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Background: Universal developmental screening is recommended at 9, 18, 24 and 36 months. The Government of India Mother and Child Protection (MCP) card is an immunization record that is used to monitor child development, and identify children requiring further evaluation. Objectives: To determine the diagnostic accuracy of the MCP card for developmental screening, and perform its item analysis. Study design: Mixed-method study (prospective study of diagnostic accuracy and qualitative study). Participants: Mother-child dyads of children between 2-36 months of age were recruited from the outpatient department or wards of a tertiary level children’s hospital from November, 2019 to October, 2021. Children with confirmed neurodevelopmental disorders/disability, and mothers with less than 6th standard education were excluded. Intervention: Each mother was given a MCP card, and taught how to mark the items. This was followed by the researcher’s evaluation (index tool). The reference tool was a comprehensive clinical assessment (CCA) by the researcher and an expert. The CCA included clinical examination of hearing, vision, and neurodevelopment; and psychometric assessment of development and adaptive function. Each mother underwent an in-depth interview. Overall and group wise psychometric properties of diagnostic accuracy were computed. The interview transcripts were analyzed thematically. Outcomes: The proportion of children with ‘fail’ and ‘delay’ by the evaluation of the researcher with the MCP card and the expert by the CCA, respectively. Results: The study population included 213 children (40.4% females). Fifty-two (24.4%) children were identified as ‘Fail’ by the MCP card and 43 (20.2%) as ‘delay’ by the expert’s CCA. The overall sensitivity and specificity was 83.7% (95% CI 69.3-93.2) and 90.6% (95% CI 85.2-94.5), respectively. Acceptable diagnostic accuracy was found in the age-group 7-9 months, 13-18 months, and 25-36 months. Conclusions: The MCP card may be used for developmental screening at 9, 18, and 36 months.
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Objectives: To compare development/cognition, adaptive function and maladaptive behaviorof HIV-infected and HIV-exposed uninfected children between 2 to 9 years with HIV-uninfected controls. Methods: This hospital-based cross-sectional study was conductedfrom November, 2013 to March, 2015. 50 seropositive HIV-infected, 25 HIV-exposeduninfected and 25 HIV-uninfected children between 2 to 9 years were administeredDevelopmental Profile 3, Vineland Adaptive Behavior Scale 2, and Child Behavior Checklistfor assessing development, adaptive function and maladaptive behaviour, respectively.Additional data were obtained by history, examination and review of records. Results:Significant developmental/cognitive impairment was observed in 38 (76%), 16 (64%) and 6(24%) HIV-infected, HIV-exposed uninfected, and HIV-uninfected children, respectively.Significant impairment in adaptive function was found in 12 (24%) and 2 (8%) HIV-infectedand HIV-exposed uninfected children, respectively. Maladaptive behavior was not seen in anygroup. Conclusions: High magnitude of impaired development/cognition and adaptivefunction in HIV-exposed and HIV-infected children warrants assessment of these domainsduring follow-up of these children, and incorporation of interventions for these deficits instandard care for this group.
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Objective: To determine the diagnostic accuracy of Indian Scalefor Assessment of Autism (ISAA) in children aged between 2-5years.Design: Study of diagnostic accuracySetting: Tertiary level hospital, (November 2015 – November2017).Participants: A consecutive sample of 500 children withsuspected Autism (delay or regression of developmentalmilestones, delay or regression in speech, age-inappropriateunderstanding, behaviour, play and/or social interaction) wasrecruited.Procedure: Each child underwent an expert comprehensiveassessment of Autism (reference tool) that included history,observation, examination, diagnostic criteria for Autism SpectrumDisorder (ASD) of the Diagnostic and Statistical Manual of MentalDisorders’, 5th edition, Childhood Autism Rating Scale-2(CARS2), developmental status and adaptive function. This wasfollowed by the administration of ISAA (test tool) in Hindilanguage. Parameters of diagnostic accuracy and ReceiverOperating Characteristic curves were computed.Main Outcome Measures: ASD based on (i) expert assessment,(ii) CARS-2, and (iii) ISAA.Results: In children aged 2-3 years, sensitivity of ISAA was 100%(95% CI 98.2% -100%), specificity 28.9% (95% CI 17.7% to43.4%), positive likelihood ratio 1.4 and negative likelihood ratio 0.In 3-5 year olds, sensitivity was 99.6% (95% CI 97.6% to 99.6%),specificity 33.3% (95% CI 15.1% to 58.3%), positive likelihoodration 1.5 and negative likelihood ratio 0.01. The degrees ofautism based on the existing cut off values were inaccurate.Conclusions: ISAA has sub-optimal performance in diagnosingand assessing severity in 2-5 year old children.
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Justification:Fragile X Syndrome (FXS) is the most common genetic cause of inherited intellectual disability and autism spectrumdisorder (ASD). Early identification results in appropriate management and improvement in functioning. Risk assessment in other familymembers can lead to prevention of the disorder. This necessitated the formulation of IAP recommendations for the diagnosis andmanagement of FXS in Indian children and adolescents.Process:The meeting on formulation of national consensus guidelines on Fragile X syndrome was organized by the Indian Academy ofPediatrics in New Delhi on 25th February, 2017. The invited experts included Pediatricians, Developmental Pediatricians, Psychiatrists,Pediatric Neurologists, Gynecologists, Geneticists, Clinical Psychologists and Remedial Educators, and representatives of ParentOrganizations. Guidelines were framed after extensive discussions. A writing committee was formed that drafted the manuscript,which was circulated among members for critical appraisal, and finalized.Recommendations: The committee recommended that early diagnosis of FXS is crucial for early, timely and appropriatemanagement. The interventions including timely occupational therapy, speech therapy and behavioral modifications help to improve thedevelopmental potential and reduce the maladaptive behavior. Pharmacotherapy may be needed to control and improve behavioralsymptoms. In addition, the emergence of targeted treatments such as low dose sertraline, metformin and /or minocycline may also behelpful for behavior, and perhaps cognition. Genetic counselling is helpful to communicate the risk for future children with FXS orpermutation involvement.
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Objective: To determine the diagnostic accuracy of Indian Scale for Assessment of Autism (ISAA) in children aged 2-9 year at high risk of autism, and to ascertain the level of agreement with Childhood Autism Rating Scale (CARS). Design: Diagnostic Accuracy study Setting: Tertiary-level hospital. Participants: Children aged between 2 and 9 year and considered to be at a high risk for autism (delayed development, and age-inappropriate cognition, speech, social interaction, behavior or play) were recruited. Those with diagnosed Hearing impairment, Cerebral palsy, Attention deficit hyperactivity disorder or Pervasive developmental disorders (PDD) were excluded. Methods: Eligible children underwent a comprehensive assessment by an expert. The study group comprising of PDD, Global developmental delay (GDD) or Intellectual disability was administered ISAA by an investigator after one week. Both evaluators were blinded. ISAA results were compared to the Expert’s diagnosis and CARS scores. Results: Out of 102 eligible children, 90 formed the study group (63 males, mean age 4.5y). ISAA had a sensitivity 93.3, specificity of 97.4, positive and negative likelihood ratios 85.7 and 98.7 and positive and negative predictive values of 35.5 and 0.08, respectively. Reliability was good and validity sub-optimal (r low, in 4/6 domains). The optimal threshold point demarcating Autism from ‘No autism’ according to Receiver Operating Characteristic curve was ISAA score of 70. Level of agreement with CARS measured by Kappa coefficient was low (0.14). Conclusions: The role of ISAA in 3-9 year old children at high risk for Autism is limited to identifying and certifying Autism at ISAA score of 70. It requires re-examination in 2-3 year olds.
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Context: Developmental concerns voiced by parents need to be responded to by structured developmental screening. Screening is the use of validated developmental screening tools to identify children with high risk of developmental delay out of an apparently normal population, while surveillance is the process of monitoring children identified as high risk by screening. Absence of routine screening can be attributed to problems at the level of parents, pediatricians or National policies. Hence vulnerable children are not detected early, and are denied benefit from appropriate developmental interventions. There are no definite guidelines for screening or for suitable tools for screening and surveillance. Objectives: To review existing developmental screening and monitoring tools for children validated in Indian under-five children, and provide a proposed practice paradigm for developmental screening in office practice. Evidence Acquisition: Scientific papers were retrieved by an electronic database search using MeSH terms ‘screening tool’, ‘developmental delay’, and filter of ‘children under 5 years’. Those relevant to office practice and validated internationally or in Indian children were reviewed. Results: Screening tools applicable to Indian office practice have been compared and certain tools have been recommended according to the level of risk of developmental delay. An algorithmic approach to screening has been given along with strategies for incorporation. Conclusions: Screening and surveillance for high risk of developmental delay are essential components of child health care. It is possible to incorporate both into routine practice.
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Objectives: To develop and validate a diagnostic tool for use by primary care physicians for diagnosing neuro-motor impairment among 2-9 year old children in primary care settings. Study design: Modified Delphi technique involving national (n=49) and international (n=6) experts was used for development of INDT-NMI. The tool was then validated through a cross sectional study. Setting: Neurology specialty clinics of three tertiary care pediatric centers in New Delhi, India. Participants: 454 children aged 2-9 years [mean (SD) age: 60.4 (23.7) mo], selected through systematic random sampling, underwent assessment for identification and classification of neuromotor impairments (NMI). Intervention: All study subjects were first administered INDTNMI (candidate test) by a trained physician followed by expert assessment for NMI and other neurodevelopment disorders (NDD) by team of two pediatric neurologists (Gold standard). Results: According to expert evaluation, 171 (37.8%) children had neuromotor impairments. There were four categories of subjects: NMI alone (n=66); NMI+other NDDs (n=105); Other NDDs without NMI (n=225) and ‘Normal’ group (n=58). Using expert evaluation as gold standard, overall sensitivity of the INDTNMI was 75.4% and specificity was 86.8%. INDT-NMI helped graduate physicians to correctly classify 86.6% (112/129) children with NMI into different types (cerebral palsy, neuromotor diseases and other NMI). Graduate physicians assigned 40 children (8.8%) as ‘indeterminate’, 38 (95%) of whom had either NDD and/or NMI and thus merited referral. Misclassification of NMI occurred in those with mild changes in muscle tone, dystonia, or ataxia and associated NDDs. Conclusion: Graduate primary care physicians with a structured short training can administer the new tool and diagnose NMI in 2-9 year old children with high validity. INDT-NMI requires further evaluation in actual primary care settings.