Pediatric Neurology
Neurology items test seizure classification and emergency sequencing, the discrimination of benign from sinister headache, recognition of neuromuscular patterns, and the static versus progressive distinction in motor disorders.
Seizures and status epilepticus
- Febrile seizures occur at 6 months to 5 years; a simple one is generalised, lasts under 15 minutes and does not recur within 24 hours. Routine electroencephalography and prophylactic antipyretics are not indicated.
- Status epilepticus: a benzodiazepine first (intravenous lorazepam 0.1 mg/kg, or intramuscular or intranasal midazolam 0.2 mg/kg), then a second-line agent such as phenytoin 20 mg/kg, levetiracetam or valproate.
- Neonatal seizures: phenobarbital 20 mg/kg is first line.
- Always check glucose and sodium before attributing a first seizure to epilepsy.
Central nervous system infection
Neonatal meningitis presents non-specifically with poor feeding, temperature instability and lethargy; perform a lumbar puncture and start ampicillin plus cefotaxime. Give dexamethasone with or before the first antibiotic dose when Hib or pneumococcal meningitis is suspected.
Motor disorders
- Cerebral palsy is a static, non-progressive disorder of movement and posture; classify function with the Gross Motor Function Classification System.
- Duchenne muscular dystrophy: boys, Gowers sign, calf pseudohypertrophy, markedly raised creatine kinase, dystrophin gene deletion.
- Guillain-Barre syndrome: ascending symmetrical weakness with areflexia and albuminocytological dissociation in cerebrospinal fluid.
Headache red flags
Headache waking the child from sleep, morning vomiting, worsening with Valsalva, focal neurological signs, onset under 6 years, or a change in an established headache pattern. These require imaging.
Prevention
Folic acid before conception and in early pregnancy reduces neural tube defects; therapeutic hypothermia improves outcome in hypoxic-ischaemic encephalopathy.
Worked example
A 3-year-old has a generalised seizure lasting 3 minutes during a fever of 39 degrees, then returns to baseline within 20 minutes. This is a simple febrile seizure. Explain the benign prognosis, treat the fever for comfort only, and do not request electroencephalography, imaging or anticonvulsants. Escalate the workup if the seizure was focal, lasted over 15 minutes, or recurred within 24 hours.
Traps
Starting maintenance anticonvulsants after a simple febrile seizure, missing hypoglycaemia as a seizure cause, and reassuring a family about a morning headache with vomiting.