Pediatric Neuro and Maltreatment Overview
1. Why Pediatric Brains Are Different
Developmental Differences
Brain growth = development.
Brain undergoes rapid growth during the first 2 years of life.
Head circumference is used as an indicator of brain growth.
A sudden increase in percentile for head circumference should raise suspicion for hydrocephalus or increased intracranial pressure (ICP).
High Oxygen Demand
Children require:
2x the amount of cerebral oxygen compared to adults.
2x the amount of glucose.
Hypoxia in children leads to faster deterioration of brain function.
Shock can cause brain injury much more quickly in children than in adults.
Open Fontanelles
Fontanelles serve as a double-edged sword:
Advantage: Allows for compensation when intracranial volume increases.
Disadvantage: Compensation can fail, leading to rapid decline in condition.
Bulging fontanel when calm and upright is considered abnormal.
Blood-Brain Barrier Immaturity
The blood-brain barrier is not fully developed in infants, leading to increased permeability.
This immaturity makes infections spread more easily, explaining why meningitis is more common and often more severe in this population.
2. Increased Intracranial Pressure (ICP)
Monro-Kellie Doctrine
The doctrine states that the skull is a fixed volume, consisting of:
Brain: 80%
Cerebrospinal Fluid (CSF): 10%
Blood: 10%
An increase in one component must lead to a decrease in one or more of the other components to maintain normal ICP.
If compensatory mechanisms fail, ICP will increase, resulting in a drop in cerebral perfusion pressure (CPP).
As ICP rises, CPP drops, potentially leading to brain ischemia.
Early Signs of Increased ICP (School-age & Older)
Morning headache (due to CO₂ retention overnight)
Nausea
Projectile vomiting (due to medulla stimulation)
Blurred vision
Diplopia (due to compression of cranial nerve VI)
Behavior changes
Decline in academic performance
Seizures
Signs in Infants
Increased head circumference
Bulging fontanel
Separated sutures
“Setting sun” eyes (due to midbrain compression)
High-pitched cry
Irritability when rocked (movement increases ICP)
Distended scalp veins
Late Signs of Increased ICP = Herniation Warning
Decreased level of consciousness (LOC)
Fixed, dilated pupils (compression of cranial nerve III)
Decorticate posturing (arms flexed)
Decerebrate posturing (arms extended, worse)
Cushing’s triad (indicative of brainstem compression):
Widened pulse pressure
Bradycardia
Irregular respirations
Once Cushing's triad appears, the brainstem is being compressed, with minutes remaining before potential herniation.
Nursing Priorities for Increased ICP
Maintain head of bed elevation at 15–30 degrees
Position head midline
Avoid neck flexion
Do not cluster care activities
Control body temperature
Avoid Valsalva maneuver (recommend stool softeners)
Control pain, as pain increases ICP
Monitor pupils and LOC frequently.
3. Hydrocephalus
Pathophysiology
Cerebrospinal fluid (CSF) is produced in the brain's ventricles.
CSF circulates and is reabsorbed in the subarachnoid space.
Problems occur when:
There is obstruction (non-communicating hydrocephalus)
There is poor absorption (communicating hydrocephalus)
When CSF accumulates, the ventricles enlarge, leading to compression of brain tissue.
Ventriculoperitoneal (VP) Shunt
Procedure to manage hydrocephalus where CSF is diverted from ventricles to the peritoneal cavity.
Ventriculoatrial (VA) Shunt:
CSF is diverted to the right atrium, but with a higher risk of infection.
Signs of Shunt Malfunction
Symptoms associated with increased ICP, i.e., “ICP is back”:
Headache
Vomiting
Lethargy
Seizures
In infants: bulging fontanel again
Signs of Shunt Infection
Fever
Redness along the shunt tract
Abdominal distention indicative of peritonitis
Irritability
If shunt is infected, interventions include:
Shunt removal
Placing an external ventricular drain (EVD)
Administering IV antibiotics
Replacing the shunt at a later time.
4. Traumatic Brain Injury (TBI)
Why Children Are Vulnerable
Children have large heads leading to heavy momentum.
They possess thin skulls.
An expandable skull permits greater brain movement, leading to countercoup injuries.
Skull Fractures
Basilar Fracture Signs:
Raccoon eyes
Battle sign
CSF leak (glucose positive)
Medical protocols advise:
No nasogastric (NG) tubes
No nasal suctioning.
Concussion
Defined as temporary neuronal dysfunction without structural damage.
Key features include:
Confusion
Amnesia
Red Flags for Complications:
Repeated vomiting
Worsening headache
Unequal pupils
Seizures.
Management of Severe TBI
Maintain airway, breathing, and circulation (ABCs).
Implement cervical spine immobilization.
Administer hypertonic saline or mannitol to manage ICP.
Prevent hypotension, as hypotension in TBI is lethal.
5. Infectious Causes
Meningitis
Bacterial Meningitis
Considered a medical emergency.
CSF findings include:
Increased WBC
Increased protein
Decreased glucose
Increased opening pressure
Classic symptoms:
Fever
Nuchal rigidity
Positive Kernig's sign
Positive Brudzinski's sign
Petechial rash associated with meningococcemia
Complications may involve:
Septic shock
SIADH
Hearing loss
Seizures
Hydrocephalus
Nursing measures include:
Initiate droplet isolation for the first 24 hours
Start antibiotics immediately
Implement seizure precautions
Conduct frequent neuro checks
Vaccines that prevent bacterial meningitis:
Hib
Pneumococcal
Meningococcal
Encephalitis
Most commonly due to HSV-1.
Distinction from meningitis lies in the infection location:
Meningitis affects the meninges, while encephalitis affects the brain tissue.
More likely to present with severe altered mental status and seizures.
Treatment generally includes IV antivirals and supportive care.
Reye Syndrome
Occurs following a viral illness when combined with aspirin use.
Pathophysiology:
Results in liver failure and hyperammonemia due to cerebral edema.
Signs include:
Persistent vomiting
Hypoglycemia
Rapid neuro decline
Monitoring parameters include:
Glucose
Ammonia
Coagulation labs
Prevention involves avoiding aspirin in cases of viral illness.
6. Epilepsy
Definition
At least two unprovoked seizures characterize epilepsy.
Pathophysiology
Hyperexcitable neurons create an epileptogenic focus, the location of which dictates the involved body parts and whether loss of consciousness (LOC) occurs.
Febrile Seizures
Occur in children aged 6 months to 5 years with a temperature greater than 101°F.
Typically last fewer than 15 minutes
Are generalized and are not classified as epilepsy.
During a Seizure
Protect the airway.
Place child on their side.
Do not insert anything in the mouth.
Avoid restraining movements.
Note the duration of the seizing episode.
If seizure lasts longer than 5 minutes, it's termed status epilepticus, and treatment should include administration of intranasal midazolam or rectal diazepam.
Long-Term Management
Antiepileptic drugs (AEDs) should be introduced gradually with low initial doses.
Implementation of a ketogenic diet may be beneficial.
Vagus nerve stimulators can be considered.
Surgery is rare but may be indicated in certain cases.
Safety Considerations
Children with epilepsy should never swim alone.
They should wear helmets while biking and avoid sleep deprivation.
Big Picture Clinical Reasoning
All pediatric neurological questions boil down to the following considerations:
Is oxygenation adequate?
Is perfusion adequate?
Is ICP rising?
Is the brainstem being compressed?
What preventive measures can be implemented to avoid worsening conditions?
7. Child Maltreatment - Complete Nursing Breakdown
Definition of Child Maltreatment
Child maltreatment refers to any act (or failure to act) by a parent or caregiver that results in harm, potential harm, or the threat of harm to a child.
This encompasses both abuse (active harm) and neglect (failure to meet needs).
A critical nursing perspective: Maltreatment is determined by its impact, not the intent of the caregiver.
Types of Child Maltreatment
Physical Abuse:
Defined as non-accidental physical injury, including hitting, shaking, burning, biting, throwing, or strangling.
Classic Injury Patterns:
Bruises: Located on soft areas (abdomen, buttocks, cheeks), patterned marks (belt, handprint, cord).
Burns: Especially “sock” or “glove” immersion burns.
Fractures: Spiral fractures in non-walkers.
Head Injury: The most common cause of death in child abuse.
Sentinel Injuries: Small, early warning injuries like frenulum tears.
Sexual Abuse:
Involves any sexual activity with a child, including touching, penetration, exposure, pornography, or exploitation.
Behavioral Signs: Symptoms may include sexualized behavior, sudden regression (bedwetting), fear of specific individuals, nightmares, academic decline, STIs, or pregnancy.
Emotional (Psychological) Abuse:
Consists of behaviors that harm a child's self-worth or emotional well-being, such as constant criticism, threats, rejection, isolation, or exposure to domestic violence.
Note that this form of abuse is the hardest to detect, but the long-term consequences can be severe.
Signs of emotional abuse may include developmental delays, low self-esteem, anxiety, depression, and attachment disorders.
Neglect:
Defined as a failure to meet basic needs, with various types of neglect including:
Physical Neglect: Failure to provide food or shelter.
Medical Neglect: Not providing medications.
Educational Neglect: Not sending a child to school.
Supervisory Neglect: Leaving a child alone unsupervised.
Emotional Neglect: Failure to provide affection and support.
Neglect is recognized as the most common form of maltreatment.
Risk Factors for Child Maltreatment
Child Risk Factors:
Disabilities, prematurity, chronic illness, behavior problems—factors that can increase caregiver stress.
Caregiver Risk Factors:
Substance use, mental health issues, domestic violence, young age, and unrealistic expectations of child behavior.
Environmental Risks:
Poverty, social isolation, high-stress levels, and community violence contribute significantly to maltreatment risk.
8. Abusive Head Trauma (Shaken Baby Syndrome)
Recognized as a major cause of death in infants under the age of 2.
Mechanism of Injury:
Shaking leads to serious consequences, such as:
Brain bleeding
Retinal hemorrhage
Brain swelling
Infants are susceptible due to weak neck muscles, large head size, and fragile brain structure.
Classic Triad Findings:
Subdural Hematoma: Caused by brain shifts during shaking.
Retinal Hemorrhage: Results from vascular tearing.
Encephalopathy: Associated brain injury.
Signs:
Symptoms may include vomiting, lethargy, seizures, poor feeding, and apnea.
Often, no external injury is evident.