Nursing Care of a Family When a Child Has a Neurologic Disorder PDF

49 Nursing Care of a Family When a Child Has a Neurologic Disorder Tasha is a 3-year-old girl you meet in an emergency department because she’s had a seizure. Her mother grabs your arm, visibly upset. “Her sister has cerebral palsy and seizures. Does this mea...

49 Nursing Care of a Family When a Child Has a Neurologic Disorder Tasha is a 3-year-old girl you meet in an emergency department because she’s had a seizure. Her mother grabs your arm, visibly upset. “Her sister has cerebral palsy and seizures. Does this mean Tasha has cerebral palsy too?” she asks you. Previous chapters described normal growth and development in children and nursing care of children with disorders of other systems. This chapter adds information about the dramatic changes, both physical and psychosocial, that occur when a child is born with or develops a neurologic disorder. Such information builds a base for care and health teaching for children with these disorders. What education does this parent need about cerebral palsy or recurrent seizures? KEY TER MS astereognosis automatism autonomic dysreflexia choreoathetosis choreoid decerebrate posturing decorticate posturing diplegia dyskinetic graphesthesia hemiplegia infantile spasms kinesthesia paraplegia pulse pressure quadriplegia status epilepticus 3000 stereognosis OBJ EC TIV ES After mastering the contents of this chapter, you should be able to: 1. Describe common neurologic disorders in children. 2. Identify 2020 National Health Goals related to neurologic disorders in children that nurses can help the nation achieve. 3. Assess a child with a neurologic disorder. 4. Formulate nursing diagnoses for a child with a neurologic disorder. 5. Establish expected outcomes for a child with a neurologic disorder to help the family manage seamless transitions across differing healthcare settings. 6. Using the nursing process, plan nursing care that includes the six competencies of Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork & Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI), Safety, and Informatics. 7. Implement nursing care, such as monitoring medicine effectiveness, for a child with a neurologic disorder. 8. Evaluate expected outcomes for achievement and effectiveness of care. 9. Integrate knowledge of neurologic disorders and the interplay of nursing process, the six competencies of QSEN, and Family Nursing to promote quality maternal and child health nursing care. Neurologic disorders encompass a wide array of problems resulting from congenital disorders, infection, or trauma. Many of these disorders severely alter the child’s life; some result in life-threatening complications. Whenever possible, prevention must be the highest priority for keeping the nervous system healthy because, in the future, stem cell research may offer a cure for neurologic disorders, but for now, because neural tissue does not regenerate like other body tissue, any nervous system degeneration is likely to be permanent. Therefore, nursing care focuses on prevention or measures to help the child and family develop strategies for dealing with the associated loss in mental or physical functioning, making the child comfortable, and providing an environment conducive to the child’s development and self-esteem (Parachuri & Inglese, 2013). The 2020 National Health Goals related to neurologic disorders in children are shown in Box 49.1. BOX 49.1 Nursing Care Planning Based on 2020 National Health Goals Neurologic disorders are major causes of long-term disability in children. The 2020 3001 National Health Goals that address these disorders are: Increase the proportion of children or youth with disabilities who spend at least 80% of their time in regular education programs from a baseline of 56.8% to a target level of 73.8%. Reduce the number of people 21 years of age and younger with disabilities who are in congregate care facilities from a baseline of 28,890 to 26,001. Increase the proportion of people with epilepsy or uncontrolled seizures who receive appropriate medical care. Reduce emergency department visits for nonfatal traumatic brain injuries from 407.2/100,000 population to 366.3/100,000 (U.S. Department of Health and Human Services, 2010; see www.healthypeople.gov). Nurses can help the nation achieve these goals through helping to prevent neurologic injury by educating children and parents about the use of helmets for bicycle and motorcycle safety, by administering and teaching paramedical personnel to administer safe care at accident scenes so children’s heads and necks are protected, and by decreasing the possible spread of bacterial meningitis through good hand washing and infection control precautions in hospitals. Nursing Process Overview FOR CARE OF A CHILD WITH A NEUROLOGIC SYSTEM DISORDER ASSESSMENT Neurologic disorders often begin with vague symptoms. Parents may report that their child seems to be “walking strangely” or is “just not herself,” making a thorough history and neurologic examination imperative for isolating the cause of the concern. The neurologic examination covers six areas of neurologic functioning as well as motor and sensory functioning. If more information is needed following an exam, additional diagnostic tests will be prescribed. The parents and child need considerable support throughout the assessment process because, although the neurologic examination can be made “fun” for a child, other procedures such as a computed tomography (CT) scan or lumbar puncture can be frightening. Additionally, the anxiety of not knowing what is wrong and fearing the worst can make the waiting period for test results especially difficult for the child’s parents. NURSING DIAGNOSIS Nursing diagnoses for children with neurologic disorders vary according to the child’s needs and level of functioning. Initially, a child may need emergency care and constant observation; later on, maintenance care to retain function is the priority. If the child has surgery, nursing diagnoses need to address not only immediate preoperative and postoperative care but also long-term care such as rehabilitation and home care. Three common nursing diagnoses that apply to almost all neurologic disorders are: 3002  Risk for disuse syndrome related to neurologic deficit affecting one area of functioning Interrupted family processes related to stress associated with the long-term effects of neurologic involvement Health-seeking behaviors related to care of a child with neurologic involvement Other nursing diagnoses are specific for disorders and thus are described along with specific disorders. OUTCOME IDENTIFICATION AND PLANNING Be realistic when establishing expected outcomes because children who have permanent limitations will not be able to achieve progress in all areas. When neurologic disorders are first diagnosed, parents may be so stressed that they may be able to focus only on short-term aspects of care, such as whether the child will survive meningitis or whether the child has stopped convulsing. Later, they’ll be able to concentrate on the long-term picture: What type of education setting will be best for their child? What type of exercise program will be required? Before a diagnosis is confirmed, parents may attribute their child’s functional deficits to immaturity (she is not walking yet because she is simply too young). This can make them unable to make plans because they have not fully acknowledged their child’s neurologic deficits. Only when parents begin to adjust to the new reality are they ready to participate in planning and problem solving. Numerous organizations are available for assistance and support, such as the Epilepsy Foundation of America (www.epilepsyfoundation.org), the National Dissemination Center for Children With Disabilities (www.parentcenterhub.org), the Children’s Tumor Foundation (www.ctf.org), the United Spinal Association (www.spinalcord.org), and the United Cerebral Palsy Association (www.ucp.org). IMPLEMENTATION Nursing interventions for a child with a neurologic problem must address both short- and long-term needs. A lot of nursing care involves modeling care, such as how to gently handle an infant with increased intracranial pressure (ICP) and how to turn an infant on the side during a seizure to prevent choking, and reviewing needed medications with parents—actions that give parents confidence to be able to care for their child at home. OUTCOME EVALUATION Evaluation of a child with a neurologic disorder should address not only the child’s progress in regaining physical function but also the child’s level of self-esteem. Some examples indicating achievement of possible outcomes are: The child states he or she is aware of potential for injury related to recurrent seizures. The parent/caregiver states understanding of potential for injury related to recurrent seizures. Family members state they are able to maintain family cohesiveness yet sustain 3003  contact with hospitalized child. The child practices exercises daily to reduce possibility of contracture from disuse syndrome. Anatomy and Physiology of the Nervous System Nerve cells (neurons) are unique among body cells in that, instead of being compact, they consist of a cell nucleus and extensions: one axon and several dendrites. The dendrite transmits impulses to the cell nucleus; the axon transmits impulses away from the cell nucleus to body organs. These cells vary in size, ranging from a few inches to several feet long, reaching from distant body sites such as the feet, through the spinal cord, and to the brain. Although their great length is vital to motor and sensory function, it also makes nerve cells more susceptible than other body cells to injury. The nervous system is not fully functioning at birth; it continues to mature through the first 12 years of life. Two separate systems are involved: the peripheral nervous system (PNS) and the central nervous system (CNS). The PNS consists of the cranial nerves, the spinal nerves, and the somatic and visceral divisions. The CNS includes the brain and the spinal cord (Fig. 49.1) surrounded by the cerebrospinal fluid (CSF), the skull, and three membranes or meninges (the dura mater, a fibrous, connective tissue containing many blood vessels; the arachnoid membrane, a delicate serous membrane; and the pia mater, a vascular membrane) that protect the brain and spinal cord from trauma. Figure 49.1 Meninges of the (A) brain and (B) spinal cord. The properties of CSF are shown in Table 49.1. Basically, it is a colorless, alkaline fluid with a specific gravity of approximately 1.004 to 1.008, containing traces of protein, glucose, lymphocytes, and body salts. TABLE 49.1 NORMAL PROPERTIES OF CEREBROSPINAL FLUID Parameter Normal Abnormal Finding: Possible Significance 3004  Finding Opening pressure Newborns: 8– Lowered pressure usually indicates there is 10 cm subarachnoid obstruction in the spinal column H2O; above the puncture site. children: Elevated pressure suggests intracranial 10–18 cm compression, hemorrhage, or infection. H2O Pressure increases if a child coughs or pressure is applied to the external jugular vein (Valsalva maneuver). Appearance Clear and If cloudy, indicates possible infection with an colorless increased number of white blood cells (WBCs). If reddened, color is probably because of red blood cells (RBCs). Cell count 0–8/mm3 Granulocytes suggest cerebrospinal fluid (CSF) infection. Lymphocytes suggest meningeal irritation and inflammation. A few RBCs and WBCs are normally present in the newborn CSF due to the trauma of birth. Protein 15–45 Elevated count (>45/100 ml) occurs if RBCs are mg/100 ml present. If both protein content and RBC count are elevated, meningitis or subarachnoid hemorrhage is suggested. If protein content alone is elevated, it more likely suggests a degenerative process such as multiple sclerosis. Glucose 60%–80% of Bacterial meningitis causes a marked decrease in serum CSF glucose; invasion of fungi, yeast, glucose tuberculosis, or protozoans into the CSF results level in some decrease in glucose level. Viral infections do not cause a decrease in CSF glucose and may occasionally cause a slight increase. Albumin/globulin 8:1 Increased level suggests infection or an A/G ratio (A/G) ratio neurologic disorder. Assessing the Child With a Neurologic Disorder 3005 Because neurologic symptoms, such as headache, unsteady gait, or lethargy, are often insidious, both a thorough history and a neurologic examination are needed to reveal the cause and extent of such symptoms (Box 49.2). BOX 49.2 Nursing Care Planning Using Assessment ASSESSING A CHILD FOR SIGNS AND SYMPTOMS OF A NEUROLOGIC DISORDER HEALTH HISTORY A child’s history may first reveal symptoms of a neurologic disorder. Because many neurologic problems that are evidenced in infants and young children result from injury that occurred in utero, it is important to obtain the mother’s pregnancy history as well. 3006  At primary care visits, always ask parents about their child’s developmental milestones and ability to perform age-appropriate tasks successfully. A screening test can be used to indicate whether a parent’s concern about a preschool child is well founded. The ability to perform well in school is important documentation for an older child. NEUROLOGIC EXAMINATION A complete neurologic examination takes at least 20 minutes and requires both patience and skill to keep a child’s attention while observing for possible indications of neurologic disease. For a full examination, six areas are assessed: cerebral, cranial nerve, cerebellar, motor, sensory, and reflex function. Cerebral Function Both general and specific cerebral functions need to be evaluated by assessing level of consciousness, orientation, intelligence, performance, mood, and general behavior (Rust, 2011). Children do best when these types of tests are presented as a game. Be certain to convey that there are no right or wrong answers because children who believe that they have failed these tests may not respond well to further testing. The best way to evaluate a child’s level of consciousness is through conversation. Note any drowsiness or lethargy. Allow the child to answer questions without prompting and listen carefully to be certain the answer is appropriate to the question. Orientation refers to whether children are aware of who they are, where they are, and what day it is (person, place, and time). Be certain to take into account a child’s age, making questions age-appropriate to the child’s developmental abilities. Children younger than 4 years of age, for example, may not know both their first and last names. Children may be of school age before they know their address. Children younger than 7 or 8 years of age may have difficulty with the days of the week, confusing “yesterday” with “today” or “tomorrow.” Intellectual performance (IQ) can be determined by the child’s score on a standard intelligence test. Estimates of intellectual function can be made by asking the child questions on common topics. Immediate recall is the ability to retain a concept for a short time, such as being able to remember a series of numbers and repeat them (a child of 4 years can usually repeat three digits; a child older than 6 years can repeat five digits). Recent memory covers a slightly longer period of time. To measure this, show the preschool child an object such as a key and ask the child to remember it because later you will ask him or her to tell you what it was. After about 5 minutes, ask whether the child remembers what object you showed him or her. Ask older children what they ate for breakfast to test recent memory. Remote memory is long-term recall. Ask preschoolers what they ate for breakfast that morning or for dinner the night before because, for them, that was a long time ago; ask older children what was the name of their first-grade teacher because most people 3007 remember this information their whole life. Specific cerebral function can be measured by assessing language, sensory interpretation, and motor integration. When assessing language, listen to the child’s ability to articulate. Remember, when listening to speech, many preschoolers substitute “w” for “r,” saying “west time” instead of “rest time”; be aware that pronunciation is altered if English is not the child’s primary language. Stereognosis refers to the ability of a child to recognize an object by touch; it is a test of sensory interpretation. For this, ask a child to close his or her eyes and then place a familiar object, such as a key, a penny, or a bottle cap, in her hand and ask her to identify it. This is a skill even preschoolers are able to do successfully. Graphesthesia is the ability to recognize a shape that has been traced on the skin. Ask a child to close his or her eyes; trace first a circle and then a square on the back of his or her hand and then ask him or her whether the shapes are the same or different. Be sure the child understands the concept of “different” by first showing him or her objects such as two keys and a bottle cap and documenting that he or she is able to identify the keys as being the same and the bottle cap as being different. For older children, trace numbers (8, 3, 0, and 1 work well) and ask the child to identify each one. Kinesthesia is the ability to distinguish movement. Have a child close her eyes and extend her hands in front of her. Raise one of her fingers and ask her whether it is up or down. Hold the finger by its sides so that your other fingers do not brush against the child’s palm or the back of her hand and reveal the finger position. Repeat the same movement with a toe on each foot. For preschoolers, be certain to first determine whether the child understands the concept of up and down. To measure motor integration, ask a child to perform a complex motor skill, such as folding a piece of paper and putting it into an envelope. A child of 4 years or older should be able to do this neatly. Remember, children do best when these tests are presented as a game. Be certain to convey that there are no right or wrong answers. A child who believes that he or she has failed these tests may not respond well to further testing. Cranial Nerve Function Testing for cranial nerve function consists of assessing each pair of cranial nerves separately. Cranial nerves and methods of cranial nerve testing are described in Table 49.2. Methods to test pupil constriction and ability to follow into fields of gaze are described in Chapter 34. TABLE 49.2 CRANIAL NERVE FUNCTION Cranial Nerve Function Assessment I (olfactory) Sense of smell Assess child’s ability to recognize common odors such as peanut butter or an orange while eyes are closed. 3008 II (optic) Vision Assess vision fields and visual acuity; examine retinas. III (oculomotor) Motor control Assess pupillary size, equality, reaction to light, and and ability to follow an object in all sensation for directions. Note any nystagmus (an abnormal eye muscles jerking motion). and upper eyelid IV (trochlear) Movement of As for nerve III major eye globe muscles V (trigeminal) Mastication Assess ability to discern light touch to test muscles and sensory component; assess symmetry and some facial strength of bite to test motor component. sensations VI (abducens) Movement and As for nerves III and IV muscle sense of eye globe VII (facial) Impulses for Assess motor strength by asking child to close facial eyes while you attempt to open them. Note muscles, symmetry of facial expression (such as salivation, smile) and movement (such as wrinkling and taste forehead). Assess taste by asking child to identify salt or sugar. VIII (acoustic) Equilibrium Assess hearing by the response to a whispered and hearing word or a Weber or Rinne test. Equilibrium is not tested routinely. IX Motor impulses Assess gag reflex by pressing on back of tongue (glossopharyngeal) to heart; with tongue blade. Note midline uvula (tested sensation together with nerve X). from pharynx, thorax, and abdominal organs X (vagus) Swallowing Assess ability to swallow; elicit gag reflex by and gag pressing a tongue blade on posterior tongue. reflexes 3009 XI (accessory) Impulses to Ask child to turn head to the side; try to turn it striated to center. Ask the child to elevate shoulders muscles of while you press down on them. pharynx and shoulders XII (hypoglossal) Motor impulses Ask child to protrude tongue. Assess for to tongue tremors. and skeletal Ask child to press on side of cheek with tongue; muscles; assess tongue strength. sensation from skin and viscera Cerebellar Function Tests for cerebellar function are tests for balance and coordination. To test these, observe the child walk to assess whether the walk is natural (most children walk at least a little self-consciously when they know they are being observed, so watch them also as they enter the exam room and move around for other activities). Ask the child to stand on one foot; a child as young as 4 years should be able to do this for as long as 5 seconds. Ask the child to attempt a tandem walk (walk a straight line, one foot directly in front of the other, heel touching toe) (Fig. 49.2A). A child older than 4 years of age should be able to do this for about four consecutive steps. Ask the child to touch his or her nose with his or her finger and then to reach and touch your finger with the same hand (held about 1½ feet in front of the child) (see Fig. 49.2B). Tell the child to repeat this action and move your finger to a new position each time. The average child rarely reaches past your finger or stops before touching it. 3010  Figure 49.2 Cerebellar function tests. (A) A child attempting a tandem walk. (B) Nose-to-finger test. (© Lesha Photography.) Ask the child to pat one knee with the palm of the hand and then quickly turn the hand over and pat the knee with the back of the hand; repeat over and over, one hand at a time. The majority of children are able to do this rapid, coordinated motion without much difficulty. Preschoolers will “mirror” the movement of the actively moving hand by moving the inactive hand as well. Older children should not demonstrate this (or should show only a small amount of movement). Other tests are to ask the child to touch each finger on one hand with the thumb of that hand in rapid succession or ask the child to run the heel of one foot down the front of his or her other leg while he or she is lying supine (children should be able to do this without “running off” the leg). With the child lying on the examining table, ask the child to close his or her eyes and draw a circle or figure 8 in the air with his or her foot (children should also be able to do this without difficulty). Tests of cerebellar function such as these are fun for children to do as long as they know that there are no passes or failures. Show approval for effort even if they are having difficulty with a task so that they have confidence to try another one. Motor Function Motor function is measured by evaluating muscle size, strength, and tone. Begin by comparing the size and symmetry of extremities. If in doubt about either of these, measure the circumference of the calves and thighs or upper and lower arms with a tape measure. Palpate muscles for tone. Move the extremities through passive range of motion to evaluate symmetry, spasticity, and flaccidity bilaterally. To test for strength, ask the child to extend her arms in front of her and then resist your action as you push 3011 down or up on her hands or push them out to the side. Do the same with the lower extremities. Sensory Function If children’s sensory systems are intact, they should be able to distinguish light touch, pain, vibration, hot, and cold. Have a child close his or her eyes and then ask the child to point to the spot where you touch him or her with an object. Light touch is tested by using a wisp of cotton, deep pressure by pressure of your finger, pain by a safety pin, and temperature by water bottles filled with hot or cold water. Vibration is tested by touching the child’s bony prominences (iliac crest, elbows, knees) with a vibrating tuning fork. Warn the child that on pin testing, he or she will feel a momentary prick. Otherwise, the child may be unwilling to close his or her eyes again for further testing. Reflex Testing Deep tendon reflex testing, which is part of a primary physical assessment (see Chapter 34), is also a basic part of a neurologic assessment. In newborns, reflex testing is especially important because the infant cannot perform tasks on command to demonstrate the full range of neurologic function (see Chapter 18). QSEN Checkpoint Question 49.1 PATIENT-CENTERED CARE Tasha, 3 years old, is scheduled for a full neurologic examination. What explanation would best prepare her for this? a. “You’ll need to answer questions carefully so you can pass this test.” b. “I’ll be asking you to move in different ways, almost like a game.” c. “I need to find out how healthy or unhealthy your brain seems to be.” d. “Seizures can be caused by a brain tumor, so that needs to be ruled out.” Look in Appendix A for the best answer and rationale. DIAGNOSTIC TESTING A variety of diagnostic tests may be prescribed to provide additional information should any abnormalities be detected in the health history, physical examination, or neurologic examination. Many of these tests are invasive, so if you are scheduling these, be certain both the child and family are well prepared for these procedures; try to schedule the least invasive procedures first to better elicit the child’s cooperation. So explanations will be well understood, take into account not only the child’s chronologic age but also the child’s level of cognitive functioning. Provide an explanation that includes not only physically what will happen but also a description of any sensory experiences the child might undergo such as anything he or she might feel, hear, smell, or taste. 3012 Lumbar Puncture Lumbar puncture, the introduction of a needle into the subarachnoid space (under the arachnoid membrane) at the level of L4 or L5 to withdraw CSF for analysis, is used most frequently with children to diagnose hemorrhage or infection in the CNS or to diagnose an obstruction of CSF flow. The procedure is contraindicated if the skin over the needle insertion site is infected (to avoid introducing pathogens into the CSF) or if there is a suspected elevation of CSF pressure (if intracranial pressure [ICP] is elevated, the higher pressure in the intracranial space could cause the brainstem to be drawn down into the spinal cord space, compressing the medulla and compromising the action of the cardiac and respiratory centers). To limit pain, EMLA or lidocaine cream should be applied to the puncture site 1 hour before the procedure. Alternatively, the child may be administered conscious sedation for the procedure (see Chapter 39). For a lumbar puncture, a newborn is seated upright with the head bent forward (Fig. 49.3A). The older infant or child is placed on one side on the examining table. Help the child flex the head forward, flex the knees against the abdomen, and arch the back as much as possible; this position opens the space between the lumbar vertebrae, facilitating needle insertion (see Fig. 49.3B). You might describe the position as “rolling into a ball” or “folding up like an astronaut in a small spaceship” to associate it with something the child knows about. Children younger than school age need to be held in this position because they may be so frightened by someone working on their back unseen that they are unable to hold this arched position (they try to turn over or turn their head to see what is happening). It helps a school-age child or adolescent if you stand by the table facing him or her and gently rest your hand on the back of the head, as a reminder to keep it bent forward. Talking quietly with the child not only assists in calming the child but also helps assess the child’s respiratory status as the child is “curled up.” Closely observe an infant for any respiratory distress. Figure 49.3 (A) Positioning an infant for a lumbar puncture. (© Barbara Proud.) (B) Positioning an older child for a lumbar puncture. Children need good preparation for a lumbar puncture because they cannot see what is happening. Be certain they know the healthcare provider performing the procedure will wash their back with a solution that feels cold and then inject a local anesthetic that might sting for a moment (if an analgesic cream was not applied before the procedure). 3013 Caution children they will feel pressure but not pain as the lumbar puncture needle is inserted. Occasionally, the needle will press against a dorsal nerve root and the child will experience a shooting pain down one leg. If this happens, reassure the child this feeling passes quickly and does not indicate an injury. When the insertion stylette is removed and CSF drips from the end of the needle, the procedure has been successful. An initial pressure reading is made. To confirm the subarachnoid space in the cord is patent with that in the skull, the examiner may ask a child who is older than 3 years of age to cough; for an infant, the examiner may ask you to press on the child’s external jugular vein. If either of these measures causes an increase of CSF pressure, it indicates that fluid is flowing freely through the subarachnoid space. Typically, three tubes of CSF, containing 2 to 3 ml each, are collected; a closing pressure reading is taken; and the needle is withdrawn. Samples are usually sent for culture, sensitivity, glucose level, and presence of red blood cells. The first sample obtained may contain blood or skin pathogens from the puncture, so it should not be the sample sent for determination of red blood cell content or culture. Additional evaluations requested might be albumin/globulin ratio or gamma-globulin level (an increased level of gamma-globulin is suggestive of multiple sclerosis or meningitis). Lumbar puncture involves at least momentary pain, so children need to be comforted afterward. A few children may develop a headache after a lumbar puncture as a result of the reduction in CSF volume or invasion of a small air pocket during the puncture, although this is rare because of the small-sized needle used. Encourage the child to lie flat for at least 30 minutes and to drink a glass of fluid afterward to help prevent cerebral irritation caused by air rising in the subarachnoid space and to help increase the amount of CSF quickly. Encourage parents to hold an infant in a flat position across their knees. If the child develops a headache despite the precautions taken, an analgesic can be given for pain relief. If a child had minimally increased CSF pressure at the time of the puncture, closely observe the child after the procedure to detect respiratory and cardiac difficulty from medulla pressure. An increase in blood pressure or a decrease in pulse and respiration rates, a change in consciousness, pupillary changes, or a decrease in motor ability are all important signs of increased intracranial compression. QSEN Checkpoint Question 49.2 TEAMWORK & COLLABORATION Tasha’s diagnostic workup will include a lumbar puncture. When collaborating with the physician to perform this procedure, what nursing action should the nurse prioritize? a. Explain to Tasha that her back will be washed with a cold liquid. b. Apply EMLA cream to Tasha’s lumbar region 5 to 10 minutes before the procedure. 3014  c. Reassure Tasha that the procedure will not hurt. d. Help Tasha into a prone position on the procedure table. Look in Appendix A for the best answer and rationale. Ventricular Tap In infants, CSF may be obtained by a subdural tap into a ventricle through the anterior fontanelle. A small space on the scalp over the insertion site is shaved or clipped, and the area is prepared with an antiseptic. The infant’s head must be held firmly in a supine position to prevent movement during the procedure so the needle does not strike and lacerate meningeal tissue. Fluid must always be removed from this site slowly, rather than suddenly, to prevent a sudden shift in pressure that could cause intracranial hemorrhage. After the procedure, a pressure dressing is applied to the site, and the infant is placed in a semi-Fowler’s position to prevent additional drainage from the puncture site. After the procedure, comfort the infant or allow the parents to do so to both reduce the stress of a painful procedure and prevent the infant from crying excessively, an action that could increase ICP and loss of additional CSF. X-Ray Techniques A flat-plate skull X-ray film may be used to obtain information about increased ICP or skull defects such as fracture or craniosynostosis (premature knitting of cranial sutures). Increased ICP is suggested if skull sutures appear separated on the X-ray. If the ICP is chronic, other subtle changes, such as a flattening of the sella turcica or an increase in the convolutions of the inner table of the skull, may be present. Cerebral Angiography Cerebral angiography is an X-ray study of cerebral blood vessels that involves the injection of a contrast material into the femoral or carotid artery. Serial X-rays are then taken as the dye flows through the blood vessels of the cerebrum, and any vessel defects or space-occupying lesions occluding cranial blood vessels are revealed. Myelography Myelography is the X-ray study of the spinal cord following the introduction of a contrast material into the CSF by lumbar puncture to reveal the presence of space- occupying lesions of the spinal cord. After the procedure, keep the head of the child’s bed elevated to prevent contrast medium from reaching the meninges surrounding the brain and causing irritation. Computed Tomography and Magnetic Resonance Imaging Computed tomography (CT) involves the use of X-rays to reveal densities at multiple 3015 levels or layers of brain tissue and is helpful to confirm the presence of a brain tumor or other encroaching lesions. Single-photon emission computed tomography (SPECT) is a similar procedure used mainly for blood flow evaluation. Magnetic resonance imaging (MRI) uses magnetic fields to show differences in tissue composition, revealing normal versus abnormal brain tissue. Both CT and MRI are discussed in greater detail in Chapter 37. Nuclear Medicine Studies (Brain Scan and Positron Emission Tomography) Brain Scan For a brain scan, a radioactive material is injected intravenously, and after a fixed time during which the injected material is deposited in cerebral tissue, radioactivity levels over the skull are measured. If the blood–brain barrier is not functioning, the radioactive material will accumulate in specific areas, suggesting possible tumor, subdural hematoma, abscess, or encephalitis. Positron Emission Tomography The diagnostic technique of positron emission tomography (PET) involves imaging after injection of positron-emitting radiopharmaceuticals into a vein. These radioactive substances accumulate at diseased areas of the brain or spinal cord. PET is extremely accurate in identifying seizure foci. Echoencephalography (Ultrasound of Head or Spinal Cord) Echoencephalography involves the projection of ultrasound (high-frequency sound waves above the audible range) toward the child’s head or spinal cord (a type of ultrasound). The technique may be used to outline the ventricles of the brain. Because this technique of scanning is noninvasive, produces no discomfort, and has no known complications, it may be repeated frequently to monitor changes in the size of ventricles or an invading lesion and is particularly effective in infants with open fontanelles. This noninvasive technique is often used in neonatal intensive care units to monitor intraventricular hemorrhages and other problems frequently encountered by preterm infants. Electroencephalography The electroencephalogram (EEG) reflects the electrical patterns of the brain summarizing the physical and chemical interactions within the brain at the time of the test (Rapin, 2011). An EEG tracing typically indicates four types of waves: delta (1 to 3 waves per second), theta (4 to 7 waves per second), alpha (8 to 12 waves per second), and beta (13 to 20 waves per second). To reduce extraneous movements of the eyes, head, or muscles that would affect the 3016 tracing, the child must be cooperative and quiet during the procedure. Traditionally, therefore, parents are asked to keep their child up later than usual the night before the exam so the child will fall asleep during the test. Educate children and their families that the room will be darkened to help them rest. Use terminology to describe the procedure in terms that the child can understand depending on age and development. Reassure them that attaching the small suction cups or leads is not painful. Use of terminology that is age appropriate will help to keep the patient and family at ease during the procedure. Sedation or conscious sedation may be necessary for children who are unable to lie still during the procedure. The goals of sedation are to (a) assure the patient’s safety and welfare, (b) assure minimal pain and discomfort during the procedure, (c) control the patient’s anxiety with minimal psychological trauma, and (d) modify behavior and movements during the procedure (Coté & Wilson, 2016). For example, chloral hydrate, a frequently used sedative for this procedure, may increase the fast activity of brain waves; chlorpromazine (Thorazine) is known to increase slow activity. Because some seizure medications also cause changes in brain waves, be certain to note on the child’s electronic record what medications the child is currently receiving. Parents should receive specific instructions whether antiseizure medication should be given on the morning of testing. Although EEGs can show important information about brain activity, they are not helpful in all circumstances because about 15% of children who have no cranial trauma or seizure activity demonstrate some abnormality on an EEG. They may not reveal a brain tumor because most brain tumors in children are in the posterior fossa, which is not revealed on an EEG. On inspection of the symmetry of brain waves in different hemispheres, local lesions such as a hematoma may be suggested. An EEG is most beneficial in diagnosing absence seizures. The typical pattern with this disorder is discussed later in this chapter. Visual stimulation, such as having a child look at a whirling disk, may be used in connection with an EEG because various types of electrical discharges increase with rapid eye movements. In a child who is sensitive to this type of stimulation, the testing may produce a seizure; therefore, it is up to the prescriber to decide if the benefits outweigh the possible effects. Following an EEG, children will be sleepy if they have been sedated or had an EEG while sleep-deprived. Allow them to sleep as long as needed. Health Promotion and Risk Management Health promotion for the nervous system begins prenatally with measures to ensure optimal fetal growth and development and prevention of problems associated with anoxia. It continues throughout childhood with routine health maintenance visits, screening for possible neurologic or developmental problems, and timely immunizations to prevent sequelae of childhood infections such as measles or 3017 chickenpox. Nurses play a key role in providing education to parents about the importance of prenatal care, obtaining immunizations, and completing medication therapy to ensure complete resolution of an infection. Nurses are able to provide parents with anticipatory guidance about safety measures to prevent injury, specifically, head and spinal cord injury by the use of seat belts or child restraints while riding in automobiles and protective gear when playing contact sports. Remind parents and children to wear helmets when riding or using anything that can move faster than the child can run such as scooters, roller skates/rollerblades, ice skates, horses, skis, skateboards or snowboards, bicycles, or motorcycles (Riesch, Kedrowski, Brown, et al., 2012). For a child with a long-term neurologic disorder, rehabilitation and early intervention play a major role in reducing the risk of complications and in promoting the child’s and family’s optimal level of functioning. Increased Intracranial Pressure Increased ICP is not a single disorder but a group of signs and symptoms that occur with many neurologic disorders (Table 49.3). It is important to assess for signs and symptoms when caring for a child with a potential neurologic disorder (Sigurtà, Zanaboni, Canavesi, et al., 2013). Increased ICP occurs because of an increase in the CSF volume, blood entering the CSF, cerebral edema, head trauma or infection, space- occupying lesions such as brain tumors, or the development of hydrocephalus or Guillain-Barré syndrome. TABLE 49.3 SIGNS AND SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE Sign or Indication of Increased Intracranial Pressure Symptom Increased head An increase >2 cm per month in first 3 months of life, >1 cm per circumference month in the second 3 months, and >0.5 cm per month for the next 6 months Fontanelle Anterior fontanelle tense and bulging; closing late changes Vomiting Occurring in the absence of nausea, on awakening in morning or after nap; possibly projectile Eye changes Diplopia (double vision) from pressure on abducens nerves; white of sclera evident over pupil (setting sun sign); limited visual fields, papilledema Vital sign Elevated temperature and blood pressure; decreased pulse and changes respiration rates Pain Headache, often present on awakening and standing; increasing with 3018  straining at stool (Valsalva maneuver) or holding breath Mentation Irritability, altered consciousness such as sleepiness The rate at which symptoms develop depends on the cause and the ability of the child’s skull to expand to accommodate the increased pressure. Children with open fontanelles, for example, can withstand more pressure without brain damage than older children, whose suture lines and fontanelles have closed. ASSESSMENT Assessment of ICP may involve only a few quick procedures, such as obtaining vital signs, evaluating pupil response, and determining levels of consciousness, motor, and sensory function, or it may include more elaborate electronic monitoring. Because symptoms are subtle at first, the initial signs children may show are headache, irritability, or restlessness. Growing pressure on the brainstem, which controls respiration and cardiac activity, soon causes pulse and respiration rates to slow. Compression of cranial vessels leads to a compensatory increase in blood pressure (or pulse pressure, the gap between the systolic and diastolic blood pressures). Pressure on the hypothalamus, the temperature-regulating center of the body, causes an increase in body temperature. An older child may be able to report symptoms such as diplopia (double vision). On funduscopic examination, papilledema may be detected. Compare a new assessment against all recordings taken in the last 24 hours so a progressive change can be detected. If ocular changes such as a dilated pupil occur, this indicates pressure is increasing posterior to the eye globe, causing compression of the second cranial nerve. Record any tendency toward strabismus, nystagmus (constant eye movement), or “sunset eyes” (white sclera showing over the top of the cornea) or inability to follow the light into any quadrant. Be sure to be specific about what you document. “Inability to follow light,” for example, is not as informative as “Inability to follow light into left superior field; vertical nystagmus noted as child follows light into other fields.” An additional test for ICP is a “doll’s eye” reflex. If a child lies supine and you turn his or her head gently but rapidly to the right, the eyes will normally turn toward the left, and vice versa. If a child has increased ICP, this phenomenon will be absent (a test useful in assessing a comatose child who is unable to cooperate by following a light). Assess the child’s level of consciousness because if the child is alert but unable to comprehend surroundings, time, or place, this may be the first indication of increased ICP. As pressure continues to increase, a pseudo-awake state will occur, in which the child is awake but unable to follow light or locate a noise. Finally, the child becomes fully comatose, unable to be roused by any stimuli. Levels of coma are rated by the Glasgow Coma Scale, discussed in Chapter 52 in connection with assessment for head trauma. Children, like adults, generally become disoriented about time first, then place, and 3019 then self. Explain to the parent and child that you will be periodically asking seemingly simple questions, such as asking the child for his or her name or to identify the day of the week. Let them know that it is important for the child to answer the questions if the child is able in order to understand the child’s level of consciousness. Be aware that many children, even when healthy, are groggy when they first awaken, especially if they have been dreaming. Make sure children are fully awake, therefore, before attempting to determine level of consciousness. Ask questions appropriate to the child’s age. Preschoolers, for example, do not usually know their whole name or the day of the week and may not know concepts such as morning or night. To assess consciousness in children this age, it is often more productive, every hour, to show them a colored block, a piece of fruit, or a cartoon character known to the child and ask them to name it. A good way to test an infant’s level of consciousness is to determine whether the child responds to sounds, such as a familiar music box or voices, or reaches for an attractive object you offer. Motor ability can be assessed by asking a child to perform some simple motor tasks, such as squeezing your hands, pushing against your hands with both feet, or performing rapid, alternating hand movements, such as turning a hand over and back several times. Evaluate cranial nerves grossly by having the child make a face, close the eyes tightly, or smile. Evaluate whether the facial responses are equal and symmetric bilaterally. Test deep tendon reflexes because these decrease in intensity with decreased level of consciousness. As a final assessment, carefully observe the child’s resting posture because when motor control grows weaker because of loss of cell function, characteristic posturing (primitive reflexes) occurs. Cerebral loss is shown mainly by decorticate posturing: the child’s arms are adducted and flexed on the chest with wrists flexed, hands fisted; the lower extremities are extended and internally rotated; the feet are plantar flexed (Fig. 49.4A). Decerebrate posturing, which occurs when the midbrain is not functional, is characterized by rigid extension and adduction of the arms and pronation of the wrists with the fingers flexed; the legs are held extended with the feet plantar flexed (see Fig. 49.4B). 3020  Figure 49.4 (A) Decorticate posturing. (B) Decerebrate posturing. Seizures are a sign of increased ICP, so if these occur, the child’s ICP is becoming greatly compromised. INTRACRANIAL PRESSURE MONITORING ICP can be measured by several additional methods: An intraventricular catheter inserted through the anterior fontanelle A subdural screw or bolt inserted through a burr hole in the skull A fiberoptic sensor implanted into the epidural space (or the anterior fontanelle in an infant) (Fig. 49.5) 3021  Figure 49.5 Devices used to monitor intracranial pressure. (A) Subarachnoid screw. (B) Epidural sensor. (C) Intraventricular catheter. (D) Intraparenchymal monitoring. Intraventricular catheters (see Fig. 49.5C) are threaded into the lateral ventricle, filled with normal saline, and then connected to an external pressure monitor (Bailey, Liesemer, Statler, et al., 2012). As pressure in the ventricle fluctuates, it registers through the filled catheter onto an oscilloscope screen plus a written printout. This method is advantageous over simple scanning because it also enables CSF drainage and administration of medication through the catheter. ICP in children normally ranges from 1 to 10 mmHg; a level greater than 15 mmHg needs further assessment. As blood pressure rises and falls with the influx of blood through vessels, so does ICP. On a monitor, this appears as A waves (plateau waves), B waves (short-duration waves), or C waves (small, rhythmic bursts). If brain ischemia is present, wave patterns change even before there is a deviation in blood pressure or pulse rate (Fig. 49.6). Because A waves appear to reflect brain ischemia, they can be used to signal when a child needs more oxygen. 3022  Figure 49.6 Normal intracranial pressure (ICP) waveform and generalized shapes of the three types of ICP waves: A waves or plateau waves, B waves, and C waves. ICP monitoring also supplies information on cerebral perfusion pressure (CPP) or the amount of cerebral blood flow available to the brain (Box 49.3) because, if ICP ever exceeds arterial blood pressure (arises above about 50 mmHg), cerebral vessels can become obstructed (Budohoski, Zweifel, Kasprowicz, et al., 2012). BOX 49.3 Calculating Cerebral Perfusion Pressure Cerebral perfusion pressure (CPP) ranges from about 60 to 150 mmHg. If it is too low, it suggests blood is having difficulty circulating to brain cells; if it rises too high, it can also result in brain ischemia from the increased intracranial pressure (ICP). 3023  CPP is calculated by subtracting the mean ICP from the mean arterial pressure (MAP) or: MAP − ICP = CPP MAP is determined by subtracting the diastolic blood pressure (DBP) level from the systolic blood pressure (SBP) level, then dividing the result by 3, and adding that sum to 80 or: To calculate CPP in a child with a blood pressure of 100/70 mmHg and an ICP of 10 mmHg, for example, first calculate the MAP: Next, calculate the CPP: 90 − 10 = 80 mmHg (the child’s CPP or a normal value) Parents can have difficulty accepting procedures such as the insertion of intraventricular catheters or screws. Explaining the brain’s anatomy can help them understand that the catheter or screw is inserted into a hollow space and thus does not puncture or tear brain tissue. Be sure to explain that this type of monitoring is advantageous not only because it enables early detection should problems arise but also because it helps to reduce the risk of further injury or complications. THERAPEUTIC MANAGEMENT The cause of ICP must be identified and remedied as quickly as possible to prevent brain injury or compression to the brainstem, which can lead to both cardiac and respiratory failure. Actions such as coughing, vomiting, and sneezing and rapid administration of intravenous (IV) fluid increase ICP. When a parent is burping an infant after a feeding, caution them to be careful not to put pressure on the jugular veins because this is another action that increases ICP. Placing a child in a semi-Fowler’s position (use an infant seat for babies) or administering a corticosteroid such as dexamethasone (Decadron) can effectively reduce cerebral edema and its accompanying pressure. An osmotic diuretic, such as mannitol, given IV, causes a shift of fluid from extravascular compartments into the vascular stream (from brain tissue into blood vessels), so it also reduces pressure. Children usually have an indwelling urinary catheter inserted before beginning an osmotic diuretic to ensure that the child’s kidneys are able to successfully excrete the intravessel fluid and prevent back pressure on the heart. If the ICP is caused by excessive fluid accumulating in the brain’s ventricles, a ventricular tap may be necessary for immediate reduction of pressure. Because increased ICP is a sign of an underlying disorder, after the pressure is reduced, the underlying cause must then be identified and rectified or the pressure will rise again from the original disorder. 3024 Neural Tube Disorders The neural tube is the embryonic structure that matures to form the CNS. Because this structure first forms in utero as a flat plate and then molds to form the brain and cord, it is susceptible to malformation. The disorders that occur as a result, such as spina bifida, are present at birth and are discussed in Chapter 27. Neurocutaneous Syndromes Neurocutaneous syndromes are characterized by the presence of skin or pigment disorders with CNS dysfunction. STURGE-WEBER SYNDROME A child with Sturge-Weber syndrome (encephalofacial angiomatosis) has a congenital port-wine birthmark on the skin of the upper part of the face that follows the distribution of the first division of the fifth cranial nerve (trigeminal nerve). Because the lesion is usually unilateral, the port-wine stain ends abruptly at the midline, although it may extend inward at that point to the meninges and choroid plexus. If the disorder is limited to the ophthalmic branch of the fifth nerve, the lesion is usually confined to the upper aspect of the face. Because of involvement of the meningeal blood vessels, blood flow can be sluggish, and anoxia may develop in some portions of the cerebral cortex. The child will develop symptoms of hemiparesis (numbness) on the side opposite the lesion from destruction of motor neurons. Intractable seizures, a cognitive challenge, or blindness caused by glaucoma may also be present. A CT scan or an MRI of the skull usually demonstrates calcification of the involved cerebral cortex, which appears as a “railroad track” or double-groove pattern on the CT or MRI screen. An EEG usually shows decreased voltage in the affected areas. When this syndrome is first diagnosed, parents may ask to have the skin lesion surgically removed in the belief that this will correct their child’s condition. Unfortunately, because the lesion is not just a surface phenomenon, it’s important that parents understand the need for long-term follow-up, particularly if the child has accompanying seizures that require long-term antiseizure therapy (Lo, Marchuk, Ball, et al., 2012). NEUROFIBROMATOSIS (VON RECKLINGHAUSEN DISEASE) Neurofibromatosis is the unexplained development of subcutaneous tumors. The disorder can occur as a mutation or it can be inherited as an autosomal dominant trait carried on the long arm of chromosome 17. It occurs in approximately 1 of every 4,000 live births and may be diagnosed prenatally (Ardern-Holmes & North, 2011). As an infant, the child typically shows irregular but excessive skin pigmentation. Later in childhood, pigmented nevi or café-au-lait (“coffee with cream”) spots appear that tend 3025 to follow the paths of cutaneous nerves (six or more spots larger than 1 cm in diameter are diagnostic). By puberty, multiple soft cutaneous tumors begin to form in the child’s skin along nerve pathways, and the child may develop seizures. Subcutaneous tumors develop by young adulthood. The acoustic nerve (cranial nerve VIII) is frequently involved, leading to hearing impairment. Involvement of the optic nerve can lead to vision loss. Approximately 8% of patients become cognitively challenged as a result of cerebral tumor formation or deterioration. Girls especially need to be aware of the disorder not only because of its inheritance pattern but also because tumor formation can increase with pregnancy (Chetty, Shaffer, & Norton, 2011). Little therapy is available to halt the tumor growth. If lesions are causing acoustic or optic degeneration, surgical removal of the tumors may be attempted to preserve hearing or sight. Be certain that both the parents and child have a source of emotional support through the disease’s slow but invariably fatal course. Cerebral Palsy Cerebral palsy (CP) is a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction. Affected children also may have speech or ocular difficulties, seizures, cognitive challenges, or hyperactivity. Muscle spasticity can lead to orthopedic or gait difficulties (Crosbie, Alhusaini, Dean, et al., 2012). CP is caused by abnormal brain development or damage to the developing brain, leading to cell destruction of the motor tracts. Nutritional deficiencies, drug use, and maternal infections such as cytomegalovirus or toxoplasmosis, as well as direct birth injury, may also contribute to the cause. CP occurs in approximately 2 of every 1,000 births, most frequently in very-low- birth-weight infants and those who are small for gestational age; it is increasing in incidence because of the number of very-low-birth-weight infants who survive today. Head injury such as from child maltreatment or automobile accidents also may lead to CP symptoms. Infections such as meningitis or encephalitis can result in CP symptoms as well. TYPES OF CEREBRAL PALSY There are four main types of CP: a pyramidal or spastic type (approximately 40% of affected children), an extrapyramidal (dyskinetic) type, ataxic, and mixed (Centers for Disease Control and Prevention, 2017). Spastic Type Spasticity is excessive tone in the voluntary muscles that results from loss of upper motor neurons. A child with spastic CP has hypertonic muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski reflex, and continuation of neonatal reflexes, such as the tonic neck reflex, well past the 3026 age at which these usually disappear. If infants with CP are held in a ventral suspension position, they arch their backs and extend their arms and legs abnormally. They fail to demonstrate a parachute reflex if lowered suddenly and tend to assume a “scissors gait” because tight adductor thigh muscles cause their legs to cross when held upright. This involvement may be so severe that it leads to a subluxated hip. By school age, tightening of the heel cord can become so severe that children walk on their toes, unable to stretch their heel to touch the ground (Fig. 49.7). Figure 49.7 Physical therapy can help a child with cerebral palsy to lengthen the heel cords. (© Tina Manley/Alamy.) Spastic involvement may affect both extremities on one side (hemiplegia), all four extremities (quadriplegia), or primarily the lower extremities (diplegia or paraplegia). Children with hemiplegia usually have greater involvement in the arm than the leg. The involved arm may be shorter and may have a smaller muscle circumference than the other arm. Most children with hemiplegia have difficulty identifying objects placed in 3027 their involved hand when their eyes are closed (astereognosis). In older children, leg involvement may be detected most easily by examining the child’s shoes as, because the child does not put the heel all the way down on the involved side, one shoe heel will be much more worn than the other. On physical examination, it may be difficult to abduct the involved hip fully, extend the knee, or dorsiflex the foot. A child with quadriplegia invariably has impaired speech (pseudobulbar palsy) but may or may not be cognitively challenged. Swallowing saliva may be so difficult that the child drools and has difficulty swallowing food (Lewis, 2011). Dyskinetic or Athetoid Type The athetoid type of CP involves abnormal involuntary movement (athetoid means “wormlike”). Early in life, the child appears limp and flaccid. Later, in place of voluntary movement, children make slow, writhing motions. This can involve all four extremities plus the face, neck, and tongue. Because of the poor tongue and swallowing movements, the child drools and speech is difficult to understand. Under emotional stress, the involuntary movements may become irregular and jerking (choreoid) with disordered muscle tone (dyskinetic). Ataxic Type Children with ataxic involvement have an awkward, wide-based gait. On neurologic examination, they are unable to perform fine coordinated motions, the finger-to-nose test, or rapid, repetitive movements (tests of cerebellar function). Mixed Type Some children show symptoms of both spasticity and athetoid or ataxic and athetoid movements. This combination obviously results in a severe degree of physical impairment. ASSESSMENT The diagnosis of CP is based on history and physical assessment. Any episode of possible anoxia during prenatal life or at birth should be documented. Determining the extent of involvement in an infant is difficult, so the full extent of the disorder may not be recognized until the child attempts complex motor skills, such as walking or coloring. Children with all forms of CP may have sensory alterations such as strabismus, refractive disorders, visual perception problems, visual field defects, and speech disorders such as abnormal rhythm or articulation. They may show an attention deficit disorder or autism spectrum syndrome. Cognitive challenge and recurrent seizures also frequently accompany all types of the disorder. A skull X-ray or ultrasound may show cerebral asymmetry. An EEG may be abnormal, although the pattern is highly variable. 3028  Nursing Diagnoses and Related Interventions Parents who are reacting to the news that their child has multiple physical disabilities often find it difficult to make long-range plans. Therefore, try to focus expected outcomes on short-term concerns to assist with family functioning. Nursing Diagnosis: Deficient knowledge related to understanding of complex disease condition Outcome Evaluation: Parents state that they understand the cause of the disease is unknown but it is not progressive. It’s important for parents to understand that CP is nonprogressive and that the brain damage that occurred during pregnancy or at birth will not extend. The child’s condition may seem to grow more apparent with age, however, as the child is expected to complete fine motor tasks. Without follow-up care, contractures from spasticity can result, further reducing existing motor function. Caution parents also that CP is a single name for a wide variety of disorders of varying consequence. Although another child they know may have such severe CP that he has no useful function in his extremities, this does not mean their own child will be affected to the same extent. Conversely, although they know someone with CP who is able to hold a full-time job, their child may not be able to do so as well. Each child needs individual assessment so the child’s maximum potential can be evaluated. Nursing Diagnosis: Risk for disuse syndrome related to spasticity of muscle groups Outcome Evaluation: Child walks with a minimum of support or equipment; skin and tissue remain intact. Children with CP need promotion of any function that is not already impaired to prevent further loss of function and allow them to master the highest level of self- care, communication, ambulation, education, nutrition, and establishment of self- esteem they can achieve. Learning to be ambulatory is an important part of self-care because it plays a large role in determining how independent the child can become. Walking can be difficult for the child to master because of lack of muscle coordination. Following surgery to lengthen heel tendons, assisted ambulation devices such as wheeled walkers may be necessary (Fig. 49.8). There are no drugs that cure CP, but a number can help relieve spasticity. Dopaminergic drugs, such as carbidopa/levodopa (Sinemet), widely used in Parkinson disease, increase the level of dopamine and, therefore, reduce rigidity. Muscle relaxants such as baclofen (Lioresal), given either 3029 orally or administered continuously by an infusion pump, and benzodiazepines such as diazepam (Valium) can also help with smoother muscle movement (Gray, Morton, Brimlow, et al., 2012). Administration of botulinum toxin (Botox) has been successful in some children to relieve spasticity and aid in walking (Placzek, Siebold, & Funk, 2010). Cerebellar pacemakers and vagal stimulation are future therapy options. Figure 49.8 Wheeled walkers give a child added stability for walking and keep heel cords from shortening. (© fotosearch.com.) Preventing contractures is vitally important to maintain motor function. To help avoid these, teach parents that the passive exercises and games their child has been prescribed are an important part of their child’s therapy and must be done consistently each day. To further prevent contractures, partial lightweight leg braces may be prescribed to encourage children to bring their heels down and to keep heel cords from tightening. If leg braces are prescribed, parents may need some encouragement and support to insist a child wears them because it is the constant 3030 stretching that offers best results. Nursing Diagnosis: Risk for self-care deficit related to impaired mobility Outcome Evaluation: Child feeds and dresses self and manages elimination independently. Children need to learn self-care measures such as dressing, tooth brushing, bathing, and toileting, so they can not only gain self-esteem by accomplishing these tasks but also achieve optimal independence. Modifications such as straps attached to their toothbrush or feeding utensils may be necessary so they can hold them more securely. Advise parents to always supervise children during bathing because lack of coordination could cause them to slip under water and drown. Toileting is often difficult because the child does not have the muscle group coordination necessary to achieve successful bowel evacuation. A high-fiber diet helps prevent constipation and aids bowel evacuation. Voiding may be equally difficult because the child may lack sufficient voluntary muscle control. Parents may need considerable support and guidance to allow a child to complete self-care tasks independently because doing so often requires extreme patience. Letting a child perform these activities, however, helps to instill confidence and self- esteem in the child and helps allow the child to reach his or her maximum potential. Nursing Diagnosis: Risk for delayed growth and development related to activity restriction secondary to CP Outcome Evaluation: Child receives environmental stimulation; expresses interest in people and activities around him or her; attends school setting that is as free of restrictions as possible. Children with CP may be unable to pursue stimulating activities and surroundings because they are not fully mobile. Therefore, encourage parents to bring these things to them as well as be certain that toys and activities are appropriate to the child’s intellectual, developmental, and motor levels, not the child’s chronologic age. Some children need more stimulating activities than others because they have difficulty concentrating on one activity for any length of time. A preschool program is important to provide exposure to the outside world. If at all possible, school-age children with CP should be mainstreamed so that they can learn alongside other children. You may need to advocate that a child be placed in a school setting that is consistent with intellectual abilities. Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements, related to difficulty sucking in infancy or difficulty feeding self in an older child Outcome Evaluation: Child’s weight remains within 5th to 95th percentile on height–weight chart; skin turgor remains good; specific gravity of urine is 1.003 to 1.030. 3031  Providing adequate nutrition to children with CP can be difficult because they often have difficulty sucking because uncoordinated movements of the tongue, lips, and jaw and tongue thrusting make this difficult. They may tend to push food out of their mouth (a retained primitive reflex) rather than swallow smoothly. Older children may have difficulty holding and controlling a spoon to bring food to their mouths. Parents may need guidance in finding a feeding pattern that works for their child. Manually controlling the jaw may help control the head, correct neck and trunk hyperextension, and stabilize the jaw to assist with feeding. If a child cannot chew or swallow well, a liquid or soft diet may be necessary. A hyperactive gag reflex or symptoms of gastroesophageal reflux may cause children to vomit after feeding. Positioning infants upright after feeding helps to prevent aspiration if vomiting occurs. Nursing Diagnosis: Impaired verbal communication related to neurologic impairment Outcome Evaluation: Child can verbally make needs known to strangers and family members. Most children with CP benefit from speech therapy, which helps them learn to speak slowly and to coordinate their lips and tongue to form speech sounds. Be patient when talking to them so they feel comfortable taking their time to form words deliberately. For the child who cannot speak clearly, provide an alternative form of communication, such as flash cards, a picture board, or a touch-screen computer, to aid communication. LONG-TERM CARE Because CP is not always diagnosed early in infancy, parents may not learn their child has a chronic disorder until 2 to 4 years later. Listen to parents during healthcare visits and encourage them to discuss the difficulties of daily living, such as feeding problems. Offer them support as needed if they grieve because their child is not able to accomplish all of the major things they had wished for during pregnancy or feel defeated by the day-to-day strain of caring for their child’s multiple special needs. Care of a child with a chronic illness is discussed further in Chapter 56. QSEN Checkpoint Question 49.3 INFORMATICS Tasha’s sister Wanda was diagnosed with CP as an infant. What information would the nurse want her parents to know about her prognosis? a. Symptoms of CP typically begin to wane just after puberty. b. The severity of cognitive deficits parallels the severity of physical deficits. c. CP may occasionally be caused by a childhood vaccine reaction. d. Symptoms may seem to grow worse as fine motor skill is needed. 3032  Look in Appendix A for the best answer and rationale. Infection Infection of the nervous system is always potentially serious. It typically occurs from illnesses such as meningitis, encephalitis, Guillain-Barré syndrome, Reye syndrome, and botulism. BACTERIAL MENINGITIS Meningitis is, as the name implies, infection of the cerebral meninges. It tends to occur most frequently in children younger than 24 months of age and most often in winter. The organisms most frequently seen are Streptococcus pneumoniae or group B Streptococcus. In children younger than 2 months of age, Escherichia coli is a common cause. If children with myelomeningocele develop meningitis, Pseudomonas infection may be the causative agent. Children who have had a splenectomy are particularly susceptible to pneumococcal meningitis unless they have received a pneumococcal vaccine. Haemophilus influenzae, once a major cause of meningitis, is now rarely seen because of routine immunization against this organism (Greenberg-Kushnir, Haskin, Yarden-Bilavsky, et al., 2012). Pathologic organisms usually spread to the meninges from upper respiratory tract infections by lymphatic drainage possibly through the mastoid or frontal sinuses or by direct introduction through a lumbar puncture or skull fracture. Once organisms enter the meningeal space, they multiply rapidly and then spread throughout the CSF to invade brain tissue through the meningeal folds, which extend down into the brain itself. Brain abscess or invasion of the infection into cranial nerves can result in blindness, hearing impairment, or facial paralysis. If a thick exudate accumulates in the narrow aqueduct of Sylvius, it can cause obstruction leading to hydrocephalus. Brain tissue edema can put pressure on the pituitary gland, causing increased production of antidiuretic hormone, resulting in the syndrome of inappropriate antidiuretic hormone secretion (SIADH), causing hyponatremia. Assessment Children usually have had 2 or 3 days of upper respiratory tract infection prior to the development of meningitis. They then grow increasingly irritable because of an intense headache. They experience sharp pain when they bend their head forward. In the newborn, symptoms such as poor sucking, weak cry, or lethargy develop. As the disease progresses, signs of meningeal irritability then occur, as evidenced by positive Brudzinski and Kernig signs. Children may hold their back arched and their neck hyperextended (opisthotonos). If third and sixth cranial nerve paralysis occurs, a child will not be able to follow a light through full visual fields. If the fontanelles are open, they bulge upward and feel tense; 3033 if they are closed, papilledema may develop. If the meningitis is caused by H. influenzae, the child may develop septic arthritis. If it is caused by Neisseria meningitidis, a papular or purple petechial skin rash may occur (Pace & Pollard, 2012). After this beginning of a myriad of general symptoms, sudden cardiovascular shock, seizures, nuchal rigidity, or apnea can occur. Because the infant has open fontanelles, nuchal rigidity appears late and is not as useful a sign for diagnosis as in the older child. As a rule, a child with a high temperature who then has a seizure is assumed to have meningitis until CSF findings prove otherwise. CSF analysis obtained by lumbar puncture confirms the diagnosis. CSF results indicative of meningitis include increased white blood cell and protein levels, increased ICP, and a glucose level less than 60% of blood glucose (because bacteria have fed on the glucose). In addition to supplying blood for glucose level, blood is cultured and examined for increased WBC count. If the child has had close association with someone with tuberculosis, a tuberculin skin test to rule out tuberculosis meningitis will be done. A CT scan, MRI, or ultrasound study will be prescribed to examine for brain abscess. Therapeutic Management Antibiotic therapy as indicated by sensitivity studies is the primary therapy. Intrathecal injections (directly into the CSF) may also be necessary, especially because the blood– brain barrier may prevent the chosen antibiotic from passing freely into the CSF. In some children, it takes a month before the CSF cell count returns to normal. A corticosteroid such as dexamethasone or the osmotic diuretic mannitol may be administered to reduce ICP and help prevent hearing loss. In addition to standard precautions, children with meningitis are placed on respiratory precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the infection to other family members or healthcare providers. In addition, an antibiotic may be prescribed prophylactically for the child’s immediate family members or for playmates who have been in close contact with the child. Meningitis is always a serious disorder because it can run a rapid, fulminating, and possibly fatal course. If symptoms are recognized early and treatment is effective, however, a child will recover with no sequelae. Neurologic sequelae, such as learning problems, seizures, hearing and cognitive challenges, and inability to concentrate urine from lessened antidiuretic hormone secretion, must be assessed in the weeks to come because these can be long-term consequences. What If... 49.1 The cause of Tasha’s seizure is found to be bacterial meningitis. Because she has severe neck pain whenever she is moved, her mother asks the nurse not to be so concerned about measuring intake and output, so her daughter can rest. How should the nurse respond? The nurse calls Tasha’s name and she does not answer. Why is this a particular cause of concern in a child with meningitis? 3034  Nursing Diagnoses and Related Interventions If a child has meningitis, the parents may feel responsible for the illness because they knew the child had an upper respiratory infection. They may ask if they could have prevented meningitis if only they had taken the child to their primary care provider as soon as the respiratory symptoms began. You can assure them the symptoms of meningitis occur so insidiously that no one can appreciate what disease process is at work from the first generalized signs. Be certain to orient parents to infection control techniques if the child is isolated so they can feel comfortable caring for their child. Nursing Diagnosis: Pain related to meningeal irritation Outcome Evaluation: Child states pain is tolerable and shows no facial grimacing or other signs of discomfort. For a child with meningitis, dealing with the number of invasive procedures, such as lumbar puncture, venipuncture, and IV therapy, necessary can make a hospital stay difficult. Remember that children feel pain when their head is flexed forward, so they usually are more comfortable without a pillow. Be careful not to flex their neck forward when turning or positioning them. Although children would probably benefit from puppet play or coloring, activities that could help them express how they feel about so many intrusive procedures, frequently, they are too uncomfortable to play and thus are not able to be comforted by these measures. Be certain that children receive a good explanation of everything that is happening and extra attention from healthcare personnel not just when they perform painful procedures but so children can feel secure. Help parents understand that their child’s acute irritableness is caused by the disease process and not by anything they did or are doing so they can continue to interact with the child. You can assure them that, as their child recovers, irritability will lessen and the child will begin to show more interest in communicating feelings. Promote rest by keeping stimulation in the room to a minimum. Nursing Diagnosis: Risk for ineffective tissue perfusion (cerebral), related to increased ICP Outcome Evaluation: Child’s vital signs return to normal; child is alert and oriented; motor, cognitive, and sensory functions are within acceptable parameters for the child’s age; specific gravity of urine is 1.003 to 1.030. Observe the child carefully for signs of increased ICP such as increased blood pressure or slowed pulse rate. Carefully monitor the rate of all IV infusions to prevent overhydration and increased ICP. Measure urine specific gravity to detect 3035  oversecretion or undersecretion of antidiuretic hormone because of pituitary pressure. Measure the child’s head circumference and weigh the child daily. Monitor hearing acuity (reduced if there is compression of the eighth cranial nerve) by asking an older child a question or observing whether an infant listens to a music box or to your voice. GROUP B STREPTOCOCCAL INFECTION A major cause of meningitis in newborns is group B streptococci. The organism is contracted either in utero or from secretions in the birth canal. It can spread to other newborns in a hospital nursery if good hand washing technique is not used. Colonization can result in either an early-onset or a late-onset illness. With the early-onset form, symptoms of pneumonia become apparent in the first few hours of life. The late-onset type leads to meningitis instead of pneumonia. With meningitis, at approximately 2 weeks of age, the infant gradually becomes lethargic and develops a fever and upper respiratory tract symptoms. The fontanelles bulge from increased ICP. The disease is extremely serious as mortality from the infection is approximately 25%; surviving infants may develop neurologic consequences such as hydrocephalus or seizures (Libster, Edwards, Levent, et al., 2012). Treatment is with antibiotics that are effective against the group B Streptococcus, such as ampicillin and cephalosporins. Because it can be difficult for parents to understand how their infant suddenly became so ill, they may need considerable support in immediately caring for the infant or if the infant is left neurologically challenged. QSEN Checkpoint Question 49.4 QUALITY IMPROVEMENT Tasha is diagnosed as having bacterial meningitis, and her plan of care is being amended in light of this diagnostic finding. How long should the care team maintain respiratory precautions for this condition after Tasha begins an antibiotic? a. 4 hours b. 24 hours c. Until her core body temperature returns to normal d. Until her arterial blood gases return to normal Look in Appendix A for the best answer and rationale. ENCEPHALITIS Encephalitis is an inflammation of brain tissue and, possibly, the meninges as well (Kneen, Michael, Menson, et al., 2012). It can arise from protozoan, bacterial, fungal, or viral invasions. Enteroviruses are the most frequent cause, followed by arboviruses. Several encephalitis viruses, such as those that cause St. Louis encephalitis, West Nile 3036 encephalitis, and Eastern equine encephalitis, are borne by mosquitoes and thus are seen most often during the summer months. Encephalitis also can result from direct invasion of the CSF during lumbar puncture. Yet, another cause is as a complication of childhood diseases such as measles, mumps, or chickenpox. In order to prevent the disease, therefore, it is crucial children receive immunization against childhood diseases and use mosquito repellents when in mosquito-infested areas. Assessment Symptoms of encephalitis begin either gradually or suddenly and include symptoms such as headache, high temperature, ataxia (loss of usual muscle movements), muscle weakness or paralysis, diplopia, confusion, and irritability; if meninges are also involved, signs of meningeal irritation, such as nuchal rigidity and a positive Brudzinski or Kernig sign, may also be present. A child becomes increasingly lethargic and eventually comatose. The diagnosis is made by the history and physical assessment. CSF evaluation will reveal an elevated leukocyte count and an elevated protein level. An EEG will demonstrate widespread cerebral involvement. A brain biopsy, usually taken from the temporal lobe or infected CSF, identifies the virus. Therapeutic Management Treatment for a child with encephalitis is primarily supportive. An antipyretic is prescribed to control fever. Mechanical ventilation may be required to maintain the child’s respirations during the acute phase. A variety of medications, such as acyclovir (Zovirax), an antiviral agent, and carbamazepine (Tegretol), an anticonvulsant, may be prescribed. A steroid such as dexamethasone or an osmotic diuretic such as mannitol may be needed to decrease brain edema and ICP. Encephalitis is always a serious diagnosis because although a child may recover from the initial attack without further symptoms, there can be residual neurologic damage, such as seizures or learning disabilities. Parents may find it hard to believe their child is so seriously ill at first because in the beginning of the illness, their child only seemed tired and had a slight headache. They can find it even harder to accept that permanent impairment, such as a learning disability, could result. This makes follow-up care after hospitalization important both for the child’s rehabilitation and to help parents deal with their grief, shock, and possible anger over this devastating turn of events in their life. REYE SYNDROME Reye syndrome is acute encephalopathy with accompanying fatty infiltration of the liver, heart, lungs, pancreas, and skeletal muscle. It occurs in children from 1 to 18 years of age regardless of gender (Ninove, Daniel, Gallou, et al., 2011). The cause is unknown, but symptoms such as lethargy, vomiting, confusion, and 3037 combativeness usually occur after a viral infection such as varicella (chickenpox) or influenza that was treated with acetylsalicylic acid (aspirin). Treatment is supportive. Untreated, the condition leads to coma and death. Anticipatory guidance to parents and children about avoiding the use of aspirin during viral infections has almost prevented the syndrome (Bennett, Starko, Thomsen, et al., 2012). GUILLAIN-BARRÉ SYNDROME Guillain-Barré syndrome (inflammatory polyradiculoneuropathy) is a perplexing syndrome that occurs in about 1 in every 100,000 children. Both motor and sensory portions of peripheral nerves are affected. Boys develop it more often than girls (Yuki & Hartung, 2012). With successful widespread polio eradication efforts, Guillain-Barré syndrome is now the most common cause of acute and subacute flaccid paralysis in childhood (Rosen, 2012). The cause of the condition is unknown, but it is suspected that the reaction is immune mediated, occurring after upper respiratory tract or gastrointestinal illnesses or, rarely, immunizations. Inflammation of the nerve fibers apparently causes temporary demyelization of the nerve sheaths. Assessment Children experience peripheral neuritis several days after the primary infection. Tendon reflexes begin to decrease and then become absent. Muscle paralysis and paresthesia (loss of sensation) begin first in the legs and then spread to involve the arms, trunk, and head. The symmetric nature of the disorder helps to differentiate it from other types of paraplegia. Cranial nerve involvement leads to facial weakness and difficulty in swallowing. As the respiratory muscles become involved, spontaneous respirations are no longer possible, leading to respiratory involvement severe enough to warrant mechanical ventilation. A significant laboratory finding is an elevated CSF protein level. An EEG may show denervation and decreased nerve conduction velocity. Therapeutic Management Treatment of Guillain-Barré syndrome is supportive until the paralysis peaks at 3 weeks and then is followed by gradual recovery. A course of prednisone to halt the autoimmune response may be tried, but its use is controversial. Plasmapheresis or transfusion of immune serum globulin may shorten the course of the illness. Cardiac and respiratory function must be closely monitored. All patients should be given subcutaneous fractionated or unfractionated heparin and support stockings until they are able to walk independently to prevent deep vein thrombosis. Other necessary measures include prevention of the effects of extreme immobility while guarding respiratory function. An indwelling urinary catheter is usually inserted to monitor urine output. Enteral or total parenteral nutrition may be used to support 3038 protein and carbohydrate needs. If the child has discomfort from neuritis, adequate analgesia is necessary. To prevent muscle contractures and effects of immobility, turning and repositioning every 2 hours is important in addition to passive range-of-motion exercises about every 4 hours. Be certain to provide adequate stimulation for the long weeks when the child is unable to perform any care independently. Fortunately, despite the long period of mandatory ventilation therapy, most children recover completely, without any residual effects of the syndrome, although some may continue to have minor problems such as residual weakness. BOTULISM Botulism occurs when spores of Clostridium botulinum colonize and produce toxins in the intestine. Infant botulism is not transmitted from person to person and occurs predominantly in infants younger than 6 months of age (American Academy of Pediatrics, 2015). Honey has been identified as a common source for infant botulism and should not be given prior to 12 months of age (American Academy of Pediatrics, 2015). Symptoms occur within a few hours after ingestion of the contaminated food. Almost immediately, there is generalized weakness, hypotonia, listlessness, a weak cry, and a diminished gag reflex, followed by a flaccid paralysis of the bulbar muscles that leads to diminished respiratory function. The organism can be cultured from stools or serum. Electromyography may be helpful to support the diagnosis. Treatment is supportive care. Human-derived botulinum immune globulin may stop the progress of the disease. Inflammatory Disorders Two neurologic inflammatory disorders are found frequently in adolescents. CARPAL TUNNEL SYNDROME Carpal tunnel syndrome is nerve compression of the median nerve that passes through the carpal tunnel at the wrist (Luckhaupt, Dalhamer, Ward, et al., 2013). Compression of the nerve causes numbness and sharp pain and burning in the thumb and the second, third, and fourth fingers of the hand. Word processing, texting, and video games have turned this previously adult disorder into a disorder that occurs in children as well. Pain usually occurs at night and is enough to keep a child awake. The usual therapy is application of a splint to the wrist, which holds the wrist in a neutral (not flexed and not extended) position. An oral anti-inflammatory medication and perhaps a corticosteroid injection into the inflamed wrist both help to relieve pain. If these therapies are not successful, the stricture at the carpal canal can be relieved surgically. 3039 FACIAL PALSY (BELL PALSY) Facial palsy is facial paralysis of the seventh (facial) cranial nerve, the nerve that innervates the muscles of facial expression. The syndrome occurs abruptly and may be associated with herpes or Lyme disease infection or occur as a result of cold air from skiing or from riding in a convertible. Therapy in adults consists of prednisone to reduce inflammation and acyclovir if the syndrome is herpes related. In children, prednisone use is variable. If the child is unable to close the eye on the affected side, eye drops three or four times daily will be needed. Although recovery is slow, usually takes about 4 months, most children recover without any permanent disability (McNamara, Doyle, McKay, et al., 2013). Paroxysmal Disorders A paroxysmal disorder is one that occurs suddenly and recurrently. Seizures, headaches, and breath-holding spells are the most frequent types seen in childhood. EPILEPSY (RECURRENT SEIZURES) A seizure is an involuntary contraction of muscle caused by abnormal electrical brain discharges. Approximately 5% of children will have at least one seizure by the time they reach adulthood (Sidhu, Velayudam, & Barnes, 2013). These episodes are always frightening to parents and other children because of the intensity. Although about 50% of seizures are idiopathic (unknown cause), they also can be attributed to infection, trauma, or tumor growth. Familial or polygenic inheritance may be responsible. Because they are not so much a disease as a symptom of an underlying disorder, all seizures need to be investigated. The term epilepsy comes from a Greek word meaning “to take hold of.” Because the word has stigmas of cognitive challenge, behavioral disorders, institutionalization, or unexplainable strangeness attached to it, a preferred term is recurrent seizures because this term explains the disease process without the effect of discrimination (Box 49.4). BOX 49.4 Nursing Care Planning to Respect Cultural Diversity The degree of understanding about the cause of disorders such as recurrent seizures varies in different cultures. The often unknown cause of recurrent (idiopathic) seizures has led to them being attributed to an invasion by evil spirits or the effect of curses. Many people today still fear that recurrent seizures will lead to cognitive impairment. Many parents worry that their child will be refused admission to a school or refused a job as an adult because their child is viewed as so unpredictable. Being aware of these common misconceptions can help you appreciate parents’ anxiety about the diagnosis of recurrent seizures, an anxiety that can accentuate the need for 3040  parent education and careful planning to maintain self-esteem in their child. The types and causes of seizures vary with age and are classified into two major categories: partial and generalized seizures. As the name implies, with partial seizures, only one area of the brain is involved; with generalized seizures, the disturbance appears to involve the entire brain; loss of consciousness usually occurs. It’s important that seizures be differentiated by their degree of severity and type so that parents can know any special precautions they need to take for their child and appropriate management and drug therapy can be instituted. Seizures in the Newborn Period Seizure activity in the newborn period may be difficult to recognize because it may consist only of twitching of the head, arms, or eyes; smacking of the lips; slight cyanosis; and perhaps respiratory difficulty or apnea. Afterward, the infant may appear limp and flaccid. Whereas seizures in older children are often of unknown cause, 75% of seizures in neonates have a known cause such as trauma and anoxia from intrauterine life or birth; metabolic disorders, such as hypoglycemia, hypocalcemia, or lack of pyridoxine (vitamin B6); neonatal infection; or acute bilirubin encephalopathy caused by a blood incompatibility. Because of the nervous system’s immaturity, EEGs in the newborn may be normal despite extensive disease. A noticeably abnormal EEG in the newborn period, therefore, generally means a poor prognosis, indicating that involvement this early in life must be severe. Because almost 20% of all newborns have abnormal CSF values compared with adult standards (protein is increased, and there may be a few red blood cells from rupture of subarachnoid capillaries from the pressure of birth), lumbar puncture also is not conclusive. High doses of antiseizure medication may be needed to control seizures in newborns because they metabolize drugs more rapidly than older children. In adults, for example, phenobarbital may be administered in the range of 1.5 mg/kg body weight per day. In newborns, the dose might be as high as 3 to 10 mg/kg/day. Seizures in the Infant and Toddler Periods Seizures commonly seen in this age group are infantile spasms, a form of generalized seizure often called “salaam” or “jackknife” seizures, or infantile myoclonic seizures. These are characterized by very rapid movements of the trunk with sudden strong contractions of most of the body, including flexion and adduction of the limbs, or the infant suddenly slumps forward from a sitting position or falls from a standing position. The episode may occur singly or