CLINICAL GUIDELINESWORK AT STARSHIPCONTACTS
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Neurology

This webpage provides guidance for outpatient referrals to the Starship Paediatric Neurology Service. Our specialty provides services for Auckland, regional and national DHBs. Referrals are accepted from paediatricians or other medical or surgical specialists. If you are a member of the public, please discuss your concerns with your family doctor or paediatrician.

Between neurology appointments, patients should consult their family doctor or paediatrician. For renewal of prescriptions please contact your family doctor.

Where are we based?
The service and our inpatient care are based at Starship Children’s Hospital. There are outpatient clinics in Starship Hospital and at regional centres including Whangarei, Point Chevalier (Waitemata), Manukau SuperClinic (Counties Manukau), Tauranga, Hamilton, Rotorua, Hastings (Hawkes Bay), Gisborne and New Plymouth (Taranaki).

 

What is Paediatric Neurology?
Paediatric neurology is the branch of medicine that diagnoses and manages babies, children and teenagers who have disorders of the brain, spinal cord, nerves and muscles.

It involves looking after patients who are acutely unwell and require inpatient treatment (often in an intensive care setting), outpatient review of neurological problems and longer-term management of patients with chronic disorders.

Consultants

  • Dr Melinda Nolan Paediatric Neurologist
  • Dr Rakesh Patel Paediatric Neurologist
  • Dr Cynthia Sharpe Paediatric Neurologist
  • Dr Claire Spooner Paediatric Neurologist
  • Dr Gina O'Grady Paediatric Neurologist
  • Dr Hannah Jones Paediatric Neurologist

Referral Expectations

Preparing for your child's hospital or daystay admission  - click here

Your child's outpatient appointment - click here

What should you expect at your child’s first visit?
During a visit with a paediatric neurologist, the doctor will take a full history of your child’s problem which will include details of your pregnancy and the birth of your child and their developmental progress. The doctor will speak to you (the parent) and your child if he or she is able to understand.
 
The doctor will do a physical examination for your child’s neurological system and other relevant physical findings. After a thorough examination, the next steps will be discussed. The doctor may request additional tests to provide a diagnosis or to aid management. The doctor may prescribe medication and will arrange to see your child again if necessary. They will also send a letter to your child’s paediatrician and/or family doctor, with their findings and suggestions for future management. Please bring a list of your questions with you when your child sees the neurologist so that you have the opportunity to address all your concerns.

Common Conditions / Procedures / Treatments

About your Child’s EEG (Electroencephalogram)

EEG is the name commonly used for electroencephalography. An EEG is an important test for diagnosing epilepsy because it records the electrical activity of the brain.

  • It is safe and painless.
  • Electrodes (small, metal, cup-shaped disks) are attached to your scalp and connected by wires to an electrical box. (The wires can only record electrical activity; they do not deliver any electrical current to your scalp.) The box in turn is connected to an EEG machine.
  • The EEG machine records your brain's electrical activity as a series of squiggles called traces. Each trace corresponds to a different region of the brain.

About your Child’s Neuroimaging (CT and MRI)

Sometimes neurological conditions are caused by changes in the structure of the brain. Tests and procedures which take pictures of the brain, called "neuroimaging," can tell doctors whether you have one of these conditions. The most common neuroimaging tests are computed tomography (CT scan) and Magnetic Resonance Imaging (MRI scan). Both produce a picture of how the brain looks. Your child may need a general anaesthetic for their imaging study.

Nerve Conduction Studies (NCS)

NCS are tests of the speed of conduction of impulses through a nerve.  A doctor performs the tests with a technician.
 
The nerve is stimulated, usually with patch-like electrodes placed on the skin. One electrode stimulates the nerve with a very mild electrical impulse and the other electrodes record the resulting electrical activity.
 
The impulse will feel like a small electric shock. Depending on how strong the stimulus is you will feel it to varying degrees and it may be uncomfortable for you. You should feel no pain once the test is finished.
This test is used to diagnose nerve damage or destruction.  Information from the test can tell the doctor what part of the nerve is damaged and give an idea as to the disease causing the damage. There are no risks from this test.
 
The test will need to be interpreted afterwards so the results will not be available at the time of the test but will be sent to the referring doctor.

Electromyography (EMG)

EMG is a test that assesses disorders of muscles and the nerves controlling them. A doctor performs this test.
For an EMG, a needle electrode is inserted through the skin into the muscle. The electrical activity detected by this electrode is displayed on a monitor.  This is usually performed with a nerve conduction study.
You may be asked to contract the muscle (for example, by bending your arm) which will give the doctor information about how muscles respond to messages from nerves.
 
There may be some discomfort with the insertion of the electrodes (similar to an injection into a muscle). Afterwards, the muscle may feel tender or bruised for a few days.
 
There is a very low risk of bleeding or infection at the site of the needle but this is minimal.
 
EMG is most often used when people have symptoms of weakness and examination shows impaired muscle strength. It can help to tell the difference between problems with a muscle versus problems with the nerves supplying the muscle.

Lumbar Puncture (LP)

Cerebral Spinal Fluid (CSF) is the fluid that surrounds the brain and spinal cord.  It is often helpful when diagnosing certain conditions to examine this fluid for cells and chemicals/proteins.  A lumbar puncture allows the doctor to examine the content and pressure of this fluid.
 
 A doctor performs the test in the following manner:
  • The patient lies on his or her side, with the knees pulled up toward the chest. Sometimes the test is done with the person sitting up, but bent over.
  • After the back is cleaned, the doctor injects a local anaesthetic which makes the skin and surrounding area numb.
  • A spinal needle (which is long but smaller in diameter to that used to take a blood test) is inserted between two of the lumbar vertebrae (bones at the base of the spine).
  • Once the needle is properly positioned, spinal fluid pressure is measured, and fluid is collected.
  • The needle is removed, the area is cleaned, and a bandage is placed over the needle site. You will need to lie flat for 20 minutes to one hour after the test.
You may find the position for the lumbar puncture uncomfortable but it is important to stay still. The anaesthetic will sting or burn when first injected. There will be a hard pressure sensation when the needle is inserted and there is usually some brief pain. This pain should stop in a few seconds. Overall, discomfort is minimal to moderate. The entire procedure usually takes about 30 minutes. The actual pressure measurements and fluid collection only take a few minutes.
 
Risks of lumbar puncture include: allergic reaction to the anaesthetic, discomfort during the test, headache after the test, bleeding into the spinal canal (very rare) and
damage to the spinal cord particularly if the person moves during the test (very rare as the needle is so small).
These will all be discussed with you before the procedure and you will be given the opportunity to ask questions.  You will be asked to sign a consent form.

 

Epilepsy

Epilepsy is a condition where people have seizures or ‘fits’.  Seizures may present in many forms but are due to bursts of electrical activity within the brain.   The problem can be with the electricity of the brain on its own or due to some underlying structural lesion of the brain.
 
Anyone can have a seizure if the stimulus is great enough to exceed a threshold in the brain. Factors such as fever, changes in blood chemistry, anxiety, sleep deprivation or alcohol may influence the onset of a seizure.  Although some disorders and traumas play a role in developing epilepsy most people who have epilepsy have no known reason. 
 
A seizure may present as a convulsion, unusual body movement, a change in awareness or simply a blank stare. The person may be unconscious or completely unaware of what is happening.  What type of symptoms people have depends on what part of the brain is involved.
 
The diagnosis of epilepsy is made on the basis of the history so it is useful when you come to clinic if someone who has witnessed an event can come with you.  Depending on your symptoms and examination findings you may undergo an EEG test and/or an MRI of your brain to aid in the diagnosis and planning of treatment.  Not everyone needs these tests and the doctor will talk with you about what is needed.
 
Epilepsy is usually treated with medication to prevent seizures.  There will also be implications for driving if you are diagnosed with this condition, as it needs to be well controlled before you can drive.  Your doctor will discuss this with you.

Headaches/Migraines

Most headaches are not due to significant underlying problems but you may be referred if your GP is worried about the nature of your headaches or you are having difficulty controlling them with standard treatment.
 
Migraine headaches are repeated or recurrent headaches, often accompanied by other symptoms. They can be triggered by certain factors/events/foods. In some people, a visual disturbance called an aura happens before the headache starts.  
Other symptoms that may precede or accompany the headache include loss of appetite, nausea, vomiting, increased sweating, irritability, fatigue, intolerance of light or noise.  The headache may last several hours to days.
 
Prior to coming to clinic for review of headaches it is useful to keep a diary. Write down: when your headaches occurred, how severe they were, additional symptoms, what you've eaten, sleep patterns, menstrual cycles, any other possible factors.
 
There is no cure for migraine headaches but treatment is aimed at: preventing migraines from occurring, stopping the migraine once early symptoms develop, and treating the symptoms of migraine (e.g. pain, nausea).

Neuromuscular Disorders

There are a number of different conditions that affect the nerves and muscles beyond the central nervous system (brain and spinal cord).   Myopathy refers to disease affecting the muscles.  Neuropathy refers to disease affecting the nerves.  There are also diseases that affect the junction between the nerves and muscles.

For more information visit http://www.mda.org.nz/

This information has been provided by healthpoint.co.nz, helping people better understand and use New Zealand health services.