Paediatric neurology

Pediatric neuro items ask you to hear the high-pitched cry, cover a neural tube sac correctly, start droplet for meningitis, and keep aspirin out of viral illness teaching.

ICP and shunts

An infant’s skull can still expand at the sutures and fontanels, so rising intracranial pressure does not always announce itself the same way as in a closed adult skull. Pressure still crowds brain tissue and venous drainage — the pediatric exam ask is recognizing the infant picture early: high-pitched cry, bulging fontanel, irritability, vomiting, sunset eyes, and a head circumference that is climbing. Adult early/late ICP staging, Cushing triad, and the “midline and thirty” positioning rules live in Increased ICP and head injury; this chapter owns the infant and shunt stems.

A ventriculoperitoneal (VP) shunt moves CSF out of the ventricles into the abdomen so pressure stays in a safer range. When the shunt obstructs, kinks, or infects, CSF backs up and the infant (or older child with a shunt) looks like rising ICP again — vomiting, irritability, headache, falling LOC, bulging fontanel. Treat that cluster as malfunction until proven otherwise. After shunt surgery, the same cues are not “expected postop fussiness”; escalate rather than wait for a perfect triad.

At the bedside: elevate the head of bed as ordered, keep the head midline when that is the plan, cut unnecessary stimulation and clustered painful care, and notify. Parent teaching often pairs fever watch with “call for the high cry / vomiting / sleepiness change” — the exam distractor is reassuring a known-shunt child who is vomiting and irritable because “kids get stomach bugs.”

Neural tube defects and CP

Myelomeningocele is an open neural tube defect: meninges and neural tissue sit in a sac on the back. Until surgical closure, that tissue is exposed — drying, pressure, urine/stool contamination, and trauma all threaten infection and further cord injury. Pre-op care is mechanical protection first: position prone or side-lying as ordered so nothing rests on the sac, cover with a moist sterile nonadherent dressing, and keep the diaper below the defect so stool never sits on the sac.

• Keep the sac moist with sterile nonadherent dressing; prone positioning as ordered.
• Measure head circumference; watch for hydrocephalus.
• CP feeding: upright, slow, suction ready if aspiration risk is high.

Many of these infants also develop hydrocephalus because CSF flow is disrupted — serial head circumference is not busywork; a sudden jump with ICP cues means escalate. Latex sensitivity is more common in this population from early repeated exposures, so latex-safe supplies are the default teaching pattern on exams. Cerebral palsy is a nonprogressive motor disorder from early brain injury; tone and coordination problems do not mean the brain lesion is still spreading, but poor swallow and uncoordinated feeding do mean aspiration risk — upright feeds, ordered textures, and suction readiness beat “force the bottle so they gain weight.”

Meningitis and seizures

Bacterial meningitis is inflammation of the meninges from organisms that can travel in respiratory droplets. On suspicion — fever with stiff neck, photophobia, lethargy, or in an infant poor feeding, irritability, and a bulging fontanel without a clear other source — start droplet precautions before the culture result returns. Waiting for a confirmed label while you share a room without a mask is the distractor that looks evidence-based and fails infection control.

1. On suspicion: droplet precautions, cultures, antibiotics per protocol.
2. Seizure: protect airway/injury, side-lying, time it, nothing in the mouth.
3. After seizure: assess breathing, recovery position, notify for prolonged/status patterns.

Workup and drugs move fast: obtain cultures, then start antibiotics as protocol allows without delaying therapy for every optional study. Isolation plus the workup is the paired answer — droplet alone without treatment planning, or antibiotics without precautions, both miss half the stem.

During a seizure the brain’s electrical storm will end; your job is to keep the child from secondary injury. Move hard objects away, ease to the floor if needed, turn side-lying when able so saliva drains, time the event, give oxygen if ordered, and never force anything into the mouth or pin the limbs down. Afterward, check breathing and color, keep a recovery position, and escalate for a seizure that does not stop or for back-to-back events (status patterns). School and parent stems use the same rules — the caring-looking wrong answer is a tongue blade or “hold them still.”

Reye syndrome is rare but still tested as a teaching trap: salicylates (aspirin) during or after viral illnesses such as varicella or influenza associate with acute encephalopathy and liver failure in children and teens. Fever teaching is acetaminophen or ibuprofen as ordered — not aspirin — unless the child has a specific indication such as Kawasaki disease where aspirin is part of the ordered regimen.

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