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Neonatal Seizures and Headaches in Children
NEONATAL SEIZURES
Nelson’s Pediatrics 18th edition pp2471-2473
Highest Risk of Development of Seizure
Reasons:
1
...
Toxic
manifested in
3
...
Infectious disease
other age group
Uniqueness of Seizures in Neonate
– Seizure is primarily a pediatric disease; in the pedia group, highest in the first 4 weeks
–
Generalized Tonic Clonic not common (most common seizure type is epilepsy; for adults, GTC is common)
Reasons: Incomplete
1
...
Myelination- dorsal induction process
– Seizure discharge cannot readily be propagated to produce GTC
Ex: twitching of corner of the eye- doesn’t propagate
Clinical Manifestation and Classification
1
...
Multifocal clonic – like #1 but many muscle groups are invalid (different sites)
3
...
Myoclonic – brief focal or generalized jerks of extremities or body that tend to involve distal muscle groups
5
...
Chewing motion – common, like rooting and sucking
reflex
b
...
Alteration in respiratory rate including apnea
d
...
Nystagmus
f
...
Changes in odor
→some of the movements may actually be
normal; it becomes abnormal if already repetitive
Neonatal Sz – Difficult to recognize clinically
Clinical feature to differentiate true neonatal Sz from Non epileptic event (study this!)

Autonomic changes
Movement suppressed by gentle restraint
Enhanced by sensory stimuli

True sz

Not true (non epileptic)

Yes - tachycardia; inc BP

None

No

Yes

No (unprovoked)

Yes

In not true, there is “jitteriness” → fast rhythmical movement

EEG Classification of Neonatal Seizures
1
...
Clinical seizures with Inconsistent EEG events
- Actual (clinical)seizures without corresponding EEG discharges
- Seen in:
1
...
subtle seizure
3
...
Electrical ((+) EEG) seizures with absent clinical seizures (Non-convulsive sz)
Electrical (EEG) seizure associated with
markedly abnormal background EEG seen in
comatose neonates and are NOT on anticonvulsants
May be seen in comatose patients
...
HIE (Hypoxic Ischemic Encephalopathy) – most common; common manifestation ng neonate – no immediate cry
2
...
Infection – poor immunity; the immune system takes some time to develop – for the first 6 months the neonate is protected from the
passive transfer of antibodies from the mother
4
...
welcome to the real world!
5
...
Hemorrhage
7
...
Maternal disturbance
Diagnosis by:
1
...

Test: TORCH Assay of mother and neonate
Iris – Coloboma
Aicardi Syndrome
Retina – Lacunae
Characteristics:
1
...
Iris and Retinal Findings
3
...
Absent corpus callosum
Skin – Hypopigmented lesion → Tuberous Sclerosis
Skin – Crusted Vesicular lesion → Incontinentia pigmenti
(blackish lesion)
Smell – Urine (caramelized)
Unusual smell
→ Inborn error of metabolism
2
...
Glucose
B
...
)
C
...
5 mg/L) – often associated ↓ Ca,
malnourished mother
- ↓ Ca with ↓ Mg – hypocalcemia is resistant to
treatment if ↓ Mg is not corrected
- Treatment: ↓ Mg by intramuscular (l
...
) 0
...
Phosphorous
E
...

-

-

4
...
Obvious metabolic
B
...
Traumatic
B
...
But if in neonate and with sepsis, even if the baby seems to be doing
ok, → it’s a must
...

- Two types according to duration
- Early → 1/3 will develop in meningitis
- Late → more than 60% or even as high as 90%
will develop meningitis
Inborn error of metabolism
A
...
Organic acid analysis
C
...
ABG
E
...


5
...
scalp); serum anesthetic level
Tx – supportive, promotion of urine output by administering I
...
fluids
-Sometime during an episiotomy (injecting xylocaine/lidocaine → the scalp may be hit → seizure!

6
...

-

Fifth day fits
Occurs on 5th day of life (4-6 days old)
Normal neonate
Seizures : multifocal, present in less than 24o

8
...
Generalized clonic seizure (Sz) shortly after birth with signs of fetal distress in utero
B
...
Essential for synthesis of Glutamic Acid decarboxylase → synthesis of GABA
Rx – 100 – 200 mg
...
V
...

Note: Not all BG dependent Sz respond dramatically and I
...
BG
6 wk trial of 10-20 mg/day is recommended
If negative responses to I
...
BG (if highly suspected especially those not responding to AED)
Rx is lifelong (10 mg/day)

–
–
–
–
–
–
–
–
–
9
...
Barbiturates
B
...
Heroin
D
...

–
–
–

Cytoarchitectural Abnormality
Lissencephaly
Schizencephaly
Tests – Chromosomal analysis; Neuroimaging

++++++++++++++++++++++HEADACHES IN CHILDREN ++++++++++++++++++++++
Nelson’s Pediatrics 18th edition Chapter 595 pp2479- 2483
Pain sensitive structures of the head
▪ Skin – increased nerve supply
▪ Subcutaneous tissues, muscles, arteries
▪ Periosteum = dura (pia is adherent to the brain, followed by the arachnoid, then dura)
▪ Cephalohematoma – a usually benign swelling formed from a hemorrhage beneath the periosteum of the skull and occurring
especially over one or both the parietal bones in newborn infants as a result of trauma sustained during delivery
▪ Epidural Hematoma
▪ Subdural Hematoma
▪ Eyes, ears, nasal cavity sinuses
▪ Intracranial venous sinuses
▪ Blood vessels within the dura-and pia-arachnoid
▪ CN V,IX,X,1st three cervical spinal nerves
▪ CN V- supplies the supratentorial region
▪ CN IX, X and 1st three cervical spinal nerves – supplies the infratentorial region of the brain
-brain itself does not feel
...
Migraine
▪ II
...
Tension or stress headache
MIGRAINE
Diagnostic Criteria for Migraine
▪ Without Aura
A
...
Headache attack lasts 4-72 hours (untreated or unsuccessfully treated)
C
...
Unilateral location
b
...
Moderate or severe intensity
d
...
During headache at least one of the ff:
a
...
Photophobia or phonophobia
E
...
At least 2 attacks
B
...
Not attributed to another disorder

▪

Typical Aura
A
...
Homonymous or bilateral visual symptoms including positive features (flickering lights, spots, lines) or negative features (loss of
vision), or unilateral sensory symptoms including positive features (visual loss, pins and needles) or negative features (numbness) or
any combination
C
...
Headache that meets criteria for migraine without aura begins during the aura or follows aura within 60 minutes

▪
▪

Youngest child reported - 1 y/o
Incidence:
– School age between 7-15 y/o - 4%, Adolescents (8-23%) (Swedish study)
– Younger than 10 y/o - male > female
– Adolescent - female > male
– Adults: Men 5-10%, Women 15-20%
> 50% - spontaneous remission after 10th Birthday
Possible to consider myasthenia gravis
Triggering factors
– Hormonal changes
– Food allergies
– Personality traits characterized by high achievement
– Stress

▪
▪
▪

–
–

Bright flashing lights
Excessive sound

Cortical Spreading Depression (CSD)
Precipitant/ Trigger
↓
↑ glutamate, nitrous oxide
↓
Release of H, K ions
↓
Regional cortical oligemia and activation of the
caudal portion of the trigeminal ganglion
↓
Excitation of the trigeminal- vascular system
Release of vasoactive instestinal peptides
↓
Vasodilation → extravasation of plasma proteins from
dural vessels (neurogenic vascular inflammation)
↓
Excitation of pain-sensitive receptors and onset of pain
–
–

Considered to be an inherited physiologic response to a variety of stimuli that are responsible for triggering the migraine process
Also possible to start without a trigger, but most likely meron

2004 International Classification of Headache Disorders
▪ Migraine
– Migraine without aura
– Migraine with aura
• Typical aura with migraine headache
• Typical migraine with nonmigraine headache
• Typical aura without headache
• Familial hemiplegic migraine
• Sporadic hemiplegic migraine
• Basilar-type migraine
– Childhood periodic syndromes that are commonly precursors of migraine
• Cyclic vomiting
• Abdominal migraine
• Benign paroxysmal vertigo of childhood
– Retinal migraine
– Complications of migraine
• Chronic migraine
• Status migraine
• Persistent aura without infarction
• Migrainous infarction
– Probable migraine
– Summary table at last page (very impt!)
Childhood Periodic Syndromes that are common precursors of migraine
1
...
Intestinal obstruction
2
...
Gastritis
4
...
Chronic pancreatitis
6
...
Abnormal GI motility
8
...


Metabolic causes(disorders of amino acid, carbohydrate metab
...

▪
▪

Abdominal migraine –not typical manifestation
Mid- abdominal pain with pain-free periods between attacks or periumbilical or poorly localized
Criteria for diagnosis:
– Child must complain at the time of abdominal pain of at least 2 of the ff:
1
...
Nausea
3
...
Pallor

3
...
o
...
V
...
Basilar Migraine
▪ (+) brainstem signs
▪ Vasoconstriction of basilar and posterior cerebral arteries (PCA)
– Vertigo
– Tinnitus
– Diplopia
– Blurred vision
– Scotoma
– Ataxia
– Occipital Headache
▪ Pupils + dilated
▪ + ptosis
▪ + altered sensorium → gen seizure
▪ After attack → complete resolution of s/sx
▪ Family hx: (+) migraine
▪ Dev classic migraine as adolescents/adults
B
...
1)
▪ Additional mutation in calcium channel gene CACNL1A4
Treatment
▪ Reduction of headache frequency, severity, duration, and disability
▪ Reduction of reliance on poorly tolerated, ineffective or unwanted acute pharmacotherapies
▪ Improvement in quality of life
▪ Avoidance of acute headache medication escalation
▪ Education and enabling of patients to manage their disease to enhance personal control of their migraine
▪ Reduction of headache- related distress and psychological symptoms
Drugs Used in the Management of Migraine Headaches in Children
▪ Acute
– Analgesics
– Triptans
▪ Prophylaxis
– Calcium channel blockers (Doc’s choice)

▪

– Antihypertensive
– Anticonvulsants
– Antihistamines
– Antidepressants
Severe Intractable

Management
▪ Prevention
– Elimination of precipitants
• Migraine precipitants: stress, fatigue, anxiety, spicy meats, foods containing MSG
• Bright flashing lights, sun exposure, excessive physical exertion, mild head trauma, loud noises, hunger, fatigue, motor
sickness, drugs (including alcohol, and oral contraceptive pills)
– Reassurance – after careful Hx, PE, NE, frequency & severity of migraine decreased by 50% once reassured by an MD
▪ Behavior management
– Biofeedback – 8 y/o and above
▪ Hypnosis
▪ Rest
▪ Prayer
ORGANIC HEADACHE
Indications for neuroimaging in a child with headache
(very impt!)
▪ Abnormal neuro exam
▪ Recent school failure, behavioral change, fall-off in linear growth
▪ HA awakens the child during sleep or early morning HA
▪ HA increase in frequency and severity
▪ Predioric HA’s and Sz’s coincide, esp if Sz has a focal onset
▪ Migraine and Sz occur in the same episode, and vascular symptoms precede the seizure (20-50% risk of tumor or AVMalformation)
▪ Cluster HA in a child; any child <5 or 6 y/o whose principal complaint is HA
▪ Focal neurologic symptoms or signs developing during HA (I
...
complicated migraine)
▪ Focal neurologic symptoms or signs (except classic visual symptoms of migraine) dev
...
EEG or neuroimaging rarely necessary

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