Neurological disorder

Neurological disorder

The nervous system is usually divided into Central Nervous System and the Peripheral Nervous System, the CNS consist of the brain and spinal cord while the PNS is made up of the sense organs that sends information to the brain and efferent nerves that sends information out to the body for a particular response, Extra CNS has been found to have a very huge influence in the child’s cognitive development, that is why in most cases health provides are tasked with the challenge of screening and identifying health problems or even when is the proper time to refer the child to a specialist.




The nervous system is divide into the CNS and PNS



CNS has a very huge influence in child’s development



Health providers have a challenge of identifying and screening neurologic problems




Neurologic Disorder

Neurologic disorder is where a disease affects the CNS and PNS, it usually has a very huge neurologic implication in case that occurs since the central neurons will have uncontrolled firing i.e. seizure, the CNS will be unable to respond or process stimuli as well as PNS being unable to receive or respond to stimuli. This things usually occur when the nervous system of an individual is damaged hence preventing neurotransmitters to work properly as expected of them.




They are diseases that affect the CNS and the PNS



They usually lead to neurologic implication



The brain could start experiencing seizures



PNS may be unable to receive or respond to stimuli




Main Objectives


Describe the Pathophysiology of the neurologic system and pediatric differences



Choose the appropriate assessment guidelines and tools to examine infants and children with altered level of consciousness and other neurologic conditions



Assessment of the Nervous System



Pain and/or headache

Sensory deficits


Reflexive responses

Behavioral changes

Motor/balance changes

Medical history


Birth history/neonatal course


Assessment of the Nervous System

Medical history

Cardiovascular/respiratory disorders

Environmental exposure to toxins

Metabolic disorders

Past neurologic diseases/tests

Drug ingestion

Urinary tract disease

Physical growth

Family disease history

Similar symptoms/pedigree


Migraine history

Intellectual functioning of family members


Assessment of the Nervous System

Developmental history

Achievement plateau/loss of skills

Functional health

Effects of symptoms on all areas of health promotion and safety

Social context

Family composition, school, community

Review all systems plus:

Allergies, immunizations, hearing, vision, dental, skin, behavior, nutrition,

Medications; recreational drugs


Physical Examination

Growth parameters

Skin abnormalities


Cardiovascular system

Musculoskeletal system


Tanner stage



Physical Examination

Specifics of the neurological examination

Behavior and mental status

Cranial nerve function

Motor examination

Sensory examination


Cranium examination

Autonomic nervous system

Meningeal signs


Physical Examination

Diagnostic studies


Laboratory studies for systemic disease, infection, inflammation

Lumbar puncture


US in infants

Polysomnography, electromyography, nerve conduction, evoked responses, cerebral arteriography


Early detection and how to suspect

We can suspect a child has neurological disorder if where he comes from is exposed to toxins such as lead

If there one of his family members has in the past experienced a long history of neurological disorder

It can be detected if a child experiences sensory deficit such as numbness or loss of pain sensation


Neurological disorder is usually suspected in a child if where he comes from the surrounding environment is exposed to toxins such as lead, which is something that must be put in consideration when examining the neurological condition of a child. We can also suspect them to have such conditions if one of their family members had experienced such condition in the past, to detect if a child might have a neurological disorder we might decide to take a look at the sensory deficit he or she is experiencing and whether or not it may be as a result of neurological condition.



Age/gender and risk factor

The gender mostly affected by this condition are the male species

They are children whose age run from 3yrs and below

Risk factor is environmental exposure to toxins such as lead

Trauma is also another risk factor

The male are the gender are mostly affected by neurological disorder since they are more exposed to the things which can lead to such conditions such as drug exposure. Children who are two years and below are the ones which this study is focused on and how neurological disorder can affect their neurodevelopment process. When a person is exposed to toxins such as lead his chances of getting neurological disorder is usually very high, likewise when he or she likes experiencing trauma and that may lead in having a negative long-term effect on his brain-functioning.



Genetics and most common diseases

Neurodegenerative disorder

White matter diseases

Rett syndrome

Multiple sclerosis



Nondegenerative Disorders

Benign paroxysmal vertigo

Cerebral palsy

Bell palsy

Epilepsy and seizure disorders

Febrile seizures

Brachial palsy

Guillain-Barre syndrome









Genetics and most common diseases

Central Nervous System Infection

Head Injury

Disturbances of Head Growth





The Hypotonic Infant

Reye Syndrome

Tethered Cord

Arnold-Chiari Malformation


Myasthenia Gravis

Central Nervous System Infection: Bacteria, viruses, fungi, spirochetes, protozoa, parasites can cause







Seizure disorder of brain; characterized by recurring and excessive discharge from neurons

Repeated, unpredictable seizures

One in 20 children will have a seizure by age 18

45,000 children develop epilepsy each year




Seizure Disorders

Causes: Traumatic brain injury (TBI)


Congenital brain defects

Metabolism disorders (such as phenylketonuria)

Brain tumor

Abnormal blood vessels (brain)

Toxic ingestion

Anoxic or hypoxic events Hypoglycemia


Classification of Seizures


Simple partial: no loss of consciousness

Complex partial: affect level of consciousness

Symptoms depend on what area of the brain is involved

Often presents as a staring episode or slight twitching of eyes and drooling


Classification of Seizures


Tonic-clonic (grand mal)

Tonic – stiff

Clonic – jerking

Sudden loss of muscle tone

Eye blinking, alter awareness, mouth, or facial


Epilepsy and seizure disorders physical examination

Focal abnormalities/weakness

Seizure activity during exam


Systemic disease

Cardiovascular disorder

Neurocutaneous disease

Signs of head trauma

Transillumination of skull in infants


Epilepsy and seizure disorders diagnostic studies


Metabolic screen later in workup

Blood glucose

Urine/serum toxicology

Lumbar puncture if <6 months


MRI in some cases

CT if marked cognitive, motor, neurologic dysfunction



Differential diagnosis

Breath-holding, inattentive staring, benign shudders, tantrums

Cyclic vomiting, benign paroxysmal vertigo, syncope, migraines, cardiovascular are symptoms

GERD, night terrors, nonepileptic seizures

Metabolic problems, tumors or CNS problems



Referral – to neurologist for diagnosis and initiation of treatment

PCP can monitor stable children

Drug monitoring

Antiepileptic medication withdrawal

Gradual withdrawal after 2 years without seizures



Ketogenic diet




Swimming, driving, sports


Pertussis vaccine on individualized basis


Febrile Seizures


Most common between 6 months and 5 years

Concurrent illness with rapid fever rise

Diagnostic studies

Lumbar puncture

Blood glucose

CBC, calcium, electrolytes, urinalysis optional

EEG if neurological signs present

MRI for complex febrile seizures


Differential diagnosis

Sepsis, meningitis, metabolic/toxic encephalopathies

Hypoglycemia, anoxia, trauma, tumor, hemorrhage


Febrile seizure Management

Protect airway, breathing, circulation

Time duration of seizure

Reduce fever with APAP or ibuprofen

Anticonvulsants only if complex, if neurological signs present

Prophylaxis not recommended

Education about febrile seizures


Disturbances of Head Growth


Head circumference >2 SD above mean

Hydrocephaly, megalencephaly, subdural hematoma, tumor, skull thickening


Head circumference 2 SD below mean

Normal shape; may have overlapping sutures

Delayed development, neurological problems



Congenital – early closure/absence of one or more sutures

Syndromic – accounts for 25% of cases

Growth along open sutures produces deformity

Secondary synostosis – outside forces put pressure growing cranium – plagiocephaly

Physical examination – cranial symmetry for first year, symmetry of neck rotation


Neural Tube Defects

Abnormalities of brain, spine, or spinal column; present at birth

Failure of the osseous spine to close around the spinal column

Spina bifida: most common type

Spina bifida occulta



Spina Bifida Clinical Manifestations

Vary depending on the level of the lesion and defect

Motor, sensory, reflex and sphincter abnormalities

Lower extremity weakness Ambulation difficulties

Flaccid paralysis of legs- absent sensation and reflexes, or spasticity Bowel and bladder control issues


Learning, attention, memory, and reasoning problems

Spina Bifida: Diagnostic Tests


Prenatal detection



Following Birth:

NB assessment


CT scan/ MRI

X-ray of spine

X-ray of skull

Spina Bifida Extensive interdisciplinary treatment

Antibiotics, sac closure (neonatal neurosurgery), and ventriculoperitoneal shunt placement

Monitoring of head size (hydrocephalus), evaluation of sphincters, and institution of bowel and bladder regimen

Dietary fiber, stool softeners, suppositories

Clean intermittent catheterization

Physical therapy, occupational therapy, speech therapy

Braces, assistive devices, weight-bearing exercises

Calcium, vitamin D, high-fiber diet


Posterior neural tube and vertebral column not closed

Protrusion of both spinal cord and meninges

Spina bifida cystica – myelomeningocele

Spina bifida occulta – no herniation; open column

Clinical findings

Poor intake of folic acid in pregnancy

Saclike cyst containing meninges/spinal fluid

Flaccid paralysis of lower extremities

Absence of DTRs; lack of pain/touch response

Constant urinary dribbling


Management and complications

Serial cranial US to monitor for hydrocephaly

Surgical resection/closure of structures at birth

Multidisciplinary supportive management

Genitourinary management


Normal intelligence in 70%

Functional mobility depends on level/degree


Folic acid supplementation for all females of childbearing age



Arnold-Chiari Malformation

Type I – downward elongation of caudal end of cerebellar vermis into foramen magnum

Type II – herniation can lead to brainstem and upper cervical cord compression and necrosis

Diagnosis by MRI

Never attempt LP in child with Arnold-Chiari malformation


Cerebral Palsy

Nonreversible disorders

Chronic, nonprogressive

May have disturbances in sensation, perception, cognition, communication, behavior

Epilepsy, musculoskeletal problems may be present

Three major types:

Spastic – muscle stiffening and tightness

Athetoid – involuntary, purposeless muscle movement

Ataxic – affects balance and coordination

1.5 – 2 cases per 1000 live births

Most common motor disability in children

Clinical Manifestations Infants

Problems with sucking and swallowing

A weak or shrill cry

Extreme irritability and crying

Jittery (easily startled)

Unusual positions (either very relaxed and floppy or very stiff)

Delay in reaching motor skills milestones (such as sitting up alone or crawling)

Delays in speech development or difficulty speaking

Clinical Manifestations Children

Abnormal motor development

Persistent primitive infantile reflexes Increased or decreased muscle tone

Hypertonia, rigidity, muscles stiff

Keeps legs extended or crossed

Rigid and unbending

Exaggerated deep tendon reflexes


Abnormal increased muscle development in arms & legs Hypotonia, muscles floppy

Smaller muscles in affected arms & legs Diminished reflexes

Clinical Manifestations Children

Abnormal posture

Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees crossing or a wide-based unsteady gait

Persistent fetal position (>5 months)

Abnormal voluntary movements

Tremors or involuntary movements

Slow, writhing movements (athetosis)

Difficulty with precise motions (hand movements)

Lack of muscle coordination (ataxia)

Abnormal sensations Abnormal touch or pain perceptions


Cerebral palsy– physical examination

Dermatologic signs of syndromes

Orthopedic exam – scoliosis, fractures, dislocations

Neurologic exam – DTR, tone, atrophy, fasciculations, reflexes, asymmetric movements, head size


Development – gross/fine motor, language, personal-social skills


Diet, height, weight, BMI


Diagnostic studies – imaging studies, chromosomal and metabolic studies, lumbar puncture if sepsis suspected

Differential diagnosis – central vs peripheral; other conditions causing motor involvement


Central Nervous System Infection

Bacteria, viruses, fungi, spirochetes, protozoa, parasites can cause

Clinical findings – history

URI or GI symptoms with fever

Increasing lethargy/irritability

Recent head injury/surgery

Immunodeficiency disease

Central Nervous System Infection

Clinical findings – physical examination

Systemic signs – fever, malaise

CNS signs – headache, stiff neck/spine, N/V, changes in mental status

Kernig/Brudzinski signs

Bulging fontanelle/papilledema

Cranial nerve palsies

Findings differ by age

Diagnostic studies – blood cultures, CBC, UA, chemistry, lumber puncture


Cerebral Palsy Management

Referral of suspected cases

Family education/support/financial resources

Nutrition, elimination










Special education

Other treatments


Head Injury

Traumatic brain injury (TBI)

Mild to severe tissue damage

Acceleration-deceleration or rotational forces

Long-term sequelae more common in children

Open trauma – more focal injuries

Closed trauma – multifocal/diffuse

Secondary effects: hypoxia, ischemia, hypotension, hemorrhage


physical examination

Vital signs

Thorough physical examination

Careful neurologic examination

Signs of CNS involvement

Glasgow Coma Scale to assess mental status

Periorbital hemorrhage, “Battle sign”


Head Injury

diagnostic studies

Severity dictates need for studies

CT for any of the following:

Penetrating trauma

Altered level of consciousness

Amnesia about injury

Focal neurological signs/deficit

Depressed skull fracture/basilar injury


Persistent vomiting

History of coagulopathy


Differential diagnosis

Differentiating minor from extensive injury important


Minor closed head injury; no loss of consciousness

Observation in clinic, ED, home

Understanding of signs to watch


Minor closed head injury

brief loss of consciousness Observation in clinic, ED, home

Understanding of signs to watch

CT scanning accepted

Hospitalization if reliable home monitoring not possible


Moderate head injury; worrisome symptoms

Admission, prolonged observation in ED

Hospitalize for the following:

Changing vital signs


Altered mental status/slurred speech

Prolonged unconsciousness/persistent memory defect

Depressed or basilar skull fractures

Persistent headache

Recurrent vomiting/unexplained fever

Unexplained injury (child abuse)

Worrisome CT/MRI findings


US statics

The government has tried making investments to overcome neurological disorder

In 2011 at least 100 million Americans had been afflicted by at least one of the neurological diseases

In 2014 US spent $789 billion on the most common neurological disease

Alzheimer and other dementias had accounted for at least $243 billion out of $789 billion spent that year.

The US government has tried making a reasonable amount of investment over the year to overcome neurological disease, reports got in 2011 had indicated that at least 100 million American had once been afflicted by at least one of the neurological disease. American Neurological Association had reported that the government had spent $789 billion to be able to overcome the most common neurological diseases in 2014. Out of this money spent by ANA Alzheimer and other dementias spent about $243 billion.




Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Maaks, D. L. G. (2012). Pediatric primary care-e-book. Elsevier Health Sciences.

Espay, A. J., Aybek, S., Carson, A., Edwards, M. J., Goldstein, L. H., Hallett, M., … & Nielsen, G. (2018). Current concepts in diagnosis and treatment of functional neurological disorders. JAMA neurology, 75(9), 1132-1141.

Kirkland, A. E., Sarlo, G. L., & Holton, K. F. (2018). The role of magnesium in neurological disorders. Nutrients, 10(6), 730.


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