What is pediatric neurology?

Science and Profession

Neurologic
illness and injury are principal causes of chronic disability when they occur in children because they result in the development of abnormal motor and mental behaviors and/or in the loss of previously existing capabilities, with a common problem in children being musculoskeletal dysfunction. Pediatric neurology involves the ongoing assessment of an infant’s or child’s neurologic function, which requires the pediatric
neurologist to identify problems; set goals; use appropriate interventions, including physical therapy, teaching, and counseling; and evaluate the outcome of treatment.

The pediatric neurologist looks for certain positive or negative signs of dysfunction in the nervous system. Positive signs of neurologic dysfunction include the presence of sensory deficits; pain; involuntary motor events such as tremor, chorea, or convulsions; the display of bizarre behavior or mental confusion; and muscle weakness and difficulty controlling movement. Negative signs are those that represent loss of function, such as paralysis, imperception of external stimuli, lack of speaking ability, and/or loss of consciousness.

Neurologic disease can manifest in a variety of ways. There are disorders of motility, such as motor paralysis, abnormalities of movement and posture caused by extrapyramidal motor system dysfunction, cerebellum dysfunction, tremor, myoclonus, spasms, tics, and disorders of stance and gait. Pain and other disorders of somatic sensation, headache, and backache may occur, such as general pain and localized pain in the craniofacial area, back, neck, and extremities. There are disorders of the special senses, such as smell, taste, hearing, vision, ocular movement, and pupillary function, as well as dizziness and equilibrium disorders. Epilepsy and disorders of consciousness, such as seizures and related disorders, coma and related disorders, syncope, and sleep abnormalities also fall under the category of neurologic disease. Derangements of intellect, behavior, and language as a result of diffuse and focal cerebral disease—such as delirium and other confusional states, dementia, and Korsakoff syndrome—fall under this category as well, as do lesions in the cerebrum and disorders of speech and language. Anxiety and disorders of energy, mood, emotion, and autonomic and endocrine functions are other signs of neurological disease, such as lassitude and fatigue, nervousness, irritability, anxiety, depression, disorders of the limbic lobes and autonomic nervous system, and hypothalamus and neuroendocrine dysfunction.

Diagnostic and Treatment Techniques

The pediatric neurologist begins with a medical history of the infant or child to determine if the problem is congenital or acquired, chronic or episodic, and static or progressive. The focus of the pediatric neurologist in taking the patient’s history is on genetic disorders, the medical history of family members, and perinatal events, with an emphasis on the mother’s health, nutrition, and medications, as well as tobacco, alcohol, or drug use during pregnancy. Considerable information about a child’s or infant’s behavior or neuromuscular function can be obtained by observation of the child’s alertness and curiosity, trust or apprehension, facial and eye movements, limb function, and body posture and balance during simple motor activities. If possible, the pediatric neurologist will ask the child about instances of weakness, numbness, headaches, pain, tremors, nervousness, irritability, drowsiness, loss of memory, confusion, hallucinations, and loss of consciousness. Headaches, abdominal pain, or reluctance to attend school may be associated with neurologic disturbances, with contributing factors including subtle developmental disabilities, specific learning disabilities, and depression. Disorders of movement include tics, developmental clumsiness, ataxia, chorea, myoclonus, or dystonia.

A complete neurologic examination includes an evaluation of mental status, craniospinal inspection, cranial nerve testing, sensory testing, musculature evaluation, an assessment of coordination, and autonomic function testing. Mental status evaluation involves the assessment of orientation, memory, intellect, judgment, and affect. Craniospinal inspection includes the palpation, percussion, and auscultation of the cranium and spine. Cranial nerve testing assesses the motor and sensory function of the head and neck. Sensory testing measures peripheral sensations, including responses to pinprick, light touch, vibration, and fine movement of the joints. In musculature evaluation, weakness is associated with altered tendon reflexes, indicating lower motor neuron lesions, whereas exaggerated tendon reflexes are associated with an extensor response of the big toe following plantar stimulation (Babinski reflex). In coordination assessment, smooth fine and gross motor movements demand integrated function of the pyramidal and extrapyramidal systems, whereas hyperreflexia, increased muscle stiffness, and problems with muscle coordination reflect spasticity. The evaluation of autonomic function involves bowel and bladder function, emotional state, and symmetry of reflex activity, particularly resting muscle tone and positioning of the head. Additional diagnostic aids include lumbar puncture (spinal tap), complete blood count (CBC), myelography, electroencephalography (EEG), and computed tomography (CT) scanning.

Perspective and Prospects

Pediatric neurologists have been greatly assisted in their recognition of neurologic disease in infants and children by brain-imaging techniques, such as CT scanning and magnetic resonance imaging (MRI). Event-mediated evoked potentials are also used to assess the conduction and processing of information within specific sensory pathways. These advances have enabled an accurate evaluation of the integrity of the visual, auditory, and somatosensory pathways and the uncovering of single and multiple lesions within the brain stem and cerebrum. Particularly noteworthy are CT scanning and sonographic detection of clinically silent intracranial hemorrhages in premature infants.

Late twentieth- and early twentieth-century success in assisting premature infants has produced a population of patients at risk for developing cerebral palsy, developmental disabilities, epilepsy, and various learning disorders. The higher incidence of neurologic disease in the pediatric age group likely results from the increased ability of medical science to detect nervous system disturbances and from the increased survival rate of premature infants. Neurologic patients are compromised in nearly every aspect of living and have a high incidence of psychiatric problems, and their recovery is often slow and unpredictable. Because medical advances have resulted in an increased survival rate following serious neurological insult, more individuals are in need of long-term rehabilitation. The financial cost associated with this care presents an ongoing challenge to health care systems and to researchers examining effective means to restore function.

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