Division of Neurology

McMaster Objectives: Pediatric Neurology

Neurology Rotation for Adult Neurology Residents

  1. Medical Expert/Clinical Decision-Maker
  2. Communicator
  3. Collaborator
  4. Manager
  5. Health Advocate
  6. Scholar
  7. Professional

1. Medical Expert

  1. Review the normal gross and microscopic anatomy of the developing nervous system, including embryologic development.
  2. Become familiar with commonly seen abnormalities in anatomic development of the central nervous system including disorders of:

    a. Neurulation

    1. Anencephaly
    2. Encephalocele
    3. Myelomeningocele & Arnold-Chiari malformation

    b. Prosencphalic development and cleavage

    1. Aprosencephaly / atelencephaly
    2. Holoprosencephaly
    3. Agenesis of corpus callosum
    4. Septo-optic dysplasia

    c. Congenital hydrocephalus

    1. Dandy-Walker malformation
    2. Aqueductal stenosis
    3. other

    d. Neuronal proliferation and migration

    1. Genetic micrencephaly / macrencephaly
    2. Schizencephaly
    3. Lissencephaly / pachygyria
    4. Polymicrogyria
    5. Heterotopia
    6. Focal malformations of cortical development

    e. Normal age-dependent myelination

  3. Understand normal child development, including specific familiarity with the major milestones in Gross Motor, Fine Motor, Language and Social / Adaptive development through infancy and early childhood.
  4. Develop an appreciation for the impact of the child’s environment on his/her development, including the effects of nutritional and social/emotional deprivation.
  5. Develop an approach to the investigation and therapy of common presenting neurologic conditions in pediatrics including:

a. Developmental delay

  1. Isolated motor (gross/fine) delay
    1. Isolated language delay
    2. expressive only
  2. receptive and expressive
  3. Global developmental delay

b. Mental retardation

  1. Definition
  2. Work-up

c. Autism

d. Cerebral palsy

e. Developmental regression

  1. Degenerative neurologic conditions in pediatrics
    1. Predominantly grey matter disorders
    2. Predominantly white matter disorders
  2. Developmental pseudo-regression

f. Seizures, including:

  1. Types of epileptic seizures
  2. Disorders in children which can mimic epilepsy
  3. Approach to provoked seizures (eg. febrile seizures)
  4. Approach to first unprovoked seizure
  5. Diagnosis and treatment of epilepsy
    1. When to start medication
    2. Risks and benefits of treatment
      1. “Brain damage” from seizures
      2. Injury / death from seizures
      3. Kindling
      4. Drug toxicities
      5. Quality of life concerns
    3. Choice of medication by seizure type
      1. Mechanisms of action of the different anticonvulsant medications
    4. Non-pharmacologic alternative treatments
    5. When to stop medication (duration of prophylactic treatment)
    6. Safety counseling for patients with epilepsy
  6. Treatment of status epilepticus
  7. Utility and limits of EEG in diagnosing and treating epilepsy

Back to Top

g. Headache / migraine in children

h. Pseudotumour cerebri

i. Stroke in the pediatric and neonatal population

  1. Ischemic
    1. arterial ischemic stroke
    2. sinovenous thrombosis
  2. Hemorrhagic stroke

j. Ataxia (acute / chronic)

k. Tic disorders

  1. Transient tic disorder
  2. Tourette Syndrome
  3. Pediatric Acquired Neuropsychological Disorders Associated with Streptococcal infection (PANDAS)

l. Neurocutaneous disorders

m. Conditions with significant psychogenic contribution:

  1. Non-epileptic seizures
  2. Chronic daily headache
  3. Conversion disorders

n. Neonatal neurologic disorders, including

  1. Neonatal seizures
  2. Perinatal asphyxia / hypoxic-ischemic encephalopathy
  3. Intraventricular hemorrhage
  4. Periventricular leukomalacia
  5. Hypotonic (‘floppy’) infant
  1. Become familiar with the approach to urgent neurologic conditions in children:
    1. Status epilepticus
    2. Acute flaccid paralysis
    3. Meningitis / encephalitis
    4. Closed head injury
    5. Increased intracranial pressure
    6. Coma
    7. Diagnosis of brain death
  1. Appreciate aspects of general pediatrics relevant to neurologic care of infants and children:
    1. Normal growth patterns (height, weight and head circumference)
    2. Failure to thrive (sparing vs. involving the brain)
    3. Normal fluid, electrolyte and nutrition requirements
    4. Pharmacokinetics in children vs. adults
  1. Be able to elicit and present a medical history in an organized fashion. This includes proper succinct summarization of some aspects of the history, as well as expansion of detail in others.
  2. Demonstrate competence and fluency with the individual maneuvers of the neurologic examination in children.
  3. Be able to select, guided by clinical knowledge and judgement, which specific aspects of the physical and neurologic examinations are particularly relevant to the clinical scenario at hand (this implies the conscious use of the neurologic examination as a tool to test a clinical hypothesis).
  4. Demonstrate the ability to anatomically localize focal neurologic processes.
  5. Be able to describe a clinical condition in terms of its chronicity (static / pseudo-static / paroxysmal / pseudo-progressive / progressive).
  6. Be able to formulate a diagnostic hypothesis making use of anatomic localization, temporal patterns of symptom evolution, clinical knowledge base and judgement.
  7. Develop familiarity with the utility, risks, and limits of diagnostic investigations including neuroimaging (CT, MRI, PET, angiography), neurophysiologic testing (EEG, EMG, nerve conduction studies, evoked potentials), neurogenetic (cytogenetic and DNA), neurometabolic and neuropathologic studies.
  8. Knowledgeably generate a differential diagnosis and an appropriate plan of diagnostic investigation for various common presenting neurologic problems in infancy and childhood.
  9. Develop an appreciation for the roles that the various forms of therapy play in the overall treatment of neurodevelopmental disorders, including education and anticipatory counseling, psychotherapy, physical therapy, occupational therapy, speech therapy, nutritional therapy, pharmacologic treatment, surgery, orthotics and mobility aids, technological assistance, and financial/societal support.
  10. Proficiency in the following skills or procedures:
    1. Conducting the neurologic examination in children of various ages (neonatal through to teenage).
    2. Performing lumbar punctures, including manometry, in children.
    3. Interpreting neuroimaging studies (CT/MRI).

Back to Top


2. Communicator

  1. Become proficient in taking a history from the parent / caregiver, involving the child in relevant aspects where appropriate.
  2. Demonstrate the ability to establish a therapeutic relationship with patients and families.
  3. Be able to conduct a “HEADS” (Home, Education, Activities, Depression/Drugs, Sex/Suicide) interview in adolescents when appropriate.
  4. Be able to listen effectively to patients and caregivers.
  5. Demonstrate the ability to provide education and counseling to families while avoiding excessive use of jargon.
  6. Understand the issues of confidentiality in the pediatric age group.
  7. Appreciate the importance of communication with referring physicians.
  8. Appreciate that coordination and cooperation among the entire health care team – physicians, nurses, therapists, dietitians, technologists – is dependent on clear and inclusive communication.
  9. Demonstrate the ability to orally present case histories in an organized, concise and accurate manner.
  10. Generate written / dictated notes which are clear, concise and informative.

Back to Top


3. Collaborator

  1. Demonstrate the ability to interact effectively with a team of health professionals by recognizing and acknowledging their roles and expertise.
  2. Show an awareness of the value that their contributions have in the diagnosis, investigation and management of children under their care, and accordingly participate fully in all relevant discussions and deliberations.

 


4. Manager

  1. Demonstrate the ability to prioritize and address competing clinical demands.
  2. Be able to effectively delegate tasks to junior residents and students, and where needed provide supervision in the completion of such tasks.
  3. Show an awareness of the possible roles of electronic personal data management devices (‘personal digital assistants’) in assisting health professionals to more efficiently manage and track clinical, academic and personal data.
  4. Be able to effectively make use of regional and internet-based databases to access patient information and to search medical literature successfully.
  5. Demonstrate an awareness of cost-benefit considerations in patient-care decisions.

Back to Top


5. Health Advocate

  1. Demonstrate an awareness of the impact that society can have on the ultimate outcome of children with neurodevelopmental handicaps.
  2. Recognize that provision of appropriate school settings, therapy, recreation and transportation are all essential elements of the care of children with neurodevelopmental handicaps.
  3. Develop an understanding of the specialist’s role to intervene on behalf of patients with respect to the social, educational and economic factors that may adversely impact on their health.
  4. Appreciate even further the particular need for advocacy on behalf of developmentally handicapped children, whose needs are significant and whose families are often ill-equipped to advocate knowledgeably on their behalf.
  5. Recognize the importance of empowering caregivers to become involved in health-related quality of life decision making for the child.
  6. Understand that developmentally delayed and special-needs children are, as a group, at greater risk of abuse and neglect, and accordingly develop an appreciation of the circumstances which would mandate that the specialist intervene for the purpose of child protection.

Back to Top


6. Scholar

  1. Demonstrate the ability to accurately assess one’s own personal learning needs.
  2. Demonstrate a commitment to continuously improving one’s knowledge, as evidenced by ongoing pursuit of unprompted self-directed learning.
  3. Be able to critically appraise information from medical literature, both in terms of the methods used in obtaining and analyzing the data, and in the applicability of the data to clinical practice.
  4. Facilitate the ongoing education of colleagues by taking advantage of opportunities to teach more junior team members.
  5. Demonstrate the ability to present, in a comprehensive and authoritative manner, a topic or issue relevant to pediatric neurology to an audience of one’s peers.

Back to Top


7. Professional

  1. Demonstrate honesty, courtesy and responsibility in interactions with patients and peers.
  2. Demonstrate appropriate empathy and compassion in patient encounters.
  3. Demonstrate respect for diversity.
  4. Demonstrate an awareness of one’s own limits and an ongoing pursuit of self-improvement.
  5. Demonstrate an awareness of the principles of medical ethics and their application to clinical practice.
  6. Recognize that the need to act as an advocate for one’s patient may supercede the directives of one’s supervisor(s), and that the resident should not participate in, or through omission of action allow to occur, an action which is detrimental to a patient’s best interests.
  7. Recognize that residency training offers the opportunity to emulate the role of the consultant under direct supervision, and as such demonstrate a willingness to undertake the responsibilities of the consultant role (integration of information, generation of hypotheses, planning of investigation and management, provision of counseling) to the extent that one’s acquired knowledge and abilities permit.