Paeds Neuro & Psych Flashcards
What are Febrile Convulsions
- 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
Simple V Complex Febrile Convulsions
Non-epileptic seizures caused by high fever
Simple
* <15 mins
* Generalised Seizure
* No reoccurence within 24h
* Complete recovery within 1H.
Complex
* 15-30mins
* Focal seizure
* Repeat seizure within 24h
Signs Febrile Convulsions
Non-epileptic seizures caused by high fever
- Usually generalised tonic-clonic; stiffening at first
- Generalised jerking of the body.
Investigations and Management of Febrile Convulsions
- 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
Complications of Febrile Convulsions
Links to Epilepsy
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
What is Cerebral Palsy
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.
Causes of Cerebral Palsy
3 types
- 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
Pathophysiology of Cerebral Palsy
- Damage to brain
- Non-progressive
- Symptoms and problems may change over time during growth and development.
Signs and Symptoms of Cerebral Palsy
Become more evident as child develops
- Abnormal tone early infancy
- Delayed motor milestones
- Abnormal gait
- Feeding difficulties.
Classification of Cerebal Palsy
4 types
- Spastic
- Hypertonia due to UMN leison
- hemiplegia, diplegia or quadriplegia - Dyskinetic
- Caused by damage to the basal ganglia and the Substantia nigra
- athetoid movements and oro-motor problems (speaking and moving) - Ataxic
- caused by damage to the cerebellum with typical cerebellar signs - Mixed
Investigations & Management of Cerebral Palsy
- 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
Non Motor Cerebral Palsy symptoms
- learning difficulties (60%)
- epilepsy (30%)
- squints (30%)
- hearing impairment (20%)
Define Epilepsy
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.
5 main Epilepsy Syndromes in Children
- Infantile Spasms (West’s)
- Typical (petit mal) Absence seizures
- Lennox-Gastaut Syndrome
- Benign Rolandic Epilepsy
- Juvenile myoclonic (Janz Syndrome)
Typical Epilepsy Symptoms
5 different ones
Tonic Clonic, Foxal, Absence, Atonic, Myoclonic
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
Management for Epilepsy
Focal and Generalised have different plans
Tonic Clonic, Foxal, Absence, Atonic, Myoclonic
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
Complications of Epilepsy
two main ones
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
Infantile Spasms
Epilpesy syndrome in child
- 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
Typical (petit mal) Absence seizures
Epilpesy syndrome in child
- 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
Lennox-Gastaut syndrome
Epilepsy syndrome in child
- 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
Benign Rolandic Epilepsy
- Most common in childhood, more common in males
- Features: paraesthesia (e.g. unilateral face), usually on waking up
Juvenile myoclonic epilepsy (janz syndrome)
- 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
Epidemiology ADHD
ATTENTION DEFICIT HYPERACTIVITY DISORDER
- 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.
Define ADHD
DSM IV
- Features relating to inattention and/or hyperactivity/impulsivity that are persistent
Signs and Symptoms ADHD
Inattention & Hyperactivity/Implusivity
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
Investigations & Management ADHD
Ten week wait and watch period
- 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)
Pathophysiology Autism Spectrum Disorder
more common in boys than girls
Autism normally apparent by 3Y
Neurodevelopmental condition characterised by qualitative impairment in social interaction and communication, as well as repetitive stereotyped behaviour, interests, and activities.
Signs of Autism Spectrum Disorder
Symptoms present in early childhood but can manifest later too.
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)
Investigations & Management of Autism Spectrum Disorder
Autism normally apparent by 3Y
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.
Pathophysiology Anorexia Nervosa
90% of patients are female
Anorexia nervosa is the most common cause of admissions to child and adolescent psychiatric wards.
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.
Signs and Symptoms Anorexia Nervosa
- 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
Management of Anorexia Nervosa
In children and young people, NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.
Diagnostic criteria Anorexia Nervosa
- 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.
- Intense fear of gaining weight or becoming fat, even though underweight.
- 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.
Pathophysiology Bulimia Nervosa
Often occurs in late teens
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
Signs and Symptoms of Bulimia Nervosa
- 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.
Complications Bulimia Nervosa
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.
Management Bulimia Nervosa
- Children should be offered bulimia-nervosa-focused family therapy (FT-BN)
- High-dose fluoxetine to control cravings (limited use)
