Monday, June 10, 2019

Non-Epileptic Paroxysmal Attacks in Children


Non-epileptic paroxysmal episodes in children are very common and are commonly misdiagnosed as epilepsy in many cases. This false positive diagnosis of epilepsy in children leads to unnecessary investigations, increased parental anxiety, and “treatment failure”. This particular blog focuses on some of the common non-epileptic phenomena seen in children which can be easily picked up by pediatricians to avoid unnecessary investigations, long term medication use and false diagnosis of epilepsy.



        Sandifer Syndrome:
Gastroesophageal reflux disease (GERD) is a very common diagnosis seen in infants particularly under 6 months of age. Severe gastroesophageal reflux can lead to prolonged episodes of crying in babies, with severe “back-arching” and in some cases babies can present with acute life-threatening events because of apnea. These are/can be easily misdiagnosed as epileptiform disorder, and dystonic movement disorder. In severe form of GERD (Sandifer Syndrome), babies cry incessantly, severe back arch for a prolonged period of times with head and neck extension and rarely become apneic. A high index of suspicion for GERD should be kept in these babies, as usually the development is completely normal, and episodes can be at times associated with the feeding times.

   Benign neonatal sleep myoclonus:
This particular non-epileptic phenomenon is seen in new born infants and can present up to few weeks of age, with quite significant episodes of sudden jerking of one or more limbs, but confined entirely in sleep. The baby is usually not distressed or woken up from these episodes, and usually do not involve the face. Although, the history is reasonably clear that these episodes during sleep, an EEG to capture some of these episodes maybe necessary to ensure that there are no ictal phenomena. Generally, no treatment is required in this condition and in a few months’ time these episodes cease.

Shuddering attacks:
Shuddering attacks are also very common, but usually under diagnosed or misdiagnosed episodes seen in normal infants as a part of their behavior. The usual story is that when the infants get very excited, which precipitates these episodes, they have involuntary shivering of the upper body, and sometimes most of the torso. This condition is not harmful or epileptic in nature. As the child matures, these episodes abate on their own without any intervention. A video of the paroxysmal episode can be very helpful in diagnosing this condition, as the shuddering attacks occur commonly at home and not usually in the outpatient clinic!

  Tic disorder:
Tics is a very common movement disorder seen in older children around the age of 5 to 6 years, when they present with repeated movements of different parts of the body, commonly involving the face with eye blinking, “screwing the eyes tight”, neck movements, and in severe cases upper and lower limb movements. These movements occur compulsively and sometimes can be associated with “vocal noises” as well called as vocal tics. The most common period or times when these episodes occur is usually in the afternoons once the children come back from school. The children are able to “supress” these movements in the school to avoid any unnecessary attention from other children (sometimes bullying), and as soon as they arrive home, they have a “release phenomena” with ample tics in the afternoon. Classically, tics get better when the children are relaxed e.g. during holidays and they get worse when they are nervous.

In the author’s opinion, a detailed history along with the video if possible is paramount to make the correct diagnosis. An EEG is usually unnecessary investigation. Author usually advises the parents to ignore these movements, because when the children are made aware of the tics, the child gets nervous and has more Tics.  As the children mature, the frequency and intensity of Tics decrease and very commonly tics stop during or before adolescence. Very rarely, if the tics are quite annoying to the child then a clinical psychologist is needed to carry out “tic reversal therapy” which can be very beneficial. On rare occasions medications are also used to supress the tics if they cause any hindrance to the day-to-day activities of the child.

  Benign myoclonus of infancy:
This is a very important non-epileptic paroxysmal phenomena which is commonly confused with infantile spasms as it resembles this particular type of epilepsy which presents in a similar age group. The benign myoclonus of infancy usually starts between the age of 1 month and 1 year and typically the child presents with sudden “jerking” movements occurring randomly during the course of the day. The infant is developmentally normal with normal milestones.
An EEG is usually required to ensure that the child does not have a EEG abnormality which can point towards the diagnosis of infantile spasm. A video of is also very important for a pediatric neurologist to delineate whether the condition is benign myoclonus of early infancy or indeed infantile spasms. Needless to say, the children with this condition do not need treatment and as they “grow out” of these episodes by second year of life.


For any informal queries, please contact the author at aman.sohal@neuropedia.ae

Wednesday, December 26, 2018

Childhood Headache: Causes & Remedies




What do we know about Childhood Headaches?

Headaches are one of the most common types of pediatric pain prompting referral to pediatric neurology clinic. The prevalence of headache ranges from 20% in children younger than 5 years, 37 to 51% in seven-year-old children, gradually increasing to 57–82% by 15 years of age. Before puberty, boys are affected more frequently than girls, but after puberty, headaches occur more frequently in girls. Headache may result in significant disability, including missed school days and extra-curricular activities, suboptimal participation in regular activities, and loss of productivity.

What are different causes of Headaches in Children?

There are various types of childhood headaches but the common ones which are encountered in Pediatric Neurology Clinic include Migraine, Tension Headache, Cluster Headache and Chronic Daily Headache. Let’s briefly go through the common headaches occurring in children.

1. MIGRAINE:

Migraine headache (without aura) is defined as multiple attacks, at least 4 or 5, of intense headaches with a throbbing sensation, around the forehead, temples, back of the head, which is usually one sided but can be both sides. These headaches (especially in younger patients) can be accompanied by nausea, vomiting, insensitivity to bright lights and sounds, photophobia, and phonophobia and the attacks can last from 1 hour to 72 hours. Children may have associated “Aura” which include commonly visual symptoms e.g seeing zig-zag lines and patterns, rainbow colours, blurred vision, smell, or speech changes etc. which van last from 5 minutes to an hour on occasions followed by a migraine headache. Younger patients also have periodic variants such as abdominal migraines (associated with tummy pains), cyclic vomiting, and vertigo or dizziness.

Why does my child have Migraine?

Migraines seem to be due to a combination of inherited genetic susceptibility (60%–70%) and environmental factors. There are a few genes implicated as Migraine causatives, and these run in the families. Therefore a family history of migraine is important for your doctor. There are also couple of theories: the vasogenic theory and the neurovascular theory, with latter being more “scientific” in the recent past.

How can I treat Migraine?

It is very important that the parents seek advice of a Child Neurologist who will carry out a proper history taking and simple bedside tests which include checking for fundi (back of the eys) before making a diagnosis of Migraine. Neuroimaging e.g. CT or MRI Brain is not needed once a convincing history and normal neurological examination is established.

The author usually recommends 2 prong approach to manage migraine which includes life style modification and medical management.
Many children quickly recognise that they have certain trigger factors causing migraine and they learn to avoid these triggers e.g caffeine containing food products. Apart from this, drinking plenty of water to remain hydrated, a regular sleep schedule, good stress management, attending school, avoiding monosodium glutamate, and regular exercise are very helpful for reducing migraines. Modifying sleep hygiene in children may play a significant role in improving headache symptoms. These life style changes are under-rated but are extremely affective and many a times are enough to stop the migraine attacks. A headache diary is extremely important for your doctor to establish the frequency, intensity etc. of the migraine before embarking on starting medications.

Once an attack starts, acting fast is very important to abort the attack, and sooner the abortive medication is given, the more effective it will be to decrease the intensity of the attack. Triptans (Sumatriptan, Zolmitriptan etc) are commonly used abortive medication which can effectively abort the attacks. Sleep and dark quiet rooms are sought by patients until the episode has passed. If a child is having to use abortive medications regularly, or has two or more Migraine attack per week, then prophylactic medication is recommended. The usual medications used in children include Pizotifen, Beta-Blockers, and anti-epileptics e.g. Topiramate which has shown immense promise in adults and children. These prophylactic medications are given for a few months on a daily basis, following which your Neurologist will slowly taper them off before completely stopping them.


2. TENSION HEADACHE

Tension headaches can occur upto 15% of young people and are usually less painful than migraines. These headaches have a “bandlike” quality and are shorter in duration, bilateral, usually in the temples. They are typically worsE in the afternoon or evening. There may be a muscular component to them, especially in the neck and upper back.
The treatment of Tension headaches is usually conservative, and the purpose is to decrease the stress related event giving rise to headaches. The usual life style changes mentioned above also apply here. The author usually treats these with simple over the counter medications like paracetamol and Ibuprofen with an advice not to overuse these medications as “overuse headaches” is commonly seen with paracetamol abuse.


3. CLUSTER HEADACHE

Cluster headaches are rare in children, but are quite distinctive. Children with cluster headaches have multiple severe headaches (up to 8 per day) in a period of several weeks or months, followed by relatively long headache-free intervals. The pain is usually unilateral, frontal and watering of the eye on the side of headache is common. The pain is so severe that children cannot lie still, bang their head with their fists, or rock back and forth.
The attack must be recognised early and treated with a Triptan (Sumatriptan, Zolmitriptan etc.)

3. CHRONIC DAILY HEADACHE

The term chronic daily headache does not define any particular type of headache, but children usually complain of “dull ache” to high intensity pain on a daily basis. The cause may include overuse of analgesic medications, depression, and poorly treated migraines or tension headaches. More often than not there are underlying psychological issues which may aggravate the headaches.
In Author’s opinion, these are by far the most difficult group of headaches to manage. Therefore a multi-disciplinary approach is important in the management of Chronic Daily headaches. It is important to discontinue overuse of analgesics and stick to various life style modifications mentioned above. Various medications e.g Topiramate, Lamotrigine, Valproate, Amitriptyline have been used with beneficial effects. It is important to involve a Child Psychologist to unpick any underlying psychological factor aggravating the headache. They would suggest various Relaxation techniques which increase a sense of control over body’s physical processes and increase both physical and psychological well-being to counteract pain states. They may also carry out Cognitive Behaviour Therapy (CBT). The usual goals of CBT include gaining a sense of control over pain, reducing fear of pain, enhancing function, increasing feelings of hopefulness and resourcefulness, and improving mood.

In Summary, Headaches in Children are under-diagnosed entities which need careful monitoring and need to be treated by experienced clinicians to avoid long term morbidity and improving the child’s psycho-social well being. A Multi-discipilary approach including Pediatric Neurologist, Pediatrician and Child Psychologists should be undertaken wherever possible.

Thursday, November 29, 2018

Headaches in Children

Headaches in Children - Diagnosis & Treatment

Headaches are one of the most common types of pediatric pain prompting referral to pediatric neurology clinic. 





















Headaches in Children are very common and it isn't serious like in adults, In some cases, kids headaches are caused by an infection, high levels of stress or anxiety, or minor head trauma. it is important to concentrate to your child's headache symptoms and consult a doctor if the headache worsens or happens oftentimes.
Headaches are one of the most common types of pediatric pain prompting referral to pediatric neurology clinic. The prevalence of headache ranges from 20% in children younger than 5 years, 37 to 51% in seven-year-old children, gradually increasing to 57–82% by 15 years of age. Before puberty, boys are affected more frequently than girls, but after puberty, headaches occur more frequently in girls. Headache may result in significant disability, including missed school days and extra-curricular activities, sub-optimal participation in regular activities, and loss of productivity.

Types of Headaches in Children



There are various types of childhood headaches but the common ones which are encountered in Pediatric Neurology Clinic include Migraine, Tension Headache, Cluster Headache and Chronic Daily Headache.



It is very important that the parents seek advice of a Child Neurologist who will carry out a proper history taking and simple bedside tests which include checking for fundi (back of the eyes) before making a diagnosis of Migraine. Neuroimaging e.g. CT or MRI Brain is not needed once a convincing history and normal neurological examination is established.When to Consult a DR.
  • Wake your kid from sleep
  • Worsen or become additional frequent
  • Change your child's temperament
  • Follow associate injury, like a blow to the top
  • Feature persistent reflex or visual changes
  • Are accompanied by fever and neck pain or stiffness


Take appointment of Dr. Aman P.S Sohal, best pediatri neuroconsultant in dubai



Dr Aman PS Sohal is a U.K Board certified Consultant Pediatric Neurologist with over 11 years of experience in Pediatrics which includes more than six years of experience as a Consultant in Pediatric Neurology.



Some of the conditions commonly encountered and managed by Dr Sohal



















Neuro-Rehabilitation in Kids

Neuro-Rehabilitation

Neurorehabilitation, also commonly referred as Neuro-Rehab, is a Mutli-Disciplinary
specialized process aimed at recovery of Child's Central and Peripheral Nervous
system. Neuro-Rehab is carried out for various complex Neurological disorders in
children which include Head Injuries, Cerebral Palsy, Multiple sclerosis, Spinal cord
injury, Peripheral nerve disorders like GBS, Neuropathies, as well as Muscle disorders
e.g Muscular dystrophies and Myopathies.


It is characterized by holistic approach towards the child with a single aim to ensure that the child reached the maximum potential of his/her recovery.


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The Neuro-Rehab is carried out by highly specialized team of professionals which
include Pediatric or Child Neurologist, Physiotherapist, Occupational Therapist, Speech
Therapist, Child Psychologist, Dietician etc amongst others. The Pediatric Neurologist
usually oversees the goals of recovery and monitors the progress of the child with
regular MDT meetings with the parents and the proffesionals involved in the child's
care.



Take appointment of Dr. Aman P.S Sohal, best pediatri neuroconsultant in dubai



Dr Aman PS Sohal is a U.K Board certified Consultant Pediatric Neurologist with over 11 years of experience in Pediatrics which includes more than six years of experience as a Consultant in Pediatric Neurology.



Some of the conditions commonly encountered and managed by Dr Sohal



Autism in Children

Autism in Children

Dr Aman PS Sohal is a U.K Board certified Consultant Autism Doctor in Dubai with over 11 years of experience in Pediatrics which includes more than six years of experience as a Consultant in Pediatric Neurology. 
Autism or Autistic Spectrum Disorder (ASD) is a common entity encountered in the
Pediatric Neurology clinic. Some recent studies suggest that up to 1 in 68 children may
have Autism. classically, ASD is diagnosed around 5 years of age, but the signs and
symptoms can be recognized as early as 2 years of age. ASD can present with varied
symptoms which include, poor response by the child when called, lack of pointing
towards objects of interest, poor eye contact, abnormal speech patterns e.g repetition
of words. If a child is not speaking, or has "lost gained words" at 2 years of age, a behavioural assessment should be carried out to see if the child needs early intervention for a working diagnosis of ASD. Children with ASD have extreme lack of
interest in their surroundings, peers and like to stay "in a world of their own"



The diagnosis of ASD is usually carried out by an experienced Child Neurologist,
Psychologist or Neuro-Developmental Pediatrician. The assessment to diagn
ose ASD can be tedious and occasionally the clinician decides to "break it up" into few sessions
to ensure the child is completely engaged during the diagnostic assessments. The
management of ASD involves "Early intervention approach" which involved various
specialized professionals including Behaviour analyst, Behavioural Therapy,
Occupational Therapy, Speech therapy etc. In older children Clinical Psychologist and
Child Psychiatrist may also be needed in case the child needs medications to manage
extreme behaviours.


Take appointment of Dr. Aman P.S Sohal, best pediatri neuroconsultant in dubai



Dr Aman PS Sohal is a U.K Board certified Consultant Pediatric Neurologist with over 11 years of experience in Pediatrics which includes more than six years of experience as a Consultant in Pediatric Neurology.



Some of the conditions commonly encountered and managed by Dr Sohal


Tuesday, November 13, 2018

Spasticity in Children

Spasticity in Children

SPACTICITY IN CHILDREN










Spasticity or Increase muscle tone is very commonly encountered in Pediatric
Neurology practice. In simple terms Spacticity means increased muscle tone which
causes resistance to any external movement. Spasticity is also commonly mentioned as
a "dynamic increase in muscle tone"; by the experienced physiotherapists. The most
common cause of spasticity in children is Cerebral palsy, usually caused by antenatal
or perinatal insult to the developing brain.

Child Spasticity treatment in dubai
If spasticity is caused by Cerebral palsy, the underlying brain problem which is
static(does not change with time), however the spasticity may get worse with time. It is
therefore important to "remain ahead in the game" by managing spasticity at the
earliest. The most common treatment of spasticity is Physiotherapy. An experienced
pediatric physiotherapist will assess your child and formulate a therapy program
depending on the severity of the spasticity.



The Pediatric Neurologist mat choose to start the child on a muscle relaxant, usually
Baclofen, which is given orally and in severe cases Baclofen can also be given via an
implantable device known as  "Baclofen Pump".
The doctor may also decide to give Botulinum toxin (Botox) injections to the spastic
muscles as a targeted therapy. This is usually given after 2 years of age.

Read More


Take appointment of Dr. Aman P.S Sohal, best pediatri neuroconsultant in dubai



Dr Aman PS Sohal is a U.K Board certified Consultant Pediatric Neurologist with over 11 years of experience in Pediatrics which includes more than six years of experience as a Consultant in Pediatric Neurology.



Some of the conditions commonly encountered and managed by Dr Sohal


Cerebral palsy in Children

Child Cerebral palsy (CP)


Cerebral palsy (CP) in children is a disorder that affects muscle tone, movement, and
motor skills (the ability to move in a coordinated and purposeful way).
CP usually is caused by brain damage that happens before or during a baby's birth,
or during the first 3 to 5 years of a child's life.



This brain damage also can lead to other health issues, including vision, hearing,
and speech problems; and learning disabilities. There is no cure for CP, but treatment,
therapy, special equipment, and, in some cases, surgery can help kids who have CP.

There are primarily three types of CP:


  • spastic cerebral palsy causes stiffness and movement difficulties
  • dyskinetic (athetoid) cerebral palsy leads to involuntary and uncontrolled movements
  • ataxic cerebral palsy causes a problem with balance and depth perception
Because cerebral palsy affects muscle control and coordination, even simple movements — like standing still — are difficult. Other functions that also involve motor skills and muscles — such as breathing, bladder and bowel control, eating, and talking — also may be affected when a child has CP. Cerebral palsy does not get worse over time.

What Causes Cerebral Palsy?

The exact causes of CP aren't always known. But many cases are the result of problems
during pregnancy when a fetus' brain is either damaged or doesn't develop normally.
This can be due to infections, maternal health problems, a genetic disorder,
or something else that interferes with normal brain development. Rarely, problems during
labor and delivery can cause CP. Premature babies especially under 28 weeks gestation
have a higher chance of having CP than babies that are carried to term.
So do other low-birthweight babies and multiple births, such as twins and triplets.

What Problems Does CP Cause?


Kids with CP have varying degrees of physical disability. Some have only mild impairment,
while others are severely affected. This depends on the extent of the damage to the brain.
For example, brain damage can be very limited, affecting only the part of the brain that
controls walking, or it can be much more extensive, affecting muscle control of the
entire body.

The brain damage that causes CP also can affect other brain functions and lead to
additional medical issues, such as:

  • visual impairment or blindness
  • Hearing loss
  • Food aspiration (the sucking of food or fluid into the lungs)
  • Gastroesophageal reflux (splitting up)
  • Speech problems
  • Drooling
  • Sleep disorders
  • Osteoprosis (weak, brittle bones)
  • Behavior problems



Epilepsy, speech and communication problems, and intellectual disabilities are more
common among kids with CP. Many have problems that can require ongoing therapy
and assistive devices such as braces or wheelchairs.


How Is Cerebral Palsy Treated?

Currently, there's no cure for cerebral palsy. But a variety of resources and therapies
can provide help and immensely improve the quality of life for kids with CP.



Children with CP commonly need Physiotherapy, Speech therapy, Occupational therapy
and sometime Behavioural therapy to improve their quality of life.
Occasionally the children need orthopaedic surgeries to help increase tendon lengths,


scoliosis etc.




Take appointment of Dr. Aman P.S Sohal, best pediatri neuroconsultant in dubai



Dr Aman PS Sohal is a U.K Board certified Consultant Pediatric Neurologist with over 11 years of experience in Pediatrics which includes more than six years of experience as a Consultant in Pediatric Neurology.



Some of the conditions commonly encountered and managed by Dr Sohal