Paediatrics Neurology and
Development
Behaviour 1. Developmentally inappropriate behaviour –
Disorders enuresis, soiling/encopresis
2. Developmentally abnormal behaviour –
hyperkinetic disorder, conduct disorder, sleep
disorder, autism
3. Psychosomatic – Functional abdo pain,
headache, chronic fatigue syndrome
4. Adolescent behaviour disorder – eating
disorder, drug abuse, overdose/suicide
attempts
Nervous System 1. Altered consciousness – encephalopathy,
encephalitis, meningitis
2. Convulsions – idiopathic epilepsy, febrile
convulsions
3. Spasticity – Cerebral palsy
4. Hypotonia/weakness – muscular dystrophy,
flop infant
5. Headache – migraine, brain tumour
6. Abnormal head size – hydrocephalus,
microcephaly
Neurodevelopme 1. Normal Developmental Milestones
nt 2. Global Developmental Delay – mental
handicap, epilepsy, FAS
3. Delayed walking – normal variation, cerebral
palsy, muscular dystrophy
4. Delayed speech – conductive deafness,
sensorineural deafness, mental handicap,
cerebral palsy, normal variation
Social paediatrics 1. Disability – cerebral palsy, extreme
prematurity, dyspraxia, dyslexia, ADHD,
autism
2. Screening growth charts
3. Child abuse – NAI
Genetics and 1. Chromosomal disorders – Down’s syndrome,
Congenital Turner’s syndrome
Malformations 2. Single gene defects – phenylketonuria,
neurofibromatosis, achondroplasia
3. X-linked – Duchenne, muscular dystrophy,
haemophilia
4. Sporadic – neural tube defects, cleft lip/palate,
congenital dislocation hip, hypospadias
5. Syndromes
,Behavioural Disorders
1. Developmentally inappropriate
behaviour – enuresis, soiling/encopresis
Enuresis
Overview
- Most children achieve day and night urinary incontinence by ¾.
- Enuresis is synonymous with bed-wetting.
- Risk factors:
o Male sex
o Genetics – sphincter competence
o Emotional stress
- Most children with enuresis are psychologically normal.
- Most grow out of enuresis by the age of 15. Only 1% patients
continue having symptoms into adulthood.
- Secondary enuresis – relapse after a period of dryness. Emotional
upset is the commonest cause.
Organic causes:
- Urinary tract infection
- Faecal retention reduction of bladder volume bladder neck
dysfunction
- Polyuria e.g. diabetes, CKD
Investigations
Urine sample
- Check for glucose, protein and infection ?constipation ?UTI ?DM
Secondary enuresis
- Urine sample
- Assessment of urine concentrating ability
- Ultrasound of renal tract
Management
Conservative
- Explanation and reassurance – advise on fluids, diet and toileting
behaviour
- Check for any psychological issues – ask about school performance,
friends and home life
- Star chart
- Enuresis alarm – first-line < 7years after advice
Medical
- Desmopressin – analogue of ADH: short-term relief: first-line > 7
years
Daytime Enuresis
Overview
,Causes:
- Lack of attention to bladder sensation – psychogenic/developmental
problem
- Detrusor instability
- Bladder neck weakness
- Neuropathic bladder
- UTI
- Constipation
- Ectopic ureter
Presentation
Examination
- Distended bladder
- Neurological examination
Investigations
- Urine sample
- Assessment of urine concentrating ability
- Ultrasound of renal tract
- Urodynamic studies
- X-ray of spine – vertebral anomaly?
- MRI – exclude non bony spinal defect
Management
Conservative
- Star charts
- Treat underlying cause
Medical
- Oxybutynin – anticholinergic drug to dampen bladder contractions.
Soiling/Encopresis
Overview
- It is abnormal to soil >4y
- Important to check whether rectum is loaded or not – abdo
examination. Loaded rectum is most common.
- Loaded rectum may be hard to shift – loaded rectum inhibits the
anus via the rectoanal reflex and stool may seep out with
spontaneous rectal contractions beyond the child’s control.
Factors with loaded rectum:
- Constipation (dehydration or illness)
- Inhibition – pain from fissure
- Inhibition – anxiety for punishment
- Anxieties about using toilet
Non-loaded:
- Psychological
, - Neuropathic bowel – secondary to spinal abnormality
- Learning disability
- Intentional
Management
Conservative
- Treat underlying factors if presents e.g. anal fissure
- Scoring system
Medical
- Stool softener e.g. macrogol
- Stimulant if necessary e.g. docusate, sodium picosulfate
- Osmotic laxative e.g. lactulose
- Maintainance therapy
2. Developmentally abnormal
behaviour – hyperkinetic disorder,
conduct disorder, sleep disorder, autism
Attention Hyperactivity Deficit Disorder
Overview
- Inherent variation in hyperactivity of children
- When their level of motor activity exceeds that regarded as normal,
they may be termed ‘hyperactive’.
- ADHD: child is undoubtedly overactive; impaired concentration
with short attention span/distractibility.
- Powerful genetic predisposition – possibly underlying dysfunction in
dopamine neural circuits.
Presentation
Core Features
- Inattention
- Impulsivity: Inability to control impulses – disorganised, poorly-
regulated and excessive activity
- Hyperactivity
Other Features
- Short tempered and poor relationships
- Poor performance in school
Often assessed by educational psychologist
DSM V
Development
Behaviour 1. Developmentally inappropriate behaviour –
Disorders enuresis, soiling/encopresis
2. Developmentally abnormal behaviour –
hyperkinetic disorder, conduct disorder, sleep
disorder, autism
3. Psychosomatic – Functional abdo pain,
headache, chronic fatigue syndrome
4. Adolescent behaviour disorder – eating
disorder, drug abuse, overdose/suicide
attempts
Nervous System 1. Altered consciousness – encephalopathy,
encephalitis, meningitis
2. Convulsions – idiopathic epilepsy, febrile
convulsions
3. Spasticity – Cerebral palsy
4. Hypotonia/weakness – muscular dystrophy,
flop infant
5. Headache – migraine, brain tumour
6. Abnormal head size – hydrocephalus,
microcephaly
Neurodevelopme 1. Normal Developmental Milestones
nt 2. Global Developmental Delay – mental
handicap, epilepsy, FAS
3. Delayed walking – normal variation, cerebral
palsy, muscular dystrophy
4. Delayed speech – conductive deafness,
sensorineural deafness, mental handicap,
cerebral palsy, normal variation
Social paediatrics 1. Disability – cerebral palsy, extreme
prematurity, dyspraxia, dyslexia, ADHD,
autism
2. Screening growth charts
3. Child abuse – NAI
Genetics and 1. Chromosomal disorders – Down’s syndrome,
Congenital Turner’s syndrome
Malformations 2. Single gene defects – phenylketonuria,
neurofibromatosis, achondroplasia
3. X-linked – Duchenne, muscular dystrophy,
haemophilia
4. Sporadic – neural tube defects, cleft lip/palate,
congenital dislocation hip, hypospadias
5. Syndromes
,Behavioural Disorders
1. Developmentally inappropriate
behaviour – enuresis, soiling/encopresis
Enuresis
Overview
- Most children achieve day and night urinary incontinence by ¾.
- Enuresis is synonymous with bed-wetting.
- Risk factors:
o Male sex
o Genetics – sphincter competence
o Emotional stress
- Most children with enuresis are psychologically normal.
- Most grow out of enuresis by the age of 15. Only 1% patients
continue having symptoms into adulthood.
- Secondary enuresis – relapse after a period of dryness. Emotional
upset is the commonest cause.
Organic causes:
- Urinary tract infection
- Faecal retention reduction of bladder volume bladder neck
dysfunction
- Polyuria e.g. diabetes, CKD
Investigations
Urine sample
- Check for glucose, protein and infection ?constipation ?UTI ?DM
Secondary enuresis
- Urine sample
- Assessment of urine concentrating ability
- Ultrasound of renal tract
Management
Conservative
- Explanation and reassurance – advise on fluids, diet and toileting
behaviour
- Check for any psychological issues – ask about school performance,
friends and home life
- Star chart
- Enuresis alarm – first-line < 7years after advice
Medical
- Desmopressin – analogue of ADH: short-term relief: first-line > 7
years
Daytime Enuresis
Overview
,Causes:
- Lack of attention to bladder sensation – psychogenic/developmental
problem
- Detrusor instability
- Bladder neck weakness
- Neuropathic bladder
- UTI
- Constipation
- Ectopic ureter
Presentation
Examination
- Distended bladder
- Neurological examination
Investigations
- Urine sample
- Assessment of urine concentrating ability
- Ultrasound of renal tract
- Urodynamic studies
- X-ray of spine – vertebral anomaly?
- MRI – exclude non bony spinal defect
Management
Conservative
- Star charts
- Treat underlying cause
Medical
- Oxybutynin – anticholinergic drug to dampen bladder contractions.
Soiling/Encopresis
Overview
- It is abnormal to soil >4y
- Important to check whether rectum is loaded or not – abdo
examination. Loaded rectum is most common.
- Loaded rectum may be hard to shift – loaded rectum inhibits the
anus via the rectoanal reflex and stool may seep out with
spontaneous rectal contractions beyond the child’s control.
Factors with loaded rectum:
- Constipation (dehydration or illness)
- Inhibition – pain from fissure
- Inhibition – anxiety for punishment
- Anxieties about using toilet
Non-loaded:
- Psychological
, - Neuropathic bowel – secondary to spinal abnormality
- Learning disability
- Intentional
Management
Conservative
- Treat underlying factors if presents e.g. anal fissure
- Scoring system
Medical
- Stool softener e.g. macrogol
- Stimulant if necessary e.g. docusate, sodium picosulfate
- Osmotic laxative e.g. lactulose
- Maintainance therapy
2. Developmentally abnormal
behaviour – hyperkinetic disorder,
conduct disorder, sleep disorder, autism
Attention Hyperactivity Deficit Disorder
Overview
- Inherent variation in hyperactivity of children
- When their level of motor activity exceeds that regarded as normal,
they may be termed ‘hyperactive’.
- ADHD: child is undoubtedly overactive; impaired concentration
with short attention span/distractibility.
- Powerful genetic predisposition – possibly underlying dysfunction in
dopamine neural circuits.
Presentation
Core Features
- Inattention
- Impulsivity: Inability to control impulses – disorganised, poorly-
regulated and excessive activity
- Hyperactivity
Other Features
- Short tempered and poor relationships
- Poor performance in school
Often assessed by educational psychologist
DSM V
