CARE PATHWAY FOR CHILDREN WITH CEREBRAL...

CARE PATHWAY FOR CHILDREN AND YOUNG PEOPLE WITH CEREBRAL PALSIES

SUBHEADINGS PAGE NUMBERSDefinition of cerebral palsy 2Goals of care of children with cerebral palsy 3Aims of follow-up at different stages 4Core principles for services for children and young people with cerebral palsy

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Application of International Classification of Functioning, Disability and Health to Cerebral Palsy

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Flow diagram of CARE PATHWAY for Cerebral Palsy

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Compiled by:Dr. Bidisha Lahoti [email protected] Community Paediatrician,Guys and St. Thomas’ Foundation TrustCommunity Services, Sunshine House, 27 Peckham Road, London SE5 8UH

Dr. Charlie Fairhurst [email protected] Paediatrician, Neurodisability, Evelina Children’s HospitalSt Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH

Dr. Karen HorridgeConsultant Paediatrician, Neurodisability, Sunderland Royal HospitalKayll Rd, Sunderland SR4 7TP

Care pathway for cerebral palsy, Sep 20121

mailto:[email protected]


DEFINITION OF CEREBRAL PALSY

Definition: ‘Cerebral palsy (CP) describes a group of permanent disorders of movement and posture causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behaviour, by epilepsy, and by secondary musculoskeletal disorders’. (Rosenbaum P et al: Dev Med Child Neurol (Suppl.) 2007;109:8-14 )

CP affects 2-4 individuals per 1000 of the general population.

The incidence, prevalence, and most common causes of CP have varied over time because of changes in prenatal and paediatric care.


GOALS OF CARE OF CHILDREN WITH CEREBRAL PALSY

Goal of clinical care: To ensure that children with cerebral palsy have the opportunity to achieve their

maximum function and potential throughout life. To manage co-morbidities and minimise the effects of secondary deformities

Core Team: The managing clinician should be the local community/ Neurodisability pediatrician,

with knowledge and skills related to children with cerebral palsy. The Multidisciplinary team at local Child Development Centre coordinates services,

working with the GP and other district and regional services. The General Practitioner provides routine medical and universal care along with

Health Visitor and other members of the primary care team. At the centre of the decision making team are the parents of the child with cerebral

palsy and the child / young person with cerebral palsy Members of the multidisciplinary team

o Developmental/ Neurodisability paediatrician and/or paediatric neurologist o Physiotherapist, o Occupational therapist, o Speech and language therapist, o Dietitian, o Orthotist, o Clinical nurse specialist/continuing care nurse o Social workero Nominated person from Education

As the life expectancy of individuals with CP approaches that of the general population, increasingly care pathways must adapt to span the lifetime of an individual with CP.

Focus of early intervention is to: improve development and function by facilitating the innate capacity of the brain to

change and adapt throughout early childhood, minimise/delay musculoskeletal deformities and manage co-morbidities.


FOLLOW-UP AIMS AT DIFFERENT AGES

As the child with cerebral palsy grows and develops, additional needs will become evident that may require other specialists and strategies. A child entering the service for the first time would receive all items indicated up through to the actual age group, as part of the initial evaluation.

Age Group Emphasis of careBirth through 2 years Global development, vision, hearing, cognitive and motor

development, hip stability, nutrition, dental, language and psycho-social concerns. Referral for appropriate early intervention community programs and services. Anticipatory notification to SEN in Education.Routine screening hip X-Ray GMFCS 1 – 5Support parents to come to terms and develop positive outlook.

3 through 5 years Evaluation of needs for preschool and early primary school. Encouragement of optimal development by promoting educational, social, and recreational interaction in the least restrictive environment. Attainment of ability to perform appropriate activities of daily living.Continuing screening of hip and spinal development. Need for X-rays dependent on clinical examination and level of walking ability

6 through 12 years Ongoing therapeutic input to build on and maintain optimal function. Urological evaluation, if indicated. Help with child’s understanding of the condition. Continued screening of musculo-skeletal integrity, especially hip and spine, throughout growth.

13 through 21 years Ongoing therapeutic input to build on and maintain function. Review of bone health in non-ambulant children, especially if on anticonvulsant therapy. Transition to adult servicesVocational counseling. Transition to independent living, or at least optimise choices.


CORE PRINCIPLES FOR SERVICES FOR CHILDREN AND YOUNG PEOPLE WITH CEREBRAL PALSY (Adapted from the North England protocol)

Overarching principles

For each individual child or young person with cerebral palsy:

The views and wishes of the child or young person and their family must be ascertained, listened to and taken into account at all times

No decision about any aspect of care should be made without full involvement of the child or young person and their family in the decision-making process. This includes provision of appropriate written information and any necessary support or advocacy to assist decision making

For the population of children and young people with cerebral palsy:

It is the responsibility of ALL practitioners to ensure that services are delivered equally to all, regardless of postcode, socioeconomic status, ethnicity or parental capacity to advocate for the child or young person

Generic services across agencies should be accessible for all children and young people with cerebral palsy, with clear signposting arrangements and referral pathways into specialist services as required

All children and young people with cerebral palsy and their families should be made aware of any research projects that they may want to choose to participate in.

Children and young people with cerebral palsy and their families should expect of services:

Timely, expert diagnostic assessment with a paediatrician competent in Neurodisability to include:

o Detailed clinical assessmento Offering a Magnetic Resonance Imaging (MRI) brain scan, best performed when

the child is over 2 years old (may need repeating later, if done before this age for clinical reasons).

If an MRI scan is NOT done, the justification for this should be clearly documented and discussed with the family

o Other investigations and referrals for further expert opinions as appropriate in the individual circumstances

Support from time of diagnosis onwardso Link with support organisations and parent groupso Refer for specialist counselling via general practitioner if need be

Holistic ongoing evidence based management (evidence of effectiveness and acceptability) with practitioners competent in the assessment and management of children and young people with cerebral palsy, including:

o Paediatric physiotherapisto Paediatric speech and language therapist with competence in the assessment and

management of communication, feeding and swallowingo Paediatric occupational therapisto A paediatrician competent in Neurology / Neurodisability and the management of

movement disorderso An orthopaedic surgeon if hip displacement or musculoskeletal deformity is

apparent


o A spinal surgeon for all children and young people with identified spinal curvatures or anomalies

Timely access to appropriate equipment in all settings that supports the best possible participation for the child or young person as judged by the multidisciplinary team

Joined up care plans across all agencies, especially at times of transition Information and support:

o in decision-making about choices in educationo about accessible leisure activities, short breaks, before and after school clubs etc o All reports and correspondence to be written to or copied to families with medical

terms fully explained to ensure transparency in communication Respect for the need to live ordinary and private lives

Each paediatric review (at least annual) should consider:o Posture and movements, including review of 24 hour postural management

programme, ability to transfer, use of splints and other equipmento Hand function o Ease of Personal care and activities of daily livingo Vision and hearingo Communication, feeding and swallowingo Bowel and bladder functiono Dentitiono Behaviouro Learning o Sleepo Specific enquiries should be made and documented, including plans for

management, about: What concerns the child or young person and their parent/carer Pain Seizures Feeding and gastrointestinal symptoms including oro-motor/ saliva

control, gastro oesophageal reflux, vomiting, constipation etc. Cough and chest/respiratory symptoms Barriers to participation

o Assessment and documentation of: Growth and nutrition (including percentiles) and pubertal status Hips – symmetry of movement, hip flexion and hip abduction. X-ray

migration screening as appropriate Spine – symmetry and tone Orthopaedic Joint ranges, muscle tone, power and selective motor control Gait pattern for those who can walk, including with aids/assistance

If barriers to the core principles are identified, the onus is on the person identifying the barriers to put in place an action plan to overcome them

These core principles should be regularly reviewed and updated in the light of new information from governance, evidence based practice and research


INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

The International Classification of Functioning, Disability and Health, (ICF, WHO, 2001), is a classification of health and health-related domains. These domains are classified from body, individual and societal perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. Since an individual’s functioning and disability occurs in a context, the ICF also includes a list of environmental factors. It identifies “participation” as an important outcome of health. It provides a conceptual framework and a universal language.

The International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) is a derived version of ICF designed to record characteristics of the developing child and the influence of environments surrounding the child. The ICF-CY can assist clinicians, educators, researchers, administrators, policy makers and parents to document the characteristics of children and youth of importance for promoting their growth, health and development in other words serve as an important tool for shared language to unify health, education and social services for children.

THE ICF AND CEREBRAL PALSY

ICF model has been successfully used in children with cerebral palsy to enhance the activity and participation of children with cerebral palsy and to prevent secondary impairments.

In clinical settings ICF can be used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement. It is a very useful tool to help the child, family and professionals take account of the child’s personal factors, environment, capacity, performance in the community, functional well being, identify barriers and thus help to set and achieve goals, jointly with family and child, that optimises the child’s


participation. The ICF model provides an opportunity from the outset to talk with parents (and older children) about primary goals that address function (“activity”) and social engagement (“participation”), rather than thinking of impairment based intervention. For example, a child with CP that affects oromotor control may benefit from assessment and intervention focused on the motor impairments that make feeding or speech challenging. At the same time, service providers who address the “activity” of eating and the child’s “participation” in family mealtimes, as well as alternative communication strategies, if necessary, are working to ensure that all components of the child’s functioning and health are addressed at the levels of “body structure and function,” “activity,” and “participation.” This is not meant to diminish the role or importance of 'impairment-based' interventions, but simply to recognise that interventions at any (perhaps all) of the components of the ICF model may be important, appropriate, and interlinked.

At a regional or national level, ICF can be used to measure health outcomes and guide disability management programs and social policy.

In research ICF can be used to assess impact, intervention and application research. Studies of children and youth with CP should include dimensions of activity and participation, as well as environmental factors, to capture the complex interactional nature of the life experiences of these children and their families.


Referral from Parents, GPs, HV,

Cerebral Palsy Clinical PresentationAbnormal tone, atypical motor development, asymmetrical movement, delayed motor skills, abnormal movement,

Referral to Community Paediatrician + MDT of CDC

History, Clinical Examination, Assessment of needs Core MDT: Paediatrician with competence in the cerebral palsies,, Physiotherapy, Occupational Therapy, Speech & Language Therapy, Dietetics, Children’s Community Nursing

Tertiary Care

Secondary Care

Primary Care

Management of CP

Co-morbidities

Developmental needs

GMFCS

CP Diagnosis-Clinical diagnosis, may require observation-Rule out progressive, regressive and treatable causes-Identify cause

CP Differential Diagnosis

Neuroimaging and other investigations

Prevention of Neurological disability- excellent antenatal/perinatal/neonatal care; prevention of injury, public health measures, etc

Follow-up of high-risk babies

Classification of cerebral palsyMotor pattern &

distribution

CARE PATHWAY FOR CHILDREN WITH CEREBRAL PALSY/COMPLEX MOTOR DISORDERS


Colour key

Pain freeComfortSecurityAttachment optimise all areas of development

ENSURE CORE

NEEDS ARE MET


Cerebral Palsy MDT Management

Assess impact of CPMovement, posture and mobility CommunicationDevelopment, ParticipationCo morbidities, sensory impairmentActivities of daily livingCare needsComfort and quality of lifePain

Management of movement disorders

Physiotherapy

Casting

Orthoses

Pharmacological therapy

Orthopaedic surgery

Neurosurgical techniques

Treat/monitor further needs of child/young person

Daily living and environment

Feeding and communication problems

Psychological issues

TRANSITION PLANNING

Liaison with Education

Liaison with Social Services, Council, voluntary sector

Other co-morbidities

Hip, spine and musculoskeletal surveillance

Patient/carer information and support

Surgery

Equipment

Oral

Invasive

Gait analysis

Early intervention to

optimise all areas of

development

MonitorSet goals, TreatReview, ReassessIdentifyemerging problems

At least every 6-12 months

Components of CP classification

1. Motor abnormalitiesA. NATURE AND TYPOLOGY OF THE MOTOR DISORDER: The observed tonal abnormalities assessed on examination (e.g. hypertonia, hypotonia) as well as the diagnosed movement disorders present, such as spasticity, ataxia, dystonia, athetosis. B. FUNCTIONAL MOTOR ABILITIES: The extent to which the individual is limited in his or her motor function, including oromotor and speech function.

2. Accompanying impairmentsThe presence or absence of later-developing musculoskeletal problems and/or accompanying non-motor neurodevelopmental or sensory problems, such as seizures, hearing or vision impairments, or attentional, behavioral, communicative and/or cognitive deficits, and the extent to which impairments interact in individuals with cerebral palsy.

3. Anatomical and neuro-imaging findingsA. ANATOMIC DISTRIBUTION: The parts of the body (limbs, trunk, bulbar region, etc.) affected by motor impairments or limitations. B. NEURO-IMAGING FINDINGS: The neuroanatomic findings on CT or MRI imaging, such as ventricular enlargement, white matter loss or brain anomaly.

4. Causation and timingWhether there is a clearly identified cause, as is usually the case with post-natal CP (e.g. meningitis, head injury) or when brain malformations are present, and the presumed time frame during which the injury occurred, if known.


Cerebral Palsy Outcome Measures

The age of assessment is critical to the discussion of appropriate outcome measurement, because the domains of interest often change as the child matures

Functional Physiological / Clinical care Psychosocial Family satisfaction Quality of service provided

A. Functional

1) Child attains/maintains a maximal level of mobility consistent with level of neurological and biomechanical involvement. Where appropriate: Family/school is provided a goal-oriented management plan necessary to achieve

maximum mobility and demonstrates knowledge of treatment plan to facilitate gross and fine motor development.

Family/school obtains prescribed adaptive equipment, assistive devices and mobility aids and can demonstrate knowledge of safe use of all equipment.

Family/carer can demonstrate safe transfer techniques. Child maintains GMFCS Classification/ GMFM scores

2) Child attains and maintains maximal urine/bladder control. Family has support to help child achieve bladder and bowel continence Child is free from urinary tract infections and is continent. Family obtains prescribed equipment/aids/supplies to assist in toileting. Has access to specialist advice at district and tertiary level, as and when needed.

3) Child attains and maintains maximal bowel control. Family has support to help child achieve bladder and bowel continence. Child receives optimal treatment of constipation, with family being aware of proper

food and fluid intake to support healthy and regular bowel evacuation. Family obtains prescribed equipment/aids/supplies to assist in toileting. Has access to specialist advice at district and tertiary level, as and when needed.

4) Child attains and maintains maximal oral motor skills. Documentation of swallowing studies/feeding evaluations, as necessary. Documentation of plan for progression of food textures, as necessary. Evaluation and follow-up by multidisciplinary team of paediatrician, occupational

therapist / physiotherapist / specialist speech therapist to maximise oral motor skills. Saliva control difficulties / Drooling managed or referrals made where appropriate.

5) Child attains and maintains maximal communication skills. Child receives periodic speech-language evaluations. Family and school has management plan to promote development of communication

skills. Child has access to augmentation devices where appropriate. Communication system appropriate to the child’s need in place at home and at school Parents have access to relevant course, such as makaton course

6) Child attains/maintains age appropriate daily living skills within the framework of his/her disability.


Family is supported to identify and manage child’s special safety needs related to the disability.

Child is helped to achieve independence with self-help needs within developmental guidelines.

Family receives guidance to help teach the child daily living, self-help skills (e.g. dressing, bathing, toileting, eating, etc.).

Child achieves skills compatible with highest developmental/educational level. Family has access to and training in the use of adaptive equipment needed to facilitate

attainment of daily living skills.

7) Sensory impairments identified and managed Visual impairment identified and management plan by ophthalmologist and visual

impairment team in place, including astigmatism, retinal and cortical problems. Hearing impairment identified and managed by teachers for the hearing impaired,

audiologists and ENT surgeons.

8) Child attains/maintains understanding of sexual and reproductive health. Young person can identify implications of his/her disability as it pertains to sexual

health.

B. Physiological / Clinical care – as appropriate to individual child

1) Maintain adequate nutritional status. Documentation of nutritional status and needs by dietitian, Paediatrician/GP

periodically. Maintenance and documentation of appropriate weight, height and head circumference,

and occasionally other anthropometric data such as skin fold thickness and tibial length as deemed appropriate.

Family is given advice on strategies for child to attain and maintain appropriate weight for height.

Access to specialist feeding services and Paediatric surgeons for assessment and intervention in feeding difficulties / poor weight gain.

2) Child attains and maintains optimal neurological function.If there is associated epilepsy Child has optimal seizure control, while maintaining function. Parent/school recognises the signs and symptoms of changes related to neurological

status / pattern of epileptic seizures and demonstrate knowledge of appropriate actions to take.

Appropriate care plan in place at home and at school including emergency anticonvulsants rectal or buccal

Parent/child can identify actions and side effects of prescribed medications.

3) Child attains/maintains maximal level of skin integrity (in the non-ambulant child). Parent/child has information about early signs and symptoms of skin breakdown,

procedures to prevent skin breakdown and recommended treatment for skin lesions. Parent/child has advice for preventive measures such as daily skin checks, wearing non-

restrictive clothing, safety with hot and cold, wheelchair cushions, paddings etc.

4) Child attains/maintains optimal lung / pulmonary function. Parent/carer/school care plan aids recognition of signs and symptoms of pulmonary

infection and other changes in pulmonary status, and identifies appropriate actions to take.

Parent/carer is supported to ensure safe feeding and positioning techniques to prevent


aspiration. Parent/carer has knowledge of proper pulmonary hygiene techniques. Parent/child can identify actions and side effects of prescribed medications and can

demonstrate correct administration. Parent/carer has had training and is competent in the use of ventilatory aids and

appropriate actions to take if problems or malfunctions occur. Child is free from respiratory distress/frequent chest infection. Appropriate care plan for management of feeding where swallow is found to be

‘unsafe’ by a video-fluoroscopy, involving teams at tertiary level.

5) Child attains/maintains optimal musculoskeletal function. Family/school has had support and training to ensure that the child’s body is maintained

in proper body alignment to prevent deformities and contractures. Family/school have understanding of proper range of movement and stimulation

activities to help prevent contractures. Family/school have access to and training in appropriate use of adaptive equipment to

prevent skeletal deformities. Evidence based, function and developmental stage appropriate tone management in

place. If appropriate generalized and focal interventions to reduce tone or dystonia. Evidence of routine hip surveillance Access to specialist movement therapy teams, Orthopaedic and spinal surgeons, wheel

chair services and Orthotists as and when necessary

6) Dentition maintained in optimal condition. Regular dental appointments with appropriate dental providers. Treatment of dental and periodontal disease, including hyperplasia. Evaluation/treatment of malocclusions at appropriate intervals. Family/care trained to ensure appropriate oral hygiene techniques. Drooling managed effectively

7) Pain Pain is recognised by parents, carers and professionals in all environmental settings,

source of pain is identified and an effective pain management plan in place. A pain profile for non-communicating children is in place to enable individual focus

on causes, signs and symptoms of discomfort in the child.

8) Sleep Sleep problems identified and managed early and effectively

C. Psychosocial

1) Psychosocial response to the condition is age appropriate. Achievement of age/development appropriate socialisation skills. Parent/child has information about support groups/peer groups. Child demonstrates positive expressions of self-esteem. Child participates in recreational activities, as appropriate to functional level.

2) Educational/vocational goals achieved. Receives education in least restrictive environment with appropriate related services

and supports. Achieves employment/post secondary educational placement/vocational training.

D. Family satisfaction


1) Parent/child achieves satisfaction with outcomes of treatment

2) Parent/child have input into care plan.

3) Parent/child has access to choice of providers.

4) Parent/child demonstrates knowledge of ‘cerebral palsy’, development and prevention of complications, treatment plan, available resources, parenting skills and support opportunities.

5) Parent/child receives information about prevention when appropriate and genetic counseling services are available.

E. Quality Management of service provided

1) The child with cerebral palsy is managed by multidisciplinary community based team with knowledge and skills related to children with cerebral palsy, in close communication with primary and tertiary care (or professionals/centres with resources and competencies to manage co-morbidities of cerebral palsy)..

Referral made to the team for evaluation as soon as condition is suspected or within the first two years of life, generally from neonatal follow up or developmental screening - see clinical pathways.

Treatment plans jointly developed and implemented by the family. Family has access to appropriate providers. Care coordination is provided by the managing Paediatrician in association with the

team. Complex diagnostic, interventional and surgical procedures restricted to tertiary

centres. Documentation of long and short term outcomes of the treatment plan.

2) Service coordination is provided at the team and/or local levels. The child has an identified local service coordinator/key worker and team service

coordinator, where available. Documentation of a comprehensive plan developed by the service coordinator which

addresses the medical, social, vocational, educational, nutritional and recreational needs of the child.

The comprehensive service/care plan is updated once or twice a year. The family has input into the comprehensive service plan and demonstrates an

understanding of, and agreement with, the content of the plan.

3) Appropriate pediatric care throughout childhood. Has an identified lead Paediatrician. Physical examinations and routine ‘well child’ care provided on a regular basis. Immunisations are performed as appropriate. Periodic monitoring for growth failure, delayed development and other problems such

as hearing and vision. Mutual communication between the specialty team and the primary care physician,

regarding the child’s plan of care, progress and special needs/problems. Also liaison point with tertiary services involved in the care of individual child.

Family demonstrates knowledge of child’s routine health needs and treatment plan.

4) Preparation for transition to adulthood is initiated at an age-appropriate level.


A transition plan is developed during the teenage years. The teen/young adult and family have input into the transition plan. Qualified adult health care providers are available to assume health care at the

appropriate time. The teen/young adult demonstrates ability to self-direct care or obtains appropriate

assistance.

5) Seamless service without multiple waiting lists Team able to respond to emerging needs in a timely manner

6) Care co-coordinated between health, education and social care Single comprehensive care plan No duplication of assessments Appropriate carer support, housing and respite care in place

REFERENCES

Peter Rosenbaum et al The Definition and Classification of Cerebral Palsy Developmental Medicine & Child Neurology2007 supplement Dev Med Child Neurol Suppl 2007; 109: 8–14


Fairhurst C. Cerebral palsy: the whys and hows Arch Dis Child Educ Pract Ed 2012;97:122–131

Gross Motor Function Classification System Expanded and Revised Robert Palisano, Peter Rosenbaum, Doreen Bartlett, Michael Livingston, 2007, CanChild Centre for Childhood Disability Research, McMaster University

NICE Clinical Guidelines 2012: Spasticity in children and young people with non-progressive brain disorders: Management of spasticity and co-existing motor disorders and their early musculoskeletal complications

Schaefer B. Genetics Considerations in Cerebral Palsy Semin Pediatr Neurol 2009, 15:21-26

Rosenbaum P. Cerebral palsy: what parents and doctors want to know BMJ 2003;326:970–4

Mindy Lipson Aisen et al Cerebral palsy: clinical care and neurological rehabilitation Lancet Neurol 2011; 10: 844–52

Rosenbaum P, Stewart D. The World Health Organization International Classification of Functioning, Disability and Health(ICF): a model to guide clinical thinking, practice and research in the field of cerebral palsy. Semin Pediatr Neurol 2004; 11: 5–10

Fairhurst CBR, Cockerill H Management of drooling in children Arch Dis Child Educ Pract Ed 2011;96:25–30. doi:10.1136/adc.2007

Pountney T, Green EM Hip dislocation in cerebral palsy BMJ 2006;332:772–5

Hough JP et al Systematic Review of Interventions for Low Bone Mineral Density in Children With Cerebral Palsy Pediatrics 2010;125;e670

Simard-Tremblay E, et al Sleep in Children With Cerebral Palsy: A Review J Child Neurol published online 13 June 2011

Florian Heinen et al The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy European journal of paediatric neurology 2010,14: 4 5 – 6 6

Dan B, Motta F, Vles JS, et al. Consensus on the appropriate use of intrathecal baclofen (ITB) therapy in paediatric spasticity. Eur J Paediatr Neurol 2010;14:19–28.

National Institute for Health and Clinical Excellence: Interventional Procedure Overview of Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy, 2009. IP 318–2.

Compiled by:

Dr. Bidisha LahotiConsultant Community Paediatrician


Guys and St. Thomas’ Foundation TrustCommunity ServicesSunshine House27 Peckham RoadLondon SE5 [email protected]

Dr. Charlie FairhurstConsultant Paediatrician, NeurodisabilityEvelina Children’s HospitalSt Thomas’ HospitalWestminster Bridge RoadLondon SE1 [email protected]

Dr. Karen HorridgeConsultant Paediatrician, NeurodisabilitySunderland Royal HospitalKayll RdSunderlandSR4 [email protected]





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