Suspected neurological conditions: recognition and referral

Refer urgently children who present with discrete episodes of loss of awareness (mid-activity vacant spells) or of attention and concentration difficulty, in line with the NICE guideline on epilepsies.

Be aware that medicines commonly used to treat epilepsy in children can adversely affect concentration and memory.

Refer children with concentration or memory difficulties that interfere with learning, school progress or behaviour to community paediatric or paediatric neurodevelopmental services for assessment.

Be aware that some children with attention and concentration difficulties do not have hyperactivity.

Refer urgently children with new-onset blackouts (transient loss of consciousness) accompanied by seizure markers for neurological assessment, in line with the recommendation for people with suspected epilepsy in the NICE guideline on transient loss of consciousness ('blackouts') in over 16s.

The committee agreed that the recommendation for people with suspected epilepsy in the NICE guideline on transient loss of consciousness ('blackouts') in over 16s is applicable to children aged under 16.

Refer urgently children with mid-activity vacant spells or behavioural outbursts associated with altered consciousness or amnesia for the events to have a paediatric assessment.

Refer urgently all children aged under 12 years with blackouts for paediatric assessment.

Do not routinely refer children aged over 12 years with blackouts if there are clear features of vasovagal syncope, even if associated with brief jerking of the limbs, in line with the recommendation on diagnosing uncomplicated faint in the section on no further immediate management required in the NICE guideline on transient loss of consciousness ('blackouts') in over 16s.

For children who have blackouts, seizures or amnesia for events after a head injury, follow the recommendations on pre-hospital assessment, advice and referral to hospital in the NICE guideline on head injury.

Be aware that isolated dizziness in children is unlikely to be a symptom of a brain tumour if there are no accompanying symptoms or signs.

Be aware that dizziness in children is often a symptom of migraine and may be the predominant feature.

Be aware that in older children (usually aged over 8 years), dizziness related to change in posture is often caused by postural hypotension.

In children with dizziness, examine the ears for any signs of infection, inflammation or eardrum perforation.

For children with recurrent episodes of dizziness:

• consider referring for cardiological assessment if there are any factors that might suggest a cardiac cause, such as blackouts (transient loss of consciousness), a family history of cardiomyopathy or unexplained sudden death, or palpitations

• if there are episodes of dizziness with a fixed symptom pattern, be alert to the possibility of epilepsy as the cause and follow the recommendations in the NICE guideline on epilepsies.

Refer immediately children aged under 12 years with headache for same-day assessment, according to local pathways, if they have any 1 of the following:

• headache that wakes them at night

• headache that is present on awakening in the morning

• headache that progressively worsens

• headache triggered or aggravated by coughing, sneezing or bending down

• headache with fever and features of meningism

• headache associated with vomiting

• headache associated with ataxia

• headache associated with change in conscious level or pervasive lethargy

• headache occurring within 5 days of a head injury

• headache associated with squint or failure of upward gaze ('sunsetting').

Refer urgently all children aged under 4 years with headache for neurological assessment.

Perform or request fundoscopy for all children with recurrent headache and refer urgently for neurological assessment if there are abnormalities.

For all children with recurrent headache:

• be aware that hypertension might be the cause

• measure the child's blood pressure and check the measurement against blood pressure reference ranges adjusted for age and height

• refer children if headaches are consistently worsened by upright posture and relieved by lying down.

Do not routinely refer children with migraine unless it is affecting their school life, social life or family activities, or they have 1 of the features listed in recommendation 1.21.1.

Be aware that emotional stress is a strong trigger of migraine and chronic, daily headache in children. Ask the child and their parent or carer about specific learning problems, bullying at school and stress in the family.

Ask about analgesic use in children with recurrent headache to ensure that medicine use is not excessive and to assess the likelihood of medication overuse headache. See the NICE guideline on headaches in over 12s for more information on medication overuse headache.

Refer urgently to paediatric services children with dysmorphic features and developmental delay.

For all children aged under 4 years with suspected abnormal head shape or size:

• take 3 consecutive measurements of the child's head circumference at the same appointment, using a disposable paper tape measure

• plot the longest of the 3 measurements on a standardised growth chart, corrected for gestational age

• if the child's head circumference is below the 2nd centile, refer for paediatric assessment.
  
  Offer follow-up measurements if needed, according to clinical judgement and taking the child's age into account.

For children with a head circumference measurement that differs by 2 or more centile lines from a previous measurement on a standardised growth chart (for example, an increase from the 25th to the 75th centile, or a decrease from the 50th to the 9th centile):

• refer to paediatric services for assessment and cranial imaging to exclude progressive hydrocephalus or microcephaly or

• refer immediately to paediatric services if the child also has any of the following signs or symptoms of raised intracranial pressure:

  • tense fontanelle

  • sixth nerve palsy

  • failure of upward gaze ('sunsetting')

  • vomiting

  • unsteadiness (ataxia)

• headache. [amended July 2019]

For children with a head circumference above the 98th centile that has not changed by more than 2 centile lines from the previous measurement on a standardised growth chart, who are developing normally and who have no symptoms of raised intracranial pressure:

• note the head size of the biological parents, if possible, to check for familial macrocephaly

• if familial macrocephaly is likely, do not routinely refer the child in the absence of any other problem.

For babies aged under 1 year whose head is flattened on 1 side (plagiocephaly):

• be aware that positional plagiocephaly (plagiocephaly caused by pressure outside the skull before or after birth) is the most common cause of asymmetric head shape

• measure the distance between the outer canthus of the baby's eye and the tragus of their ear on each side

• if the measurements differ, confirm positional plagiocephaly and do not routinely refer if the baby is developing normally

• if the measurements are the same, suspect unilateral premature closure of lambdoid suture and refer to paediatric services.

Advise parents or carers of babies with positional plagiocephaly that it is usually caused by the baby sleeping in 1 position and can be improved by changing the baby's position when they are lying, encouraging the baby to sit up when awake, and giving the baby time on their tummy.

Refer immediately children with sudden-onset or rapidly progressive (hours to days) limb or facial weakness for neurological assessment.

Refer urgently children with progressive limb weakness for neurological assessment.

Refer children with limb weakness that is part of a developmental disorder to paediatric services, in line with the recommendations on looking for signs of cerebral palsy in the NICE guideline on cerebral palsy under 25s.

For boys with limb weakness, see the recommendations on boys with motor development delay and motor development regression.

Refer immediately children with new-onset gait abnormality to acute paediatric services.

Refer children to a child development service, and consider referring for physiotherapy or occupational therapy, in line with the recommendations in the NICE guideline on cerebral palsy in under 25s, if they:

• are not sitting unsupported by 8 months (corrected for gestational age) or

• are not walking independently by 15 months (girls) or 18 months (boys) (corrected for gestational age) or

• show early asymmetry of hand function (hand preference) before 1 year (corrected for gestational age).

If the child is a boy, consider measuring creatinine kinase level to exclude Duchenne muscular dystrophy before the boy has had a specialist review.

Refer children with motor development regression to a paediatric neurodevelopmental service or paediatric neurology depending on locally agreed pathways.

If the child is a boy, consider measuring creatinine kinase level to exclude Duchenne muscular dystrophy before the boy has had a specialist review.

Refer immediately children with abnormal neck posture and a recent head or neck trauma to an emergency department for assessment, and follow the recommendations on cervical spine immobilisation in the section on initial assessment and care in the NICE guideline on head injury, and the recommendation on spinal immobilisation in the section on assessment for spinal injury in the NICE guideline on spinal injury.

In children with abnormal neck posture, check whether painful cervical lymphadenopathy is the cause.

Refer children who develop abnormal limb posture that has no apparent musculoskeletal cause for neurological assessment.

Be aware that abnormal head tilt in children can be a symptom of posterior fossa tumour.

Refer urgently children who have tingling accompanied by other peripheral nervous system symptoms such as weakness, bladder dysfunction or bowel dysfunction for neurological assessment.

Be aware that tingling in children may be the first symptom of an acute polyneuropathy (Guillain–Barré syndrome) or other neuro-inflammatory conditions. If the child has features suggesting motor impairment, refer urgently for neurological assessment.

Refer children with isolated tingling, altered sensation or paraesthesia for neurological assessment if the symptoms are episodic and are not associated with compression of a nerve. For more information, see the recommendations on diagnosis and investigations in the NICE guideline on epilepsies.

Do not routinely refer children for neurological assessment of temporary tingling or numbness if there is a clear history of the symptom being triggered by activities known to cause nerve compression, such as carrying a heavy backpack or sitting with crossed legs.

Be aware that in children, hyperventilation is a common cause of transient tingling in the limbs.

Refer urgently children with neuromuscular disorders who have early-morning headaches or new-onset sleep disturbance for a respiratory assessment.

Refer urgently children who have symptoms suggestive of new-onset epileptic seizures in sleep for neurological assessment.

Refer children with symptoms suggestive of narcolepsy, with or without cataplexy, for neurological assessment or a sleep clinic assessment according to local pathways.

Refer children with symptoms of sleep apnoea to ear, nose and throat or paediatric respiratory services, as appropriate, and offer advice on weight loss if the child is obese.

Refer children aged over 5 years with new-onset night terrors and children with night terrors that persist after age 12.

Reassure parents or carers of children aged under 5 years who have night terrors, repetitive movements, sleep talking or sleep walking that these are common in healthy children and rarely indicate a neurological condition.

Offer advice on sleep hygiene to parents or carers of children with insomnia, and consider referring to a health visitor if the child is aged under 5 years.

Consider referring children with sleep disorders associated with neurodevelopmental disorders or learning disabilities to community paediatric services.

Be aware that sleep disorders in children may be a symptom of gastro-oesophageal reflux or constipation. See the recommendations on diagnosing and investigating gastro-oesophageal reflux disease in the NICE guideline on gastro-oesophageal reflux disease in children and young people, and the NICE guideline on constipation in children and young people.

Refer urgently children with new-onset slurred or disrupted speech that is not attributable to prescribed medicines, recreational drugs or alcohol for neurological assessment.

Consider referring children aged over 2 years with abnormal speech development to speech and language services.

Be aware that delay or regression in speech and language in children can be a symptom of autism. Follow the recommendations in the NICE guideline on recognition, referral and diagnosis of autism spectrum disorder in under 19s for recognising children and young people with possible autism and referring children and young people to the autism team.

Refer immediately children with new-onset squint that occurs together with loss of fundal ('red') reflex in 1 or both eyes to ophthalmology services. (Also see recommendations on childhood cancers in NICE's guideline on suspected cancer.)

Refer immediately children with new-onset squint that occurs together with ataxia, vomiting or headache to acute paediatric services.

Refer urgently children with paralytic squint for neurological assessment, even in the absence of other signs and symptoms of raised intracranial pressure.

Refer children with non-paralytic squint to ophthalmology services.

Refer immediately children who have sudden-onset chorea, ataxia or dystonia for neurological assessment.

Do not routinely refer children with simple motor tics that are not troublesome to the child.

Advise parents or carers of children with a tic disorder to discuss the disorder with the child's school, emphasising that the tic is an involuntary movement and the child should not be reprimanded for it.

Do not offer medicine for motor tics in children without specialist referral and advice (see recommendation 1.31.6).

Be aware that tics and stereotypies (repetitive or ritualistic movements such as body rocking) are more common in children with autism or a learning (intellectual) disability.

For children with a tic disorder that has a significant impact on their quality of life, consider referring according to local pathways, as follows:

• referral to mental health services if the tic disorder is associated with symptoms of anxiety or obsessive compulsive behaviour

• referral to the neurodevelopmental team if the tic disorder is associated with symptoms suggestive of autism or attention deficit hyperactivity disorder

• referral for neurological assessment if the tic disorder is severe.

Refer urgently children presenting with tremor for neurological assessment if:

• they have additional neurological signs or symptoms such as unsteadiness or

• the onset of the tremor was sudden.

Be aware that isolated postural tremor in children may be a side effect of sodium valproate or a beta-adrenergic agonist.

Consider thyroid function tests for children with postural tremor and other symptoms or signs suggestive of thyroid overactivity.

Refer children with postural tremor for occupational therapy only if the tremor is affecting activities of daily living such as writing, eating or dressing.