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This introductory section on pediatric neurology provides a clinically oriented
guide to the evaluation of a child with suspected neurologic dysfunction.
First we review a basic clinical approach and then we tackle specific
neurologic presentations. We attempt to provide a broad framework
that will help clinicians begin a thoughtful, focused workup of
a child suspected of having a neurologic problem. After review of
a basic approach, our discussions are organized around common neurologic
presentations and physical findings. This section is not intended
to be a comprehensive review of all neurologic disorders; instead,
it should be used a starting point. The later sections of this chapter
provide further detail about the pathophysiology, diagnoses, and
management of these disorders. For reviews of the neurologic examination
of infants and children, we refer the reader to Chapter 44 and the monographs and
chapters by Dodge and Volpe referenced at the end of this chapter.1,2
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Diseases of the nervous system have a profound impact on the lives
of infants, children, and their families. These disorders include epilepsy,
cerebral palsy, mental retardation, learning disabilities, complex
metabolic diseases, nerve and muscle diseases, and a host of other
highly challenging conditions. The clinician approaching an infant
or child suspected of having a neurologic disorder faces an imperative
to provide an accurate diagnosis. The diagnosis will direct therapy
and help the patient and family prepare for possible disability,
as well as inform decision making regarding future children.
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Medical students, residents, and experienced clinicians often
find pediatric neurology inaccessible. Many are intimidated by the intricacy
of neuroanatomy, the complexity of biochemical pathways, and the
subtlety of a neurologic examination. This situation is compounded
by the use of advanced diagnostic technologies such as electroencephalogram (EEG)
and sophisticated brain imaging techniques that receive little emphasis
in medical school training.
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We believe clinicians can overcome many of the difficulties they experience
in this area by adhering to the basic principles of clinical medicine
and neurology.3 We will review these principles and the
important contributions each makes to the diagnostic process.
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1. Recognition of impaired neurologic function through
careful history and physical examination
2. Identification of the specific part of the nervous system
that has been affected (the section “Localization”)
3. Definition of the most likely etiologies, using mode and speed
of onset, evolution of illness, and involvement of other organ systems,
as well as relevant past and family histories (the section “Differential
Diagnosis”)
4. Use of laboratory tests and other diagnostic technologies
to determine which of the different possible etiologies is present
5. Assessment of the degree of disability
6. Initiation of therapy, if available, after weighing potential
risks and benefits
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Eliciting a careful history remains the cornerstone of the evaluation of
children suspected of having neurologic disease. The purpose of the
history is to define the nature and temporal profile of the neurologic
complaint. ...