Lumboperitoneal shunts are used to drain fluid from lumbar subarachnoid space to the peritoneal cavity in

well enough to undergo surgery. 4. Hydrocephalus shunts - CSF is usually drained from the ventricular system via a ventricular catheter (a valve with reservoir mechanism and diatal catheter) into the peritoneal cavity. Lumboperitoneal shunts are used to drain fluid from lumbar subarachnoid space to the peritoneal cavity in some pts with communicating hydrocephalus. 23. CEREBRAL PALSY (Little's disease) Definition - Non-progressive central motor deficit due to prenatal or perinatal causes. Distinct from mental retardation. Causes - Perinatal asphyxia (hypoxic-ischemic encephalopathy). 2 Birth injury. 3. Congenital malformations of the brain. 4. Kernicterus. 5. Inborn errors of metabolism. 5. Parenteral infective or vascular insults. Clinical picture - Clinical types: 1 Spastic CP - Quadriplegia, hemiplegia, paraplegia or monoplegia. Hyperexcitability, persistence of neonatal reflexes, arching of the back, scissoring of the legs, brisk deep jerks, swallowing difficulties and drooling of saliva. 2. Extrapyramidal CP - Choreoathetosis or dystonia. Hypotonia in early life, choreoathetosis in later life. Choreathetosis with weakness seen with kernicterus. 3. Atonic CP - (a) Atonic diplegia, characterised by hypotonia, severe mental retardation and brisk tendon reflexes or rarely (b) congenital cerebellar ataxia. Cerebellar signs develop by second year of life. Mental retardation mild. Prevention - Good antenatal and perinatal care. Proper management of premature and jaundiced babies. Management -Team approach by pediatrician, neurologist, psychologist, physiotherapist, occupation therapist, orthopoedic surgeon, and speech therapist. Positive prenatal approach is helpful. Prognosis will depend upon the extent of brain damage and facilities available. Surgery in carefully selected cases to reduce spasticity. 24. CHILDHOOD ENURESIS Definition - Bed-wetting by children beyond the age when control of urinary bladder should have been acquired, due to delay in the maturing of physiological reflex bladder control. Etiology - More common in - Boys, first born children, children who have experienced stress in early life, lower social classes TYPES - (a) Intermittent - Only occasional dry night. (b) Primary or true - Child has never had a single dry night (rare over age of 5 years). (c) Secondary or acquired - Enuresis develops of the age of 5 in a child who has been previously dry at night for atleast 12 months CAUSES - 1. Genetic factors - A boy with intermittent nocturnal enuresis has 75% chance of having a first degree relative who also wet the bed after age of 5 years. 2. Delay in establishment of bladder control - due to maturational delay, chronic illness, improper or inadequate training, or small functional bladder capacity. 3. As a symptom of organic illness - (a) Neurological - Epilepsy, spina bifida, cerebral palsy, nutritional deficiency. (b) Endocrine - Polyuria in diabetes mellitus, diabetes insipidus. (c) Urinary - Pyelonephritis -- TB, congenital malformations, calculi, chronic nephritis, ectopic ureter. (d) Genitalia - Balanitis, meatal ulcer, vulvo-vaginitis, threadworms. (e) Post-operative anxiety, trauma induced. 4. As a symptom of psychological ill-health and without evidence of organic disease. Investigations - (a) Urine test - for glucose, albumin and blood. Microscopy and culture to exclude UTI. (b) Ultrasound or other radiological investigation - if urinary tract infection or history suggesting anatomical abnormality of urinary tract (e.g straining on micturition or persistent dribbling of urine). Management: 1. CONFIDENCE AND TRAINING -Aim is to treat the bed wetter not the bed-wetting. Scolding and punishment should be avoided. Child should empty bladder before going to bed. For some time child may be awakened 2-3 hours after sleep and made to evacuate bladder, and again in the early morning. Restriction of fluid in latter part of day. Bladder capacity training in daytime by holding of urine for progressive increase of time before voiding. 2. CORRECTION OF PHYSICAL DEFECTS and improvement of general health. 3. CONDITIONING THERAPY - (a) Dry bed training - requires skilled therapist and maximum compliance by the family. (b) Enuresis alarms - depend on the completion of an electrical circuit when urine is passed and then an alarm goes off. The child then has to get out of bed, switch off the alarm, and go to the toilet before setting up the system again. Types of alarms - (i) Pad and bell - The sensor pad is a plastic mat imprinted with electric current. (ii) Body-worn alarm - A tiny electrical sensor is attached to the child's thigh or pants and is connected to a mini alarm worn on the shoulder or in the pocket of the pyjama jacket. 4. DRUGS - can be used when conditioning therapy is inappropriate, or to achieve dryness quickly e. g. temporary period during a school trip or holiday. (a) Antidiuretics - Desmopressin - given as metered-dose aerosol intranasally, starting with 20 g last thing at night and increasing to maximum of 40 g. (b) Oxybutynin - 2 5 mg at bed time. (c) Tricyclic antidepress ants - Imipramine 25 mg at night increased to 50 mg or 75 mg depending on size of the child. 25. DOWN'S SYNDROME (MONGOLISM) Etiology: Chromosomal abnormality. Majority borne to elderly mothers, have trisomy 21 due to nondisjunction at meiosis due to ageing of the oocyte. A small percentage born to young mothers, have translocation of the