The Child with Cerebral Dysfunction

Developmental Characteristics of the Pediatric Nervous System

• Immaturity at Birth: The nervous system is not fully mature when a child is born.
• Brain Growth Indicators: Brain volume and growth are directly reflected in measurements of head circumference.
• Physiological Performance: Cerebral blood flow and oxygen consumption in children up to the age of $6$ are twice that of adults.
• Trimester Development:     * The brain and spinal cord develop during the FIRST trimester of pregnancy.     * Malformations during this period can be attributed to maternal infection, substance abuse, or dietary deficiencies.
• Growth Patterns:     * Rapid growth occurs during infancy and early childhood.     * Growth becomes more gradual during later childhood and through adolescence.     * Growth follows a cephalocaudal (head-to-toe) and proximodistal (center-outward) direction.
• Cranial Anatomy:     * The fontanels are not closed at birth, which allows the head to expand to accommodate swelling or other causes of increased intracranial pressure (ICP).     * The infant's brain is highly vascular, making it more prone to hemorrhage when subjected to force or shaking.     * Critical anatomical layers include the dura layer, the subdural space, and the blood-brain barrier ($BBB$).
• Spinal Development: The vertebrae are not completely ossified in children, leading to a greater risk for compression fractures and spinal injury.

Clinical Evaluation of Neurological Status

• Comprehensive Assessment Components:     * Medical History: Identifying baseline and onset of symptoms.     * Physical Examination: Evaluating core physical indicators.
• Physical Findings:     * Vital Signs: Monitoring for fluctuations related to neurological distress.     * High-Pitched Cry: A specific "cat-like" cry is often indicative of neurological trauma or dysfunction.     * Ocular Signs (Pupils): Assessment for unequal, "blown" (dilated/unresponsive), or pinpoint pupils (referencing Figure $30.3$, p. $1118$).     * Cranial Signs: Increased head circumference and bulging fontanels.     * Motor Activity: Changes in activity levels, strength, symmetry, and coordination of movement.     * Reflex Activity: Assessment of primitive and deep tendon reflexes.     * Sensory Responses: Reaction to stimuli.     * Alertness/Behavior: Evaluation of the child's behavioral baseline.     * Posturing: Identification of abnormal neurological positioning.

Pediatric Glasgow Coma Scale ($P-GCS$)

• Level of Consciousness ($LOC$): Altered $LOC$ is the earliest indicator of a change in neurological status.
• Three-Part Assessment Structure (Figure $30.2$):     1. Eyes: Maximum score of $4$.     2. Verbal Response: Maximum score of $5$.     3. Motor Response: Maximum score of $6$.
• Scoring Thresholds:     * Score of 15: Indicates an unaltered or normal $LOC$.     * Score of 8 or Below: Defines a state of coma.     * Score of 3: Represents the worst possible score, indicating an extremely decreased $LOC$, deep coma, or death.

Diagnostic Procedures for Neurological Evaluation

• Imaging:     * Computed Tomography ($CT$) scans.     * Magnetic Resonance Imaging ($MRI$).     * Nuclear brain scans.
• Laboratory Testing:     * Comprehensive blood testing, inclusive of drug testing.
• Specialized Tests:     * Lumbar puncture ($LP$) or spinal tap.     * Electroencephalogram ($EEG$).     * Auditory and visual evoked potential tests to assess sensory pathways.

Traumatic Brain Injury ($TBI$) and Head Trauma

• Definition: Unintentional head injury or $TBI$ ranges from mild bruises or cuts to serious internal conditions.
• Etiologies: Commonly caused by sports injuries, road traffic accidents, and child abuse.
• Pathology: Dependent on the specific force of impact.
• Concussion:     * The most common head injury observed in pediatric patients.     * Manifestations: Headache ($HA$) is most common. Also includes sleep-related issues, cognitive difficulties, dizziness, visual disruptions, balance issues, nausea/vomiting ($N/V$), light sensitivity, and tinnitus (ringing in ears).     * Management: Limit physical and cognitive activity for the first $24-48$ hours; rest and Over-the-Counter ($OTC$) Non-Steroidal Anti-Inflammatory Drugs ($NSAIDs$).
• Contusion and Laceration:     * Refers to the actual bruising or tearing of cerebral tissue.     * Causes slowing of blood flow and localized swelling.     * Manifestations: Loss of consciousness, $N/V$, seizures, and impairments in speech, vision, or hearing.     * Timeline: May occur within $12$ hours of the initial $TBI$.     * Intervention Threshold: Medical intervention is required if intracranial pressure ($ICP$) exceeds $20\,mmHg$.     * Example: Shaken Baby Syndrome ($SBS$).

Complications of Head Injury

• Epidural Hematoma:     * Occurs more frequently in children older than $2$ years of age.     * Common examples include Motor Vehicle Accidents ($MVAs$) and child abuse.
• Subdural Hematoma:     * Occurs primarily in infancy (ages $0-4$ months).     * More common than epidural hematomas.     * Causes: Birth trauma, violent shaking, or falls.
• Subarachnoid Hematoma:     * Characterized by a sudden onset of a severe headache ($HA$).     * Associated with vascular malformations or brain tumors.
• Cerebral Edema:     * Typically peaks within $24-72$ hours post-injury.     * Results in changes to neurological status and elevated $ICP$.
• Postconcussion Syndrome: Diagnosis made when concussion symptoms persist for more than $4$ weeks after the initial injury.
• Posttraumatic Headache: Occurs days to months following the head injury.
• Posttraumatic Seizures: Typically occur between $24$ hours to $1$ week following a head injury.

Medical Referral Criteria for Head Injuries

• Seek immediate medical attention if the child:     * Vomits $3$ or more times or continues vomiting for $4-6$ hours after injury.     * Shows swelling in front of or above the earlobe.     * Exhibits fluid leakage from the ears or nose.     * Presents with blackened eyes.     * Displays confusion or abnormal behavior.     * Has difficulty speaking or arousing from sleep.     * Reports blurred vision or diplopia (double vision).     * Demonstrates an unsteady gait.     * Has dilated, fixed, or unequal pupils.     * Experiences seizures.     * Sustained injury at high speeds, with great force, or under suspicious circumstances.     * Experienced a fall from a height greater than the height of the child.     * Experienced loss of consciousness or amnesia.     * Reports discomfort lasting more than $10$ minutes after injury.     * Reports a headache that is severe, worsening, interfering with sleep, or lasting more than $24$ hours.

Submersion Injury

• Pathophysiology: Death results from the aspiration of water while the child is submerged. This can occur in even small quantities of water, such as a pail, toilet, or bathtub.
• Clinical Presentation: Depends heavily on the duration of loss of consciousness and the neurological status following resuscitation.
• Treatment and Nursing Care:     * Requires rapid assessment to determine specific needs.     * Interventions: $CPR$, Oxygen ($O_2$), or mechanical ventilation; continuous monitoring of vital signs ($VS$).     * Laboratory Monitoring: Blood gases and $pH$ levels.     * Metabolic/Therapeutic Care: Rewarming for hypothermia; treatment for seizures; management of hypo/hyperglycemia.     * Hospitalization: All children should be hospitalized for $48-72$ hours.     * Complication Surveillance: Monitor for aspiration pneumonia, respiratory compromise, and cerebral edema.     * Supportive Care: Provide chest physiotherapy; assist parents with coping mechanisms.     * Prevention: Crucial focus for nursing education.

Encephalitis

• Definition: Inflammation of the brain tissue leading to neurological dysfunction.
• Etiology: Usually caused by a virus or an autoimmune condition.
• Prognosis: High rate of mortality; can cause permanent neurological damage.
• Epidemiology: Most cases occur between ages $2-10$ years.
• Clinical Manifestations:     * Neurological: Headache, confusion, hallucinations, seizures, behavioral changes, and light sensitivity.     * Systemic: Fever, rash, weakness, respiratory distress, and Gastrointestinal ($GI$) distress.     * Infants: May present with a bulging fontanel.
• Medical Treatment:     * Acyclovir (Zovirax): Administered for $14-21$ days.     * Corticosteroids: Used to reduce inflammation.

Reye Syndrome

• Definition: Acute encephalopathy characterized by cerebral edema and fatty changes in the liver, usually following a viral illness.
• Etiology: Exact cause is unknown. There is a strong association with the use of aspirin during viral infections (e.g., varicella/chickenpox or influenza).
• Manifestations: Fever, profound impairment of consciousness, disordered hepatic function, $N/V$, malaise, and progressive neurological deterioration.
• Diagnosis:     * History of a viral illness $4-7$ days prior to symptom onset.     * Liver biopsy is the definitive diagnostic tool.
• Treatment and Management:     * Requires early diagnosis and aggressive treatment.     * Maintain effective cerebral perfusion and control rising $ICP$.     * Conduct frequent neurological assessments and monitor Intake and Output (I&O).     * Provide a restful, non-stimulating environment.     * Monitor for signs of bleeding and impaired coagulation due to liver involvement.

Epilepsy and Seizure Types

• Definition: Characterized by $2$ or more unprovoked seizures occurring at least $24$ hours apart.
• Statistics: Approximately $1$ in $10$ children will experience one or more seizures in their first $16$ years. Onset is highest in the first few months of life.
• Etiological Factors:     * Infants: Malformations or genetics (e.g., Dravet Syndrome).     * Childhood: Acute infections or idiopathic (unknown) causes.     * General: Trauma or alcohol exposure.
• Classification of Seizures:     * Motor or Non-Motor Nature.     * Tonic-Clonic: Tonic phase (stiffening) and Clonic phase (jerking).     * Myoclonic: Brief jerking lasting less than $1$ second.     * Atonic: Sudden loss of muscle tone and limpness.     * Epileptic Spasms: Sudden bending or extension of limbs and trunk.     * Absence Seizures: Staring and unresponsiveness.
• Categorization by Awareness and Scope:     1. Generalized: Involves jerking, limb weakness, rigidity, twitching, spasms, sudden loss of movement, eyelid movements, or staring.     2. Focal: Starts with an "aura." Can include impaired or complete awareness. Motor/non-motor signs: repeated mouth/hand movements, muscle spasms, heat/cold sensations, inability to move, altered consciousness, and increased heart rate ($HR$).     3. Unknown: Involves both motor and non-motor movements. May include stiffness, convulsions, bladder/bowel incontinence, and bluish pallor of the face due to lack of oxygen.

Management and Education for Epilepsy

• Pharmacological Treatment: Antiepileptic Drugs ($AEDs$) decrease seizure incidence and severity. Examples include Phenytoin (Dilantin), Carbamazepine (Tegretol), and Valproic Acid (Depakote).
• Alternative Therapies:     * Diet: High fat, low carbohydrate, and moderate protein (Ketogenic diet).     * Vagus Nerve Stimulation (VNS).     * Brain Surgery.
• Patient and Family Education:     * School: Inform the school of medication use.     * Documentation: Maintain a trigger journal to track time, severity, and potential causes.     * Safety: Adolescents must be educated on alcohol use. Children should never be unsupervised around water or in areas where falls are possible. Address driving regulations for adolescents.     * Identification: Wear a medication ID bracelet or necklace.     * Medication Withdrawal: A child may be considered for coming off medication after remaining seizure-free for $2$ years.
• Emergency Care During Seizure:     * Remain calm.     * Place the child on their side.     * Keep the child away from hazards.     * NEVER put anything in the mouth and do NOT restrain the child.

Febrile Seizures

• Epidemiology: Typically occur in children younger than $5$ years with a fever over $100.4^\circ F$. Often accompanies viral fever-inducing illnesses.
• Subtypes:     1. Simple: Most common; affects the whole body; lasts less than $15$ minutes; does not recur within $24$ hours. Recovery takes about one hour.     2. Complex: Focal (affects one part of the body); lasts longer than $15$ minutes; occurs more than once in a $24$-hour period. Recovery takes longer than one hour.
• Clinical Presentation: Presentation matches other seizures (jerking, stiffening, rolling eyes, loss of consciousness) but is uniquely tied to a fever present at the time or developing within hours.
• Management: Usually no specific treatment required. Focus on parent education.
• Hospitalization Criteria: Recommended only if the seizure lasts over $15$ minutes, a serious infection is present, the child remains unresponsive, or the child is under $6$ months old.

Headache Disorders in Children

• Primary Headaches: Not caused by an underlying condition; prevalent in children.
• Tension Headaches:     * Described as bilateral pressure or tightness around the head, neck, or shoulder muscles.     * Often triggered by stress.     * Treatment: OTC medications (Motrin/Ibuprofen or Tylenol/Acetaminophen), hydration, or Oral Rehydration Solution ($ORS$). Medication should not be used more than $2-3$ days per week.
• Migraines:     * Can affect all ages, including infants.     * Episodic: Occurs fewer than $15$ days per month.     * Chronic: Occurs $15$ or more days per month for at least $3$ months.     * Phases:         1. Prodrome: Up to $72$ hours prior; includes aura, restlessness, fatigue, mood changes, and light/sound sensitivity.         2. Headache Phase: Pulsing/throbbing pain (moderate to severe, 1 or both sides), $N/V$, light/sound sensitivity, vision changes. Duration: $4-72$ hours (younger children may only last $2$ hours).         3. Postdrome: Fatigue, mood changes, or concentration difficulty after pain subsides.     * Notes: Facial pallor is common in younger children.

Hydrocephalus

• Classification:     * Acquired vs. Congenital.     * Communicating: No obstruction; caused by inadequate absorption or over-production of cerebrospinal fluid ($CSF$).     * Non-communicating: Flow of $CSF$ is blocked by an obstruction.     * Expected Pressure or Ex-vacuo.
• Infant Manifestations: Increased head circumference, bulging/non-pulsating anterior fontanels, dilated scalp veins, "sun-setting" eyes (eyes deviated downward), irritability, lethargy, seizures, vomiting, and low muscle tone.
• Child Manifestations: Irritability, $HA$, $N/V$, vision problems/crossed eyes, difficulty walking or staying awake, poor appetite, gait/balance issues, urinary incontinence, and poor school performance.
• Diagnosis:     * Fetal ultrasound as early as $14-15$ weeks.     * Infants: Head circumference crossing $1$ or more percentile lines.     * Older children: $CT$ and $MRI$.
• Surgical Treatment:     * Ventriculoperitoneal ($VP$) Shunt: Drains into the peritoneal cavity (used for neonates and young infants).     * Ventriculoatrial ($VA$) Shunt: Drains into the right atrium (used for older children).     * Endoscopic Third Ventriculostomy ($ETV$): A hole is made in the bottom of the ventricle allowing drainage (used for children younger than $2$).
• Nursing Care: Educate on signs of shunt failure (malfunction) or infection. Meningitis vaccination is a key prevention method.

Pediatric Brain Tumors

• Gliomas: Tumors originating from Central Nervous System ($CNS$) cells. Classified as low-grade (benign) or high-grade (malignant).     * Astrocytoma: Most common; can occur anywhere in the brain/spinal cord; typically does not spread.     * Ependymoma: Third most common; usually found in the back of the brain.     * Brainstem Glioma: Affects brainstem functions; can be diffuse or focal.     * Optic Nerve Glioma: Affects vision.
• Medulloblastoma: Embryonal brain tumor located in the lower back of the brain (midline of the $4^{th}$ ventricle).     * Traits: Highly aggressive, malignant, and spreads easily.
• Clinical Presentation: Morning headaches that resolve after vomiting; loss of balance, changed handwriting, fatigue, personality changes, and sensory problems.
• Diagnosis & Treatment: $MRI$ and biopsy. Treatment includes surgery to remove the tumor and surrounding tissue. Infants under $6$ months with low-grade tumors may simply be monitored.

Neuroblastoma

• Definition: A tumor that starts in the adrenal glands, originating from "neuroblasts" (immature embryonic nerve cells).
• Epidemiology: Primarily seen in children under $5$ years old.
• Detection: Can be congenital and seen on prenatal ultrasound, but usually diagnosed after symptoms appear from metastasis.
• Manifestations: Lump or pain in the abdomen, chest, or pelvis; blue/purple skin lesions; changes in eye appearance; difficulty breathing; limb weakness; and sudden muscle movements.
• Diagnosis: Bone marrow aspiration and testing for catecholamines in the urine ($UA$).
• Treatment: Radiation, chemotherapy, bone marrow transplant, and/or immunotherapy.

Test Yourself: Discussion and Questions

• Question 1 (Chronic Migraines): A nurse is reviewing the health history of a pediatric client who reports chronic migraines. Which of the following would the nurse expect to find?     * Options: A. The headaches occur once a week; B. The client is more than $12$ years old; C. The headaches have been occurring for at least $3$ months; D. The client experiences painful headaches occasionally.     * Correct Answer: C (Definition of chronic migraines involves at least $3$ months of symptoms).
• Question 2 (TBI Match):     * 1. Concussion = C (A bump from a fall causes the brain to bounce against the skull)     * 2. Contusion/laceration = D (A blow to the head from a hockey stick causes a cut)     * 3. Epidural hematoma = A (Car accident trauma causes blood to pool between the skull and the membrane covering the brain)     * 4. Subdural hematoma = B (A fall from a horse causes blood to pool on the surface of the brain and press against tissue)
• Question 3 (Encephalitis Assessment Questions):     * Correct Inquiries: "Was the child bitten by an insect lately?" (A); "Have you noticed a change in behavior in your child?" (B); "Have you traveled outside the country lately?" (D); and "Does the child have any immunodeficiency disorders?" (E). Smoking during pregnancy (C) is not a standard assessment question for acute encephalitis.