speech therapy, drugs to control seizures, relax muscle spasms, and alleviate pain, surgery to correct anatomical abnormalities or release tight muscles, braces and other orthotic devices, wheelchairs and rolling walkers, and communication aids.

Oral Care In Children With Cerebral Palsy :

• Daily Oral Hygiene - Try to Aim at Independent Daily Oral Care.
• Ask you Pediatric Dentist to Demonstrate How to Maintain Oral Hygiene :
  • Use of Power Tooth Brush
  • Use of Floss / Floss Holder
• Be Consistent About Oral Hygiene - Same Location, Timing and Positioning.
• Clean After Meals :
  • Rinse with Water
  • Check for Food Pouching Between Gums and Cheek
• Use Fluoride Free Toothpaste if the Child Cannot Spit.
• Prefer Sugar Free Medicines and Less Sugary Meals.
• Ask Your Dentist About :
  • Open Bite (Tendency to Keep Mouth Open)
  • Use of Chlorhexidine Spray
  • Need for Professional Cleaning
  • How to Make a Tooth Saving Kit
  • Frequency of Follow Up
  • Fluoride Gel Use to Prevent Decay

Pediatric Dental Surgeon :

• Name : Dr. Dhaval Parikh, BDS, MDS
• Phone : 9638820627

Constipation in Cerebral Palsy :

Among the major complications associated with CP is constipation, which affects approximately 74% of CP patients. In patients with quadriplegic CP, the origin of constipation is organic and is secondary to extra - intestinal abnormalities. Dryness of the stools is a result of inadequate water and food intake due to dysphagia, low mobility of the body, and slow peristalsis due to rigid abdominal muscles.

Constipation was defined as the presence of fecalomas or dry or hard stools for the past 30 days or less than 3 bowel movements per week, except in children not yet weaned. Thus, bowel frequency and consistency of faces were the diagnostic parameters of constipation. The desired result in the treatment of constipation was a bowel frequency of at least 3 stools per week and mushy and/or soft stools. Most of the CP patients present with dysphasia, they should be oriented on a pasty diet that contained solid food that was liquefied.

Fibre :

• Wholegrain Cereals (e.g. Porridge)
• Rice (may be Eaten Whole or Ground)
• Fresh or Stewed Fruits
• All Vegetables - Raw, Cooked, Mashed or Pureed (Leave the Skin on)
• Baked Beans, Lentils, Dried Peas and Beans

These foods can be eaten whole, mashed or pureed depending on your child's feeding ability.

Fluid :

• Encourage a good intake of fluid. The amount of fluid your child requires depends on how old they are. Thicken drinks as required and remember thickened fluids are just as hydrating as thin fluids.
• Pear juice or prune juice may help with relieving constipation.
• Good sources of fluid include : Water, Milk, Juice, Formula, Ice, Iceblocks, Jelly, Yoghurt, Custard, Ice Cream.

Activity :

• Limit periods of inactive sitting time as much as possible.
• Assist or encourage your child or change positions regularly to include lying in different positions, sitting and standing. Encourage your child to participate in 'Huff and Puff' activities for a minimum of 60 minutes per day.
• Your physiotherapist will be able to suggest individualised activities your child can participate in and recommend a range of exercises that assist trunk and pelvic movement, this may include flexing the hips fully up and down, 'Running The Legs', trunk rotation and active trunk flexion.

How much fibre is enough?

• 0 - 6 Months - No recommendation has been set
• 7 - 12 Months - No recommendation has been set

Children and Adolescents :

• 1 - 3 yr - 14g / day
• 4 - 8 yr - 18g / day
• 9 - 13 yr - (Girls) - 20g / day
• 0 - 13 yr - (Boys) - 24g / day
• 14 - 18 yr - (Girls) - 22g / day
• 14 = 18 yr - (Boys - 28g / day

Toileting :

Ask your occupational therapist how to personalize a toileting program for your child. The following principles can be applied :

• Maintain a regular toileting schedule that includes sufficient time for your child to sit on the toilet (up to 10 minutes).
• For many children, the bowel is activated by eating or sitting in water. 15 minutes after a meal or straight after the bath can be a good time to encourage toileting.
• To optimize balance on the toilet and assist with adequate muscle contraction and sphincter release, children should be seated on a toilet or potty with an appropriately sized seat (reducer rings that fit under the normal toilet seat are stable). They should also have their feet supported (e.g on a small step or stool).
• For children with balance difficulties, a rail to hold onto will keep them more secure and allow them to concentrate on their toileting.
• As much as possible, children should sit with their backs straight and leaning slightly forwards. Some children need to be taught to push and require verbal prompts to "squeeze the muscles in their tummies".

Medications :

• Sometimes children with CP will require medication to assist with maintaining regular bowel habits.
• Talk to your doctor to find out if medication may be suitable for your child.

Managing constipation properly will improve the child's quality of life significantly.

Consult a Paediatric gastroenterologist for advice on medications, specific dietary changes, fecal disempaction.

• Autistic disorder (sometimes called autism or classical ASD) is the most common condition in a group of developmental disorders known as the autism spectrum disorders (ASDs).
• Autistic children have difficulties with social interaction, display problems with verbal and nonverbal communication, and exhibit repetitive behaviors or narrow, obsessive interests. These behaviors can range in impact from mild to disabling. Autism varies widely in its severity and symptoms and may go unrecognized, especially in mildly affected children or when more debilitating handicaps mask it. Scientists aren't certain what causes autism, but it's likely that both genetics and environment play a role.

Developmental Disabilities Include

• Attention Deficit Hyperactivity Disorder (ADHD)
• Autism Spectrum Disorders, Including Medication Management of Behavioural Disorders Associated with Autism Spectrum Disorders
• Behavioural Sleep Disturbances
• Behaviour problems in early Childhood, such as Tantrums and Oppositional Behaviours
• Developmental aspects of other Genetic Disorders, such as Down Syndrome, Turner's Syndrome, etc.
• Feeding Disorders
• Learning Disorders

What is a migraine headache?

• A migraine headache is a primary headache disorder that effects approximately 12% of the population. It is a headache that tends to recur in an individual and is moderate to severe if left untreated. It can be one sided, throbbing and aggravated by routine physical activity. It can be associated with light and sound and even smell sensitivity and many patients will become nauseated with it. In a minority of patients there can be visual or sensory changes before, during or after the headache, known as auras.
• Although refractory errors and sinusitis are thought to cause headaches, it is not true in most children presenting with headaches.
• There are many variants of migraine particularly in children.

• Traumatic head injuries are a major cause of death, and disability. The preferred term is traumatic brain injury (TBI).
• The purpose of the head, including the skull and face, is to protect the brain against injury. In addition to the bony protection, the brain is covered in tough fibrous layers called meninges and bathed in fluid that may provide a little shock absorption.
• Skull fracture may or may not be associated with TBI.
• When an injury occurs, loss of brain function can occur even without visible damage to the head. Force applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the brain tissue, or damage the nerve connections within the brain.

• Multiple diseases affecting the brain, spinal cord or nerves present acutely.
• In Newborns, Some Common Acute Neurological Illnesses Include
  • HIE (Hypoxic Ischemic Injury)
  • Intracranial Bleed
  • Neonatal Seizures
  • Neonatal Encephalopathy
  • Meningitis
• In Pediatric Intensive Care Units, Common Acute Neurological Disorders May Include
  • Acute Flaccid Paralysis
  • Acute Febrile / Afebrile Encephalopathy
  • Meningitis
  • Status Epilepticus

• Central nervous system infections can be categorized as meningitis, encephalitis, and brain abscess.
• Viruses and bacteria cause most central nervous system infections, but fungi and parasites can also cause one.
• Treatment for a central nervous system infection varies depending on the kind of infection and the site.
• Tuberculous meningitis is an important cause of morbidity and mortality in India and this condition requires early diagnosis and appropriate treatment.
• CNS infections can lead to many complications hence vigilant management is mandatory.

• Diseases affecting muscles are of many types.
• These can be acute like viral polymyositis or chronic.
• Most muscle diseases are inherited although there are some acquired disorders which require early treatment like Juvenile dermatomyositis.
• Muscular dystrophy (MD) refers to a group of genetic diseases characterized by progressive damage and weakness of facial, limb, breathing, and heart muscles. It is due to the lack of a key protein that is needed to maintain the integrity and proper function of the muscle. As the muscle tissue is damaged, the muscle bulk is reduced. Sometimes the muscle tissue can be replaced with fat and excessive scar tissue to make muscle appears larger than normal.

• Diseases Affecting Anterior Horn Cell
  • Spinal Muscular Atrophy
• Disease Affecting the Nerves
  • Acquired and Inherited Neuropathies
• Diseases Affecting Neuromuscular Junctions
  • Myesthenia Gravis

• Stroke though more common in adults, children also may suffer ischemic or hemorrhagic strokes
• Ischemic strokes are arterial in origin.
• Stroke can occur even in infancy. Infants are prone to basal ganglia ischemic stroke and venous sinus thrombosis.
• The cause of stroke needs to appropriately investigated to avoid recurrence.
• There are many congenital and acquired disorders affecting blood vessels. Such diseases may be restricted to the brain or affect blood vessels elsewhere in the body too.
• Some diseases like Moyamoya disease need appropriate surgical management.

• Many disease are inherited
• Syndromes like Fragile X in males and Turner's syndrome in females are common examples of diseases caused due to chromosomal abnormalities and leading to intellectual disability.
• Inborn errors are metabolisms definitely require an appropriate diagnosis as many of them are inherited in an autosomal recessive manner and hence have high chance of recurrence in the next baby.
• Many special investigations are required to diagnose these conditions and apart from treatment of the patient, it is important to prevent recurrence of such diseases.