15.3 Pediatric Neurologic, Musculoskeletal, and Endocrine Conditions

15.3 Pediatric Neurologic, Musculoskeletal, and Endocrine Conditions

Children are not small adults, and nowhere is that clearer than here: an open fontanel changes how raised pressure presents, growing bone changes how fractures behave, and growth itself changes how endocrine disease is managed.

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Raised Intracranial Pressure in Children

Measure head circumference at every infant assessment and plot it — a crossing of centiles is often the earliest objective evidence. Nursing care for raised pressure: head of bed elevated about 30 degrees with the head midline and the neck unflexed, a calm quiet environment, cluster care to minimise stimulation, avoid anything that raises intrathoracic pressure such as suctioning beyond necessity or straining, maintain normothermia, and monitor neurological status frequently.

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Bacterial Meningitis

Presentation varies by age. Older children show the classic picture: fever, severe headache, photophobia, neck stiffness, and positive Kernig and Brudzinski signs. Neonates and young infants show almost none of it — instead there is temperature instability, poor feeding, lethargy alternating with irritability, a high-pitched cry, a bulging fontanel, and apnoea. Meningococcal disease adds a non-blanching petechial or purpuric rash, which is confirmed with the glass test and signals a rapidly progressive septicaemia.

Nursing priorities:

1. Droplet precautions from the moment of suspicion, maintained until 24 hours of effective antibiotic therapy for meningococcal and Haemophilus disease.
2. Blood cultures and antibiotics without waiting for the lumbar puncture, if the puncture will be delayed.
3. A darkened, quiet environment with minimal handling; position of comfort, usually side-lying.
4. Strict neurological observation, seizure precautions, and careful fluid balance because of the risk of inappropriate antidiuretic hormone secretion.
5. Chemoprophylaxis for close household and childcare contacts of meningococcal disease, and public health notification.
6. Audiological follow-up, because sensorineural hearing loss is the commonest long-term sequela.

The lumbar puncture picture distinguishes the cause: bacterial meningitis produces cloudy fluid with a high neutrophil count, high protein, and low glucose, while viral meningitis produces clear fluid with lymphocytes, mildly raised protein, and normal glucose.

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Hydrocephalus and Shunts

A ventriculoperitoneal shunt diverts cerebrospinal fluid to the peritoneum. Shunt malfunction presents as recurrence of the signs of raised intracranial pressure, and shunt infection presents with those signs plus fever, and often occurs within the first two months after insertion.

Post-operative positioning is a classic exam point: position the infant flat or as prescribed, on the side opposite the shunt, to avoid pressure on the valve and to prevent too rapid decompression of the ventricles, which can cause subdural haematoma. Monitor head circumference, fontanel tension, neurological status, and the shunt tract for redness or swelling, and teach parents to recognise and report malfunction promptly and lifelong.

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Spina Bifida and Cerebral Palsy

Myelomeningocele — the most severe open form of spina bifida — presents at birth as a sac containing meninges and neural tissue. Pre-operative nursing is highly specific:

• Nurse the infant prone or side-lying, never supine, to avoid pressure on the sac.
• Cover the sac with a sterile, non-adherent dressing moistened with warm sterile normal saline, and keep it moist; never allow it to dry.
• Maintain strict sterile technique and prevent faecal contamination.
• Use latex-free equipment — children with spina bifida have a high incidence of latex allergy from repeated early exposure.
• Maintain thermoregulation, assess lower limb movement and sensation, measure head circumference for associated hydrocephalus, and monitor bladder emptying.

Folic acid supplementation before conception and in early pregnancy is the principal preventive message.

Cerebral palsy is a non-progressive disorder of movement and posture from an insult to the developing brain. Early signs are persistent primitive reflexes beyond the expected age, abnormal muscle tone, feeding and swallowing difficulty, and failure to meet motor milestones. Care is multidisciplinary and functional: safe feeding with attention to aspiration risk, nutrition and growth monitoring, positioning and contracture prevention, communication support, seizure management where present, and family support. Remember that cognitive ability varies widely and must never be assumed from motor impairment or speech difficulty.

Febrile seizures are covered separately with paediatric fever, but the core parental teaching bears repeating: protect the child from injury, place them on their side, never restrain or put anything in the mouth, time the seizure, and seek care if it lasts more than five minutes, recurs, or is focal.

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Musculoskeletal Conditions

Developmental dysplasia of the hip is screened for at every infant check. Findings include asymmetrical thigh and gluteal skin folds, limited hip abduction, apparent limb-length inequality (Galeazzi sign), and a positive Ortolani or Barlow manoeuvre in the newborn period. Treatment in infancy is a Pavlik harness, which holds the hips flexed and abducted. Teach parents to check skin under the straps daily, dress the infant in a vest under the harness, and not to adjust the straps themselves. Double or triple nappies are not a treatment and merely delay effective management.

Fractures in children differ from adults: the greenstick fracture bends and cracks incompletely, the buckle (torus) fracture compresses, and the physeal (growth plate) fracture threatens future growth, which is why any injury near a growth plate is treated seriously. Children's bones remodel and heal faster, but they also deform faster in a tight cast — neurovascular assessment of the limb distal to any cast is mandatory and frequent. A fracture pattern inconsistent with the stated mechanism, a spiral fracture in a non-ambulant infant, or multiple fractures at different stages of healing must raise a child protection concern.

Scoliosis is screened with the forward bend test, looking for rib hump and shoulder, scapular, and hip asymmetry. Bracing aims to halt progression rather than to correct the existing curve, and adherence is the whole battle in adolescence; the brace is typically worn most of the day over a snug cotton shirt, with daily skin checks. After spinal fusion, nursing focuses on log-rolling, pain control, neurovascular assessment, and monitoring for ileus and blood loss.

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Type 1 Diabetes in Children

Onset is typically acute, with polyuria, polydipsia, weight loss despite good appetite, and frequently diabetic ketoacidosis at presentation. New-onset bedwetting in a previously dry child is a classic presenting clue that non-specialists miss.

Management is lifelong and developmentally staged:

• Insulin regimens matched to school and family routine; carbohydrate counting; injection or infusion site rotation.
• Exercise increases insulin sensitivity: plan extra carbohydrate before sport and teach recognition of delayed post-exercise hypoglycaemia hours later.
• Sick-day rules: never omit insulin during illness, even if the child is eating little; illness raises counter-regulatory hormones and insulin requirements often rise. Check glucose and ketones more frequently, maintain fluid and carbohydrate intake, and know when to seek help.
• Hypoglycaemia: treat a conscious child with 15 g of fast-acting carbohydrate, recheck after 15 minutes, and follow with a complex carbohydrate. Glucagon must be available at home and school, with a trained adult.
• School liaison is a genuine nursing responsibility: an individual care plan, staff awareness, and permission to test and treat in class.
• Developmental adjustment: expect adolescents to struggle with adherence as autonomy grows, and negotiate rather than police. Long-term complication screening — retinal, renal, and foot — begins during adolescence.

In Qatar, Ramadan raises specific questions for older children and adolescents with diabetes. Children are not obliged to fast, but many wish to participate; any decision to fast requires a pre-Ramadan medical review, an individualised insulin plan around Iftar and Suhoor, more frequent glucose monitoring, and clear criteria for breaking the fast.