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Early Neurologic Red Flags in Pediatrics: What Primary Care Providers Need to Know · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr Bob Underwood: Welcome to Pediatrics in Practice, A CME podcast.
• 0:06
  I'm Dr.
• 0:07
  Bob Underwood, and today I'm joined by Dr.
• 0:09
  Justin Kugel, pediatric neurologist at Children's Mercy, Kansas City.
• 0:14
  Today we're exploring how primary care clinicians can recognize early
• 0:20
  and often subtle neurologic red flags across childhood development.
• 0:24
  Dr.
• 0:25
  Kugel, thanks for taking the time to join us this morning.
• 0:28
  Dr Justin Coogle: Yeah, happy to be here.
• 0:29
  Thanks for having me on, Bob.
• 0:31
  Dr Bob Underwood: Absolutely.
• 0:32
  So from a primary care perspective, what are some early neurologic signs or
• 0:39
  symptom patterns that should raise concern beyond typical developmental variation?
• 0:46
  Dr Justin Coogle: I think whenever people think about.
• 0:48
  Developmental concerns and things that, perk up a neurologist's EARS.
• 0:54
  You know, the obvious one is clearly like a global developmental delay.
• 0:58
  that's classified and defined as having, two different
• 1:01
  domains of developmental delay.
• 1:03
  And so, if someone's exhibiting, delays in speech, behind in their word
• 1:08
  counts or, responding to what would be expected, like as appropriate commands
• 1:12
  or whatever in a certain developmental stage, but then like maybe two or
• 1:16
  three months later, also showing lags in their gross motor development.
• 1:20
  And all of this, especially contextualized by, if they were, Introduced to period
• 1:24
  of therapy, for maybe like one or two months and, continued to have lags
• 1:28
  in development in a different domain.
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  That's always perks of a concern for us.
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  And, You know, we're always happy to see kids with global
• 1:36
  delays, earlier than later.
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  I think the domain of development that, at least for me personally as a pediatric
• 1:44
  neurologist, concerns me the most.
• 1:47
  Is, a prolonged period of speech delay.
• 1:50
  especially, there's a lot more of a stronger, conscientious awareness of
• 1:55
  things like autism spectrum disorder.
• 1:57
  but even when we think of things like, rare, genetic epilepsies and,
• 2:00
  epileptic disorders, speech delays always, raise a higher level of concern.
• 2:05
  the other thing that when I hear about a, neurologic symptom I'm, I'm
• 2:10
  always more than happy to see that kid sooner than later is, weakness as well.
• 2:15
  You know, I think, focal weakness, especially can be kind of hard
• 2:19
  to recognize for some people, outside of like a very obvious.
• 2:23
  patient that had a, traumatic birth or a very, dicey early life, where, the
• 2:28
  concern for like a cerebral palsy or a static encephalopathy would be higher,
• 2:32
  at the forefront of your thoughts.
• 2:33
  But, when a kid maybe has a very subtle, asymetry in using their left
• 2:38
  arm versus their right arm, or even like having maybe like a more subtle.
• 2:42
  dragging of a toe, a foot.
• 2:44
  I think these are things that, are easier to overlook.
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  You know, parents always say their kid's quirkier, but those would be kids
• 2:49
  that I'm more prone to see as well.
• 2:51
  Dr Bob Underwood: Got it.
• 2:52
  Now, are there age specific red flags, like infants versus toddlers versus
• 2:57
  school-aged children that pediatricians should be particularly mindful of
• 3:03
  during routine Well-child visits.
• 3:06
  Dr Justin Coogle: when I think of age specific outside of, the developmental
• 3:12
  milestone grids that, You know, we're all.
• 3:15
  Reasonably, aware of.
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  And then think of things, like the ages and stages questionnaire
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  three, the ass Q3, You know, these like developmental screening tools.
• 3:23
  I think those do a good enough job, without having
• 3:26
  to add too much extra detail.
• 3:29
  when I think of things that, are a little bit more age specific,
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  any sort of speech difference.
• 3:37
  you know, I know I kind of comment on this a little bit earlier, but like any sort
• 3:39
  of like speech difference, especially like loss of speech in a Two to 3-year-old plus
• 3:46
  child, if they had words or if they had the ability to string together phrases
• 3:51
  and they lose or stagnate in that ability between like that two to four year of age.
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  definitely like is concerning to me, especially with young girls.
• 3:59
  We think of RET syndrome, and other forms of, neurodevelopmental disorders.
• 4:05
  That, we'd like to see and evaluated further.
• 4:08
  You know, when we think of children in their, school age years.
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  Maybe between like four to seven years of age.
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  And maybe they're a little bit of a restless sleeper, but their
• 4:19
  school performance starts to drop.
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  And they also are maybe having it feels like a stutter, but
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  it's not a classic stutter.
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  Or they start struggling to finish their sentences.
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  They start like really forgetting particular words, like more
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  of an expressive speech delay.
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  And then they're struggling and reading comprehension and all kinds of like.
• 4:35
  reading and, language learning skills.
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  These are things where we start think about is this child maybe suffering
• 4:39
  from a nocturnal epilepsy or an epileptic syndrome, such as like a
• 4:43
  Lando cleft syndrome where, having, seizures sometimes overlooked at night.
• 4:48
  And then, the, language disorder is, a major component of that.
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  So Those are things when I think of age specifics, the
• 4:54
  easy anchoring developmental.
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  Sign tends to be speech tied with those ages, but outside of that, unless
• 5:02
  they're having very obvious focal neurologic, symptoms, you know, I think
• 5:05
  those would be the things I'd think of.
• 5:06
  Dr Bob Underwood: Sure.
• 5:07
  Now those were kind of subtle in some of your explanations, so in your
• 5:10
  experience, which neurologic symptoms are most likely to be subtle or even
• 5:16
  overlooked in early primary care?
• 5:19
  Ings.
• 5:20
  Dr Justin Coogle: I think one that.
• 5:21
  Sometimes catches people maybe overlooked, is something as
• 5:25
  simple as like febrile seizures.
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  febrile seizures we're all pretty well aware of, right?
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  It's a, child that has a, provoked seizure between six months and five years of.
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  And, I think one thing that people often forget about that
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  requirement though, ' is, that the child is developmentally normal.
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  It's part of the definition, febrile seizures by itself.
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  the reason it's its own diagnosis is because it informs a prognosis.
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  And so, you know, when you're saying that this child has something
• 5:53
  like a febrile seizure, more specifically a simple febrile seizure.
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  Diagnosis.
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  you're saying that their risk of epilepsy is anywhere between 0.5
• 6:00
  to 1%, which basically the same as the general population.
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  but if the child later on, let's say they have their first fibro seizure
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  at like one-year of age, but then they get diagnosed with autism spectrum
• 6:10
  disorder at two years of age, or they start developing speech delay at three
• 6:13
  years of age, et cetera, et cetera.
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  This child no longer qualifies for that.
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  if they're continuing to have fevers And the seizures in the setting
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  of fevers, they actually are at an increased risk of epilepsy down the road.
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  And so.
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  I think that's an example of a neurologic symptom that's, you're kind of blindsided
• 6:27
  by your early definition or your early diagnosis and you think oh, febrile
• 6:30
  users, they'll just grow out of it.
• 6:31
  But these other context clues maybe change that.
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  I think other things is like visual symptoms.
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  and balance are, maybe subtle.
• 6:41
  lemme cluster a movement disorder there too.
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  I think kids that maybe experience chorea, they seem restless, they seem agitated.
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  They're may be moving a little bit too much.
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  I just had a, clinic appointment recently where.
• 6:52
  the concern was for Tick because this patient she keeps like
• 6:55
  twitching her hands, twiddling them around by her, tummy.
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  She keeps like fiddling with her clothes nonstop.
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  And then, when I walked in and looked at the girl, it was very clear
• 7:03
  that she was in flu diffuse chorea.
• 7:06
  and, she'd been experiencing these Creo formm movements for sounds like months.
• 7:09
  And, her primary care was concerned for like, tick a movement disorder.
• 7:13
  But, Actually a little bit more, robust than that.
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  So I think like movement disorder.
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  And then things like balance, the kids aren't uncoordinated,
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  the kid's tumbling a lot.
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  The kids, maybe struggling to do good, fine motor skills.
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  And sometimes you can have examples of symptoms like ataxia, which
• 7:27
  is a discoordination symptom, or hypotonia look, poor muscle
• 7:30
  tone, um, that can be indicative of other, genetic abnormalities.
• 7:34
  and that's a little bit easier to, under the radar.
• 7:37
  Dr Bob Underwood: Sure.
• 7:37
  Absolutely.
• 7:38
  And you know, as an emergency physician, certainly, the.
• 7:41
  Febrile seizure component that you spoke of I'm quite familiar with
• 7:44
  and have seen many, many times.
• 7:46
  so how should pediatricians approach that?
• 7:49
  Wait and see, when do you wait and see?
• 7:52
  Versus initiating earlier workup, you said that you'd rather
• 7:55
  see 'em earlier than later.
• 7:57
  so when do we refer versus when do we wait and see?
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  Dr Justin Coogle: I think there's definitely many chief complaints where, I
• 8:04
  think people refer too quickly And then I think, people don't refer quickly enough.
• 8:09
  We kind of touched a little bit on that.
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  I'd say as a general rule, whenever, two years and under, if there's ever
• 8:16
  developmental concerns, I don't think me or any of my partners would ever feel.
• 8:21
  On an earlier developmental delay referral than a later one, And so as I
• 8:26
  said, like in my personal practice, if there's ever global developmental delay.
• 8:30
  I would give maybe no longer than a three-month opportunity for therapies
• 8:36
  to show, some improvement before at least getting us established.
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  if you have a single domain of developmental delay, especially
• 8:44
  like motor delay, I think is.
• 8:46
  Very common.
• 8:47
  maybe a month or two behind on walking or a month or two behind on sitting
• 8:50
  up, one of my daughters is that way.
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  those tend to bounce back pretty quick with isolated therapies.
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  But if you're having multiple domains, we prefer a sooner than, later referral.
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  of course anything in regards to concerns for.
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  Movements, strange movements.
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  Abnormal movements is probably our most common chief complaint
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  outside of developmental delays.
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  So whether it's a seizure risk concern or just a movement disorder concern,
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  I think these are really hard and challenging for anyone but neurology
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  to kind of give a good weighted eye on.
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  And so.
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  if you don't feel confident that something like is a tick or like
• 9:20
  a clear febrile seizure, please feel free to refer very early.
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  I think things where there can be a little bit more room to, watch and
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  wait, would be, clear ticks, right?
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  Ticks are, involuntary suppressible, non rhythmic movements that follow
• 9:35
  a very common developmental pattern like four, eight years of age, or
• 9:38
  like headaches, And so if the headache doesn't have any red flags, like they're
• 9:41
  not waking them up at night, they're not having continued worsening vision.
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  they're not having associated fevers, focal allergic deficits or, persistent
• 9:48
  vomiting, and that's worsening over time.
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  then I think, these are things that you can give, I, kind
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  of use the two strikes rule.
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  give them an opportunity for lifestyle changes.
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  Give them opportunity for a first-line, either, preventative medication.
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  example for like, you know, magnesium oxide for pediatric headaches, or.
• 10:05
  clonidine for, TIC disorder, if it's causing dysfunction,
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  but when they pass that,
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  I think very reasonable for the referral.
• 10:14
  Dr Bob Underwood: got it.
• 10:15
  Now, we made some mention earlier of regular developmental screening
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  tools, And so where do you see those as playing a good role in identifying
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  neurologic concerns, which we kind of already touched on, but where
• 10:29
  are there limitations on these.
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  Dr Justin Coogle: I think the screening tools.
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  In regards to catching, especially like motor and speech concerns are pretty good.
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  the biggest limitation, across the board, at least what's routinely
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  done outside of like research settings is, probably like cognitive.
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  we've been seeing a little bit more patient's and sort of the like.
• 10:54
  three to six year range where, it was, pretty clear that as they are entering
• 11:00
  their early elementary school years, that these are kids with lower IQs, that these
• 11:04
  are kids with, worse cognitive processing.
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  And, with the continued, sophistication and availability of things like genetic
• 11:14
  testing, being able to historically look at like very specific genes.
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  thinking of things like Fragile X, looking at, chromosomal disorders,
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  thinking of things like Trisomy 21 or like deletion Syndromes 22 Q.
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  But, as we've gone on, we're now able to do whole exomes and now whole genomes,
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  methylation assessments, acetylation assessments, like all of these.
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  in a very, timely manner.
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  these results can come back within four to eight weeks sometimes.
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  And so, we've had like a few patient's where, simply on their cognitive
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  delays, I've opted in for getting some genetic testing and we've, caught
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  neurodevelopmental genetic disorders, due to just being behind in their IQ and such.
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  And so there's a future where we get better about either, at least like.
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  Paying attention to or, assessing and, determining,
• 12:01
  follow-up to cognitive delays.
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  Right now it's often mixed with speech and, the latest changes to
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  the developmental screening has like separated cognitive from speech as a
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  more clear delineation on the most recent CDC review and developmental screening.
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  And so, that's like one step.
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  so I think that's kind of like where I see some room for changes.
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  Dr Bob Underwood: yeah, no, those sound really important.
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  So say I have done the screening and I think that we need to refer
• 12:26
  a patient to you, what are some of the key history exam findings?
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  Preliminary.
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  Workup that would be helpful for a pediatric neurologist to receive
• 12:38
  upfront as we make that referral.
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  Dr Justin Coogle: one, I would say like, anything, I think the most
• 12:42
  common, referral sentences are like, dizzy, my favorite one is getting a
• 12:47
  referral that said thumb, and I didn't quite know what to make of that one.
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  I would say that simply in like one sentence, conveying what you're
• 12:55
  concerned you might be missing, I think helps a lot with focusing my visit.
• 12:59
  the chief complaint may say like, potential, concern for seizure.
• 13:03
  but more accurately when I talk with the parents in the room, they'll be
• 13:07
  like, the patient's uncle, my brother.
• 13:10
  Had a brain tumor and had a seizure from that.
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  Does my child have a brain tumor?
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  Right?
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  So like the question was actually deeper than do they have a seizure?
• 13:16
  the question was, do they have cancer?
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  just adding that extra little bit of context helps me really focus my visit
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  and address the concerns of the family.
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  putting like, one to two relevant focal neurologic.
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  exam findings, even if it's exam seemed normal, is helpful, or reflexes
• 13:31
  seemed poor, right leg is weak.
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  That's very, very helpful to just help me lock in a little bit better.
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  and just saying no neuroimaging acquired, or like, no neuro testing
• 13:41
  acquired, that just also helps me set the stage for what's been done.
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  I think a lot of.
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  Pediatricians especially, more so than their adult colleagues in internal
• 13:49
  medicine, are a little bit more hesitant on acquiring certain neurologic testing.
• 13:54
  I have many, many referrals where the referral is simply to get an
• 13:58
  MRI or think about an MRI, where, if you have Headaches with red
• 14:01
  flags or global developmental delay.
• 14:03
  standard of care simply on looking up, on UpToDate even neuroimaging is more than
• 14:08
  appropriate And so don't feel afraid.
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  no one will ever look down on you or blame you for getting, a little bit
• 14:14
  of a overzealous MRI of the brain.
• 14:16
  and, sometimes those results preliminarily can help me say yes or no or, guide,
• 14:21
  future testing and So, It doesn't mean get it all the time, but when it's
• 14:24
  pretty clear you don't feel like you.
• 14:26
  Have to refer to me just to have permission to do that.
• 14:28
  Dr Bob Underwood: Dr.
• 14:29
  Kugel, thank you so much for sharing your expertise today on recognizing
• 14:33
  some of these early signs and guiding a thoughtful and timely process, for
• 14:38
  children in the primary care setting.
• 14:39
  Really appreciate you being on today.
• 14:42
  Dr Justin Coogle: yeah, thanks for having me.
• 14:43
  This was a lot of fun.
• 14:44
  Dr Bob Underwood: And as a reminder to our audience, claim your CME
• 14:47
  credits after listening to this fascinating episode today, you
• 14:50
  could do so by visiting C KC Link.
• 14:54
  Slash CME podcast And then click the claim CME button.
• 15:00
  If you enjoyed this podcast, please share it on your social channels and
• 15:03
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• 15:05
  For topics of interest to you, I'm Dr.
• 15:08
  Bob Underwood, And this has been Pediatrics in Practice, A CME podcast.