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Facts and delusions of perinatal neurology. Seven neurologists have a child without a diagnosis …
By The keyword: neurology newborn, postnatal cerebral depression (nervous gipovozbudimost), postnatal nervous hyperexcitability, convulsions, tserebrastenicheskom syndrome, a birth tumor cephalohematoma, gipertnezionno-hydrocephalic syndrome, movement disorders in the first year of life, muscular dystonia, delay and disruption psychoverbal and emotional development.
When identifying disorders of the nervous system in children of the first year of life, manifested by delayed psychomotor development, it is necessary to take into account the associated neurological symptoms. The physiological immaturity of the nervous system of a young child makes it very difficult to diagnose, causing the fragmentary, partial and non-specific nature of the symptoms of nervous disorders. Below are the main options for neuropsychiatric response in the first year of life.
- GENERAL INSPECTION OF THE NEWBORN – WHAT TO PAY ATTENTION TO PARENTS
- POSTNATAL (POST-NORTHERN) BRAIN DEPRESSION (NERVOUS HYPOSPETICITY)
- POSTNATAL (POST-NORTHERN) HYPERTENSIBILITY
- TRAFFIC SYNDROME
- Cerebral Syndrome
- SYNDROMES OF MOTOR DISORDERS (MUSCLE DISTONIA, Cerebral Palsy)
General examination of the newborn – what to look for?
Given the high frequency of perinatal pathology of the nervous system and the possible difficulties in obtaining timely, qualified neurological care, the need for parents to obtain relevant popular science information seems undoubted.
What can parents see on their own, or with the help of a pediatrician? – general examination of the newborn
The child normally breathes rhythmically, performs automatic movements of the limbs in sufficient volume and symmetrically. The slightest restriction of movement in the arms or legs should be the basis for a focused study – are there any movement disorders? The nature and volume of the crying child is important. Much can suggest posture of the newborn. In some cases, the child is sluggish, inactive, sometimes – literally spread. In other cases, on the contrary, tone in the limbs evenly elevated – when swaddling immediately draws attention to the peculiar stiffness of the limbs and the apparent difficulty in carrying out passive movements in the arms and legs (flexion and extension). It is very important not to miss when inspecting even small convulsive jerks.
Very much gives the inspection of the head of the newborn. Generic tumor Typical for most babies. The larger the size of this tumor, the more difficult, therefore, the birth of a child has passed, and such a child must be the subject of a particularly careful examination. In some children, bruising on the face, neck, and body as a result of traumatic labor draws attention — in these cases, neurological symptoms are more often detected. Head deformities (the so-called “configuration”) almost always indicate a birth trauma of the skull, and among these children, craniocerebral symptoms are much more common, which is quite understandable and easily explained.
In everyday practice, the manifestations of generic cefalohematomas usually only because it is “often found” and “located outside the skull”. In fact, it seems, this is a simple bump, an external, subperiosteal hematoma, sometimes quite large in size, which is not so rare, but these facts cannot be a cause for complacency and a light-weight attitude to the problem. Cefalohematoma – this is always a birth trauma, and it is important to be confident and know for sure that at the level of such a hematoma in the underlying brain regions there will not be microbromous zones and cerebral circulation disorders that can later determine the specific microneurological symptoms in a child. Some species cephalohematomas require mandatory consultation not only a neurologist, but also a neurosurgeon (the question of the puncture and suction of cephaloghematomas).
One of the important evidence of serious mechanical stress in the head of the child, in the process of labor, may be a symptom finding the bones of the skull on each other. Such a small dislocation, as a rule, does not lead to brain damage, since it is a physiological mechanism to facilitate the passage of the head through the birth canal. But everything is good in moderation: significant deformations, shifts and finding the cranial bones of each other unconditionally testify to those powerful mechanical forces that are compressing the head in the birth canal, while symptoms of brain damage are often noted.
A major role in assessing the condition of the child is the state springs: tension, bulging of fontanelles is a very terrible symptom of increased intracranial pressure. They say a lot to the doctor the size of the head of the newborn: signs of hydrocephalus, if they are found from the first days of life, usually indicate intrauterine pathology of the brain, whereas the gradual development of hydrocephalus may often be the result of generic brain damage.
Another (already 100th!) Reminder of the tragic frequency of an unreasonably extended diagnosis will not interfere. hypertensive-hydrocephalic syndrome, which in 9 cases (and more) out of 10 is completely untrue. The most unpleasant in such cases of overdiagnosis of intracranial hypertension is unjustified, prolonged therapy with diacarb and other diuretic drugs, often causing certain side effects.
Intracranial hypertension (if it really is) can be easily noticed by attentive parents: it is characterized by persistent or paroxysmal headaches (usually in the morning), nausea and vomiting, not associated with food. The child is often sluggish and sad, constantly naughty, refuses to eat, he always wants to lie down and cuddle up to his mother.
A very serious symptom can be strabismus or pupil difference, and, of course, impaired consciousness. In infants, the bulging and stress of the fontanel, the divergence of the seams between the bones of the skull, as well as excessive growth of the head circumference are very suspicious. Without a doubt, in such cases, the child should be shown to specialists as soon as possible. Quite often, quite a single clinical examination to exclude or pre-diagnose this pathology. Sometimes requires additional research methods (fundus, neurosonography, as well as magnetic resonance imaging or computed tomography of the brain (MRI and CTG).
In some newborns, the head has a size smaller than normal, and besides, the cerebral part of the skull is smaller than the facial – sometimes, this is evidence of fetal or genetic pathology (microcephaly – literally, small brain) and, unfortunately, has dire consequences. Recently, cases of very early fontanel closure are much more common, while the dynamics of head growth noticeably lag behind the average statistical norm, but the child develops normally and does not have nervous system disorders. Such variants of the norm may include microcraniums (literally, a small skull) – a constitutional, genetic feature that does not cause any concern among specialists.
In any case, the external singularities of the head of a newborn (large or small; it grows very quickly or slowly, the spring is closed or huge; strange shape or deformation, a lump and
Quite often is a sign short neck, it is easy to see even unprepared person. One explanation for the causes of the short neck is considered to be an intense mechanical effect on the head-neck-torso axis during difficult labor activity, while the muscles of the neck over-stretch, and then, reflexively over-contracted, the phenomenon of accordion occurs. There are no structural disorders and malformations of the cervical vertebrae, but it seems that the head is directly “stuck” to the torso and neck is not at all visible. In such babies, the transverse folds in the neck are pronounced and deep, there is often skin irritation and weeping dermatitis, which is difficult to treat. Gradually, with each week, the visible gap between the neck and torso increases. However, after some time, some of these children show excessive (protective?) Tension of the posterior neck muscles, another proof of birth damage and the prospect of future friendship with a children’s orthopedist.
The evaluation is very indicative. abdominal wall conditions is important. It is known that in some newborns the belly is flabby, sprawled, and in these cases a violation of the contractile ability of the abdominal muscles as a result of birth injuries of the thoracic spinal cord cannot be ruled out. This is especially demonstrative with a predominantly one-sided localization of the lesion – the weak half of the abdominal wall bulges slightly, the navel is shifted with a cry. With bilateral lesions, it is more difficult to judge this. The following test is useful: if such a newborn has a weak cry, then with pressure from the doctor’s hand on the child’s belly, the voice becomes much louder.
Priapism should also be considered unfavorable. spontaneous erection penis in the newborn. Pediatricians often encounter this symptom, but do not know how to interpret it. At the same time, in adult neurology, this symptom is well known, and may indicate a possible spinal pathology.
We tried to consider some possibilities of a general examination of the newborn to look for signs that would allow one or another neurological pathology to be suspected.
Each of the above signs can not be considered as evidence, but in the aggregate, they acquire a great diagnostic meaning. In any case, only a doctor specializing in perinatal neurology can resolve your doubts.
Perinatal Brain Depression (Nervous Hypoxia)
Small motor and mental activity of the child, which is always lower than its motor and intellectual capabilities; high threshold and long delayed period of occurrence of all reflex and arbitrary reactions. Depression is often combined with low muscular tension and reflexes, slower switching of nervous processes, emotional lethargy, low motivation and weak willpower.
Hypoexcitability can be expressed in varying degrees and manifest itself either sporadically or tenaciously. Episodic occurrence of the syndrome is characteristic of somatic (non-neurological) pathology, for example, dysfunction of the gastrointestinal tract, accompanied by hypotrophy. Sometimes light, but steady manifestations of decreased excitability are simply explained by the type of higher nervous activity (temperament). The predominance of cerebral depression in the first months of life is often observed in premature infants who have suffered from oxygen starvation, intracranial birth injury. Severe and persistent depression is often accompanied by a delay in psychomotor development, which acquires some characteristic features.
The delay in psychomotor development in the hypodynamic syndrome is characterized by a slow formation of all conditioned reflexes. In the neonatal period and in the first months of life, this is manifested in a lag in the development of the conditioned reflex at the time of feeding; further development of all food conditioned reflexes is delayed (reflex to the feeding position, type of breast or bottle with milk, etc.), development of food and then visual and auditory dominant and sensitive local reactions is delayed. The delay in the development of chain motor combined reflexes is especially characteristic, which most clearly begins to manifest itself from the second half of the year of life! Such a child at the age of 6-8: month does not pat his hand on a blanket or toy, does not knock the object on the object, does not re-eject the object by the end of the year, does not put the object into the object. This is also manifested in voice reactions: the child rarely repeats sounds, syllables, that is, by performing single movements and uttering individual sounds, he does not seek to repeat them. As a result of the delay in the formation of conditioned reflexes on the combination of a word with an object or action, both in a specific and in a non-specific situation, the initial understanding of speech and submission to verbal: commands for these children occur at a later time. At the same time, the lag of such functions as subject-manipulative activity, crawling, babble, speech comprehension, own speech is formed.
In the case of the hypovitability variant, the formation of positive emotional reactions is noted at a later date. This is manifested both in communication with an adult and in the spontaneous behavior of the child. In the neonatal period, when dealing with an adult, these children usually lack oral attention, at the age of 2 months the reaction of joyful animation at the sight of an adult and a tender voice is not pronounced or weakly expressed. Often, instead of mimicking a child, one can only see the reaction of concentration. A smile appears after 8-9 weeks, for its occurrence requires a complex of stimuli, including proprioceptive, their repetition; the latent period of the appearance of a smile in response to an irritant is lengthened.
In the waking state, the child remains sluggish, passive, orienting reactions occur mainly on strong stimuli. The reaction to the novelty is sluggish and in most cases has the character of passive amazement, when a child with wide eyes remains motionless at the sight of a new object, without making active attempts to approach it, to seize it. The longer the period of absence of active wakefulness and orienting-exploratory behavior, the more pronounced is the delay in psychomotor development.
The revitalization complex is one of the main manifestations of active forms of emotional behavior in a child during the first months of life — with hypo-excitability either absent or manifests itself in a rudimentary form: a weak mimic reaction without eye gloss and voice reactions or the absence of a motor component, distinct vegetative manifestations. Active negative emotional reactions are also poorly defined and have almost no effect on the child’s general behavior.
Features of the emotional sphere determine the secondary underdevelopment of the intonational expressiveness of voice reactions, as well as the specifics of the formation of sensory functions. So, at the second age stage, a hypovo-excitable child usually captures and traces the object well, but the movement of the eyeballs after the moving object does not begin immediately, but after a certain latent period, as is typical of a newborn: the eyes constantly seem to catch up with the moving view subject. These visual reactions are impermanent, and special optimal conditions are often necessary for their occurrence: a certain child’s condition, sufficient strength and duration of the stimulus, etc. In the second age period, these reactions most clearly and often do not occur in the back position, but in the vertical position on the hands of an adult. A special feature of visual perception during hypo-excitability at this age stage is also the fact that the child spontaneously hardly considers the surrounding objects, he does not have an active search for an irritant. A hypo-excitable child usually turns its head and eyes to an invisible source of sound after repeated repetitions and a long latent period; auditory perception, as well as visual, usually does not acquire a dominant character.
Delayed psychomotor development in the syndrome of hypoexcitability is characterized by developmental imbalance, which manifests itself in all forms of sensory-motor behavior. Thus, with sufficient development, the emotional reactions to “one’s own” and “alien” children are differentiated by active joy in communicating with acquaintances, protest in communicating with unfamiliar persons, that is, in the age stages insufficient communication activity remains pronounced. Along with the timely development of individual sensory functions, there is a lag in the formation of intersensory connections, especially in the system of tactile-kinesthetic analyzer, so the hypo-excitable children later begin to examine and suck their hands, feel toys, and visual-motor coordination is delayed. The lack of active research behavior is reflected in the disproportionality of the development of visual perception. Therefore, with sufficient development in the child of differentiated visual perception, the automatic nature of tracking the subject can be maintained.
In a dynamic quantitative assessment of age development, a child with a syndrome of hypo-excitability loses 7–9 points at different periods, and the maximum loss is observed at the age of 4–5 months, when normally the first intersensory connections and active forms of behavior should be actively formed.
Perinatal cerebral hyper-irritability
Motive anxiety, emotional instability, sleep disturbance, enhancement of congenital reflexes, increased reflex excitability, a tendency to pathological movements often in combination with a reduced threshold of convulsive readiness. Hyper-irritability in the causal relation is not very specific and can be observed in children with perinatal pathology, some hereditary fermentopathies and other metabolic disorders, congenital childhood nervousness and with minimal brain dysfunction. There may be no pronounced lag in psychomotor development in these children, but upon careful examination, it is usually possible to note some minor deviations.
For disorders of psychomotor development in hyper-excitability syndrome, there is a lag in the formation of voluntary attention, differentiated motor and mental reactions, which gives psychomotor development a kind of unevenness. In such children, by the end of the first year of life, cognitive interest in their surroundings is usually well expressed, active forms of communication, and at the same time, with strong emotions, a general revitalization complex with diffuse motor responses may occur.
All motor, sensory and emotional reactions to external stimuli in a hyper-excitable child occur quickly, after a short latency period, and just as quickly die out. Having mastered these or other motor skills, children continuously move, change poses, constantly stretch to some objects and capture them. At the same time, manipulative research activities, imitative games and gestures are weakly expressed in them. Usually, children show a keen interest in their surroundings, but increased emotional lability often makes it difficult for them to contact others. Many of them have a prolonged fear reaction to communication with unfamiliar adults with active protest reactions. Typically, hyperviability of the syndrome is combined with increased mental exhaustion. When assessing the age development of a hyper-excitable child, it is usually referred not to the delay group, but to the risk group if hyper-excitability is not combined with other neurological disorders.