PEDIATRIC NEUROLOGICAL CONDITIONS Unit 4: Part 2 Module - PowerPoint PPT Presentation

Loading...

PPT – PEDIATRIC NEUROLOGICAL CONDITIONS Unit 4: Part 2 Module PowerPoint presentation | free to view - id: 3b3665-NThhO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

PEDIATRIC NEUROLOGICAL CONDITIONS Unit 4: Part 2 Module

Description:

PEDIATRIC NEUROLOGICAL CONDITIONS Unit 4: Part 2 Module 3 Prepared by: C. Sargo RN (EC) Reviewed by: Maj. Quinn RN (EC) REFERENCES C 290- Nelson s Essentials of ... – PowerPoint PPT presentation

Number of Views:633
Avg rating:3.0/5.0
Slides: 145
Provided by: joycreate
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: PEDIATRIC NEUROLOGICAL CONDITIONS Unit 4: Part 2 Module


1
PEDIATRIC NEUROLOGICAL CONDITIONS
  • Unit 4 Part 2 Module 3

Prepared by C. Sargo RN (EC) Reviewed by Maj.
Quinn RN (EC)
2
REFERENCES
  • C 290- Nelsons Essentials of Pediatrics
  • C 306- Toronto Sick Kids manual
  • 277- Toronto Notes
  • 2001 Anti-infective Guidelines
  • Class handout

3
OUTLINE
  • Embryonic Development of the CNS
  • Primary Pathways and Symptoms Of Neurological
    Disorders in Children
  • Neural Tube Defects
  • Acute Pediatric Coma
  • Seizure Disorders

4
OUTLINE
  • Headaches
  • Head Injuries
  • Meningitis
  • Hypotonia in the Neonate
  • Hydrocephalus
  • Childhood Neurological Malignancies

5
EMBRYONIC DEVELOPMENT OF THE CNS
  • CNS arises from the neural plate of embryonic
    ectoderm
  • Neural plate gives rise to neural tube
  • Neural tube forms the brain , spinal cord and
    neural crest cells which form the peripheral NS,
    meninges, melanocytes and adrenal medulla
  • NT begins to form on day 22 of gestation
  • The lumen of the NT forms the ventricles and
    central canal of the spinal cord

6
PRIMARY PATHWAYS OF CNS DISORDERS
  • Congenital anomalies e.g NTD- spina bifida
  • Congenital inborn errors of metabolism e.g.
  • Infection - e.g meningitis
  • Neoplasm - brain tumors
  • Vascular anomalies - e.g. AV malformation

7
PRIMARY PATHWAYS OF CNS DISORDERS
  • Nutritional deficiency
  • Autoimmunity
  • Cellular degeneration
  • Intoxication - acute poisoning
  • Trauma - e.g acute head injury
  • Anoxia

8
PRIMARY SIGNS SYMPTOMSOF CNS DISORDERS
  • Cognitive deficits- memory,mood , concentration,
    personality changes
  • Seizures
  • Headache
  • Dizziness

9
PRIMARY SIGNS SYMPTOMSOF CNS DISORDERS
  • Vision or hearing loss
  • Impairment of swallowing or respiration
  • Weakness/numbness/paresthesia
  • Difficulty walking/talking
  • Incontinence

10
NEURAL TUBE DEFECTS
  • Spina bifida
  • - Defective closure of the caudal end of NT at
    the end of 4th week of gestation
  • - Results in anomalies of the lumbar and sacral
    vertebrae or spinal cord
  • - Range of severity of CNS affects
  • - Preventable with pre-conceptual Folic acid
    supplements 0.4 mg /day

11
NEURAL TUBE DEFECTS
  • Spina bifida "oculta" (meaning "hidden" in latin)
  • - There may be no signs or symptoms
  • - The spinal arch has not closed, but the spinal
    cord underneath has retained its normal position
    and is not damaged
  • - Skin of back intact, small dimple or tuft of
    hair may be present over affected vertebrae
  • - A child could grow up and never know that he or
    she has the defect

12
MYELOCELE
13
(No Transcript)
14
ANENCEPHALY
  • Defective closure of the rostral neural tube
    results in anencephaly or encephalocele
  • Neonates with anencephaly have a rudimentary
    brainstem , or midrain , no cortex or cranium
  • Rapidly fatal condition if born alive

15
ANENCEPHALY
16
ANENCEPHALY
17
NEURAL TUBE DEFECTS
  • Diastemamyelia
  • - A bone or fibrous band divides spinal cord in
    two longitudinal sections
  • - Associated lipoma may be present, which tethers
    cord to vertebra
  • - SS include weakness, numbness in feet, urinary
    incontinence, decreased or absent reflexes in
    feet
  • - Rx - surgery to free cord

18
ENCEPHALOCELE
  • Skull defect with exposure of meninges alone or
    meninges and brain
  • Sometimes defect can cause protrusion of frontal
    lobe through the nose

19
ENCEPHALOCELE
20
MACROCEPHALY
  • Results from
  • Macrocrania- increased skull thickness
  • Hydrocephalus- enlarged ventricles
  • Megalencephaly -enlargement of brain

21
MICROCEPHALY
  • Causes include
  • - Premature closure of skull sutures
    ((craniosynostosis)
  • - Microencephaly - small brain due to insult (
    infectious, toxic, metabolic, vascular)
    sustained in the perinatal or early infancy
    period e.g rubella,CMV, Fetal alcohol syndrome
  • - Genetic disorder - microencephaly vera
  • - Many syndromes and metabolic disorders are
    associated See table 18-1, PG 769, Nelsons

22
PEDIATRIC COMA
  • Most common pattern in children is diffuse
    impairment of cerebral hemispheres
  • Less commonly results from brainstem dysfunction

23
PEDIATRIC COMA
  • Useful mnemonics for Differential Dx of causes
  • T - trauma
  • I - insulin/hypoglycemia/inborn errors of
    metabolism/intususception
  • P - Psychiatric
  • S - seizures, stroke, shock, shunt malfunction

24
PEDIATRIC COMA
  • A- alcohol abuse
  • E- electrolytes, encephalopathy, endocrinopathy
  • I - infection
  • O - overdose/ingestion
  • U - uremia

25
PEDIATRIC COMA-INITIAL APPROACH
  • Primary Survey
  • - ABCs - C-spine precautions
  • - Pediatric Glasgow Coma Scale
  • - Vital signs including rectal temperature
  • - Check for signs of obvious trauma
  • - Check for SS of raided ICP
  • - Hypoglycemia- give glucose 0.5 g/kg( D50W, 1-2
    ml/kg IV empirically - chemstrip sugar low
  • - Narcan empirically 0.1 mg/kg if pupils
    small/pinpoint

26
PEDIATRIC COMA-INITIAL APPROACH
  • Secondary survey
  • - History - known underlying cause, acute fever,
    trauma, ingestion, PMH, Medications, allergies,
    last meal
  • - General CPX including CNS exam
  • - Look for evidence of infection, intoxication,
    traumatic and metabolic causes
  • - Fontanelle, neck stiffness, neck bruits, fundi(
    retinal hemorrhages), oculomotor movements
  • - Breathing patterns
  • - Motor responses ( focalizing/lateralizing
    signs)

27
PEDIATRIC COMA-INITIAL APPROACH
  • Investigations - depends on potential etiology
    and clinical condition
  • Blood work may include
  • - CBC, cultures, glucose, electrolytes, BUN,
    creatinine, Calcium, magnesium, LFTs, ammonium,
    blood clotting screen, ABG

28
PEDIATRIC COMA-INITIAL APPROACH
  • Diagnostic Imaging
  • - CT of head essential if focal causes suspected
    e.g trauma not if diffuse cause e.g infection
  • - CRX, C-spine XR, Flat plate of Abdomen, limb XR
  • - urinalysis, CS, latex agglutination
  • - LP- CSF analysis
  • - ECG
  • - EEG

29
PEDIATRIC COMA-INITIAL APPROACH
  • Further management directed at underlying cause
  • Serial Glasgow coma scale assessments
  • Maintain homeostasis with
  • - Oxygen/CO2
  • - IV fluids
  • - Acid base , electrolytes
  • - Nutrition

30
PEDIATRIC GLASGOW COMA SCALE
  • Eye Opening
  • Spontaneous 4
  • To speech 3
  • To pain 2
  • No Response 1

31
PEDIATRIC GLASGOW COMA SCALE
  • Best Verbal Response
  • Oriented (Infant coos or babbles) 5
  • Confused (Infant irritable cries) 4
  • Inappropriate words (Infant Cries to pain) 3
  • Incomprehensible sounds (Infant Moans to pain) 2
  • No Response 1

32
PEDIATRIC GLASGOW COMA SCALE
  • Best Motor Response
  • Obeys (Infant moves spontaneous/purposefully) 6
  • Localizes (infant withdraws to touch) 5
  • Withdraws to pain 4
  • Abnormal Flexion to pain (Decorticate) 3
  • Extensor Response to pain (Decerebrate) 2
  • No Response 1

33
PEDIATRIC GLASGOW COMA SCALE
  • Scoring- Total 3-15
  • Minor head injury 13-15
  • Moderate head injury 9-12
  • Severe head injury (coma) lt 8
  • Confers Significant Mortality Risk lt 8

34
SEIZURES
  • Classification of Seizures
  • Partial
  • Generalized

35
SEIZURES
  • Simple Partial Seizure
  • - Affects only part of brain (focal, motor or
    sensory)
  • - Formerly called focal seizures
  • May progress to generalized seizures
  • Complex Partial Seizure
  • Partial seizure with affective or behavioral
    changes
  • Absence seizures( spells)

36
SEIZURES
  • Febrile Seizure
  • - Associated with temperature gt38C
  • - Occurs in children lt6 years old (prevalence is
    2 to 4 among children lt5 years old)
  • - No signs or history of underlying seizure
    disorder
  • - Often familial
  • - Uncomplicated and benign if seizure is of
    short duration (lt15 minutes), only 1 in 24
    hours,and normal CNS exam after seizure
  • - Involves tonic-clonic movements, bilaterally

37
SEIZURES
  • HISTORY
  • Previous episodes (i.e., known seizures)
  • Nature of Current Seizure episode
  • - Onset (sudden or gradual), time ,
    setting, duration of seizure
  • - Whether consciousness has been regained since
    onset of seizure activity
  • - post ictal state - drowsiness, stupor,
    headache, transient paralysis

38
SEIZURES
  • HISTORY ( continued)
  • Sequence of seizures
  • Type of seizure (generalized or partial)
  • Association with fever, cyanosis, incontinence
  • Association with head injury
  • Ingestion of poisonous substance or other
    poisoning (e.g., lead encephalopathy)

39
SEIZURES
  • HISTORY ( continued)
  • Medication use -compliance with anticonvulsant
    therapy if child known to have seizures
  • Other chronic disease
  • Allergies
  • Symptoms of inter-current illness (e.g., fever,
    malaise, cough)
  • Growth/Developmental history
  • Family Hx. Of seizure disorders

40
SEIZURE DISORDERS
  • Differential Diagnosis
  • - Epilepsy
  • - Drugs (non-compliance with prescription,
    withdrawal syndrome, overdose, multiple drug
    abuse)
  • - Hypoxia
  • - Brain tumor
  • - Infection (e.g., meningitis)
  • - Metabolic disturbances (e.g., hypoglycemia,
    uremia, liver failure, electrolyte disturbance)
  • - Head injury

41
SEIZURE DISORDERS
  • Diagnostic tests
  • - Pulse oximetry
  • - Glucose, electrolytes, calcium, magnesium
  • - Anticonvulsant drug levels in on Rx
  • - Diagnostic Imaging for undiagnosed cases
  • - EEG
  • - CT or - MRI
  • - ? LP- CSF analysis

42
SEIZURE DISORDERS
  • Complications
  • - Hypoxia during seizures
  • - Status epilepticus
  • - Arrhythmia
  • - Injury during seizure (e.g., from a fall)
  • - Brain damage
  • - Death

43
MANAGEMENT ACUTE SEIZURE
  • ABCs are the first priority
  • Ensure airway is clear and patent
  • Suction secretions as necessary
  • Insert oropharyngeal airway
  • Assist ventilation as needed by means of Ambu-bag
    with oxygen

44
MANAGEMENT ACUTE SEIZURE
  • Oxygen as necessary to maintain oxygen saturation
    gt97
  • Start IV therapy with normal saline, adjusting
    rate according to state of hydration
  • Nurse child in side-lying position
  • Keep child warm
  • Give nothing by mouth until child has fully
    recovered

45
MANAGEMENT ACUTE SEIZURE
  • Pharmacologic Interventions
  • Lorazepam (Ativan), 0.050.10 mg/kg IV (maximum
    4 mg per dose), repeat q10min for 2 more doses
    (administer slowly over 5 minutes, maximum rate 2
    mg/min)
  • OR
  • Diazepam (Valium), 0.3 mg/kg IV (maximum 5 mg
    per dose for child lt5 years old, 10 mg per dose
    for child gt5 years old)
  • Repeat q5-10 min for 2 more doses (administer
    slowly over 5 minutes, maximum rate 2 mg/min)

46
MANAGEMENT ACUTE SEIZURE
  • If cannot get IV access - give per rectum
  • - diazepam (Valium) 0.5 mg/kg per dose PR
    (maximum dose 10 mg)
  • - repeat q510min for total of 2 doses (maximum
    rate 2 mg/min)

47
MANAGEMENT ACUTE SEIZURE
  • Monitoring and Follow-Up
  • - Admit
  • - Identify focal neurological deficits, clinical
    conditions e.g infection
  • - Observe for return to normal level of
    consciousness
  • - Monitor vital signs, ABCs, pulse oximetry (if
    available)
  • - Monitor closely for continued seizure activity

48
MANAGEMENT CHRONIC SEIZURE
  • Provide reassurance
  • Client Education
  • - Explain prognosis - most children outgrow
  • - Emphasize importance of adhering to medication
    regimen
  • - Counsel about first aid during seizures
  • - Advise supervision during swimming, use of
    helmets
  • - Advise that the child be treated as a normal
    child would be
  • - Advise about possible teratogenic effects of
    medications (e.g., phenytoin) for sexually active
    females

49
MANAGEMENT CHRONIC SEIZURE
  • Commonly Used Anticonvulsants
  • carbamazepine (Tegretol)
  • lamotrigine (Lamictal)
  • phenobarbital (Phenobarb) - kids lt 2
  • phenytoin (Dilantin)
  • primidone (Mysoline)
  • valproic acid (Depakene)
  • vigabatrin (Sabril)

50
MANAGEMENT CHRONIC SEIZURE
  • Monitoring and Follow-Up
  • - Follow up every 6 months if seizures are well
    controlled, more frequently if child is having
    breakthrough seizures
  • - Assess adherence to medication regimen
  • - Monitor serum drug levels every 6 months if
    stable, more frequently if necessary
  • - Refer urgently if child is having breakthrough
    seizures
  • - Consider neurological follow-up if symptoms are
    not controlled on current medications

51
HEADACHES
  • Occurs in 20 of school-age children. Onset may
    occur at any age
  • The most common causes of headache in children
  • - benign vascular headaches (leading to migraine)
  • - muscle contraction (leading to tension
    headaches)

52
HEADACHES
  • Vascular Organic Causes
  • - Arteriovenous malformation
  • - Berry aneurysm
  • - Cererbral infarction
  • - Intracranial hemorrhage

53
HEADACHES
  • Other causes
  • Infection
  • Trauma
  • Toxic Effects
  • Psychogenic
  • Organic -Traction

54
HEADACHES
  • Food allergy or sensitivity
  • Refractive error
  • Ocular muscle imbalance
  • Temporomandibular joint (TMJ) dysfunction
  • Hypertension

55
HEADACHES
  • History - CHLORIDE PEPPS
  • Associated symptoms - ROS
  • PMH
  • Family HX
  • Social Hx - stress, environmental factors
  • CPX including Neurological exam

56
HEADACHES
  • Physical exam- Physical findings are usually
    minimal with headaches
  • - Blood pressure usually normal
  • - Temperature may be elevated with infectious
    process (e.g., meningitis)
  • - Height and weight

57
HEADACHES
  • HEENT
  • - Pained facial expression
  • - Nuchal rigidity ( neck stiffness)
  • - Funduscopic examination (disks, blood
    vessels) results usually normal
  • - Spasm or tenderness of neck muscle, tenderness
    of TMJ

58
HEADACHES
  • HEENT Exam
  • - Deficits of cranial nerves
  • - Purulent rhinorrhea
  • - Halitosis, dental abscesses
  • - Cephalic bruits use bell of stethoscope over
    the fronto-temporal areas and orbits

59
HEADACHES
  • Neurologic Examination
  • - Level of consciousness,
  • - Mental status general demeanor, confusion,
    depression, stress
  • - Cutaneous lesions (café au lait spots)
  • - Focal abnormalities (e.g., tics, limb paresis)
  • - Sensory deficits
  • - Abnormal deep tendon reflexes

60
CLINICAL CHARACTERISTICS OF SPECIFIC HEADACHES
  • Organic -Traction
  • - Headaches increase rapidly in frequency and
    severity
  • - Headache is worst upon awakening in the
    morning, diminishes during the day
  • - Headache wakens child from sleep
  • - Aggravated by coughing or valsalva maneuver
  • - May be relieved by vomiting
  • - Associated symptoms focal neurological
    findings altered gait changes in behavior,
    personality, cognition or learning ability

61
CLINICAL CHARACTERISTICS OF SPECIFIC HEADACHES
  • Migraine
  • - Headache - pulsatile (throbbing)
  • - Headaches are periodic, separated by
    symptom-free intervals
  • - Associated with at least three of the following
    symptoms abdominal pain and nausea or vomiting,
    aura (motor, sensory, visual), family history of
    migraine
  • - Unilateral or bilateral
  • - Headache relieved by sleep

62
CLINICAL CHARACTERISTICS OF SPECIFIC HEADACHES
  • Tension Headache
  • - Band-like tightness or pressure in the
    bifrontal, occipital or posterior cervical
    regions
  • - Seen at any age
  • - Lasting for days or weeks but not disrupting
    regular activities
  • - Not associated with a prodrome
  • - Associated symptoms tight neck muscles, sore
    scalp, nausea, vomiting and aura are uncommon

63
CLINICAL CHARACTERISTICS OF SPECIFIC HEADACHES
  • Refractive Error
  • - Persistent frontal headache, which is worse
    while reading or doing schoolwork
  • TMJ Dysfunction
  • - Temporal headache
  • - Associated symptoms local jaw discomfort,
    malocclusion (crossbite), decreased range of
    motion of mouth, click with jaw movement, bruxism
    (grinding of teeth)

64
CLINICAL CHARACTERISTICS OF SPECIFIC HEADACHES
  • Chronic Sinusitis
  • - Frontal headache
  • - Tenderness to percussion over the frontal,
    maxillary or nasal sinuses
  • - Associated symptoms prolonged rhinorrhea and
    congestion, chronic cough and postnasal drip,
    anorexia, low-grade fever, malaise
  • It is unusual for children lt10 years old to have
    recurrent headaches secondary to chronic sinusitis

65
HEADACHES
  • Complications
  • - Recurrent or chronic headaches can be
    debilitating and may cause absences from school
    and social withdrawal
  • - Intracranial lesions, masses or infections are
    life-threatening
  • Diagnostic Tests
  • - Most headaches can be diagnosed from the
    history and physical examination.
  • - For recurrent or chronic headache, diagnostic
    information may include daily headache record
  • - CT scan if suspect organic cause

66
MANAGEMENT OF HEADACHES
  • Goals of treatment depend on the cause
  • Acute
  • - Rule out serious organic pathology
  • - Relieve pain
  • Recurrent or Chronic
  • - Relieve pain
  • - Prevent recurrence
  • - Avoid disruption of normal life tasks, such as
    attending school

67
MANAGEMENT OF HEADACHES
  • Consult a physician immediately in the following
    circumstances
  • - Concern about an underlying organic cause for
    headaches
  • - Uncertainty about the diagnosis
  • - Headaches are chronic and unresponsive to
    simple analgesia

68
MANAGEMENT OF HEADACHES
  • Supportive reassurance and education are
    appropriate for non-organic headaches
  • - Advise parents or caregiver that headaches in
    children are common and real
  • - Reassure family that headache is unlikely to
    indicate brain tumor
  • - Explain underlying pathophysiology of vascular
    and muscle contraction headaches (which are
    benign and have a favorable prognosis)
  • - Counsel about avoiding factors that trigger
    headaches

69
MANAGEMENT OF HEADACHES
  • - Identify stressors and advise on how to deal
    with them
  • - Counsel about use of medications (dose,
    frequency, side effects)
  • - Relaxation and Imagery Therapy
  • - Abdominal breathing exercises
  • - Visual imagery exercises

70
MANAGEMENT OF HEADACHES
  • For tension headaches and mild -moderate
    migraines,
  • - Acetaminophen (Tylenol), 10-15 mg/kg per dose
    (usually analgesic of choice)
  • - Children gt6 years old may be given 325 mg, and
    children gt12 years old may be given 325-650 mg
    PO q4h prn.
  • OR
  • - Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • ibuprofen (Motrin), 5-10 mg/kg per dose PO q8h
    prn, to daily maximum of 40 mg/kg

71
MANAGEMENT OF HEADACHES
  • Avoid narcotics
  • Migraine prophylaxis
  • Conduct follow-up visits
  • - Review headache diary if unable to identify
    cause on first visit, as well as to monitor
    management
  • - Reinforce balanced health habits of sleep,
    exercise and diet

72
HEAD INJURIES
  • HISTORY-Ascertain the following
  • - Mechanism of injury
  • - Time of injury
  • - Loss of consciousness (a brief seizure at the
    time of injury) may not be clinically significant
  • - Loss of memory , amnesia
  • - Irritability

73
HEAD INJURIES
  • History (continued)
  • - Visual disturbance
  • - Disorientation
  • - Abnormal gait
  • - Lethargy, pallor or agitation may indicate
    severe injury
  • - Vomiting
  • - Symptoms of increased intracranial pressure
    (vomiting, headache, irritability)

74
HEAD INJURIES
  • Physical Examination
  • - Vital Signs
  • - Tachypnea
  • - Bradycardia (with hypertension - Cushing
    response)
  • - Hypertension
  • - Hypotension

75
HEAD INJURIES
  • Signs of Skull Fracture
  • - Hematotympanum
  • - Periorbital or post-auricular ecchymosis
  • - Cerebrospinal fluid otorrhea or rhinorrhea
  • - Depressed fracture or penetrating injury
  • - Palpate scalp for hematomas and contusions,
    underlying depressions, which may signify
    depressed skull fracture

76
HEAD INJURIES
  • Neurologic Examination
  • - Pediatric Glasgow coma scale
  • - Papilledema
  • - Pupillary light reflexes (PERRLA)
  • - Cranial nerve examination
  • - Movement of extremities
  • - Abnormal posture (decorticate or decerebrate)
  • - Muscle flaccidity, spasticity
  • - Plantar responses

77
HEAD INJURIES
  • Classification of HI Canadian Pediatric Society
  • Mild
  • Moderate
  • Severe

78
(No Transcript)
79
HEAD INJURIES
  • MANAGEMENT MILD INJURY
  • Children with mild intracranial injury may be
    discharged home
  • An instruction sheet should be given to the
    parents or caregiver concerning observation and
    precautions
  • See Home Care Instructions for minor head
    injuries

80
(No Transcript)
81
HEAD INJURIES
  • MODERATE TO SEVERE INJURY
  • - ABCs first priority
  • - C-spine control
  • - Suture scalp lacerations, as major blood loss
    can occur
  • - Start IV therapy with normal saline to keep
    vein open (unless the child is in shock from
    other injuries)
  • - Restrict fluids to 60 of normal intake (except
    in cases of shock)
  • - Oxygen

82
HEAD INJURIES
  • MODERATE TO SEVERE INJURY
  • - Elevate head of bed by 30 to 45
  • - Place head and neck in midline position
  • - Minimize stimuli (e.g., suctioning and
    movement)
  • - To control increased intracranial pressure
    above measures
  • plus establish controlled hyperventilation
  • - CT scan of head
  • - C-spine x-ray

83
HEAD INJURIES
  • MODERATE TO SEVERE INJURY
  • - Diuretics if intracranial pressure is increased
    (and there is documented deterioration) despite
    measures outlined abovemannitol, 0.5-1 g/kg IV
  • - Monitor ABCs, vital signs, pulse oximetry,
    level of consciousness (with serial pediatric
    Glasgow coma scores), intake and output

84
MENINGITIS
  • Definition
  • - Inflammation of the meningeal membranes of the
    brain or spinal cord
  • - Most cases (70) occur in children lt5 years old
  • - May be secondary to other localized or systemic
    infections (e.g., otitis media).
  • Causes
  • - Meningitis may be caused by bacteria, viruses,
    fungi and (rarely) parasites.

85
MENINGITIS
  • Bacterial
  • - In children lt1 month old group B
    Streptococcus, Escherichia coli
  • - In children 4-12 weeks old E. coli, Hemophilus
    influenzae type B, Streptococcus pneumoniae,
    group B Streptococcus, Neisseria meningitidis
    (meningococcal)
  • - In children 3 months to 18 years old
    Streptococcus pneumoniae (most common cause), N.
    meningitidis, H. influenza type B (rare)
  • - Mycobacterium tuberculosis

86
MENINGITIS
  • Viral
  • - Approximately 70 strains of enteroviruses
  • Fungal
  • - Candida
  • Aseptic
  • - Lyme disease

87
MENINGITIS
  • Transmission
  • - Meningitis caused by H. influenzae airborne
    droplets and secretions
  • - Meningococcal meningitis (caused by N.
    meningitidis) direct contact with droplets or
    secretions

88
MENINGITIS
  • Incubation
  • - Meningitis caused by H. influenzae 2-4 days
  • - Meningococcal meningitis (caused by N.
    meningitidis) 2-10 days
  • Contagion
  • - Meningitis caused by H. influenzae moderate
    high risk of transmission in daycare centers and
    other crowded environments
  • - Meningococcal meningitis (caused by N.
    meningitidis) low spreads most rapidly in
    crowded conditions

89
MENINGITIS
  • Communicability
  • - Meningitis caused by H. influenzae as long as
    organisms are present non-communicable within
    24-48 hours after treatment is started
  • - Meningococcal meningitis (caused by N.
    meningitidis) until organism is no longer
    present in secretions from nose and mouth

90
MENINGITIS
  • HISTORY - In children lt12 months old
  • - Usually preceded by URTI
  • - High fever
  • - Irritability
  • - Child sleeps "all the time
  • - Child is "not acting right
  • - Child cries when moved or picked up

91
MENINGITIS
  • History- Infant lt 12 months
  • - Child won't stop crying
  • - "Soft spot bulging"?
  • - Vomiting
  • - Poor feeding
  • - Seizures may develop
  • - Rash (purple spots

92
MENINGITIS
  • History- Older children
  • - Preceding URI
  • - Fever
  • - Photophobia
  • - Headache that becomes increasingly severe
  • - Headache made worse with movement, especially
    bending forward
  • - Vomiting( without nausea)

93
MENINGITIS
  • History- Older children
  • - Neck pain
  • - Back pain
  • - Changes in level of consciousness, progressing
    from irritability through confusion, drowsiness
    and stupor to coma
  • - Seizures may develop
  • - Rash (purple spots)

94
MENINGITIS
  • PHYSICAL EXAM
  • - Temperature- elevated
  • - Tachycardia or bradycardia with increased
    intracranial pressure
  • - Blood pressure normal (low if septic shock has
    occurred)
  • - Child in moderate-to-acute distress
  • - Flushed

95
MENINGITIS
  • PHYSICAL EXAM ( continued)
  • - Level of consciousness variable
  • - Possible enlargement of the cervical nodes
  • - Focal neurologic signs
  • - photophobia
  • - nuchal rigidity (in children gt12 months old)
  • - positive Brudzinski's sign ( in children gt12
    months)
  • - positive Kernig's sign (in children gt12
    months )

96
MENINGITIS
  • DIFFERENTIAL DIAGNOSIS
  • - Bacteremia
  • - Sepsis
  • - Septic shock
  • - Brain abscess

97
MENINGITIS
  • COMPLICATIONS
  • - Seizures
  • - Coma
  • - Blindness
  • - Deafness
  • - Death
  • - Palsies of cranial nerves III, VI, VII, VIII

98
MENINGITIS
  • Diagnostic Tests
  • - Blood culture x3, drawn 15 minutes apart
  • - Urine for routine and microscopy, culture and
    sensitivity
  • - Throat swab for culture and sensitivity
  • - CBC, lytes, creatinine,glucose, INR,platelets,
    ABGs
  • - LP

99
MENINGITIS
  • Management
  • - Admit- Bed rest
  • - Nothing by mouth
  • - Foley catheter (optional if the child is
    conscious)
  • - Start IV therapy with normal saline, and adjust
    rate according to state of hydration

100
MENINGITIS
  • Pharmacotherapy
  • Antipyretic
  • - Acetaminophen (Tylenol) 1015 mg/kg q4h prn
  • Antibiotics- Infants lt6 Weeks Old
  • - Ampicillin (Ampicin), 75 mg/kg per dose, IV q6h
    (maximum 2.5 g/dose)
  • AND
  • Gentamicin (Garamycin), 2.5 mg/kg per dose q8h

101
MENINGITIS
  • Antibiotics -Infants 6 Weeks to 3 Months Old
  • Ampicillin (Ampicin), 75 mg/kg per dose, IV q6h
    (maximum 2.5 g/dose)
  • AND
  • Ceftriaxone (Rocephin), 80 mg/kg per dose, IV
    q12h (for the first 48 hours) (maximum 2 g/dose,
    4 g/day)

102
MENINGITIS
  • Antibiotics -Children 3 Months to 18 Years Old
  • ceftriaxone (Rocephin), 80 mg/kg per dose, IV
    q12h (for the first 48 hours) (maximum 2 g/dose,
    4 g/day)

103
MENINGITIS
  • Monitor
  • ABCs, vital signs
  • Level of consciousness, intake
  • Urine output
  • Watch for focal neurological symptoms
  • Monitor serum sodium

104
MENINGITIS
  • Prevention and Control - Meningitis Caused by
    Hemophilus influenzae
  • - A vaccine is now routinely given to infants as
    part of the usual childhood immunizations.
  • - The type of vaccine and the immunization
    schedule vary by province
  • - The vaccine is usually given at 2, 4, 6 and 18
    months of age, along with the DPTP vaccine.

105
MENINGITIS
  • Meningococcal Meningitis -prevention
  • - Vaccines for certain subtypes are available and
    are sometimes used in epidemics
  • Chemoprophylaxis for household contacts
  • Rifampin (Rifadin)
  • Infants lt1 month old 5 mg/kg bid for 2 days
  • Children 10 mg/kg bid for 2 days
  • Adults 600 mg bid for 2 days

106
CASE STUDY
  • Elaine, a 7 month old girl is brought in by
    mother for 6 month well child visit
  • Child born at term , birth weight 7.5 pounds
  • Pregnancy healthy, mom thought fetus was kicking
    less than in utero than she had with her previous
    baby
  • Labor /delivery were uneventful

107
CASE STUDY
  • Health to date good, feeding well
  • Showed visual attention at 2-3 weeks, smiled
    socially at one month
  • Pushed self up on arms while prone at 2 months,
  • Rolled over at 4 months, no longer does this
  • No longer reaches for mobile in crib or toys like
    rattle
  • No attempts to sit up- cannot balance

108
CASE STUDY
  • Physical Examination results
  • - Infant lies quietly on table , watches examiner
    intently
  • - Growth parameters including head circumference
    are normal
  • - Vital signs are normal
  • - See-saw breathing, frog leg posture noted
  • - Cranial nerves are normal except eyes did not
    follow past the midline, and head turning
    strength was decreased

109
CASE STUDY
  • Physical Examination results
  • - When she is pulled to a sitting position by the
    hands , her head lags far behind and her arms are
    fully extended at the elbows
  • - She could not raise her arms off table
  • - When a rattle was placed in her hand , she
    manipulates the toys which she regards from the
    corner of her eye
  • - Deep tendon reflexes were absent
  • - Pain sensation intact

110
CASE STUDY
  • Resolution
  • Elaine was judged to have hypotonia with a
    neuromuscular cause in part because of her alert
    appearance and absent DTRs
  • Neuropathic abnormalities on EMG and muscle
    biopsy confirmed a diagnosis of spinal muscular
    atrophy
  • Family received genetic counseling and become
    involved in a support group
  • Elaine died of respiratory failure in a chronic
    care hospital at age 17 months

111
HYPOTONIA IN ONFANTS
  • Definition
  • Lower-than-normal muscular resistance to passive
    motion across a joint
  • Muscle strength is a key component of this
    resistance

112
ETIOLOGY-HYPOTONIA IN INFANTS
  • Central causes
  • - Neonatal asphyxia and /or intracranial
    hemorrhage
  • - Chromosomal disorders - trisomy 21
  • - CNS malformations- NTDs
  • - Metabolic/endocrine causes - hypothyroidism,
    celiac disease, inborn errors of metabolism)
  • - Benign congenital hypotonia ( a Dx of exclusion
    only)
  • - Direct trauma - spinal cord transection

113
ETIOLOGY-HYPOTONIA IN INFANTS
  • Anterior horn Cell
  • - Spinal muscle atrophy( genetic)
  • Peripheral nerve
  • - Guillain-Barre syndrome, hereditary
    neuropathies, metabolic, toxins, trauma

114
ETIOLOGY-HYPOTONIA IN INFANTS
  • Neuromuscular junction
  • - Myasthenia gravis, infant botulism
  • Muscle
  • - Muscular dystrophies( Duchenne), congenital
    myopathies, myotonic dystrophy

115
NEUROLOGIC SIGNS of CENTRAL LESION
  • Alertness - decreased, Cry -decreased
  • Muscle power- normal--gt decreased
  • Muscle bulk - normal---gt decreased
  • Fasiculations- absent
  • DTRs - increased
  • Primitive newborn reflexes persist or reappear
  • Plantar response- extensor
  • Sensation - normal

116
NEUROLOGIC SIGNS of ANTERIOR HORN CELL LESION
  • Alertness normal, Cry- normal/weak
  • Muscle power- decreased
  • Muscle bulk - proximal atrophy
  • Fasiculations- present
  • DTRs - decreased to absent
  • Primitive newborn reflexes - absent
  • Plantar response- flexor or nonreactive
  • Sensation - normal

117
NEUROLOGIC SIGNS of PERIPHERAL LESION
  • Alertness/Cry normal
  • Muscle power- decreased
  • Muscle bulk - distal atrophy
  • Fasiculations- variable
  • DTRs - decreased
  • Primitive newborn reflexes - absent
  • Plantar response- flexor or non-reactive
  • Sensation - decreased

118
NEUROLOGIC SIGNS - LESION NEUROMUSCULAR JUNCTION
  • Alertness normal, Cry weak
  • Muscle power- fluctuating weakness
  • Muscle bulk - normal
  • Fasiculations- absent
  • DTRs - normal to decreased
  • Primitive newborn reflexes - absent
  • Plantar response- flexor
  • Sensation - normal

119
NEUROLOGIC SIGNS - MUSCLE LESION
  • Alertness normal Cry normal/weak
  • Muscle power- decreased
  • Muscle bulk - decreased
  • Fasiculations- absent
  • DTRs - decreased
  • Primitive newborn reflexes - absent
  • Plantar response- flexor to nonreactive
  • Sensation - normal

120
ASSESSMENT OF HYPOTONIA
  • HISTORY
  • Onset (acute or gradual), progression
  • Past history of any acute illness (e.g.,
    meningitis)
  • Family history of myopathy
  • Social history infantparent interaction,
    siblings history (many babies are floppy
    because of lack of stimulation)

121
ASSESSMENT OF HYPOTONIA
  • Associated Symptoms
  • Respiratory
  • Feeding difficulties
  • Seizures
  • Fasciculations
  • Ptosis
  • Delays in reaching developmental milestones

122
ASSESSMENT OF HYPOTONIA
  • Inappropriate weight gain
  • Maternal health problems (e.g., hypertension,
    diabetes mellitus)
  • Physiologic insults during pregnancy or delivery
  • Maternal use of neurotoxic drugs
  • Neonatal problems- Apgars, sepsis, respiratory
  • Family History

123
ASSESSMENT OF HYPOTONIA
  • PHYSICAL EXAM
  • General survey- dysmorphic features
  • Vital signs
  • General physical examination to rule out any
    underlying cause
  • Complete - detailed CNS exam
  • Assessment of developmental milestones for age
  • Assessment of primitive reflexes

124
MANAGEMENT OF HYPOTONIC INFANT
  • Diagnostic approach
  • - CBC, electrolytes, BUN, creatinine, calcium.
    CPK, bilirubin, LFTs, urinalysis
  • - Consider Head U/S, CT scan, MRI, LP if central
    cause suspected
  • - Chromosomes studies if dysmorphic features
  • -

125
MANAGEMENT OF HYPOTONIC INFANT
  • Diagnostic approach
  • - DNA analysis for dystrophies
  • - EMG, nerve conduction studies
  • - Tensilon test for myasthenia gravis
  • - Muscle/nerve biopsies

126
HYDROCEPHALUS
  • Increased CSF volume
  • Communicating hydrocephalus
  • - Results from unsatisfactory absorption of CSF
    by the arachnoid gratulations or overproduction
    of CSF by the choroid plexus
  • Non-communicating hydrocephalus
  • - Results from an obstruction to CSF flow ,
    causing enlargement of only those ventricles
    proximal to the obstruction

127
HYDROCEPHALUS
  • Congenital- Aqueductal anomalies
  • - Primary aqueductal stenosis, or secondary to
    intrauterine infections i.e. varicelal, mumps,
    TORCH
  • - Dandy-Walker malformation
  • - Chiaria malformation
  • - Myelomeningocele

128
HYDROCEPHALUS
  • Acquired
  • - Post meningitis
  • - Post hemorrhage- (SAH, IVH)
  • - Masses - vascular malformations, neoplastic

129
HYDROCEPHALUS
  • Clinical presentation -age related
  • - Increased head circumference
  • - Irritability, lethargy, poor feeding, vomiting
    -infant
  • - Headache, lethargy, vomiting- older child
  • - Bulging anterior fontanelle
  • - Widened cranial sutures
  • - Cracked pot sound on cranial percussion
  • - Scalp vein dilatation

130
HYDROCEPHALUS
  • Clinical presentation -
  • - Sunset sign - eyes deviate downward
  • - Episodic bradycardia, apnea
  • - Loss of color and peripheral vision(older
    child)
  • Cranial nerve palsies - e.g abnormal pupil
    size/reactivity, EOMs, nystagmus
  • Spasticity limbs
  • - Hyperreflexia, clonus

131
HYDROCEPHALUS
  • Diagnostic Investigations
  • Ultrasound of skull- through anterior fontanelle
  • - Shows ventricular enlargement
  • CT of head
  • - Shows ventricular enlargement, peri-ventricualr
    lucency, narrow/absent sulci, /- 4 th
    ventricular enlargement

132
HYDROCEPHALUS
  • RX
  • Serial Spinal taps
  • Surgery- remove obstruction if possible
  • Shunts
  • Acetazolamide- decreases blood flow to choroidal
    arteries , therefore decreasing CSF production

133
HYDROCEPHALUS
  • Complications
  • - Shunt blockages
  • - Infection of shunt
  • - Over shunting
  • - Seizures
  • - Blindness
  • - Cranial nerve dysfunction
  • - ICP
  • - Cognitive impairment

134
CHILDHOOD MALIGNANCIES
  • Cancer is the most common cause of disease
    related deaths in children 1-19 years
  • Incidence has increased slowly, but mortality
    rates have declined significantly
  • Common cancers in childhood include
  • - Leukemias
  • - Lymphomas
  • - Brain tumors

135
CHILDHOOD MALIGNANCIES Clinical
Clues/Manifestations
  • Hematologic
  • - Pallor, anemia, petechiae, thrombocytopenia,
    neutropenia, fever, paryngitis
  • - Signifies bone marrow infiltration
  • - Example- Leukemia, neuroblastoma

136
CHILDHOOD MALIGNANCIES Clinical
Clues/Manifestations
  • Systemic
  • - Fever, weight loss, night sweats, painless
    lymphadenopathy ( Hodgkins, Non-Hodgkins
    lymphoma)
  • - Bone pain, limp, arthralgias ( Osteosarcoma,
    Ewings sarcoma)
  • - Cutaneous lesions ( neuroblastoma, leukemias)

137
CHILDHOOD MALIGNANCIES Clinical
Clues/Manifestations
  • - Soft tissue mass ( Osteosarcoma, Ewings
    sarcoma)
  • - Vomiting/ Diarrhea, abdominal mass (Lymphoma)
  • - Thoracic mass- Lymphoma, neuroblastoma
  • - Visual disturbances, headache, ataxia, cranial
    nerve palsies, papilledema ( Brain tumour)

138
CHILDHOOD MALIGNANCIES Clinical
Clues/Manifestations
  • Ophthalmologic signs
  • - Leukokoria ( retinoblastoma)
  • - Peri-orbital ecchymosis ( neuroblastoma)
  • - Ptosis, miosis (neuroblastoma)
  • - Exopthalmous, proptosis ( orbital tumour)
    lymphoma,

139
BRAIN TUMOURS
  • Primarily infratentorial involving cerebellum,
    midbrain, brainstem
  • Glial( cerebellar astrocytomas most common)
  • Presenting SS
  • - Poor feeding, Vomiting , FTT( failure to
    thrive)
  • - Arrest or regression of developmental
    milestones
  • - Morning headache, increased head circumference
  • ( hydrocephalus)
  • - Diploplia, nystagmus,papilledema
  • - Focal neuro deficits, seizures , ataxia

140
BRAIN TUMOURS
  • Diagnosis
  • Comprehensive history and complete CPX
  • Careful CNS exam
  • Rule out other causes - infection/trauma/metabolic
  • CT head and/or MRI
  • Referral to Pediatric neurosurgery

141
LYMPHOMA
  • Third most common childhood cancer
  • Hodgkins
  • - Occurs in older child gt 15 years, similar to
    adult
  • - Presents as a painless firm lymhadenopathy
  • Non- Hodgkins
  • - Occurs in younger child 7-11 years
  • - Rapid growing , commonly metastesizes
  • - Common disease sites abdomen, mediastinal mass,
    head/neck mass
  • - SS vary according to site affected

142
NEUROBLASTOMA
  • Most common cancer occurring in the first year of
    life
  • Neural crest tumour arising from sympathetic
    tissues
  • Adrenal medulla- 45
  • Retroperitoneal- 25
  • Posterior mediastinum - 20
  • Pelvis - 4
  • Neck - 4

143
NEUROBLASTOMA
  • Presents a s a neck mass or chest mass, or
    abdominal mass( adrenal gland)
  • Hypertension, headache,palptation,sweating (
    increased catecholamines), diarrhea, hypokalemia,
    FTT, are other possible SS
  • Direct extension to spinal cord - compression
  • Metastases common at presentation

144
NEUROBLASTOMA
  • Referral to Pediatric oncology
  • Diagnostic tests can include
  • - LFTs, renal function, ferritin, urine( VMA,
    HVA)
  • - CT scan chest, abdomen
  • - Bone scan
  • - Bone marrow examination
  • - Tissue biopsy
  • Rx surgery/radiation/chemotherapy /- bone
    marrow transplant
About PowerShow.com