Common Medical Issues In Neurodisability ✅ Flashcards
Give 7 medical issues that are more common in chidlren with neurodisability
- Gastro-oesophageal reflux disease (GORD)
- Respiratory complications
- Drooling
- Constipation
- Temperature regulation
- Sleep difficulties
- Orthopaedic complications
What is gastro-oesophageal reflux?
The non-forceful regurgitation of gastric contents into the oesophagus
Why may GORD be more common in children with neurodevelopmental problems?
- Incraesed intra-abdominal pressure
- Functionally immature lower oesophageal sphincter
- Difficulties in upright position
Why may intra-abdominal pressure be increased in children with neurodevelopmental problems?
Structural reasons, e.g. scoliosis
Why might the lower oesophageal sphincter be functionally immature in children with neurodevelopmental problems?
As a reflection of abnormal muscle tone elsewhere in the body
What is the first line management of GORD in children with neurodevelopmental problems?
- Postural management
- Adjustment of feed consistency if required
How can GORD be managed positionally?
- Supportive upright seating
- Sleeping positioners
What can be done if conservative management for GORD is ineffective in children with neurodevelopment problems?
Pharmacological management
What might be involved in pharmacological management of GORD in children with neurodevelopmental problems?
- Proton-pump inhibitors
- H2-receptor antagonists
- Dopamine receptor antagonists
- Compound alginate preperations
Give 3 examples of PPIs
- Omeprazole
- Lansoprazole
- Esomeprazole
How do PPIs work?
They block the hydrogen-potassium adenosine triphosphate enzyme system of the gatsric parietal cell - the ‘proton pump’ - inhibiting acid production
Give an example of a H2-receptor antagonist
Ranitidine
How do H2-receptor antagonists work?
Reduce gastric acid output by antagonism of histamine H2-receptors
Give an example of a dopamine receptor antagonist
Domperidone
How do dopamine receptor antagonists work?
- Stimulate gatric emptying and small intestinal transit
- Enhance tone of oesophageal sphincter
Give 3 examples of compound alginate preparations
- Gaviscon
- Gaviscon Infant
- Peptac
How do compound alginate preperations work
- Increase viscosity of stomach contents
- Protect oesophagal mucosa from acid reflux
What additional actions do some preperations of compound alginates have?
They form a viscous substance which floats on the surface of stomach contents, thus reducing episodes of reflux
What may be required in children with severe symptom of GORD?
Surgical intervention
What surgical intervention is done for GORD?
Nissen’s fundoplication
What happens in Nissen’s fundoplication?
The gastric fundus is plicated around the lower end of the oesophagus and sutured into place, reinforcing the lower oesophageal sphincter
Why can neurological problems lead to respiratory complications?
- Impaired ability to protect airway
- Structural impairment to respiratory function
- Impaired immune function
What can the impaired ability to protect the airway in neurodevelopmental problems lead to?
Acute or chronic (‘silent’) aspiration, with chemical pneumonitis or secondary infection with anaerobic organisms
Where are the neural control centres responsible for coordination of breathing and swallowing located?
- In the dorsomedial and ventrolateral medullary regions in the brainstem
- Element of cortical control
What muscles are controlled by swallowing centres?
Muscles of the mouth, pharynx, and larynx
What areas are involved in swallow-related motor output?
- Trigeminal motor nucleus
- Facial motor nucleus
- Nucleus ambiguus
- Hypoglossal motor nucleus
Where is the trigeminal motor nucleus located?
Near the level of the mid pons
Where is the facial motor nucleus located?
At the level of the caudal pons
Where is the nucleus ambiguus located?
Runs rostocaudally in the medulla
What is the underlying mechanism leading to aspiration in neurodevelopmental conditions?
- Abnormal tone of facial and swallowing muscles
- Direct damage to swallowing and respiration control dentres
What might abnormal tone of the facial and swallowing muscles occur as part of?
A condition causing abnormal tone throughout the body
Give 2 conditions causing abnormal tone that may cause swallowing difficulties
- Cerebral palsy
- Spinal muscular atrophy
What can cause direct damage to swallow and respiration centres in neurodevelopmental problems?
- Traumatic brain injury
- Stroke
- Brain tumour
What structural problems may children with neurodevelopmental problems have that put them at risk of respiratory complications?
- Impairment to chest movement and lung capacity
- Difficulty clearing respiratory secretions
Give an example of a condition causing structural impairment to chest movement and lung capacity
Scoliosis
What can cause difficulty in clearing respiratory secretions in neurodevelopmental problems?
- Direct weakness
- Reduced cough reflex
Give an example of a condition causing reduced cough reflex
Brain injury
Why are children with Down’s syndrome more at risk of respiratory complications?
- Low tone
- Structural differences
- Impaired immunity
What impairment in immunity may be present in children with Down’s syndrome?
- Low levels of blood immunoglobulins
- Impaired vaccine responses
- Abnormal lymphocyte subsets
What age is drooling considered normal?
Up to 4 years
Why might children with neurodevelopmental conditions continue to drool past 4 years?
- Abnormalities in swallowing
- Difficulties moving saliva to back of throat
- Poor mouth closure
- Tongue thrusting
What are the management options for drooling in neurodevelopmental conditions?
- Conservative
- Pharmacological
- Surgical
What are the conservative treatment options for drooling in neurodevelopmental problems?
- Rewarding
- Behavioural methods
What are the pharmacological options for the management of drooling in neurodevelopmental conditions?
- Anti-muscarinic drugs
- Botulinum toxin
Give 2 anti-muscarinic drugs that may be used to treat drooling
- Hyoscine hydrobromide
- Glycopyrronium bromide
How do anti-muscarinic agents reduce drooling?
Act as competitive antagonist at muscarinic acetylcholine receptors. This causes blockade of parasympathetic innervation of the salivary glands, producing a reduction in saliva production
Which muscarinic receptor do anti-muscarinic drugs act on to reduce drooling?
M1 receptors
How does botulinum toxin work in drooling?
It inhibits acetylcholine release in nerve terminals, mainly at the neuromuscular junction but also at sympathetic and parasympathetic ganglion cells and in postganglionic parasympathetic nerves
How can botulinium toxin be adminstered?
Can be injected directly into the parotid gland
What is the effect of injecting botulinum toxin directly into the partoid gland?
It inhibits parasympathetic innervation and reduces saliva production
What are the surgical options in the management of drooling in neurodevelopmental problems?
- Diversion of parotid ducts in tonsillar fossae region
- Salivary gland resection
Why may consipation more common in children with neurodevelopmental conditions?
- Abnormalities of muscle tone
- Restricted diet low in fibre
- Mobility difficulties
Where in particular might abnormalities in muscle tone lead to constipation?
Bowel wall
Why might children with neurodevelopmental problems have a restricted diet low in fibre?
Difficulties in chewing and swallowing
How is mobility important in constipation
Normal upright mobility will aid transit of waste through the bowel
How is constipation treated in children with neurodevelopmental problems?
- Diet and lifestyle modification
- Laxatives
What types of laxatives are used in children with neurodevelopmental problems?
- Stimulant laxatives
- Osmotic laxatives
Give 5 examples of stimulant laxatives
- Bisacodyl
- Docusate sodium
- Glycerol suppositories
- Senna
- Sodium picosulphate
How do stimulant laxatives work?
They increase intestinal motility
What may need to be used in combination with stimulant laxatives?
Faecal softeners
Why might faecal softeners need to be used with stimulant laxatives?
To lessen the possibility of abdominal cramps
Give 4 exampels of osmotic laxatives
- Lactulose
- Macrogol
- Phosphate enema
- Sodium citrate enema
How does lactulose work?
It draws fluid from the body into the bowel
How does movicol work?
It is taken with fluid which is then retained within the bowel lumen
Where are the body’s thermoregulation centres?
In the anterior hypothalamus (preoptic area)
What do the themoregulation centres recieve input from?
- Peripheral thermoreceptors
- Central thermoreceptors, including hypothalamus itself
Where are peripheral thermoreceptors located?
In the skin and mucous membranes
What is the result of sensory signals from the peripheral and central thermorepcetors?
They are combined the posterior hypothalamus to control heat producing and conservating actions of the body
By what systems does the body produce/conserve heat?
- Autonomic nervous system
- Neuroendocrine system
What can the body do to produce/conserve heat?
- Shivering
- Piloerection
- Skin vasoconstriction
Why might a child with a neurodisability present with temperature dysregulation?
- Hypothalamic dysfunction
- Unable to voluntarily response to temperature change, e.g. seeking warmth
What problems with sleep do many disabled children have?
Problems with sleep initiation and maintenance
Why might children with neurodisabilities have sleep problems?
- Disruption of bsleep
- Circadian rhythm abnormalities
Give 3 factors that may disturb sleep in children with neurodevelopmental problems
- Pain
- Epileptic seizures
- Sleep disorder,s e.g. sleep disordered breathing
In what neurodevelopmental conditions is it particularly common to have circadian rhythm abnormalities?
- ADHD
- Visual impairment
What is the link between ADHD and circadian rhythm abnormalities?
There is a genetic link, with polymorphisms in genes common to ADHD and circadian rhythm
Why are children with visual impairments at a higher risk of circadian rhythm abnormalities?
Environmental clues about sleep can be missed
How should sleep difficulties in children with neurodevelopmental problems be managed initially?
- Advice about good sleep hygiene
- Explanation of sleep-wake cycle
What can it be useful to explain about the sleep-wake cycle?
It is normal to have short periods of wakening during the night
Why might normal periods of wakening during the night be a problem for children with neurodevelopmental problems?
The ability to self-soothe back to sleep during these periods may be delayed or impaired
When do children normally acquired the ability to self-soothe back to sleep from periods of wakening during the night?
Under 1 year of age
What can be used in children where sleep initiation is an ongoing difficulty despite well-established and healthy bedtime routines?
Melatonin
What is melatonin?
A hormone
Where is melatonin naturally produced?
Pineal gland
What is melatonin produced in response to?
Stimulation of the suprachiasmatic nucleus
What stimulates the suprachiasmatic nucleus?
The onset of darkness
What do circaridan clock mechanisms involve?
Period gene expression
What is the periodic gene expression involved in circadian clock mechanisms synchronised by?
The hypothalamic suprachiasmatic nuclei
What are the genes involved in circadian clock control?
- Per
- Frq
- Clock
- Tau
How do the clock genes control circadian rhythm?
Unknown
How can supplemental melatonin help?
Can promote sleep initiation
What other medications can be used to help with sleep in children with neurodevelopmental problems?
- Sedating antihistamines
- Hypnotics
Give an example of a sedating antihistamine
Alimemazine
Give an example of a hypnotic
Chloral hydrate
How long can sedating anti-histamines or hypnotics be used in sleep disorders?
Short term only
When might sedating anti-histamines or hypnotics be considered to treat sleep disorders in children with neurodevelopmental problems?
Last resort when sleep difficulties are severe or disabling
What orthopaedic complications may occur in children with neurodevelopmental problems?
- Hip subluxation and dislocation
- Spinal deformity
What % of children with cerebral palsy who are not walking at the age of 5 years does hip subluxation or dislocation occur in?
60%
What problems can hip subluxation or dislocation cause?
- Pain
- Increasing deformity
- Inability to sit
- Functional restrictions
- Spinal deformity
What conditions increase the risk of hip subluxation or dislocation?
Any condition causing disorders of muscle tone
Are children with hypo- or hypertonia at higher risk of hip subluxation or dislocation?
Hypertonia
What is theorised to cause hip dislocation/subluxation in neurodevelopmental conditions?
- Change in proximal femoral artery
- Spasticity and shortening of muscles around hip joint
- Lack of ambulation
What causes a change in proximal femoral artery anatomy in children with neurodevelopmental conditions?
Effects of delayed motor development and tonal asymmetry
Why can spasticity and shorteneing of muscles and lack of ambulation lead to hip subluxation and dislocation?
Impacts bony development and joint position
What are the elements of hip subluxation/dislocation?
- Acetabular dysplasia
- Femoral head displacement
Is the hip joint normal at birth in hip subluxation and dislocation caused by neurodevelopmental problems?
Yes
Who should receive surveillance for hip subluxation/dislocation?
Children with bilateral cerebral palsy
What is looked at in routine surveillance for children with bilateral cerebral palsy to look for hip subluxation/dislocation?
Migration indices of hips
How is the migration indices of the hips calculated?
Measurement of the migration percentage on an AP pelvic x-ray
What hip migration index is suggestive of hip subluxation or dysplasia?
No agreed figure, but more than 33% is suggestive
What is scoliosis?
Lateral curvature of the spine
Which children are at increased risk of spinal deformities?
Those with abnormal tone
Why are children with abnormal tone at higher risk of spinal abnormalities?
Due to motor imapirment due to absence fo normal weight bearing and movement
How can spasticity or low tone lead to spinal deformity?
It can lead to abnormal forces on the spine leading to curvature
What should be done due to the increased risk of spinal defomrity in child with neurodisability?
Regular assessment of clinical evidence of spinal deformity and prompt referral for assesesment by a specialist spinal team when spinal deformity is detected
