Department of Neurology

Milestone 12: Child Neurology — Patient Care

Specifics about each Level and each Item:  What you do you need to know:
 

Level 2

● Lists the elements of a neurological examination of infants and children

Observation
General Medical Examination
Mental Status
Cranial Nerves
Motor
Reflexes
Sensory
Cerebellar
Gait

 
● Recognizes broad patterns of neurologic disease in infants and children

Disorders affecting the central nervous system  brain
Encephalopathy
Speech delay
Cognitive disorders
Seizures
Hyperreflexia

Spinal cord
Sensory level
Bowel or bladder issues
Mixed reflexes with hyper and hyporeflexia depending upon timing of injury

Disorders affecting the peripheral nervous system
*Pain
*Distal greater than proximal weakness
*Hypo to areflexia
*Typically cognitive sparing

Disorders affecting the neuromuscular junction
Fatigue with repetitive movement
Worsening as the day progresses
Involvement of bulbar muscles
Typically cognitive sparing

Disorders affecting the muscle
Proximal greater than distal weakness
Typically cognitively normal

● Lists normal developmental milestones

*Documentation of gross motor, fine motor, social and language milestones.
*Age at which skills are acquired
*Loss of milestones
*Developmental arrest or slowing of developmental progress
*Documentation of handedness and what age this was acquired.

Level 3

● Obtains a complete and age-appropriate neurologic history of infants and children

 Chief Complaint:

       What is the parent’s perception of the problem

History of Present Illness

Birth History

• Prenatal
  Birth
  Perinatal/neonatal

Developmental history

*Documentation of gross motor, fine motor, social and language milestones.
*Age at which skills are acquired
*Loss of milestones
*Developmental arrest or slowing of developmental progress
*Documentation of handedness and what age this was acquired.

 Past Medical History

Review of systems
*Lead exposure
*Head trauma
*Birth marks
*Seizures
*Headaches
*Fainting
*Behavioral issues
*School performance 

Social History

Family History

*Multiple birthmarks
*Seizures
*Fainting/ prolonged QT
*Muscular dystrophy
*Cerebral palsy
*Bleeding disorders
*Stroke in the young
*Consanguinity

● Performs a complete and age-appropriate neurological examination of infants and children

 General

*Complete general exam included
*Documentation of growth parameters/percentiles*Head circumference

 Observation
* Activity level of child
* Documentation of anterior fontanelle, sutures and head shape
* Dysmorphic features
* Birth marks
* Presence/absence of sacral dimple
* Presence/absence of scoliosis

Cranial Nerves 

Motor

Reflexes

• Newborn reflexes and persistence of these
  Presence of clonus
  Biceps, triceps brachioradialis, knee, ankle

Sensory

Coordination

Gait

* Tandem walk
* Standing up from a seating position

 ● Diagnoses common child neurologic disorders

• Pediatric Epilepsy Syndromes
  New onset seizures
  Febrile Seizures
  Pediatric Headache
  Developmental Delay
  Tic Disorders
  ADHD
  Cerebral Palsy
  Neurofibromatosis/tuberous sclerosis
  Autism
  Abnormal head size
  Hypotonic infant

Level 4 

● Initiates management of common childhood neurologic disorders

Pediatric Epilepsy Syndromes

Neuromuscular disorders of Childhood and management considerations

Pediatric Headache

Cognitive/Behavioral Disorders Evaluation and management
ADHD
Autism
Learning disability
Developmental Delay

Movement Disorders
Tourette Syndrome
Paroxysmal dystonias
Tremor
Pediatric Brain Tumors

Metabolic disorders           

Disorders of head size

Hypotonia

Ataxia

CNS Malformations

Stroke in the Young

Pediatric Sleep Disorders/ parasomnias

Neonatal neurology
 

● Initiates management of common neurologic emergencies in infants and children

• Status epilepticus

• Myasthenic crisis

• Acute paraparesis

-Cord compression
-Spinal cord injury
-Transverse myelitis
-Guillain Barre syndrome

• Increased ICP

• Head trauma

• Stroke

• Infections

● Initiates management of common neurologic emergencies in infants and children

Status epilepticus
Myasthenic crisis
Acute paraparesis

-Cord compression
-Spinal cord injury
-Transverse myelitis
-Guillain Barre syndrome

Increased ICP
Head trauma
Stroke
Infections

Level 5

● Diagnoses uncommon childhood neurologic disorders

Pediatric Epilepsy Syndromes

Early infantile epileptic encephalopathies
Infantile Spasms

Metabolic disorders

Mitochondrial
Leukodystrophies
Grey matter diseases
Storage Diseases
Perioxosomal disorders

CNS Malformations

Management considerations

Chiari malformations
Dandy Walker syndrome
Septo optic dysplasia
Holoprosencephaly
Myelomeningocele

Post-infectious Demyelinating disorders

Childhood MS
Acute Cerebellar Ataxia
Childhood Transverse Myelitis
Guillain Barre syndrome
Chronic Inflammatory Demyelinating Polyneuropathy
 

Neuromuscular junction disorders
Congenital myasthenic syndromes
Pediatric myasthenia gravis

Peripheral nervous system

*Anterior horn cell disease
*Hereditary motor sensory neuropathies

Level 2 Resources

Pediatric Neurology Exam

1) http://library.med.utah.edu/pedineurologicexam/html/home_exam.html

2) http://www.pediatricneurology.com/neuro.htm

3) Pediatric Neurology Exam Video of the small child.  Jessica Goldstein and Nancy Bass

4) Pediatric  Neurology Exam: Nancy Bass

5) In-patient rounds/Out patient clinics

Developmental Milestones

1)  http://www.rsd.k12.pa.us/Downloads/Development_Chart_for_Booklet.pdf

Broad patterns of neurological disease in infants and children

1) ADHD review 

 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313479/pdf/10621994.pdf

2) Autistic Spectrum Disorder Signs/Symptoms

 http://www.cdc.gov/ncbddd/autism/signs.html

3) Practice Parameters Child Neurology Society

  http://www.childneurologysociety.org/resources/practice-parameters

Corticosteroid Treatment of Duchenne Dystrophy

Diagnostic Assessment of the Child with Status Epilepticus (An Evidence-based Review)

Evaluating a First Non-febrile Seizure in Children Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society

Evaluation of Children and Adolescents with Recurrent Headaches
Valuation of the Child with Global Developmental Delay

Evaluation of the Child with Microcephaly (an Evidence-based Review)

Level 3 Resources

 1) Complete neurological history and exam (see resources above for level 2)

2) Common childhood neurological disorders

Pediatric Epilepsy Syndromes

J Child Neurol. 2009 Aug;24(8 Suppl):6S-14S. doi: 10.1177/0883073809338151.  Zupanc Medical College of Wisconsin

New onset seizures

http://www.alape.org/docs/Present_Cart/79.Bourgeois-Evaluation%20and%20treatment%20.pdf

http://www.neurology.org/content/55/5/616.full                                

Febrile Seizures

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-42302010000400026&lng=pt&nrm=iso&tlng=en

 Pediatric Headache

Winner P, Hershey AD. Epidemiology and diagnosis of migraine in children. Curr Pain Headache Rep 2007; 11: 375–82.

Developmental Delay

Global Developmental Delay Practice parameter:  http://www.neurology.org/content/60/3/367.full.pdf

Tic Disorders

Tourette Syndrome and other tic disorders in childhood:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523260/

 ADHD

(See resources listed under level 3)

Cerebral Palsy

http://www.hvidovrehospital.dk/NR/rdonlyres/08A96C9F-84A0-4A1D-B040-6B6844ECB182/0/7aDiagnosticassessmentofthechildwithcerebralpalsy.pdf

 Neurofibromatosis/tuberous sclerosis

Neurofibromatosis type I ( Gene Reviews)  http://www.ncbi.nlm.nih.gov/books/NBK1109/

Tuberous sclerosis OMIM entry  http://www.omim.org/entry/191100

 Autism

http://www.cdc.gov/ncbddd/autism/signs.html

Abnormal head size

Microcephaly practice parameter:

 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744281/

Evaluation of macrocephaly in children

http://www.uptodate.com/contents/etiology-and-evaluation-of-macrocephaly-in-infants-and-children

 Hypotonic infant

A systematic approach to the hypotonic infant

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722561/

Level 4 Resources

1) Management of common neurological problems       

2) Management of common neurological emergencies in infants and children

a) Status epilepticus

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043041/

Status Epilepticus in children protocol Rainbow Babies and Childrens Hospital

b) Myasthenic crisis:

 http://www.hindawi.com/journals/ad/2011/404101/

Maria F. Finnis and Sandeep Jayawant   Autoimmune Diseases Volume 2011 (2011), Article ID 404101, 7 pageshttp://dx.doi.org/10.4061/2011/404101 Juvenile Myasthenia Gravis: A Paediatric Perspective. Department of Paediatric Neurology, Children's Hospital, John Radcliffe Hospital, Oxford OX3 9DU, UK August 2011

 Agnes Jani-Acsadi, Robert P. Lisak.   Myasthenic crisis: Guidelines for prevention and treatment.  Journal of the Neurological Sciences 261 (2007) 127–133

c) Acute paraparesis (cord compression, spinal cord injury)

Pediatric Spinal cord injury/trauma

http://www.neurosurgery.org/sections/section.aspx?ShowPrint=TRUE&Section=PD&Page=ped_spine.asp

d) Transverse myelitis

Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol. 2012 Nov;27(11):1426-36. Baylor College of Medicine

e) Guillain Barre syndrome

http://www.uptodate.com/contents/overview-of-guillain-barre-syndrome-in-children

f) Increased ICP

g) Head trauma

h) Stroke

L. C. Jordan, A. E. Hillis  Challenges in the diagnosis and treatment of pediatric stroke. Nat Rev Neurol.

Nat Rev Neurol. 2011 April; 7(4): 199–208. Published online 2011 March 8. doi: 10.1038/nrneurol.2011.23

i) Infections