Neurologic

Disorders in
Children

Pediatric Neurology
Objectives
• Describe the various modalities for assessment of cerebral
function.
• Differentiate among the stages of consciousness.
• Outline a care plan for head injuries, drowning and the serious
complications.
• Outline a care plan for the child with bacterial meningitis.
• Differentiate between the various types of seizure disorders.
• Demonstrate an understanding of the manifestations of a
seizure disorder and the management of a child with such a
disorder.
• Describe the preoperative and postoperative care of a child
with hydrocephalus or spina bifida
• Evaluation of neuro status in child
Neurologic Development

First system to develop in utero; last system to

complete development after birth
Brain volume 12% of newborn’s weight; 2% of adult’s
weight
Brain volume is reflected in Head Circumference (HC)
 Define Risk Factors Associated with
Neurologic Disorders 4

Take a good Health History!

Past Medical History
Mother’s pregnancy (drugs, ETOH, illness)
Birth history: Prematurity, difficult birth, infection during
pregnancy
Symptoms: nausea, vomiting, headaches, changes in gait,
falls, visual disturbances or recent trauma
Family History
Genetic disorders with neuro manifestations, seizure
disorders or headaches
History of  Present Illness
When symptoms started and how they progressed
Treatments used at home
Pediatric Neurological Assessment

Mental Status
Cranial Nerve Function
Motor & sensory Function
Cerebellum and Gait
Reflexes
90% of a child’s neuro exam can be done by
observing the child run, play, touch, climb and
interact with parents
Toys used in evaluation: balls, funny lights, wooden
puzzle, book and pencil
Important Neurological Indicators

Level of consciousness: orientation,

responsiveness
Eye contact/ PEARL
Ability to follow commands
Behavior
Pain (headache)
Vomiting NOT preceded by nausea
Increased ICP
Motor function: gait
Sensory function
Posturing
Pediatric Modifications to Glasgow
Coma Scale
Measures /quantifies the LOC
Consider developmental stage
Eye opening response
Motor response
Verbal response
Higher score indicates less
neurologic alteration**
 Neurological Diagnostic Testing 8

• Spinal tap or lumbar puncture- check:

• Pressure
• Cell count
• Culture & sensitivity
• Glucose & protein
• Bacterial
• Protein high
• Glucose low
• Possible blood culture
• Brain CT scan or MRI
• EEG
• Electrolytes and CBC
• Metabolic work-up
Pediatric Trauma

• Water related accidents

• Diving
• Swimming
• Falls
• Fights
• Playing
• Sports
Trauma

Incidence and prevalence of accidental injury: the

number 1 killer of children
MVA is high incidence in all age groups
36% of all teen deaths in the U.S. are a result of MVA!
poor judgment
lack of knowledge
over-estimates abilities
peer pressure
risk-taking behaviors
feelings of invincibility: personal fable
Head Injury
Prevention is key!
Concussion
Contusion/Laceration
Fractures
Complications:
 hemorrhage
(epidural/subdural),
 edema (cerebral)
 infection
 herniation
Head Injuries
Assessment: Management:
1. Level of consciousness- 1.ABC’s, Oxygen
Glasgow Coma Scale 2. Frequent neurologic
2. Pupil reaction checks
3. Vital signs 3. Stabilize neck
4. Respiratory Status 4. Keep NPO
5. The Standard 5. No sedative or analgesics
Neurological Maneuvers during the acute phase
     A. Hand-eye 6. Observe for signs of
coordination increase in ICP: Osmotic
diuretics short term
     B. Gait & Balance
• What are those signs??
 Drowning: Peak Incidence
13
Demographic
 Younger than 4 years: baths < 1 year
Preschooler: residential pools
Adolescent to Young Adult:15-24 years in
ponds, lakes & rivers
Frequency:
 5th leading cause of accidental death in the
US in all ages
 Male-to-female 12:1 for boat related
drowning and 4:1 for non-boat
Drowning Interventions

Immediate resuscitation Neurological support

& treatment of Support to parents
respiratory failure
Evaluate associated Investigation of causes
injuries Rehabilitation for
Supplemental oxygen brain damage
ET intubation Degree of CNS injury
ECMO depends on severity
Bronchoscopy and duration of
hypoxia
Re-warming
Patient Education
Community education is the key to prevention
 Supervision
Water safety and survival skills for school age children
 Home pools – Fence, alarm/cover, know CPR, safety
equipment, avoid flotation toys
Regulation floatation devices/ Boating safety
Teach to swim early; should never swim alone
 Avoid alcohol or drugs while in water
 Close observation with underlying medical conditions
such as: diabetes, seizures, heart disease,
neuromuscular dysfunctions
 Intracranial Infections 16

Intracranial Types of Meningitis

Infections CNS infection, is potentially
fatal. Begins elsewhere in the
• Meningitis body, such as in the ears,
• Encephalitis sinuses, or upper respiratory
tract.
• Brain Abscess
Bacterial
Viral or Aseptic
TB
Fungal
 Hard to treat; very rare
Bacterial Meningitis

Organisms Risk factors:

Haemophilus influenza • 1. Age: 90% of cases occur between
 Streptococcus 1mo.- 5yrs of age
pneumonia 2. Immunocompromised
 Neisseria meningitidis 3. Chronic Disease- Sickle cell,
( meningococcus) DM, CF
4. Preexisting CNS anomaly
 Meningitis Clinical Findings

Infants Child & adolescent

• Fevers Onset is more abrupt-
• Poor feeding, • Fever/Chills
• Headache/ Photophobia
• Irritable
• Vomiting
• Bulging fontanel
• Confusion
• Nuchal rigidity (neck • Stiff neck
stiffness)
• Kernig/ Brudzinski sign
• Seizures Later signs-
• Positioning • Petechial or purpuric rash
• Arched back • Septic shock-like appearance
 Meningitis signs 19

Kernig's sign- severe Brudzinski's sign- severe

stiffness of the hamstrings neck stiffness that causes
causing the inability the hips and knees to flex
straighten the leg when when the neck is flexed
the hip is flexed to 90
degrees.
Diagnostic Work-up

Lumbar Puncture (Prior to abx. if pt. stable)

Glucose (reduced)
Cell count (elevated WBC)
Protein (elevated)
Culture &Sensitivity
Fluid may appear cloudy
blood culture
Interventions
Droplet isolation until 24 hrs on antibiotics
Antibiotics
Bedrest with HOB elevated / Decrease ICP
Fluid and electrolyte balance: no bolus
Analgesics for pain/Antipyretics
Monitor/control seizures
Comfort measures
Monitor cultures, antibiotic peak and trough levels
 Gentamycin (ototoxic), vancomycin
Treat complications
Bacterial Meningitis

Complications Prevention
Seizures
HiB vaccine
Cerebral edema
Pneumococcal vaccine
Hydrocephalus
Household/close contacts:
Cranial nerve damage:
prophylactic antibiotics
Cognitive
impairment Meningococcal vaccine
Deafness  Menactra
Blindness  MenB
Viral meningitis
Less severe than bacterial (fewer long-term effects)
Care & diagnostic evaluation similar to Bacterial
Meningitis
LP
 Glucose normal
 Protein slightly elevated or normal
WBCs elevated
Gram stain negative
Reye Syndrome: extremely rare but serious
illness that can affect the liver and brain, studies have
24
linked the use of aspirin (salicylates) or aspirin-containing
medications during viral disease as a factor in the
development of Reye syndrome.

Occurs following a common viral illness or varicella

(damages cell mitochondria)
Associated with aspirin therapy (exacerbates cell
damage)
Causes cerebral edema and decreased hepatic
function; will have long-term neuro deficits
How child presents: child getting better begins
vomiting, listless, drowsy then irritable, aggressive,
personality changes followed by disorientation &
confusion into delirium, convulsions & coma
No ASA for children < 19 years old!!
25
 Seizures
Involuntary disturbance of brain function that26
may be manifested as an impairment, or
alteration in consciousness, abnormal motor
activity or behavioral abnormalities
Most seizures are caused by disorders that
originate outside of the brain such as a high
fever, infection, head trauma, hypoxia,
toxins, or cardiac arrhythmias
Epilepsy- recurrent seizures unrelated to
fever or an acute cerebral insult,
Fewer than one-third of seizures in children
are caused by epilepsy
 General Seizures: Clinical
Manifestations
Tonic- clonic (“grand mal”)-Rigidity and rhythmic
27

jerking
Clonic seizures – clonic muscle activity
Atonic – flaccid muscle activity
Myoclonic - short muscle contractions
Absence seizures (petite mal) – brief period of
unconsciousness
Status epileptics- recurrent or continuous seizures
with a risk of a cardiac arrest or brain damage
Partial seizure- focal motor or sensory activity; ie
movement of leg or tingling or smell
http://www.youtube.com/watch?v=0j-pwZSKOpc
 Seizures 28

Types of seizures:
• Tonic- Clonic
• Absence
• Atonic
• Myoclonic
 Seizures in Children 29

Tonic-Clonic Seizure
Absense Seizure
Drop Seizure Tess
Children and Seizure dogs
Seizure Dogs
Managing a seizure in school
 Diagnosis of Seizure Disorders
Best when observed and documented accurately
Medical history
Family history
Neurological exam & physical exam
EEG with video
 Deprive of sleep the night before
Radiology: CT/MRI
Labs and LP
Active Seizure: Nursing Care

Assessment Interventions
1. Monitor vital signs
1. Airway (suction and oxygen
2. Neuro assessment at bedside)
3. Quality of respirations 2. IV line for fluids/medications
and color changes
3. Protect from injury (pad
4. Monitor LOC rails)
5. Note time of onset &
4. Position on side, nothing in
duration
mouth
6. Note any precipitating
factors 5. Anti-seizure medication:
Lorazepam/ Diazepam
 Preventive measures

Preventive:
Wear medical identification band
Identify and avoid triggering factors
Protective helmet prn
Maintenance medication, as indicated
 Ketogenic diet
 Vagus nerve stimulation
 Surgical treatment (if incapacitating)
Control Medications
Administering medications
 Anti-epileptics: Control
 Phenytoin (Dilantin)
 Valproic Acid (Depakote)
 Carbamazepine (Tegretol)
 Levetiracetam (Keppra)
Mix the liquid thoroughly before giving
Give with food or full glass of liquid (no carbonated beverages)
Give at the same time every day
Do not abruptly stop giving the medication
Monitor for toxicity and therapeutic levels: frequent level
checks
MVI w/ Calcium supplement
Ketogenic Diet 34

High fat, adequate protein and low carbohydrate.

Induces ketosis  slow electrical impulses that cause
myoclonic or absence seizures
Febrile Seizures
“Seizure in association with a febrile illness in the
absence of CNS infection or acute electrolyte
imbalance in children older than 1 month of age
without prior afebrile seizures”
Isolated events (usually)
Occurs in children between 3 months to 6 yrs old
- Fever usually exceeds 102 f (38.3) occurs on rise
- Rapid rise of fever is thought to cause febrile
seizures
30% of children have recurrence
- Associated with disease outside CNS
 Treatment Interventions
36
• Anticonvulsants not recommended for a febrile sz.
• Reduce temp
• Protect child from injury
• Place in side-lying position when able
• Observe and record
• Suction the nasopharynx and administer oxygen
• Observe behavior and LOC after Sz
• Teach parents to give antipyretics at first sign of
increase temp.
Neural Tube Defects
Neural Tube Defects: result from malformations of
the neural tube during embryonic development
Three types:
1. Anencephaly-absence of the entire brain;
brain stem or cerebellum maybe present  usually
not conducive to life
2. Encephalocele - meningeal and cerebral tissue
protrudes in a sac through a defect in the skull
3. Spina bifida – is a defective closure of the
verterbral column
 Meningocele
 Myelomeningocele
Zika
Transmitted by mosquito bites to a pregnant
38

woman to her fetus, through sex from a

person who had Zika
Causes microcephaly and other fetal brain
defects
Babies born with smaller brains, eye defect,
hearing loss and impaired growth
At this point a Zika virus infection in a
woman does not pose a risk for birth defects
in future pregnancies

 https://www.cdc.gov/zika/intheus/maps-zika-us.html
 Spina Bifida: Neural Tube Defect
Spina Bifida: Congenital malformation of the spinal canal and
39 cord

Occulta: rarely visible , minimal complications

Cystica: meningocele, myelomeningocele
Failure of total enclosure of spinal cord within
vertebrae/meninges
Results in neurosensory/ neuromotor dysfunction
Manifestations vary with the degree of the defect--directly
related to the anatomic level of the defect and the nerves
involved.
Neural Tube Defects

Spina bifida occulta: posterior

laminae of the vertebrae fails to
fuse
see dimpling and/or tuft of hair
at defect
Collection of fat
Spina bifida occulta is the
mildest and most common form
of neural tube defects and
rarely causes disability or
symptoms
May have mild elimination
symptoms
Spina Bifida Cystica:Meningocele
Meninges protrude through a spinal opening and the
malformation may or may not be covered by a layer of
skin
Symptoms depend on location of the defect.
The higher up the defect the greater the probability for
impairment
Spinal cord develop normally
Spina Bifida Cystica: Myelomeningocele
Spinal canal remains open along several vertebrae.
Spinal cord and the meninges protrude through the
vertebral defect forming a sac
Tissue and nerves are directly exposed
The higher the defect, the greater risk of
hydrocephalus and the greater the motor disability
Result may be partial or complete paralysis of the
parts of the body below the spinal opening
inability to walk
urinary and bowel dysfunction
Spina Bifida: Diagnosis
43

Prenatal
Elevated alpha fetoprotein levels
Ultrasound (US)
US, MRI, CT scan of brain & spinal cord
Myelography
Evaluation of the lesion, the amount of nerve
involvement, and degree of hydrocephalus
Neural Tube Defects:
primary prevention/interventions

Reducing risk in women of child bearing age by taking

folic acid
Prophylactic folic acid (Vitamin B) women at least 30
days prior to planning pregnancy
400 micrograms/day
Dietary supplementation
eggs, OJ, dark green leafy vegetables, cereal
Neural Tube Defects: Pre-op
Interventions
provide moisture to sac, good
skin care  wet, sterile cover
protect sac from injury
Positioning prone or side lying
protect infant from infection no
rectal temps  keep clean from
stool
maintain urinary
elimination/bowel function
Treatment: 
Surgical repair; replace contents
and prevent infection 
 Prevention infection and
injury

Maintain a dry sterile dressing

Spina Bifida: Examine dressing for CSF

leakage
Nursing
Protect suture line with an
Management apron

Post- Position the infant side lying

operatively or prone

No rectal temps

Continue antibiotics

46
 Catheterization 90% of children with
(family & patient self Prevent bowel myelomenigocele
Assess for UTI’s
catheter)  self-cath obstruction have a neurogenic
by 7-8 y/o colon

Colon training consists

of timing, exercise, Diet high in fiber, low
Suppository/laxatives
diet, posture, rectal in carbohydrates
stimulation

Ongoing Nursing
Management: Elimination 47
Spina Bifida
Associated Conditions and Complications 48

Hydrocephalus
Meningitis
Urinary Tract Infections
Bowel Obstructions
Orthopedic complications from immobility
Additional problems may arise as children get older: latex
allergies, skin problems, gastrointestinal conditions and
depression
Nursing Management: Latex 49

Maintain latex free environment

 Administer an antihistamine or steroid before
procedure or surgery
Parent Teaching:
Latex free pacifiers, feeding nipples, dental dams
Avoid : chewing gum, rubber bands, cleaning
gloves, latex art supplies
Avoid bananas, kiwis, strawberries
Imbalance in production and absorption of CSF
in ventricles of brain
fluid overproduction
obstruction: non-communicating
absorption problems: communicating
Occurs in 1:500 live births
risk factors: premature infants, intrauterine
infections, incomplete closure of the spinal
column

Hydrocephalus
Ventricular Dilatation in Hydrocephalus
51
 Hydrocephalus in Infants: 52
Video
Clinical Findings: Emma

Infants-
1. Bulging fontanels with or without head enlargement
2. Prominent scalp veins
3. Frontal bossing: high forehead
4. Setting- sun sign
5. High-pitched cry
6. Opisthonus
7. Head lag especially important after 4-6 months (due to weight of the head)
8. Due to the increase in ICP- projectile vomiting, irritable and/or lethargic,
poor feeding, sz
 Hydrocephalus
Sunset eyes with
53
Frontal bossing
hydrocephalus
 Hydrocephalus 54

• Treatment:
1. Relief of Hydrocephalus
A. Removal of the obstruction if that is the cause
B. Mechanical shunting of fluid to another area
of the body- Ventricular Peritoneal Shunt (VP)
Shunts the CSF to the abdominal cavity
C. Treatment of complications
D. Management of problems that cause
psychomotor problems
 Hydrocephalus:
Treatment & Nursing Care 55

Preoperative
Neurological assessments
Assess head circumference and other sx of ICP
Support head and neck when holding the
infant. Position for comfort
Provide skin care; observe for breakdown
Give small frequent feedings to prevent
vomiting
Decrease stimulation but encourage bonding
Hydrocephalus: Nursing
interventions-VP shunt
Post-op care:
Positioning, frequent neuro assessments,
monitor fluid balance, monitor abdomen.
 Flat for 24 hrs
 ICP monitoring
 Pain management
 Neuro & pain assessments
 Antibiotics/ IV fluids (restrictions)
 No sedation: to monitor neuro status
 Monitor for shunt malfunction, no pumping
 keep diaper off peritoneal insertion site
Hydrocephalus:
Treatment & Nursing Care 57

Major complications of shunts:

Infection
Peritonitis
Meningitis
Malfunction/blockage
Subdural hematoma can develop if there is rapid
reduction of CSF
Perforation of organs
Behavioral Signs of Increasing
ICP: Important to know these!

Irritability, restlessness
Drowsiness, indifference, decrease in physical
activity and motor skills
Complaint of fatigue, somnolence
Inability to follow commands, memory loss
Weight loss
Late Signs of Increasing ICP:
Important!  59

• Decreased LOC
• Decreased motor response to command
• Decreased sensory response to painful stimuli
• Decerebrate or decorticate posturing
• Bradycardia, increased BP
• Irregular respirations
• Cheyne-Stokes respirations
• Fixed & dilated pupils