ABSTRACT
Justification: Global developmental delay (GDD) is a relatively common neurodevelopmental disorder; however, paucity of published literature and absence of uniform guidelines increases the complexity of clinical management of this condition. Hence, there is a need of practical guidelines for the pediatrician on the diagnosis and management of GDD, summarizing the available evidence, and filling in the gaps in existing knowledge and practices. Process: Seven subcommittees of subject experts comprising of writing and expert group from among members of Indian Academy of Pediatrics (IAP) and its chapters of Neurology, Neurodevelopment Pediatrics and Growth Development and Behavioral Pediatrics were constituted, who reviewed literature, developed key questions and prepared the first draft on guidelines after multiple rounds of discussion. The guidelines were then discussed by the whole group in an online meeting. The points of contention were discussed and a general consensus was arrived at, after which final guidelines were drafted by the writing group and approved by all contributors. The guidelines were then approved by the Executive Board of IAP. Guidelines: GDD is defined as significant delay (at least 2 standard deviations below the mean with standardized developmental tests) in at least two developmental domains in children under 5 years of age; however, children whose delay can be explained primarily by motor issues or severe uncorrected visual/ hearing impairment are excluded. Severity of GDD can be classified as mild, moderate, severe and profound on adaptive functioning. For all children, in addition to routine surveillance, developmental screening using standardized tools should be done at 9-12 months,18-24 months, and at school entry; whereas, for high risk infants, it should be done 6-monthly till 24 months and yearly till 5 years of age; in addition to once at school entry. All children, especially those diagnosed with GDD, should be screened for ASD at 18-24 months, and if screen negative, again at 3 years of age. It is recommended that investigations should always follow a careful history and examination to plan targeted testing and, vision and hearing screening should be done in all cases prior to standardized tests of development. Neuroimaging, preferably magnetic resonance imaging of the brain, should be obtained when specific clinical indicators are present. Biochemical and metabolic investigations should be targeted towards identifying treatable conditions and genetic tests are recommended in presence of clinical suspicion of a genetic syndrome and/or in the absence of a clear etiology. Multidisciplinary intervention should be initiated soon after the delay is recognized even before a formal diagnosis is made, and early intervention for high risk infants should start in the nursery with developmentally supportive care. Detailed structured counselling of family regarding the diagnosis, etiology, comorbidities, investigations, management, prognosis and follow-up is recommended. Regular targeted follow-up should be done, preferably in consultation with a team of experts led by a developmental pediatrician/ pediatric neurologist.
ABSTRACT
Justification: Pediatricians are usually the first point of contact of children with the health system. Studies worldwide have shown that there is insufficient knowledge about child abuse recognition and management among health workers. Presently no uniform guidelines exist in India for pediatricians regarding the appropriate response to child abuse. Process: As part of the Child Rights and Protection Programme (CRPP) under IAP VISION 2007 of Indian Academy of Pediatrics, a ‘Training of Trainers (TOT) Workshop on Child Rights and Protection’ was held in Mumbai in January 2007. It was attended by participants from all over the country. The workshop recommended ‘developing country-specific teaching and training material’. A Task force of IAP CRPP was formed and it developed a module for ‘Training of Trainers Workshops for Pediatricians’. A National Consultative Meet was held in October, 2007 at New Delhi, where the program was discussed and ratified. Objectives: To train pediatricians to: recognize and respond to child abuse; engage in a multi-disciplinary networking mode to deal with child abuse; and, document, record and report instances of child abuse. Recommendations: Guidelines for recognition and management of child abuse are presented. All pediatricians should assess suspected harm with the same thoroughness and attention as they would do with a life threatening condition. Poor management after disclosure can increase psychological damage. Pediatrician should believe, support, reassure, treat and ensure rehabilitation of victims of child abuse, keeping the best interest of the child as the primary goal.