Paeds Neuro & Psych

Question 1

What are Febrile Convulsions

Answer 1

• Non-epileptic seizures caused by high fever (viral)
• Often seen in children 6M to 5Y
• 3% of children get them.

Due to temperature rising rapidly

Question 2

Simple V Complex Febrile Convulsions

Non-epileptic seizures caused by high fever

Answer 2

Simple
* <15 mins
* Generalised Seizure
* No reoccurence within 24h
* Complete recovery within 1H.
Complex
* 15-30mins
* Focal seizure
* Repeat seizure within 24h

Question 3

Signs Febrile Convulsions

Non-epileptic seizures caused by high fever

Answer 3

• Usually generalised tonic-clonic; stiffening at first
• Generalised jerking of the body.

Question 4

Investigations and Management of Febrile Convulsions

Answer 4

• Control the fever with simple analgesia
• First episode should always result in trip to hospital for assessment
• Complex cases may need further investigation.

if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes

Question 5

Complications of Febrile Convulsions

Links to Epilepsy

Answer 5

Risk of developing epilepsy:
- 1.8% risk for general population
- 2-7.5% after a simple febrile convulsion
- 10-20% after a complex febrile convulsion

Question 6

What is Cerebral Palsy

Answer 6

Disorder of movement and posture due to a non-progressive lesion of the motor pathways in the developing brain.
* It affects 2 in 1,000 live births and is the most common cause of major motor impairment.

Question 7

Causes of Cerebral Palsy

3 types

Answer 7

• Antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV)
• Intrapartum (10%): birth asphyxia/trauma during birth
• Postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma

Question 8

Pathophysiology of Cerebral Palsy

Answer 8

• Damage to brain
• Non-progressive
• Symptoms and problems may change over time during growth and development.

Question 9

Signs and Symptoms of Cerebral Palsy

Become more evident as child develops

Answer 9

• Abnormal tone early infancy
• Delayed motor milestones
• Abnormal gait
• Feeding difficulties.

Question 10

Classification of Cerebal Palsy

4 types

Answer 10

1. Spastic
   - Hypertonia due to UMN leison
   - hemiplegia, diplegia or quadriplegia
2. Dyskinetic
   - Caused by damage to the basal ganglia and the Substantia nigra
   - athetoid movements and oro-motor problems (speaking and moving)
3. Ataxic
   - caused by damage to the cerebellum with typical cerebellar signs
4. Mixed

Question 11

Investigations & Management of Cerebral Palsy

Answer 11

• Diagnosis by clinical examination
• MDT approach to treatment
• Treat spasticity using diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy
• anticonvulsants, analgesia as required

Question 12

Non Motor Cerebral Palsy symptoms

Answer 12

• learning difficulties (60%)
• epilepsy (30%)
• squints (30%)
• hearing impairment (20%)

Question 13

Define Epilepsy

Answer 13

Epilepsy is a condition where there is predisposition to epileptic seizures. Can be generalised seizures – discharge from both hemispheres, or focal seizures – seizures arise from one part of one hemisphere.

Question 14

5 main Epilepsy Syndromes in Children

Answer 14

1. Infantile Spasms (West’s)
2. Typical (petit mal) Absence seizures
3. Lennox-Gastaut Syndrome
4. Benign Rolandic Epilepsy
5. Juvenile myoclonic (Janz Syndrome)

Question 15

Typical Epilepsy Symptoms

5 different ones

Tonic Clonic, Foxal, Absence, Atonic, Myoclonic

Answer 15

Generalised tonic-clonic: loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements. May be associated tongue biting, incontinence, groaning and irregular breathing. There is prolonged post-ictal period after the seizure where the person is confused, drowsy and feels irritable and low.
Focal: typically start in the temporal lobes and main ways they present can be with hallucinations, memory flashbacks, déjà vu and doing strange things on autopilot.
Absence: child becomes blank and stares into space, then abruptly returning to normal. During the episode they are unaware of surroundings and won’t respond – typically last 10-20 seconds.
Atonic: also known as drop attacks; characterised by brief lapses in muscle tones. Don’t usually last more than 3 minutes.
Myoclonic: presents as sudden brief muscle contractions, with the patient usually remaining awake.
Infantile spasms: characterised by clusters of full body spasms

Question 16

Management for Epilepsy

Focal and Generalised have different plans

Tonic Clonic, Foxal, Absence, Atonic, Myoclonic

Answer 16

Tonic Clonic : Sodium Valproate 2nd , Lamotrigine
Focal: Lamotrigine 2nd line Carbamazepine
Absence: Ethosuximide Sodium Valproate
Atonic: Sodium Valproate, Lamotrigine
Myoclonic: Sodium Valproate or levetiracetam in women

Question 17

Complications of Epilepsy

two main ones

Answer 17

Status Epilepticus epilepticus is an epileptic seizure lasting 30 minutes or repeated episodes lasting 30 minutes in total with no full recovery between – medical emergency.
Sudden unexpected death in epilepsy (SUDEP) is very rare in childhood.

Status Epliepicus tyreatment First-line drugs are IV benzodiazepines such as diazepam or lorazepam
in the prehospital setting PR diazepam or buccal midazolam may be given

Question 18

Infantile Spasms

Epilpesy syndrome in child

Answer 18

• Breif spasms in first few mths of life
• Salaam Attack, Flexion of head, trunk, Limbs -> extension of arms repeats 50x
• EEG: Hypsarrythmia
• 2ndry to TB, Encephalitis, Birth asphyxia
• Treat with Vigabatrin & Steroids
• Poor prognosis

Question 19

Typical (petit mal) Absence seizures

Epilpesy syndrome in child

Answer 19

• Onset 4-8 yrs
• Duration few-30 secs; no warning, quick recovery; often many per day
• EEG: 3Hz generalized, symmetrical
• Sdium Valprote, ethosuximide
  good prognosis: 90-95% become seizure free in adolescence

Question 20

Lennox-Gastaut syndrome

Epilepsy syndrome in child

Answer 20

• May be an extension of infantile spasms
• Onset 1-5 yrs
• Features:
  atypical absences, falls, jerks
  90% moderate-severe mental handicap
• EEG: slow spike
  Treatment: ketogenic diet may help

Question 21

Benign Rolandic Epilepsy

Answer 21

• Most common in childhood, more common in males
• Features: paraesthesia (e.g. unilateral face), usually on waking up

Question 22

Juvenile myoclonic epilepsy (janz syndrome)

Answer 22

• Typical onset is in the teenage years, more common in girls
• Features:
  infrequent generalized seizures, often in morning//following sleep deprivation
• Daytime absences
• Sudden, shock-like myoclonic seizure (these may develop before seizures)
• Treatment: usually good response to sodium valproate

Daytime absences: Juvenile Absence Epilepsy

Question 23

Epidemiology ADHD

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Answer 23

• ADHD has a UK prevalence of 2.4%, about twice that of autism, and is more common in boys than in girls (M:F 4:1);
• Most children are diagnosed between the ages of 3 and 7;
• There is a possible genetic component.

Question 24

Define ADHD

DSM IV

Answer 24

• Features relating to inattention and/or hyperactivity/impulsivity that are persistent

Question 25

Signs and Symptoms ADHD

Inattention & Hyperactivity/Implusivity

Answer 25

Inattention
- Not following through on instructions
- Reluctant to engage in mentally-intense tasks
- Easily distracted
- Finds it difficult to sustain tasks
- Finds it difficult to organise tasks or activities
- Often forgetful in daily activities
- Often loses things necessary for tasks or activities
- Often does not seem to listen when spoken to directly
Hyperactivity
- Unable to play quietly
- Talks excessively
- Does not wait their turn easily
- Will spontaneously leave their seat when expected to sit
- Is often ‘on the go’
- Often interruptive or intrusive to others
- Will answer prematurely, before a question is finished
- Will run and climb in situations where it is not appropriate

Question 26

Investigations & Management ADHD

Ten week wait and watch period

Answer 26

• Refer To CAMHS
• Mild-moderate disorder is the active promotion of behavioural and educational progress
• Pharmacological over 6Y but last resort
• Methylphenidate first line. given for 6wks trial first

side effects of meds (particularly anxiety, weight loss and hypertension; height and weight measured every 6 months)

Question 27

Pathophysiology Autism Spectrum Disorder

more common in boys than girls

Autism normally apparent by 3Y

Answer 27

Neurodevelopmental condition characterised by qualitative impairment in social interaction and communication, as well as repetitive stereotyped behaviour, interests, and activities.

Question 28

Signs of Autism Spectrum Disorder

Symptoms present in early childhood but can manifest later too.

Answer 28

Social Interaction : Lack of eye contact, unable to read non-verbal cues, difficulty establishing friends.
Communication: Delay in language development, lack of non-verbal cues, repetitive use of words
Behaviour: Greater interests in objects and patterns than people, stereotypical repetitive movements (hand flapping)

Question 29

Investigations & Management of Autism Spectrum Disorder

Autism normally apparent by 3Y

Answer 29

Screening Questionaire
Non pharmacological therapies include:
- Early educational and behavioural interventions
- Family support and counselling
- Speech and language input
- Social worker involvement

pharmacological therapies do not help.

Question 30

Pathophysiology Anorexia Nervosa

90% of patients are female

Anorexia nervosa is the most common cause of admissions to child and adolescent psychiatric wards.

Answer 30

These patients feel they are overweight despite evidence of normal or low body weight. Leads to obsessive restriction of calories with the intention of losing weight, and the person often exercises excessively.

Question 31

Signs and Symptoms Anorexia Nervosa

Answer 31

• Excessive weight loss
• Amenorrhoea
• Lanugo hair – fine, soft hair across most of the body
• Low blood pressure
• Hypothermia
• Changes in mood, anxiety or depression
• Solitude

Question 32

Management of Anorexia Nervosa

Answer 32

In children and young people, NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.

Question 33

Diagnostic criteria Anorexia Nervosa

Answer 33

1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Question 34

Pathophysiology Bulimia Nervosa

Often occurs in late teens

Answer 34

Eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.

Lack of control during period of binge

Question 35

Signs and Symptoms of Bulimia Nervosa

Answer 35

• Erosion of teeth (due to acid from vomit)
• Swollen salivary glands
• Mouth ulcers
• Gastro-oesophageal reflux and irritation
• Calluses on the knuckles where they have been scaped across the teeth – this is called Russell’s sign.

Question 36

Complications Bulimia Nervosa

Answer 36

Blood alkalosis can occur due to vomiting hydrochloric acid from the stomach. Hypokalaemia can also occur due to this loss.
Repeated vomiting and/or laxative abuse can lead to seizures, tetany, haematemesis or stomach rupture.

Question 37

Management Bulimia Nervosa

Answer 37

• Children should be offered bulimia-nervosa-focused family therapy (FT-BN)
• High-dose fluoxetine to control cravings (limited use)