The infant or child with abnormal development or poor school performance

Question 1

Neurological assessment history

Answer 1

1. Pregnancy/neonatal
2. Development
   - >Regression in developmental milestone
   - >Pattern of the delay
3. Headache
4. Vomiting early morning
5. Involuntary movements, convulsions, unexplained collapse, ALOC
6. Sensory
7. Bladder and bowel
8. Ataxia, clumsiness, incoordination
9. Hearing and vision
10. Behaviour, mood, apathy, concentration
11. School performance
12. Function
13. Home environment->parents, siblings
14. Additional support->parental respite
15. Family history of neurological->epilepsy, hearing/vision,metabolic, congenital, learning difficulty

Question 2

Neurological physical examination

Answer 2

1. Observation
   - >AVPU, GCS
   - >Posture, movement, gait
   - >Limb deformity
   - >Growth/HC
   - >Skin sigs->pigmentation, vascular birth marks
   - >dysmorphic features, xsomal, CNS malformation, FAS
   - >equiptment to aid neurological problems
2. Eye->movement, pupils, fundoscopy
3. Peripheral
   - >Muscle bulk, tone, power, coordination, reflexes
   - >Sensory
4. Developmental exam
5. Hepatosplenomegaly (metabolic)

Question 3

Neurological examination in infants

Answer 3

1. Moving spontaneously
2. Positioning->hypoT= frogs legs
3. Palpate posterior fontanelle/head circumference
4. Assess tone by posture and handling->ventral position, pull to sit->++tone= resistance, scissoring of legs

Question 4

Define cerebral palsy

Answer 4

Motor impairment
Permanent
Non-preogressive lesion in developing brain->however clinical picture changes

Question 5

Most common form of cerebral palsy and location of lesion

Answer 5

Spastic type

Question 6

Types of cerebral palsy (5)

Answer 6

1. Hemiplegia
2. Diplegia
3. Total body involvement
4. Atatxic
5. Athetoid

Question 7

Features of hemiplegia

Answer 7

Arms more affected than legs
Delayed walking
Tiptoe gait, dystonic posture when running

Question 8

Athetoid cerebral palsy

Answer 8

Basal ganglia
Writhing movement
Intelligence often normal
Major physical impairment

Question 9

Ataxic cerebral palsy

Answer 9

Cerebral damage

Ataxia and poor coordniation

Question 10

Diplegia

Answer 10

Both legs
++Hip adduction, nappy difficult to put on
Scissoring of legs
Feet in equinovarus and walking on tiptoe

Question 11

Total body involment

Answer 11

All limbs
\+Learning difficulties
Seizures
Swallowing difficulties and GOR
Flexion contractur    es of knees and elbows often present by late childhood

Question 12

Prevalence of cerebral palsy

Answer 12

Is 2 / 1000

Question 13

Etiology- pre, peri, post-natal of cerebral palsy

Answer 13

1. Prenatal
Cerebral malformation
Maternal infection
Metabolic
2. Perinatal
Birth trauma
Hypoxic-ischemic
Prematurity
3. Postnatal
Head injury
Non-accidental injury
Meningitis/encephalitis
Cardiopulmonary arrest

Question 14

Diagnosis of cerebral palsy

Answer 14

Clinical, based on findings abnormalities:

1. Tone->spasticity
2. Patterns of development ->abnormal in quality
3. Motor developmental delay
4. Persistent reflexes

If cause not clear:

1. Urine/plasma metabolic screen
2. Consider congenital infections
3. Xsomal analysis
4. MRI->vascular, malformations, periventricular leucomalacia

Question 15

Associated problems (8) in cerebral palsy

Answer 15

Hearing
Vision->50%, squint
Epilepsy->50%
Respiratory problems
Undernutrition, poor intake
Learning difficulties
Behavioural

Question 16

Multidisciplinary team involved in managment of cerebral palsy

Answer 16

Child development team

1. Pediatrician->support, liason
2. Physiotherapist->handling and mobilising, prevent contractures
3. Occupational therapist->equiptment and play materials
4. Speech and language therapist->feeding and language
5. Health visitor
6. Psychologist

Question 17

Define visual impairment and blind

Answer 17

Impairment= visual acuity

Question 18

Prevalence of blind/partially sighted

Answer 18

1 in 2500

Question 19

Etiology of blindness in children, most common 3

Answer 19

Optic atrophy
Congenital cataracts
Choirodoretinal abnormalities

Question 20

Clinical features of visually impaired children

Answer 20

Eyes may appear different
Smilining inconsistent
Do not turn head toward sound
Slower language development
Pincher, reach abnormal
May have associated hearing/learning difficulties

Question 21

Management of visual impairment

Answer 21

1. Opthalmological referral
2. Advice to parents, adaptations to home, stimulation in non-visual way
3. Mainstream preschool generally appropriate with support
4. Attend to learning difficulties
5. Mobility training

Question 22

Prevalence of hearing deficits

Answer 22

Prevalence 4%

Question 23

Etiology

Answer 23

Most commonly conductive due to OM
Genetic
Pre, peri, post natal problems
Cerebral insult

Question 24

Risk of deafness->neurosensory and conductive

Answer 24

1. Neurosensory
Meningitis
Cerebral palsy
FHx
Aminoglycoside
Congenital CMV

2. Conduction
   Cleft palate
   Recurrent OM

Question 25

Clinical presentation of hearing impairment

Answer 25

Universal neontal screening Audiology->at risk, speech, concerns about deafness 1. Lack response to sound 2. Poor speech 3. Behavioural 4. Associated->learning disabilities, neurological, visual

Question 26

management of hearing impairment

Answer 26

1. Grommets in conductive 2. Hearing aids in sensorineuronal 3. Cochlear 4. Genetic counselling may be needed

Question 27

Management considerations for cerebral palsy->3 categories (4, 9, 4)

Answer 27

``` 1. Associated disability Hearing and vision Epilepsy and cognitive assessment 2. Health Growth Obesity Reflux Chronic lung disease Constipation VP shunt Osteoporosis Dental Emotional 3. Consequences of motor Drooling->speech therapy, anticholinergics Incontinence due to cognition, access, communication, overactive bladder Orthopedic->contractures, dislocations, scoliosis Spestcity->diazepam, inhibitory casts, BTA, intrathecal baclofen (GABA), selective dorsal rhizotomy ```

Question 28

Common presentations to the ED with cerebral palsy

Answer 28

Respiratory problems particularly pneumonia Uncontrolled seizures / status epilepticus Unexplained irritability - consider acute infections, oesophagitis, dental disease, hip subluxation, pathological fracture. Review medications.

Question 29

History in speech delay

Answer 29

1. Birth/developmental 2. Family history of speech/hearing 3. Isolated developmental delay->Ages and stages screening 4. Features of ASD present 5. History of saying words in the past

Question 30

Examination in speech delay

Answer 30

1. General, behaviours to suggest ASD 2. Neurocutaneous marking 3. Dysmorphic features 4. Neurological examination 5. Hearing 6. Motor, fine motor, social development

Question 31

What investigation must be done with speech delay and why

Answer 31

Audiogram->a high frequency deafness can only be diagnosed this way

Question 32

Next steps for speech delay

Answer 32

1. Referral to pediatrician | 2. Referral to speech and language therapist

Question 33

Causes of developmental delay

Answer 33

1. Idiopathic 2. CNS malformations 3. Xsomal 4. Metabolic 5. Pre/per/post natal

Question 34

Investigations for developmental delay

Answer 34

Xsome analysis Thyroid function Urine screen for metabolic abnormalities

Question 35

Follow up for developmental delay

Answer 35

``` Complete developmental assessment with: Pediatrician Psychologist Speech and language therapist OT Physiotherapist ```