CDC Kerala 15: Developmental Evaluation Clinic (2-10 y)--developmental diagnosis and use of home intervention package.

OBJECTIVE: To describe the last 5 years' experience of Child Development Centre (CDC), Kerala Developmental Evaluation Clinic II for children between 2 and 10 y, referred for suspicion of developmental lag in the preschool years and scholastic difficulty in the primary classes with specific focus on developmental profile and the experience of the home based intervention package taught to the mothers. METHODS: A team of evaluators including developmental therapist, preschool teacher with special training in clinical child development, speech therapist, special educator, clinical psychologist and developmental pediatrician assessed all the children referred to CDC Kerala. Denver Developmental Screening Test (DDST-II), Vineland Social Maturity Scale (VSMS) and Intelligent Quotient (IQ) tests were administered to all children below 6 y and those above 6 with apparent developmental delay. RESULTS: Speech/delay (35.9%), behavior problem (15.4%), global delay/ intellectual disability (15.4%), learning problem (10.9%), pervasive developmental disorders (7.7%), seizure disorder (1.7%), hearing impairment (0.7%), and visual impairment (0.7%) were the clinical diagnosis by a developmental pediatrician. Each child with developmental problem was offered a home based intervention package consisting of developmental therapy and special education items, appropriate to the clinical diagnosis of the individual child and the same was taught to the mother. CONCLUSIONS: The experience of conducting the developmental evaluation clinic for children between 2 and 10 y has shown that a team consisting of developmental therapist, speech therapist, preschool teacher, special educator, clinical child psychologist and developmental pediatrician, using appropriate test results of the child could make a clinical diagnosis good enough for providing early intervention therapy using a home based intervention package.

CDC Kerala 16: Early Detection of developmental delay/disability among children below 6 y--a district model.

OBJECTIVE: To develop a district model for establishing early detection of childhood disability below 6 y of age and to develop appropriate referral linkages for confirmation of the diagnosis and establish home based early intervention therapy to all needy children. METHODS: Trained Accredited Social Health Activist (ASHA) workers conducted the preliminary survey for identifying developmental delay/disability among children below 6 y of age using Trivandrum Developmental Screening Chart (TDSC) (0-6 y) and a team of experts assessed the screen positives in developmental evaluation camps conducted at primary health centres (PHCs). RESULTS: Community survey was carried out and 1,01,438 children below 6 y of age in Thiruvananthapuram district were screened by ASHA workers and 2,477 (2.45%) positive cases (TDSC two or more item delay) were identified and these children were called for the developmental evaluation camps conducted at 80 PHCs in the district. Among the 1,329 children who reached the evaluation camps 43.1% were normal. 24.98% children had speech and language delay and 22.95% children had multiple disabilities. Developmental delay was observed among 49.89% children and cerebral palsy in 8.43% and intellectual disability 16.85% were confirmed. Visual impairment in 3.31% and neuromuscular disorders in 1.35 were found among children evaluated in the camp. CONCLUSIONS: The results of this district wide early detection of disability survey by trained ASHA workers among children below 6 y of age showed a community prevalence of 3.08% observed, based on two or more item delay in TDSC and among these children, 43.1% were normal, 49.89% had developmental delay, 24.98% had speech and language delay and 22.95% had multiple disabilities.

CDC Kerala 4: TDSC items based developmental therapy package among low birth weight babies--outcome at 18 months using DASII.

OBJECTIVE: To assess the effectiveness of Trivandrum Developmental Screening Chart (TDSC) items based intervention package developed at Child Development Centre, Kerala on the developmental outcome of children at 18 mo of age using Developmental Assessment Scale for Indian Infants (DASII) and compare the same in different birth weight groups. METHODS: Five hundred consecutive discharges from the Neonatal Intensive Care Unit (NICU), Sree Avittam Thirunal hospital, were recruited and followed up till 18 mo of age including 240 low birth weight (LBW;<2,500 g) babies and 260 normal birth weight babies. All 240 LBW babies were offered early intervention at monthly intervals till 12 mo of age, whereas the normal birth weight (NBW) group received only immunization service as per the routine of the hospital. The early intervention package for the low birth weight group was designed based on Trivandrum Developmental Screening Chart (TDSC 0-2 y) items delay. At 18 mo of age both the groups were offered developmental assessment using DASII by specially trained and experienced developmental therapists who were blind to the intervention status of the babies. RESULTS: It was observed that the LBW (<2,500 g) group, who received intervention had a DASII mental age of 18.31 as against 18.16 in the NBW (≥2,500 g) group and mental DQ 101.84 (LBW group) and 98.65 (NBW group) and the observed differences were not statistically significant. Similarly, the LBW, who received intervention group had a DASII motor age of 18.68 as against 18.47 in the NBW group and motor DQ 139.40 (LBW group) and 135.39 (NBW group) and the observed differences were not statistically significant. CONCLUSIONS: The results of this TDSC based intervention package among low birth weight babies showed that at 18 mo of age there was no statistically significant difference in the developmental outcome using DASII, between low birth weight babies on intervention and the normal birth weight babies without any intervention.

CDC Kerala 1: Organization of clinical child development services (1987-2013).

OBJECTIVE: The main objective of establishing the Child Development Centre (CDC), Kerala for piloting comprehensive child adolescent development program in India, has been to understand the conceptualization, design and scaling up of a pro-active positive child development initiative, easily replicable all over India. METHODS: The process of establishing the Child Development Centre (CDC) Kerala for research, clinical services, training and community extension services over the last 25 y, has been as follows; Step 1: Conceptualization--The life cycle approach to child development; Step 2: Research basis--CDC model early stimulation is effective; Step 3: Development and validation of seven simple developmental screening tools; Step 4: CDC Diagnostic services--Ultrasonology and genetic, and metabolic laboratory; Step 5: Developing seven intervention packages; Step 6: Training--Post graduate diploma in clinical child development; Step 7: CDC Clinic Services--seven major ones; Step 8: CDC Community Services--Child development referral units; Step 9: Community service delivery models--Childhood disability and for adolescent care counselling projects; Step 10: National capacity building--Four child development related courses. RESULTS: CDC Kerala follow-up and clinic services are offered till 18 y of age and premarital counselling till 24 y of age as shown in "CDC Kerala Clinic Services Flow Chart" and 74,291 children have availed CDC clinic services in the last 10 y. CONCLUSIONS: CDC Kerala is the first model for comprehensive child adolescent development services using a lifecycle approach in the Government sector and hence declared as the collaborative centre for Rashtriya Bal Swasthya Karyakram (RBSK), in Kerala.

CDC Kerala 7: Effect of early language intervention among children 0-3 y with speech and language delay.

OBJECTIVE: To assess the effect of systematic clinic and home based early language intervention program in children reporting to the early language intervention clinic with full partnership of specially trained developmental therapist and the parents. METHODS: All babies between 0 and 3 y referred to Child Development Centre (CDC) Kerala for suspected speech/language delay were assessed and those without hearing impairment were screened first using Language Evaluation Scale Trivandrum (LEST) and assessed in detail using Receptive Expressive Emergent Language Scale (REELS). Those having language delay are enrolled into the early language intervention program for a period of 6 mo, 1 h at the CDC clinic once every month followed by home stimulation for rest of the month by the mother trained at CDC. RESULTS: Out of the total 455 children between 0 and 3 y, who successfully completed 6 mo intervention, the mean pre and post intervention language quotient (LQ) were 60.79 and 70.62 respectively and the observed 9.83 increase was statistically significant. The developmental diagnosis included developmental delay (62.4%), global developmental delay (18.5%), Trisomy and other chromosomal abnormalities (10.5%), microcephaly and other brain problems (9.9%), misarticulation (8.4%), autistic features (5.3%) and cleft palate and lip (3.3%) in the descending order. CONCLUSIONS: In the present study among 455 children between 0 and 3 y without hearing impairment, who successfully completed 6 mo early language intervention, the mean pre and post intervention LQ were 60.79 and 70.62 respectively and the observed 9.83 increase was statistically significant.

CDC Kerala 6: Validation of Language Evaluation Scale Trivandrum (0-3 y) against Receptive Expressive Emergent Language Scale in a developmental evaluation clinic population.

OBJECTIVE: To validate Language Evaluation Scale Trivandrum (LEST) 0-3 y against the reference standard, Receptive Expressive Emergent Language Scale (REELS) in a population of children attending CDC developmental evaluation clinic 0-3 y. METHODS: All the children clinically diagnosed as having speech and language problem in the developmental evaluation clinic of CDC Kerala over a period of 3 y were assessed using LEST (0-3) by trained developmental therapist and REELS by a speech therapist, both blind to the results of each other. RESULTS: Out of a total of 761 children between 0-3 y diagnosed as having speech problems by a Developmental Pediatrician in the developmental evaluation clinic (0-3 y) of CDC Kerala, both LEST and REELS could be administered among 679 children. The screening tool LEST 0-3 had a high sensitivity (84.4%), specificity (80.3%), Positive Predictive Value (PPV) (91.5%), Negative Predictive Value (NPV) (67.1%) and accuracy (83.2%) against the reference standard REELS. CONCLUSIONS: The observation of this study that LEST 0-3 had a high sensitivity, specificity and accuracy against REELS, suggest that in a developmental/speech evaluation clinic LEST could be effectively used in resource poor settings.

CDC Kerala 3: At-risk baby clinic service using different screening tools--outcome at 12 months using Developmental Assessment Scale for Indian Infants.

OBJECTIVES: To describe CDC Kerala experience of establishing an at-risk baby clinic and the comparison of different developmental screening tools at 12 mo against the gold standard Developmental Assessment Scale for Indian Infants (DASII). METHODS: At risk baby clinic of CDC, Kerala was established as a facility for follow up of NICU graduates from Sree Avittam Thirunal Hospital at 2, 4, 6, 8 and 12 mo corrected age and during each visit the mother is taught the CDC model early stimulation by developmental therapists and encouraged to continue to do the same at home. At 12 mo, assessment results of four simple developmental tools were compared with the gold standard DASII administered by a senior developmental therapist. RESULTS: Out of a total of 800 babies, outcome measurements at 12 mo were available for 604 infants. The prevalence of developmental delay using the screening tools, CDC grading for standing, Amiel Tison angles and DDST II (Denver II) gross motor were 24.8, 24 and 24.3% respectively and using DASII, a diagnostic tool (13.3%). Also the combination of Amiel Tison angles, CDC standing grading and DDST gross motor against DASII motor DQ had high specificity (94.15%) and negative predictive value (NPV) (70.18%) but with a very low sensitivity of 14.58% and low positive predictive value (PPV) of 53.85%. It was observed that a significant odds ratio for DASII mental deviation quotient (DQ) was seen for neonatal seizures (2.34) and low birth weight (1.49). CONCLUSION: The prevalence of developmental delay using the screening tools, CDC grading for standing, Amiel Tison angles and DDST II (Denver II) gross motor were 24.8, 24 and 24.3% respectively and together they had a high specificity, NPV and accuracy against DASII motor DQ as gold standard at one year assessment.

CDC Kerala 5: Developmental therapy clinic experience--use of Child Development Centre grading for motor milestones.

OBJECTIVES: To document the experiences of the intervention given to children who attended the developmental therapy clinic of Child Development Centre (CDC) Kerala, a specialized clinic for providing developmental intervention/therapy for babies less than two years with developmental delay/disability. METHODS: All the babies referred to this speciality clinic from developmental screening/evaluation clinics of CDC were registered in the clinic and re-evaluation was done using CDC grading for head holding, sitting, standing, Amiel Tison passive angles, and Trivandrum Developmental Screening Chart (TDSC) 0-2 y. RESULTS: Out of a total of 600 consecutive babies below 2 y with developmental delay/disability referred to developmental therapy clinic, on comparing the test results at enrollment and after 6 mo of intervention, a statistically significant reduction was observed (i) in the 2-4 mo age group with regard to abnormal TDSC (25.5%), (ii) in the 4-8 mo age group with regard to abnormal head holding grade (87.1%) and abnormal TDSC (19.4%), (iii) in the 8-12 mo age group, with regard to abnormal sitting grade (71.7%) and (iv) in the above 12 mo age group with regard to abnormal sitting grade (35.3%) and abnormal standing grade (78.8%). CONCLUSIONS: The experience of organizing the developmental intervention/therapy clinic at CDC Kerala has shown that therapy services by developmental therapists in a centre and supportive therapy by mother at home is useful in improving the developmental status of children with developmental delay.

Development and validation of Trivandrum Development Screening Chart for children aged 0-6 years [TDSC (0-6)].

OBJECTIVE: To develop and validate a simple screening tool for identifying developmental delay among children of 0-6 y of age in the community. METHODS: The 51-items of Trivandrum Development Screening Chart for children of 0-6 y [TDSC (0-6 y)], were carefully prepared from the norms in various existing developmental charts/scales, by experts keeping in mind the face validity and content validity. The criterion validity was assessed in a community sample of 1,183 children of 0-6 y with a mean age of 35.38 mo (SD of 19.25) including 597 (50.46%) boys and 586 (49.54%) girls. TDSC (0-6 y) was validated against Denver Developmental Screening Test (DDST) as the 'Reference Standard'. RESULTS: When one item delay in TDSC (0-6 y) was considered as 'TDSC delay' (test positive), the sensitivity and specificity of TDSC (0-6 y) was found to be 84.62% (95% CI: 71.92-93.12) and 90.8% (95% CI: 88.97-92.43) respectively with a Negative Predictive Value of 99.23% (95% CI: 98.48-99.67) and LR (negative) of 0.17(95% CI: 0.09-0.32). The test-retest and inter-rater reliability [an interclass correlation (ICC) of 0.77 for test-retest and ICC of 0.97 for inter-rater] were good and acceptable. CONCLUSIONS: TDSC (0-6 y) is a simple, reliable and valid screening tool for use in the community to identify children between 0 and 6 y with developmental delay, enabling early intervention practices.

Systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy.

The use of lidocaine in spinal anaesthesia is associated with transient neurological syndrome (TNS). Bupivacaine has a lower incidence of TNS as an alternative but it may have a prolonged action. This study systematically reviews the literature about the recovery profile of patients undergoing spinal anaesthesia, using bupivacaine for arthroscopic knee surgery. We identified 17 eligible randomized clinical trials (RCTs) (1268 patients). All the articles in this review, except one, used hyperbaric bupivacaine. Five trials compared different doses of bupivacaine (range 3-15 mg). Large doses of bupivacaine (10 and 15 mg) were associated with delayed recovery, and supine positioning was associated with a high incidence of failure. With unilateral positioning, a dose as low as 4-5 mg seems to be sufficient. Five trials comparing bupivacaine or levobupivacaine with ropivacaine showed no significant difference in the time to home discharge. When bupivacaine was combined with fentanyl in two trials, marginal delay in recovery was found [time to discharge (min); weighted mean difference (WMD) 14.1, 95% CI 11.9-40.1] and increased nausea and pruritus but had reduced postoperative pain. Unilateral and bilateral spinal anaesthesia were assessed in two trials, and the latter group was associated with early recovery and discharge [time to discharge (min); WMD -41.6, 95% CI -63.6 to -19.6). The results of our systematic review suggest that 4-5 mg of hyperbaric bupivacaine can effectively produce spinal anaesthesia for knee arthroscopy with unilateral positioning. Ropivacaine or the addition of adjuvants did not improve the recovery time. There is a need for tighter RCTs with more consistent endpoints.

Occurrence of vesicular - arbuscular mycorrhizae in medicinal plants.

Observations on the occurrence of vesicular arbuscular mycorrhizae association in 16 medicinal plants are reported in this communication.