Pediatric Neurology

👩‍⚕️ Pediatric neurology is a service offered by a physician who is sub-specialized in disorders of the central and peripheral nervous system. This translates to conditions that affect a child’s development, sleep, learning, or school performance.

Among the services offered are the management and treatment, particularly in the office, of headaches, developmental delay, behavior problems, seizures or epilepsy, intellectual disability, cerebral palsy, autism spectrum disorder, micro and macrocephaly, attention deficit and hyperactivity disorder, movement disorders, tics or tourette syndrome.

🏥 Also, pediatric neurologists evaluate hospitalized patients. Those most common conditions in the hospital include head bleeds, seizures, motor weakness, and central nervous system infections such as meningitis and encephalitis.

🩺 Professional help must be sought when there is a concern, for example, in the child’s development (delay in speaking, walking, crawling, turning around, poor social communication, eye contact, among others). Also, if there are neurological crises such as seizures. It is very common to see migraine or tension headaches in children, especially if there is a family history of migraine. There are many patients who come to the office referred by the school, teachers, or psychologists due to poor school performance to evaluate if there is attention deficit and hyperactivity or indeed seizures. For example, there are patients referred by teachers as they notice that they become spaced or their grades begin to drop for no apparent reason.

📚 Neurological evaluation often involves studies such as head images, either CT or MRI. In many cases, another head study called electroencephalogram (EEG) is recommended. EEG is an office-based study to assess for abnormal discharges that predispose the patient to seizures. There are cases needing referral to a psychologist for psychometric and psychoeducational tests to rule out intellectual disability, specific learning problems or multiple behavioral problems such as oppositional defiant disorder.

📱 If you understand that your child should be evaluated by a pediatric neurologist, you just have to call for an immediate appointment.

Healthy habits at bedtime.

  • Set a time to sleep.
  • Set a routine before bedtime.
  • Bedtime and waking time should not differ by more than 1-2 hours, both on school nights and on nights when there is no school.
  • Keep your child’s room dark and quiet.
  • Do not use your child’s room as a place of punishment.
  • Avoid high energy and stimulating activities 1-2 hours before bedtime (Ex: Running, Video Games, etc).

👶 Febrile seizures are the most common neurological disorder in infants from 6 months of age to children before 5 years of age. These seizures are divided into 2 types: simple and complex.

🌡 Simple febrile seizures are defined as seizures generated by fever for less than 15 minutes, without focal findings, and that do not recur within 24 hours. Most febrile seizures fall under this classification, and they can recur in about 1/3 of children during early life. It is important to remember that they are a benign phenomenon, and their association with future epilepsy risk is only slightly higher than the general population

⏰ Complex febrile seizures are those that last longer than 15 minutes, seizures involving multiple events in a 24-hour period, or when they involve a focal event such as movement of a single hand or foot. They have a higher risk of recurrence during the young age of the child.

🤒 It should be mentioned that there are various types of seizures including generalized, myoclonic, absence seizures, among others. For example, if a teenager drops things in the morning, or has difficulties while brushing his or her teeth, this could be a type of seizure. In contrast, a child who stares into the distance, and does not respond to name or touch could be another type of seizure.

🤝 Regardless of the type of seizure, it is necessary to help the patient. If a child is seen having a seizure with vigorous movements of all limbs, the most important thing is to place the patient on the side while holding the head either on the assistant’s lap or by placing a towel under the patient. You have to be aware of the clock as if the seizure reaches 5 minutes you have to prepare to get to the nearest emergency room or call 911 because the patient will probably require intravenous medications to stop the seizure.

📱 If you understand that your child should be evaluated by a pediatric neurologist, you just have to call for an immediate appointment.

  • Divide up homework.
  • Provide clear, short and simple instructions.
  • Establish a homework routine

A concussion is a mild brain injury that commonly causes confusion, memory loss, and a headache. A concussion can happen as a result of a fall or other type of accident directly or indirectly impacting our brain. It can also commonly happen during participation in sports. Among adolescents who play sports, concussion is one of the most common injuries.

If your child gets a concussion (either on or off the field), it’s very important that they stop playing sports until a doctor says it’s safe to start again. Be aware that kids sometimes lie about their symptoms or simply do not recognize them. Moreso, if they are afraid that they will not be allowed to play if keep having symptoms.

Among boys, the sports most often linked to concussions are soccer, and football. Among girls, the sports most often linked to concussions are soccer, lacrosse, and field hockey.

The symptoms that can happen minutes to hours after a concussion include:

● Memory loss – children sometimes forget what caused their injury, as well as what happened right before and after the injury

  • Confusion
  • Headache
  • Dizziness or trouble with balance
  • Nausea or vomiting
  • Feeling sleepy
  • Acting cranky, irritable, or strange
  • Passing out (but this is not very common)

Symptoms that can happen hours to days after a concussion include:

  • Trouble walking or talking
  • Memory problems or problems paying attention
  • Trouble sleeping
  • Mood or behavior changes
  • Vision changes
  • Being bothered by noise or light

Depending on your child’s mechanism of injury and symptoms they need to be worked up. To check if your child has a concussion, the doctor will ask about their symptoms and behavior, and do an exam. The doctor will also ask your child questions to check that they are thinking clearly.

If the doctor suspects a serious injury, they might order an imaging test of the brain, such as a CT or MRI scan. These tests create pictures of the skull and inside of the brain. But these tests are not usually needed for a routine concussion. In fact, a CT scan can be risky, because it involves radiation. Studies show that doing unnecessary CT scans in children and adolescents increases the risk of cancer later.

Your child should see a doctor who has experience treating concussions. This might be your child’s regular doctor, or they might refer you to a Child Neurologist.

Treatment of a concussion involves:

  • Preventing further injury – Most concussions get better on their own. While your child is healing, it’s important that they don’t do too much cognitively speaking (mental rest) and also not playing any organized sports. Having a second injury while the brain is healing from a concussion can seriously damage the brain. Even if your child seems fine, they should not go back to school or do organized sports until the doctor says that it’s OK.
  • Physical rest – Your child should rest for 24 to 48 hours. After that, they can slowly start to get back to regular activities. This includes light physical activity, as long as it doesn’t make symptoms worse. Your child should continue to avoid contact sports, or other sports that could cause a head injury, until they have completely recovered.
  • Mental rest – Doctors also call this “cognitive rest.” It involves avoiding things that make symptoms worse, such as reading; playing video games; or using a smartphone, tablet, or computer. Most children can go back to school after 1 to 2 days of rest. In general, this is when they are able to stay focused and concentrate for at least 30 to 45 minutes at a time. Missing more than 5 days of school is usually not recommended either.
  • Treating symptoms – In addition to rest, there are ways to help relieve your child’s symptoms. For example:
  • Headache – If your child has a headache, it is suggested taking an over-the-counter pain reliever though not to abuse. These include acetaminophen and NSAIDs such as ibuprofen, and naproxen. These medicines should only be used for a few days.
  • Nausea – This sort of medicine should only be used for 1 to 2 days after injury. In some cases, it can make other symptoms worse.
  • Sleep problems – After a concussion, some children have trouble falling or staying asleep. This can lead to feeling tired during the day. The best way to treat this is to follow good “sleep hygiene.” This involves going to bed and getting up at the same time each day. It also means removing things from the bedroom that make it harder to fall asleep, such as light, noise, and screens. You can help your child by creating a relaxing bedtime routine to follow each night.
  • Symptoms are typically not life-threatening and resolve usually within a month. If your child still has symptoms after 3 or 4 weeks, they might need additional treatment, and this is called Post-Concussion Syndrome (a condition in which concussion symptoms persist after the brain has healed). Along with your Child Neurologist who has experience treating concussions, other specialists might see your child, too. These include a physical therapist (exercise expert) and a person who is an expert on the brain and behavior such as a psychologist.
  • Call the doctor if any of the following happen after a concussion:
  • Your child vomits more than 3 times.
  • Your child has a severe headache, or a headache that gets worse.
  • Your child has a seizure.
  • Your child has trouble walking or talking.
  • Your child’s vision changes.
  • Your child feels weak or numb in part of their body.
  • Your child loses bladder or bowel control.
  • You cannot wake your child.

Image: Starke Kopfschmerzen – Migräne – Medizinische Illustration – 3D Rendering

A parasomnia is a sleep disorder that involves unusual and undesirable physical events or experiences that disrupt your sleep. A parasomnia can occur before or during sleep or during arousal from sleep. If your child have a parasomnia, he or she might have abnormal movements, talk, express emotions or do unusual things. Your child is really asleep, although you might think he or she is awake. Here are the most common ones.

Night terrors (also called “sleep terrors”) are episodes in which children wake up suddenly at night and act very upset. They might scream and jump out of bed, as if running away from something scary. They might be sweating, breathing fast, or have a racing heart. During a night terror, you won’t be able to calm your child down, even if you try. It usually lasts about 10 to 20 minutes, and they might have it twice or 3 episodes a week.

Confusional arousals are episodes in which children behave in a confused way because they are in between sleeping and waking up. They sit up in bed, moan, or cry. During this episode, you won’t be able to calm your child down, even if you try. These episodes usually last 10 to 30 minutes.

Although it can be scary to see your child having a night terror or confusional arousal, it’s important to know that these conditions aren’t dangerous. Also, your child won’t remember them the next day.

Nightmares are very scary, sad, or upsetting dreams that wake a person up. After a nightmare, children often have trouble going back to bed. Nightmares usually happen in the second half of the night.

Another common condition is sleepwalking, which is when a child walks or talks while asleep. It happens more often in children than adults. Most children outgrow their sleepwalking as they get older. It usually happens in the first part of the night. Sleepwalking children can crawl, walk, run, or talk while asleep. They might try to do something, like start to get dressed or walk out of the house. When children sleepwalk, they can have their eyes open and a blank look on their face. They will not respond to you when you talk to them. An episode of sleepwalking can last a few seconds to minutes, but usually lasts 10 to 20 minutes. After the episode is over, the child will fall back asleep. This might be in their own bed or in another place in the house.

When your child sleepwalks, there are things you should and should not do. You should not try to hold your child down or wake them up. Instead, you should gently guide your child back to their bed.

You can help your child by making sure they don’t get hurt when sleepwalking. To help keep your child safe, you can:

  • Keep the windows and doors locked at night so your child can’t get outside.
  • Make sure your child does not sleep in a top bunk bed (if they sleep in a bunk bed).
  • Keep sharp, breakable, or dangerous items away from your child’s bed or out of the bedroom.
  • Put a safety gate in the doorway of your child’s bedroom or at the top of the stairs.
  • Keep the floor clear of clutter or other objects that could make your child trip and fall.

Night terrors, confusional arousals, and sleepwalking sometimes run in families. Children can have 1 or more of these conditions. If these conditions don’t happen very often and don’t lead to other problems, your child will probably not need further tests. Most children outgrow their night terrors and confusional arousals over time, but it can take up to a few years.

Some children might need tests to make sure another medical problem isn’t causing their night-time behavior. Your Child Neurologist might order tests if your children have frequent night terrors or confusional arousals, or any of the following symptoms:

  • Loud snoring or gasping for breath during sleep
  • Wetting the bed (if the child used to stay dry at night)
  • Seizures, which are waves of abnormal activity in the brain that can make people pass out or move or behave strangely

If your child has a night terror or confusional arousal, you should stay with them until the episode stops. You should not try to wake them up. Once the episode stops, your child will go back to sleep.

If your child has a nightmare, there are things you can try that might help. You can:

  • Remind your child that it was only a dream and not real
  • Help your child think of a new, happy ending to the dream
  • Draw a picture or write about the dream, which often makes it less scary

You might be able to prevent night terrors and confusional arousals by making sure your child gets enough sleep. To do this, try to stick to a regular sleep schedule. In general, children 3 to 5 years old should get 10 to 13 hours of sleep (including naps). Older children should get 9 to 11 hours each night, and teens should get 8 to 10 hours.

If your child has trouble falling asleep or getting a good night’s sleep, here are some things you can try:

  • Have a set bedtime and bedtime routine for your child.
  • Keep your child’s bedtime and wake-up time about the same every day (on school and non-school days).
  • Make the hour before bed a quiet time. Avoid TV or other screens and high-energy activities.
  • Keep your child’s room quiet and dark. If your child is scared of the dark, use a night light that is not too bright. Eventually, try to keep darkening the room.
  • Don’t have a TV in your child’s bedroom.

Headaches are common in children. Two of the most common types of headaches in children are:

  • Tension-type headaches– Tension-type headaches cause pressure or tightness on both the left and right sides of the head. Tension headaches are usually not severe enough to keep children from doing their daily activities, such as going to school.
  • Migraine– Migraine is a condition that causes attacks of headaches and other symptoms. Headaches due to migraine often start mild and then get worse. The headache might affect just one side of the head or both. Migraine can cause your child to feel sick or vomit, or make them sensitive to light and sound. Migraine can also cause temporary problems with vision. For example, before a migraine attack, some children see spots or colored lights. When they have a migraine attack, children are often not able to do their normal daily activities, such as go to school.

Children also tend to get headaches if they have a cold, the flu, a sore throat, or a sinus infection. In rare cases, headaches in children are caused by a serious infection (such as meningitis), severe high blood pressure, or brain tumors.

Take your child to the doctor right away (without giving any medicine) if they have a headache that:

  • Starts after a head injury
  • Wakes them up on multiple occasions
  • Is sudden and severe and happens with other symptoms, such as:
  • Vomiting
  • Neck pain or stiffness
  • Double vision or changes in vision
  • Confusion
  • Loss of balance
  • Fever of 100.4°F (38°C) or higher

Tremor is a medical term for trembling or shaking. A person with tremor has a body part that rhytmically shakes, and cant be controlled. It most commonly involves the hands, but can also affect the arms, head, vocal cords, trunk, or legs. It may be a single condition or the result of another or even a medication side effect.

There are many different types of tremors, and there are several possible trigers such as:

  • Damage to brain structures (e.g. stroke, head trauma)
  • Genetics
  • Kidney or liver failure
  • Overactive thyroid
  • Medicines side effects

In most cases, tremors in children have no serious, progressive, underlying condition but when they occur a diagnostic evaluation should be made.

Bell’s palsy also is known as acute peripheral facial palsy of unknown cause. It can affect people of any age. Males and females are equally affected. It is thought to be due to swelling (inflammation), and irritation of the facial nerve in the area where it travels through the bones of the skull, but the exact cause is not known. The facial nerve controls movement of the muscles of the face.  

Even though the cause is often not clear, a type of herpes infection called herpes simplex or herpes zoster might be involved. This is the most common cause. The possible causes of facial nerve palsy are many and may be congenital, infectious, traumatic, neoplastic or idiopathic.

Symptoms of acute peripheral palsy come on suddenly and may include:

  • Mild weakness to total paralysis on one side of the face 
  • Facial droop and trouble making facial expressions, such as closing an eye, blinking, or  smiling
  • Drooling
  • Pain around the jaw or pain in or behind the ear on the affected side
  • Increased sensitivity to sound on the affected side
  • Headache
  • Loss of taste
  • Changes in the amount of tears and saliva produced

Often, acute peripheral facial palsy can be diagnosed just by taking a health history and doing a complete physical exam. Symptoms often begin to improve right away, but it may take weeks or even months for the muscles to get stronger. Sometimes, corticosteroids are used.