The infant or child with abnormal development or poor school performance Flashcards
Neurological assessment history
- Pregnancy/neonatal
- Development
- >Regression in developmental milestone
- >Pattern of the delay - Headache
- Vomiting early morning
- Involuntary movements, convulsions, unexplained collapse, ALOC
- Sensory
- Bladder and bowel
- Ataxia, clumsiness, incoordination
- Hearing and vision
- Behaviour, mood, apathy, concentration
- School performance
- Function
- Home environment->parents, siblings
- Additional support->parental respite
- Family history of neurological->epilepsy, hearing/vision,metabolic, congenital, learning difficulty
Neurological physical examination
- 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 - Eye->movement, pupils, fundoscopy
- Peripheral
- >Muscle bulk, tone, power, coordination, reflexes
- >Sensory - Developmental exam
- Hepatosplenomegaly (metabolic)
Neurological examination in infants
- Moving spontaneously
- Positioning->hypoT= frogs legs
- Palpate posterior fontanelle/head circumference
- Assess tone by posture and handling->ventral position, pull to sit->++tone= resistance, scissoring of legs
Define cerebral palsy
Motor impairment
Permanent
Non-preogressive lesion in developing brain->however clinical picture changes
Most common form of cerebral palsy and location of lesion
Spastic type
Types of cerebral palsy (5)
- Hemiplegia
- Diplegia
- Total body involvement
- Atatxic
- Athetoid
Features of hemiplegia
Arms more affected than legs
Delayed walking
Tiptoe gait, dystonic posture when running
Athetoid cerebral palsy
Basal ganglia
Writhing movement
Intelligence often normal
Major physical impairment
Ataxic cerebral palsy
Cerebral damage
Ataxia and poor coordniation
Diplegia
Both legs
++Hip adduction, nappy difficult to put on
Scissoring of legs
Feet in equinovarus and walking on tiptoe
Total body involment
All limbs \+Learning difficulties Seizures Swallowing difficulties and GOR Flexion contractur es of knees and elbows often present by late childhood
Prevalence of cerebral palsy
Is 2 / 1000
Etiology- pre, peri, post-natal of cerebral palsy
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
Diagnosis of cerebral palsy
Clinical, based on findings abnormalities:
- Tone->spasticity
- Patterns of development ->abnormal in quality
- Motor developmental delay
- Persistent reflexes
If cause not clear:
- Urine/plasma metabolic screen
- Consider congenital infections
- Xsomal analysis
- MRI->vascular, malformations, periventricular leucomalacia
Associated problems (8) in cerebral palsy
Hearing Vision->50%, squint Epilepsy->50% Respiratory problems Undernutrition, poor intake Learning difficulties Behavioural
Multidisciplinary team involved in managment of cerebral palsy
Child development team
- Pediatrician->support, liason
- Physiotherapist->handling and mobilising, prevent contractures
- Occupational therapist->equiptment and play materials
- Speech and language therapist->feeding and language
- Health visitor
- Psychologist
Define visual impairment and blind
Impairment= visual acuity
Prevalence of blind/partially sighted
1 in 2500
Etiology of blindness in children, most common 3
Optic atrophy
Congenital cataracts
Choirodoretinal abnormalities
Clinical features of visually impaired children
Eyes may appear different Smilining inconsistent Do not turn head toward sound Slower language development Pincher, reach abnormal May have associated hearing/learning difficulties
Management of visual impairment
- Opthalmological referral
- Advice to parents, adaptations to home, stimulation in non-visual way
- Mainstream preschool generally appropriate with support
- Attend to learning difficulties
- Mobility training
Prevalence of hearing deficits
Prevalence 4%
Etiology
Most commonly conductive due to OM
Genetic
Pre, peri, post natal problems
Cerebral insult
Risk of deafness->neurosensory and conductive
1. Neurosensory Meningitis Cerebral palsy FHx Aminoglycoside Congenital CMV
- Conduction
Cleft palate
Recurrent OM
Clinical presentation of hearing impairment
Universal neontal screening
Audiology->at risk, speech, concerns about deafness
- Lack response to sound
- Poor speech
- Behavioural
- Associated->learning disabilities, neurological, visual
management of hearing impairment
- Grommets in conductive
- Hearing aids in sensorineuronal
- Cochlear
- Genetic counselling may be needed
Management considerations for cerebral palsy->3 categories (4, 9, 4)
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
Common presentations to the ED with cerebral palsy
Respiratory problems particularly pneumonia
Uncontrolled seizures / status epilepticus
Unexplained irritability - consider acute infections, oesophagitis, dental disease, hip subluxation, pathological fracture. Review medications.
History in speech delay
- Birth/developmental
- Family history of speech/hearing
- Isolated developmental delay->Ages and stages screening
- Features of ASD present
- History of saying words in the past
Examination in speech delay
- General, behaviours to suggest ASD
- Neurocutaneous marking
- Dysmorphic features
- Neurological examination
- Hearing
- Motor, fine motor, social development
What investigation must be done with speech delay and why
Audiogram->a high frequency deafness can only be diagnosed this way
Next steps for speech delay
- Referral to pediatrician
2. Referral to speech and language therapist
Causes of developmental delay
- Idiopathic
- CNS malformations
- Xsomal
- Metabolic
- Pre/per/post natal
Investigations for developmental delay
Xsome analysis
Thyroid function
Urine screen for metabolic abnormalities
Follow up for developmental delay
Complete developmental assessment with: Pediatrician Psychologist Speech and language therapist OT Physiotherapist