DrNB Paediatric Neurology In India: Check Out NBE Released Curriculum

The National Board of Examinations (NBE) has released the Curriculum for DrNB Paediatric Neurology.

I. PROGRAM GOAL AND OBJECTIVES:

1. Goal

The goal of DrNB in Pediatric Neurology is to produce a Pediatric Neurologist who is clinically competent, skilled, and compassionate. The DrNB graduate must possess skills in the diagnosis and management of neurological disorders affecting the newborn, infant and children thus providing quality care for children with neurological disorders in the country.

2. Objectives

Objectives of this program are:

a. To acquire skills in eliciting complete history, perform examination and arrive at possible differential diagnosis for a child with neurological problem.

b. To provide scientifically based, comprehensive and rationale management for children with neurological disorders.

c. To acquire skills in ordering, and interpreting the diagnostic investigations including neuroimaging, neurophysiological, neuro metabolic and neurogenesis tests and correlate it clinically.

d. To demonstrate skills of professional ism including counselling of patients and families.

e. To acquire basics kills in teaching the medical and paramedical professionals, and develop basic research skills.

3. Competencies in Pediatric Neurology Subject specific competencies:

a. Clinical Skills: At the end of acquiring a DrNB in Pediatric Neurology, the student should be able to

i. Elicit, document, and present a detailed neurological history and other relevant histories pertaining to nervous system

ii. Perform and demonstrate the correct method of physical examination including detailed neurological examination in neonates, infants, and children.

iii. Document, organize and present the clinical findings

iv. Analyze the symptoms and signs and propose a provisional diagnosis or differential diagnosis

v. Formulate a plan for diagnostic evaluation of children with neurological disorders like epilepsy, stroke, neuromuscular disorders, movement disorder, neuro metabolic disorders, neurodegenerative disorder, neuroinfections, and neuro developmental disorders.

vi. To set priorities for laboratory studies, electro physiology, imaging, genetic studies as required.

vii. Perform and interpret all electro physiological procedures like electoencephalogrpahy (EEG), Nerve conduction study (NCV), electromyography (EMG), visual evoked potentials (VEP), brainstem auditory response (BERA), and repetitive nerve stimulation test (RNST).

viii. Formulate a plan for sub sequent therapy for children with neurological disorders like neuro-infections, epilepsy, neuro metabolic disorders, cerebro vascular disorders, auto immune disorders, demyelinating disorders, and neuro degenerative disorders.

ix. Describe a plan for evaluating and managing neonates with neurological problems including intracranial hemorrhage, neonatal seizure, neonatal meningitis, hypoxic is chemicencephalopathy, kernicterus, metabolicencephalopathies, and congenital infections

x. Decide the evaluation and management of neurological disorders in pediatric intensive care unit including status epilepticus, management of raised intracranial pressure, coma, central nervous system infections, acute flaccid paralysis, and neurological complications of surgical patients and post-operative care of neuro surgical patients.

xi. Interpret the reports of all investigations like cerebrospinal fluid analysis, electroencephalography, nerve conduction study, electromyography, evoked potentials, and polysomnography, neuroimaging (CT brain, MRI brain and spine), neuro metabolic investigations and genetic investigations and correlate its findings in clinical context.

xii. Decide the evaluation and subsequent management of neurological conditions in children when called for consultations.

xiii. Explain the principles of rehabilitation emphasizing on the role of physio therapy, occupational therapy, speech therapy and special education

xiv. Decide the right candidate for administration of Botulinum toxin where indicated, and administration of the same.

xv. Decide the extent of disability in children with neurological disorders and be able to calculate the degree of impairment required for disability certification.

b. Theoretical Knowledge: At the end of acquiring a DrNB in Pediatric Neurology, the student should have acquired comprehensive knowledge about all aspects of Pediatric Neurology and ancillary fields like Developmental Pediatrics, Pediatric Neuro radiology, Clinical Genetics, Pediatric Physical Medicine and rehabilitation, through the prescribed syllabus.

i. General competencies

Communication skills - At the end of acquiring a DrNB in Pediatric Neurology, the student should be able to:

Develop attitudes and behaviors that are consistent with the team approach to medical care of children with neurological disorders.

Develop skills in supervision of and interactions with other medical and nursing personnel involved in the management of the patient.

Demonstrate and teach (early) stimulation and rehabilitative care to parents and their families

Communicate with children with neuro developmental disorders and lack of communication skills

Develop competency in communicating the diagnosis, investigation plan and subsequent management of neurological disorders in children to their parents.

To communicate with allied specialists

Develop professionalism

ii. Research and continuing medical education

At the end of acquiring a DrNB Pediatric Neurology, the student should be able to:

Engage in appropriate research on pediatric neurology related topics

Interpret the results of original research papers

Develop a basic research protocol

Perform and interpret summary statistics

Maintain accurate records of tests results for reasonable periods of times that these may be retrieved as and when necessary

Make and record observations systematically that is of use for archival purpose and for furthering the knowledge of pediatric neurology.

Able to systematically write a paper and publishing are Levant journal.

Present a paper in a conference through an oral presentation and poster presentation.

Acquire self-directed learning skills by constantly updating his / her knowledge of recent advances in Pediatric neurology and allied subjects.

iii. Teaching

Teach pediatric neurology to under graduates, post graduates, nurses and paramedical staff including laboratory personnel.

Develop competency in communicating the diagnosis, investigation plan and subsequent management of neurological disorders in children to their parents.

Develop professionalism, and must be able to communicate with allied specialists

II. TRAINING, TEACHING AND RESEARCH ACTIVITIES:

1. Training: Recommended guidelines for Clinical Postings:

a. Total duration in Core Pediatric Neurology: 2years (including Ward, OPD, PICU, NICU, Emergency)

b. Neuro physiology- 6 months (the candidate will continue to do ward work and OPDs, as per requirement of the department.)

c. Rotations-6 months

d. Adult neurology – 2 months

e. Developmental Pediatrics including child psychiatry & amp; child psychology –

1 month

f. Neuro surgery –15 days

g. Neuro -rehab-15 days

h. Genetics- 15 days

i. Neuro radiology -15 days

j. Electives- 1 month

The HOD can decide the distribution of the postings according to feasibility. A general year wise guideline has been provided below: -

i. First year

Posting in the Pediatric Neurology Ward -10 months in the Ward posting, the DrNB resident will learn the clinical evaluation, diagnosis and management of children admitted with neurological problems such as seizures, meningitis, encephalitis, neuro degenerative disorder set under the supervision of faculty.

They will also learn procedures such as performing lumbar puncture and interpreting the CSF examination.

Posting in Adult Neurology-2 month (In dedicated Pediatric hospitals, necessary tie up with adult Neurology hospital nearby which is accredited for DM / DrNB in Neurology for this posting may be done).

ii. Second year

Posting in the Core Pediatric Neurology – 9 months

Posting in the Clinical Neuro Physiology Lab (EEG, Nerve conduction studies, EMG, Evoked potential studies) – 3 months

The DrNB resident will be trained in the procedure and interpretation of EEG, nerve conduction studies, electromyography, and evoked potential studies.

iii. Third Year

Posting in the Clinical Neuro Physiology Lab (EEG, Nerve conduction studies, EMG, Evoked potential studies)-3 months

The DrNB resident will be trained in the procedure and interpretation of EEG, nerve conduction studies, electromyography, and evoked potential studies.

Posting in Neurosurgery-15 days. During the Neuro surgery posting, which is 15 days, the candidate is required to attend all the operations and see for himself / herself, the surgical techniques. Post-operative care and complications and selection of cases for surgery are Also taught.

Posting in Neuro radiology-15 days Posting in Core Pediatric Neurology Ward-5 months

Elective posting based on the interest of the DrNB candidate-1 months which may be external elective posting- (posting to any other accredited Institute of the candidate's choice is permitted)

Posting in Genetics unit- 15month

Posting in Physical Medicine and Rehabilitation - 15days.

Posting in Developmental Pediatrics/ Child Psychiatry & amp; Psychology - 1 month in this posting, the resident will learn the approach to psychiatric problems in children, (which frequently co-exist with neurological problems) such as behavior problems, obsessive compulsive disorder, schizophrenia etc. They will also learn about the use of psycho pharmacological drugs in children.

They will also learn procedures such as performing lumbar puncture and interpreting the CSF examination.

Posting in Adult Neurology-2 month (In dedicated Pediatric hospitals, necessary tie up with adult Neurology hospital nearby which is accredited for DM / DrNB in Neurology for this posting may be done).

ii. Second year

Posting in the Core Pediatric Neurology – 9 months

Posting in the Clinical Neuro Physiology Lab (EEG, Nerve conduction studies, EMG, Evoked potential studies) – 3 months

The DrNB resident will be trained in the procedure and interpretation of EEG, nerve conduction studies, electromyography, and evoked potential studies.

iii. Third Year

Posting in the Clinical Neuro Physiology Lab (EEG, Nerve conduction studies, EMG, Evoked potential studies)-3 months

The DrNB resident will be trained in the procedure and interpretation of EEG, nerve conduction studies, electromyography, and evoked potential studies.

Posting in Neurosurgery-15 days. During the Neuro surgery posting, which is 15 days, the candidate is required to attend all the operations and see for himself / herself, the surgical techniques. Post-operative care and complications and selection of cases for surgery are Also taught.

Posting in Neuro radiology-15 days Posting in Core Pediatric Neurology Ward-5 months

Elective posting based on the interest of the DrNB candidate-1 months which may be external elective posting- (posting to any other accredited Institute of the candidate's choice is permitted)

Posting in Genetics unit- 15month

Posting in Physical Medicine and Rehabilitation - 15days.

Posting in Developmental Pediatrics/ Child Psychiatry & amp; Psychology - 1 month in this posting, the resident will learn the approach to psychiatric problems in children, (which frequently co-exist with neurological problems) such as behavior problems, obsessive compulsive disorder, schizophrenia etc. They will also learn about the use of psycho pharmacological drugs in children.

2. Teaching Activities:

a. Seminar (Once weekly)

b. Clinical Case presentation (Once weekly)

c. Journal Club (Once monthly)

d. Mortality meet discussion (Once a month)

e. Difficult case / neuro electro physiology meeting (Once fort nightly)

f. Neuro radiology Conference: in conjunction with the Department of Radiology: Once weekly to fortnightly (as feasible)

g. Faculty lecture (Once monthly), including Guest Faculty Lecture(Oncein3months)

h. Symposium – once in 3 months. This will be jointly prepared by 3-4 residents and can be multi-disciplinary as per the topic.

i. A poster and have one oral presentation at least once during their training period in a recognized National or International conference.

The rounds should include bedside sessions, file rounds & documentation of case history and examination, progress notes, round discussions, investigations and management plan) interesting and difficult case unit discussions. The training program would focus on knowledge, skills and attitudes (behavior), all essential components of education. It is being divided into theoretical, clinical and practical in all aspects of the delivery of the rehabilitative care, including methodology of research and teaching.

i. Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary in view of an in adequate exposure to the subject in the under graduate curriculum.

ii. Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in a period of three years to the combined class of teachers and students. A 9 free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

iii. Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing and management in rehabilitation practice. Bedside: The trainee would work up cases, learn management of cases by discussion with faculty of the department.

iv. Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation by other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

3. Research:

a. The student would carry out the research project and write a thesis / dissertation in accordance with NBEMS guidelines.

b. He / she would also be given exposure to partake in the research projects going on in the departments to learn their planning, methodology and execution so as to learn various aspects of research.

III. SYLLABUS:

The following is the comprehensive list of topics which will be covered over the three- year period.

1. These topics will be covered / taught through a combination of didactic teaching, seminars, journal clubs, difficult case meetings, clinical case presentations and hands-on wards and clinic case discussions and management rounds.

2. Multi-disciplinary meetings with allied specialties (Neuroradiology, Neuro rehabilitation, Pathology, Neurosurgery, Child Psychology and Psychiatry etc.,) will be made part of teaching roster (through combined seminars and case discussions) to broaden the Trainee's' approach and outlook

a. Development of the Infant and young child

Anatomy of Neuro development (Including embryology of nervous system)

Physiology of Neuro development

Assessment of normal development

Variations of the normal development

Developmental surveillance of at-risk neonates and infants

Approach to infants and children with global developmental delay

Diagnosis and management of children with Cerebral Palsy

Screening and interventions for Autism spectrum disorders

Screening and interventions for Attention deficit per activity disorders

Evaluation and management of children with Learning disorders / Scholastic difficulties

Intellectual disability: Comprehensive evaluation and rehabilitation

b. Malformations of Nervous system

Normal embryology and anatomy of the Nervous system

Common CNS malformations: Identification and holistic evaluation

Medical and Surgical management of CNS malformations

c. Seizures and Epilepsy in childhood

Epileptic Seizures and non-epileptic events

Febrile seizures

Classification and evaluation of epilepsy

Epilepsy syndromes in childhood

Status epilepticus

Pharmacy therapy of epilepsy

Refractory epilepsy

Surgical management of epilepsy

Non-pharmacological treatments of refractory epilepsy-ketogenic diet and vagal nerve stimulation.

d. Infections of the Central Nervous System

Acute bacterial (Pyogenic) meningitis

Aseptic meningitis

Chronic meningitis including tubercular meningitis

Brain abscess

Acute encephalitis

Cerebral malaria

Acute febrile encephalopathy (Acute Encephalitis Syndrome)

Neuro cysticercoids

Neurological manifestations of HIV in children

Subacute SclerosingPanencephalitis (SSPE)

Congenital infections

Neonatal CNS infections (Meningitis, Ventriculitis, Abscess)

Laboratory diagnosis of CNS infections

e. Neuro Immunology

Demyelinating disorders of the CNS

ADEM, optic neuritis, acute transverse myelitis, Neuro my elitis optics (NMO), Multiple sclerosis

Immunologically mediated diseases affecting the CNS gray matter, peripheral nervous system

Autoimmune encephalitis

Opsoclonusmyoclonusataxia syndrome

Systemic vasculitides with nervous system manifestations

f. Neuro Degenerative Disorders

Classification and approach to a child with neuro regression (Gray matter, white matter, cerebellar and basal ganglia disorders)

Grey matter degenerative brain disorders

Leukodystrophies and leukoencephalopathies

Diagnostic evaluation of children with suspected degenerative disorder

Management

Genetic counseling

Recent advances in therapies

g. Neuro metabolic disorders including mitochondrial disorders

Classification, evaluation and approach to child with suspected neuro metabolic disorder

Diagnostic evaluation (Biochemical, molecular and histological)

Dietary management of Metabolic disorders

Long-term management, follow-up and prenatal counseling

h. Genetics

Patterns of Inheritance

Chromosomal abnormalities

Approach to child withdysmorphism

Uses and interpretation of various genetic tests in the diagnosis of neuro genetic disorders (Karyotyping, FISH, MLPA, Chromosomal microarray, clinical exome sequencing, whole exome sequencing, Whole genome sequencing and Sanger sequencing)

i. Toxic and Nutritional disorders

Toxic disorders: Acute and chronic exposure to Lead, thallium, arsenic, mercury, aluminum, organic toxins, alcohol, bacterial toxins

Neuro logical manifestations of Nutritional deficiencies (Protein energy malnutrition, Cobalamine and Thiamine deficiency, infantile tremor syndrome etc.,)

j. Neuro cutaneous syndromes (Phakomatoses)

Spectrum of neuro cutaneous syndromes

Neuro fibromatosis

Tuberous Sclerosis Complex

SturgeWeber Syndrome etc.

Hypomelanos is of I to and Incontinentiapigmenti

Other neuro cutaneous syndromes

k. Movement disorders

Approach to child with movement disorder

Chorea: Approach and management

Dystonia: Approach and management

Tic disorders: Evaluation and treatment

Approach to child with Ataxia

l. Cerebrovascular disorders (Stroke in children)

Epidemiology of pediatric stroke

Arterial is chemic stroke(AIS)

Cerebral Sino venous thrombosis (CSVT)

Hemorrhagic stroke

Perinatal stroke (Presumed perinatal and Neonatal stroke)

m. Neonatal Neurology

Neuro logical assessment of neonate

Neonatal encephalopathy: Approach

Neonatal seizures

Hypoxic is chemic encephalopathy

Encephalopathy of prematurity

Intra ventricular Hemorrhage and Hydrocephalus

Meningitis and Ventriculitis

Cranial ultrasonography

Approach to neonate with suspected IEM

Floppy neonate: Evaluation and management

Hemorrhagic disease of newborn

CNS malformations

Floppy neonate

n. Brain tumors

Features and Classification

Evaluation and management

Role of Radiotherapy

o. Spinal cord disorders

Approach and localization of spinal cord disorders

Spinaldysraphism (Types, evaluation and management)

Vascular, Nutritional and Inflammatory disorders of spinal cord

Neuro genic bladder: Evaluation and management

p. Neuro muscular disorders

Approach and Evaluation

His to pathological changes in different disorders

Developmental disorders of muscle (Congenital myopathies)

Muscular dystrophies

Endocrine and metabolic myopathies

Inflammatory myopathies (including Guillain Barre syndrome)

Disorders of Neuro muscular transmission

Spinal muscular atrophy

Autonomic neuropathies

Advances in treatment of neuro muscular disorders

Brachial plexus injuries: Diagnosis and management

Hereditary neuropathies

Approach to floppy infant and floppy child

q. Coma in Pediatric Patient/Brain Death

Approach to child with coma

Neurological Monitoring of a comatose child

Coma in Pediatric population/metabolic coma

Brain death in children

Management of child with raised in tracranial pressure

r. Neurological manifestations of systemic diseases

Metabolic encephalopathies

Disorders of acid/base/ electrolyte disturbances

Neurological complications of pulmonary, gastrointestinal, hepatic, renal, cardiac, hematological, neoplastic and endocrine diseases

s. Neurological and Neurosurgical emergencies

Management of hydrocephalus

Surgical management of raised in tracranial pressure

Traumatic brain injury

Management of Refractory status epilepticus

t. Clinical Epidemiology and Research Methodology

Study designs

Hypothesis testing

Biostatistics

Critical appraisal of a journal article

u. Ethics in Medicine

Ethical dilemmas in neuro critical care

End of life care in chronic neurological illnesses

Ethics in research and publication

v. Neuro informatics

Use of technology in neurology education/training

Tele medicine in Child Neurology

Role of technology in health care access

w. Rehabilitation in Pediatric Neurology

Early intervention: Principles and practice

Principles of physiotherapy

Orthoses and Assistive devices

Treatment of spasticity

Occupational therapy

Orthopedic management of children with Cerebral palsy

x. Community Pediatrics

National Programme

Acute flaccid paralysis (AFP) surveillance

Vaccine prevent able neurological disorders

y. Non-epileptiform paroxysmal disorders and sleep disorders

Headache

Breath holding spells

Syncope

Parasomnias

z. Neuro endocrine and autonomic nervous system disorders

Disorders of Hypothalamus & Pituitary gland in Childhood and Adolescence

Disorders of micturition and defecation

Disorders of autonomic nervous system

aa. Neuroimaging

Principles of neuroimaging (Neuro sonogram, CT and MRI)

Imaging in epilepsy

Newer imaging modalities

Metabolic imaging

Interventional radiology

bb.Electrophysiology

Electroencephalography

Nerve conduction studies

Needle electromyography and single fiber EMG (SFEMG)

Evoked potentials

cc. Therapeutic advances in neurological disorders

Gene therapy

Regenerative medicine (Stem cell therapy)

Exon skipping

Therapies for Lysosomal storage disorders

Precision medicine

dd.Basic neuro anatomy including localization of neurological lesion in central nervous system and peripheral nervous system

ee. Climate Change

Effect of climate change on Neurodevelopment of children

Changing epidemiology of Infectious and vector borne diseases due to

climate change

Impact of Climate change on other Neurological disorders in children

ff. Air pollution

Effect of air pollution on the developing brain

Air pollution and neurological disorders in children

gg.Other environmental pollutants (water, soil)

Other environmental pollutants (water, soil) and neurological disorders

hh.Heat Wave

Heat stroke: Acute neurological manifestations of heat stroke

Neurological Sequelae of heat stroke

IV. LOG BOOK:

A candidate shall maintain a logbook of operations (assisted / performed) during the training period, certified by the concerned post graduate teacher / Head of the department / senior consultant. This logbook shall be made available to the board of examiners for their perusal at the time of the final examination.

The logbook should show evidence that the before mentioned subjects were covered (with dates and the name of teacher(s). The candidate will maintain the record of all academic activities under taken by him/her in logbook.

1. Personal profile of the candidate including the address, contact number, parent contact details,

2. Educational qualification / Professional data

3. List of leaves availed during the course

4. Posting schedules with due signature on completion of posting from the concerned faculty including extramural postings along with written feedback of the faculty

5. Record of bed side case presentation, journal clubs, seminars, symposium including inter departmental meets presented during the tenure

6. Record of oral paper or /and poster presented in national or international conferences

7. Record of conferences, CME sat tended during the training period

8. Record of research publications and other publications during the training period

9. Procedures carried out including EEG, NCV, EMG, BERA, VEP, Lumbar puncture, botulinum toxin administration, and any other procedure

10. Every candidate, at the time of practical examination, will be required to produce performance record (logbook) containing details of the work done by him/her during the entire period of training as per requirements of the log book. It should be duly certified by the supervisor as work done by the candidate and counter signed by the administrative Head of the Institution.

11. In the absence of production of logbook, the result will not be declaring.

Journals

a. Annals of Indian Academy of Neurology Epilepsies

b. Epilepsy and Behavior Epilepsy Research

c. European Journal of Pediatric Neurology Journal of Child Neurology

d. Journal of Developmental and Behavioral Pediatrics. Journal of Pediatric Neurology

e. Lancet Neurology Pediatric Neurology Seizure

f. Seminars in Pediatric Neurology Developmental Medicine & Child Neurology