ignore - ex pt 2 of final Flashcards
(22 cards)
differentiate seizures (general, focal, abscance!!!!, febrile!!!!!)
-seizure = sudden, transient disturbance of brain activity manifested by involuntary motor, sensory, autonomic, or psychic phenomena, often accompanied by alteration of consciousness
-triggered by any factor that disturbs brain function (acute metabolic, traumatic, anoxic, or infectious insults)
-Unprovoked seizures -> chronic abnormalities/genetic mutations
-Epilepsy: 2 seizures separated by at least 24 hours
-single seizure w/ > 60% risk of recurrence, or dx of epilepsy syndrome
-Risk of 2nd seizure after unprovoked seizure -> 50%
-Risk of recurrence after 2nd unprovoked seizure -> 85%
-Epilepsy highest in newborn period, flattens after age 10-15 years
-70% have remission w/ 1st appropriate medication
-Classified by The international League Against Epilepsy (ILAE)
-FOCAL, GENERALIZED, UNKNOWN
-Focal: With or w/o alteration of awareness, motor versus nonmotor (autonomic, emotional, or sensory)
-Generalized: Tonic-clonic (stiffening-shaking), absence, myoclonic (twitching/jerking), atonic (sudden loss of tone), myotonic atonic (jerk followed by sudden loss of tone), tonic, and clonic
-Epilepsy syndromes defined by nature of seizures, age of onset, EEG findings, and other clinical factors
-onset: Determines if its a seizure and if there is localized (focal) onset
-Events prior to, during, and after (even videos are useful)
-Generalized convulsions (observed by others), aura (alterations in behavior or feelings of extreme fear, happiness/anxiety, odd or unusual taste/smell, rising feeling in abdomen)
-Specific sx may help define location of seizure onset
-Behavior and movements are key in classifying
-Lateralized motor movements (eye deviation to one side, dystonic posturing of a limb) w/o impaired awareness -> focal, motor seizures
(simple, partial seizures)
-Automatisms (blinking, chewing, or hand movements) assoc with “zoning out” (partially impaired awareness) -> focal, motor seizures
-Acute, complete LOC and “whole body” (generalized) motor activity -> generalized, convulsive seizures
-Tonic posturing, tonic-clonic activity, or myoclonus may occur
-Behavioral arrest w/ “staring” and automatisms -> absence versus focal motor
-Main differentiator: No postictal state w/ absence, myoclonic, or atonic seizures
-Many focal and most generalized seizures have postictal sleepiness state
-< 3yo with new onset of unprovoked seizures -> EEG and MRI (most have structural, genetic, or metabolic cause)
-Routine EEG useful primarily for defining interictal activity and/or recording clinical seizure (when seizures are easily provoked)
-EEG showing epileptiform activity may confirm and clarify dx -> not always dx
-Other dx used selectively:
-Routine labs -> unnecessary in well child w/ seizures (unless high clinical suspicion of serious medical conditions)
-Further workup for suspicion of acute systemic etiology (renal failure, sepsis, or substance abuse)
-Emergent imaging -> unnecessary if no trauma or acute abnormalities on exam
seizure tx - just know ethosuximide
-Turn to side
-Do not place any objects in mouth or try to restrain tonic-clonic movements
-Prolonged seizures (> 5 mins) or seizure clusters (> 6 hrs): Acute home tx with benzos (rectal diazepam gel (Diastat) or intranasal midazolam!!!!!!!!!!!!!!!!)
-No ASM prevents or cures epilepsy
-Unnecessary until dx of epilepsy established
-Some are effective for focal seizures, but make generalized seizures worse (oxcarbazepine, carbamazepine)
-Some are effective for most and relatively safe (levetiracetam)
-!!!!Ethosuximide- absence seizures
-SE can help guide tx
-Ex: Topiramate tends to suppress appetite; valproic acid often precipitates weight gain
-If monotherapy unsuccessful -> a 2nd and sometimes 3rd med may be required
-Tx of acute, symptomatic (provoked) is correction of cause -> however short-term ASM may be necessary
-continue meds until no seizures for at least 1-2 years
-Most tapered off over 6-8 weeks
-Recurrent seizures affect 25% of kids who attempt tapering off from meds -> restart ASM and maintain for at least another 1-2 years
-Favorable prognosis: Younger age of onset, normal EEG, undetermined etiology, ease of controlling seizures
-Poor prognosis: Identified etiology, older onset, continued epileptiform EEG, difficulty in establishing seizure control, polytherapy, generalized tonic-clonic or myoclonic seizures, abnormal neurologic examination
seizure complications
-Psychosocial impact:
-Mood disturbances, especially anxiety/depression, anger, feelings of guilt and inadequacy
-School-aged kids- increased risk of suicide
-Actual/perceived stigmas (limiting activities at school adds to this)
-Cognitive Impairment:
-epilepsy, untreated/poorly controlled -> can develop reduced cognition and memory
-Some ASMs have reversible cognitive impairment effects (phenobarbital, topiramate, and zonisamide)
-Psychosis following seizures or as a SE of meds
-Injury/Death:
-Direct physical injuries frequent with atonic seizures, at times necessitating protective headgear
-Must promote water safety (monitoring, showers versus baths)
-Most deaths are related to underlying neurologic disorder, not the seizures
education:
-Supervision while swimming, protective headgear
-No absolute CI to sports
-Some literature suggests exercise decreases overall seizure burden
-Avoid sleep deprivation/alcohol -> triggers
-Driving: Varies by state
-Most states - learner’s permit or driver’s license if seizure free for at least 6-12 months
-Pregnancy: Discuss interactions of oral contraceptives w/ ASMs, potential teratogenic effects of ASMs, and management of pregnancy as soon as appropriate w/ adolescents
-School intervention
-Schools required by federal law to work w/ guardians to establish a seizure action plan for child w/ epilepsy
-School authorities should be encouraged to avoid needless restrictions and to address emotional/educational needs of children
febrile seizures
-Criteria: 6mo-6yrs, fever > 38.8C, non-CNS infection
->90% are generalized, last < 5 mins, and occur early in the illness
-Dx:
-evaluate for source of fever (to exclude CNS infections)
-Always consider meningitis/encephalitis!
-Routine labs/imaging/EEG seldom helpful (unless warranted based on H&P)
-Tx:
-Prophylactic ASMs not recommended
-Control of fever is ineffective at preventing recurrence (not recommended solely for prevention of seizure)
-Prognosis:
-Recurrent febrile seizures in 30-50%, as well as other forms of seizures
-Cognitive function not significantly different from that of siblings w/o febrile seizures
sleep disorders overview
- Sleep is a developmental phenomenon:
- Infants are not born w/ sleep-wake cycles
- REM > NREM in newborns, decreases by 3-6 months of age
- Newborns sleep 10-19 hours/day in 2- to 5-hour blocks
- First year: Consolidation of sleep into a 9- to 12-hour block, naps x 1/day
- By 3-5 years, no more naps
- Recommendations for hours of sleep by National Sleep Foundation
- 1-2 years: 11-14 hours/day
- 3-5 years: 10-13 hours/day
- 6-13 years: 9-11 hours/day
- Adolescents: 9-9.5 hours/day
- Often get only 7-7.25 hours due to 1-3 hour sleep delay phase (from changes in hormonal regulation of circadian rhythm)
- Some school districts begin at later start times for high schoolers
BEARS screening tool:
* Bedtime resistance
* Excessive daytime sleepiness
* Awakening during the night
* Regularity and duration of sleep
* Sleep-disordered breathing
* Medical psychosocial history, physical examination
* Assessment for allergies, lateral neck films, polysomnography
* GER, dental pain, eczema, medications
* Treatment: ABCs of SLEEPING
* Age-appropriate Bedtimes and wake times w/ Consistency, Schedules and routines, Location, Exercise and diet, no Electronic in bedroom or before bed, Positivity, Independence when falling asleep, Needs of child met throughout the day, equals Great sleep
* Little evidence to support use of melatonin/clonidine for sleep disorders
*
sleep disorders: parasomnias: night terrors
-Night Terrors
-w/in 2 hrs of sleep, during deepest stage of NREM sleep
-3% of kid affected- 3-8yo
-sit up in bed screaming, thrashing about, rapidly breathing, tachycardic, and sweating
-incoherent and unresponsive to comforting
-Episode may last 30 minutes
-goes back to sleep w/o memory of event next day
-Tx:
-Parental reassurance
-Measures to avoid stress, irregular sleep schedule, or sleep deprivation (prolongs deep sleep)
sleep disorders: parasomnias: somnambulism
-sleepwalking
-Also occurs during slow-wave/deep sleep
-4-8yo
-Typically benign -> but pt may injure themselves while walking around
-create safe environment (lock doors, bells on bedroom door)
-Tx: Avoid stress, sleep deprivation
sleep disorders: insomnia
a
-Difficulty initiating sleep and nighttime awakenings
-daytime fatigue for both parents and child, parental discord about management, and family disruption
-Several factors contribute to disturbances:
-Quantity and timing of feeds in 1st yr
-Most infants >6mo can go through night w/o feedings (waking for feeds is probably a learned behavior)
-Bedtime habits
-Child’s temperament
-Low sensory thresholds and less rhythmicity (regulatory disorder)
-Separation anxiety (9 months)
-Psychosocial stressors
-Complex medical conditions: Neurological, developmental, psychiatric disorders
sleep disorders: nightmares
- Nightmares
- Frightening dreams that occur during REM sleep (later in night), typically followed by awakening (alert)
- Peak occurrence between ages 3 and 5, with incidence between 25-50%
- Child can typically describe frightening images, recall the dream, and talk about it during the day
- Seeks and responds well to parental comfort; often wants to stay w/ parents for rest of the night
- Treatment: Self-limited; may be associated w/ stress, trauma, anxiety, sleep deprivation
*
sleep disorders: sleep apnea and Restless Legs Syndrome (RLS) & Periodic Limb Movement Disorder (PLMD)
Sleep-Disordered Breathing/Obstructive Sleep Apnea
* Obstructed breathing during sleep accompanied by loud snoring, chest retractions, morning headaches, dry mouth, and daytime sleepiness
* OSA occurs in 1-3% of preschoolers, peaks between ages of 2 and 6
* Associated w/ daytime behavioral disorders, including ADD/ADHD
Restless Legs Syndrome (RLS) & Periodic Limb Movement Disorder (PLMD)
* Frequency in children of 2%
* RLS: Uncomfortable sensation in the lower extremities at night when trying to fall asleep, relieved by movement
* Described by children as “creepy-crawly” or “itchy bones”
* PLMD: Stereotyped, repetitive limb movements often associated with a partial arousal or awakening
* Both have been associated w/ iron deficiency and drugs (caffeine, nicotine, antidepressants)
* No studies on medications for children
Sleep Disorders: Narcolepsy
- Chronic, inappropriate daytime sleep that occurs regardless of activity or surroundings and is not relieved by increased sleep at night
- Half of individuals experience their initial symptoms in childhood, typically around/after puberty (sometimes in early childhood)
- Diagnosis: Short latency between sleep onset and transition into REM sleep
- Treatment: Sleep hygiene/behavior modification
- CNS stimulants/antidepressants off-label
cerebral palsy- know spastic
-0.2% of live births
-Static impairment of motor development -> affecting tone, strength, coordination, or movements
-Causes: Vast range from perinatal brain injury (preterm birth), hypoxic ischemic injury, stroke, or infection to brain malformations and genetic conditions
-Nonprogressive, full degree of impairment may not be evident until 2-4yo when motor expectations are more robust
-Subtypes: !Spastic (80%), ataxic (15%), athetoid/dyskinetic (5%), persistent hypotonia w/o spasticity (<1%)
-!!Spastic: Described based on limb(s) affected: Monoplegia, hemiplegia, diplegia, and quadriplegia
-Affected extremity may be smaller/shorter than others
-Ataxic: Upper extremity predominantly involved
-Athetoid/dyskinetic: Choreoathetosis or dystonia
-MC comorbid conditions: Epilepsy (25%) and intellectual disability (50%)
-Others: Vision impairment, language delay, AS, learning disabilities
cerebral palsy dx and tx
-Dx:
-H&P guides workup
-MRI of brain is essential to understand extent of cerebral involvement and may reveal etiology or identify perinatal stroke/brain malformation
-Genetic testing, metabolic testing: Targeted based on clinical context
-Tx:
-Directed at maximizing child’s neurologic functioning w/ physical, occupational, and speech therapy
-Task-specific approach: Encourages neuroplasticity
-Intensive constraint-induced movement therapy: Benefits affected extremity
-Monitoring for orthopedic issues, neurophysiological testing to provide optimal school support, and treatment of spasticity and seizures
-Support/counseling for family
spina bifida: know all types
- Defective closure of the caudal neural tube (end of week 4 of gestation) resulting in anomalies of the lumbar and sacral vertebrae or spinal cord
- Anomalies range in severity from clinically insignificant defects of L5 or S1 vertebral arches to major malformations, leaving the spinal cord uncovered by skin or bone on infant’s back
- Myelomeningocele: Flaccid paralysis and loss of sensation in the legs, incontinence of bowel and bladder
- Extent and degree of deficit dependent on location
- Usually have associated Chiari type II malformation, resulting in hydrocephalus and weakness of face/swallowing
- Meningocele: Spinal canal and cystic meninges exposed on back, but underlying spinal cord is anatomically and functionally intact
- Spina bifida occulta: Skin of back is intact, but defects of underlying bone or spinal cord present
- Meningoceles/spina bifida occulta may:
- Be associated w/ lipoma, dermoid cyst, or dimple/tuft of hair over affect area
- Have dermoid sinus: Epithelial tract extending from skin to meninges > increased risk of meningitis
- Have weakness/numbness in feet (ulcerations) or difficulties controlling bowel/bladder function (UTIs, reflux nephropathy, renal insufficiency)
*
spina bifida dx and tx
Diagnostic Studies
* Myelomeningocele suggested by elevated a-fetoprotein (AFP) in mother’s blood and confirmed by US and high concentrations of AFP and acetylcholinesterase in the amniotic fluid
* After birth: Screening US w/ MRI to confirm less dramatic spinal abnormalities
Treatment/Prevention
* Myelomeningocele
* Operative closure of the open spinal defects
* Treatment of hydrocephalus by placement of VP shunt
* Toddlers/children w/ lower spinal cord dysfunction require PT, bracing of lower extremities, and intermittent bladder catheterization
* Most survivors have normal intelligence
* Learning problems and epilepsy are more common than general population
* Prevention via folate administration in pregnant mother
infections -> bacterial meningitis, tetanus, polio -> what causes it and whats the tx
Attention Deficit/Hyperactivity Disorder
dx
ADHD -> mangement after therapy
Diagnosis
Symptoms of ADHD fall into two categories: hyperactive/impulsive or inattentive (also a combined form)
Significant impairment in attention or concentration and/or significant hyperactivity and impulsivity in excess of what is expected for age
Functional impairment in at least two settings is required for diagnosis (parents and teachers for historians) – specialized forms exist for this
Not all hyperactivity and/or inattention can be attributed to ADHD!
Medical, psychiatric, learning, neurodevelopmental disorders may all present w/ symptoms suggestive of ADHD
Attention Deficit/Hyperactivity Disorder
tx
-Behavioral therapy is 1st line
-Stimulants are most effective and MC prescribed meds (75% of children experience sx improvement)
-Children who do not respond favorably to one stimulant may respond to a stimulant from other class (amphetamine versus methylphenidate)
-If stimulants not well-tolerated, non-stimulants may be used
-FDA approved: Atomoxetine, selective noradrenergic reuptake inhibitors, central a-adrenergic receptor agonists (guanfacine, clonidine) -> dont need to know
-External trigeminal nerve stimulation (ETNS): Device placed on forehead overnight to stimulate trigeminal nerve has FDA approval for those 7-12 years of age, not being treated w/ medication
-Effect is mild and did not separate from placebo until 4 weeks
-Side effects: Appetite increase, sleep difficulties, teeth clenching, headache, and fatigue
ADHD: special considerations w/ stimulant meds
-ADRs: Anorexia, wt loss, abdominal distress, headache, insomnia, dysphoria/tearfulness, irritability, lethargy, mild tachycardia, mild elevation in BP
-Less common SE: Interdose rebound of ADHD symptoms, anxiety, tachycardia, HTN, depression, mania, and psychotic symptoms
-Caution taken w/ cardiovascular hx, personal/family hx of drug abuse/addictive disorders (transdermal patches may be better)
-Use w/ caution in those w/ psychotic disorders and those w/ bipolar affective disorder (worsen symptoms)
-After initiating medications: Pulse, BP, height/weight recorded every 3-4 months and at times of dosage increases; also record abnormal movements (tics)
-Prognosis:
-60-85% of those diagnosed w/ ADHD in childhood continue to carry diagnosis into adolescence
-1/3rd of adults previously diagnosed w/ ADHD in childhood require ongoing medication management
oppositional defiant disorder (OOD)
-More common in families where caregiver, family-level, and/or environmental dysfunction (substance abuse, parental psychopathology, significant psychosocial stress) is present
-More prevalent in children w/ hx of multiple changes in primary caregivers, inconsistent/harsh/neglectful parenting, abuse, exposure to violence, or serious caregiver relational discord
-Dx: Usually evident < 8yo and may precede conduct disorder; symptoms first at home, then at school/peers
-Pattern of negativistic, hostile, and defiant behavior lasting at least 6 months
-Loses temper, argues w/ adults, defies rules
-Blames others for own mistakes and misbehavior
-Angry, easily annoyed, vindictive
-Does not meet criteria for conduct disorder
-Tx:
-Assessment of the psychosocial situation and recommendations to support parenting skills and optimal caregiver functioning
-Assessment for comorbid psychiatric diagnoses: Learning disabilities, depression, and ADHD (w/ appropriate interventions recommended)
conduct disorder
- -approx 9% of males and 2% of females <18yo
-Overlap w/ ADHD, substance abuse, learning disabilities, neuropsychiatric disorders, mood disorders, and family dysfunction
-RF: homes with domestic violence, child abuse, drug abuse, shifting parental figures, and poverty
-Hx of reactive attachment disorder
-Inconsistent and severe parental disciplinary techniques, parental alcoholism, and parental antisocial behavior
-Dx:
-Prototypical is boy w/ turbulent home life and academic difficulties
-Hyperactive, aggressive, and uncooperative behavior patterns in preschool/early school years tend to predict conduct disorder in adolescence w/ high accuracy
-Defiance of authority, fighting, tantrums, running away, school failure, and destruction of property
-With increasing age: Fire-setting, theft, truancy, vandalism, and substance abuse; sexual promiscuity, sexual perpetration, and other criminal behaviors may develop as well
-Tx:
-Multisystemic therapy (MST)- Intensive home-based model of care that seeks to stabilize and improve the home environment and strengthen the support system/coping skills of individual and family
-Identification of learning disabilities and placement in optimal school environment
-Addressing assoc neurologic and psychiatric disorders
-Early involvement in programs (Big Brothers, Big Sisters, scouts, team sports) in which consistent adult mentors and role models interact w/ youth
-Involvement of juvenile system in cases where behaviors lead to illegal activities, theft, or assault
-Prognosis:
-Generally worse if disorder presents <10yo, antisocial behaviors across multiple settings, pts raised in environments w/ antisocial behaviors of parent
-50% develop antisocial personality disorder as adults
k so he basically highlighted all of behavioral medicine ppt so skip
