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Care of the Child with a Chronic Neurologic Condition

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Laura Hart

on 15 September 2012

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Transcript of Care of the Child with a Chronic Neurologic Condition

by Laura Hart, RN Care of the Child with a
Chronic Neurologic Condition Mild
Resolves quickly
Not associated with psychosocial issues or cognitive delays
Does not impair normal development Epileptic Syndromes EPILEPSY Incidence 1% of the worldwide population
10% of people will have a seizure
1/3 of those will develop epilepsy
Rates are highest in early childhood
Rates slightly higher in males Types of Seizures Non-Epileptic Seizures Epileptic Seizures A response to a physiologic event: Fever
Hypoxia Associated with abnormal electrical activity in the brain Partial Seizures AKA Focal Seizures Seizure activity is in a specific area of the cortex & occurs in one hemisphere

Effects are usually unilateral Simple Partial Seizure Complex Partial Seizure Remains conscious & alert
Individual recalls event
Can respond to questions & directions during seizure
May progress to a complex partial seizure or a generalized seizure Impaired consciousness
Ability to pay attention or respond to questions & directions is impaired
Child is confused, disoriented, or unresponsive
May experience an AURA An aura is actually a simple partial seizure gen Generalized Seizures Involves large parts of the brain
Activity in both hemispheres
Loss of consciousness
No memory of seizure
Movements are usually bilateral Absence Seizures Atypical Absence Seizures Typical Absence Seizures Brief ( < 20 sec) loss of consciousness
Child appears to be staring into space
Totally attentive after seizure
Often goes on for a while before diagnosis
Respond well to pharmacologic treatment Last up to 30 seconds
Not as abrupt
Begins and ends more gradually
Usually associated with structural brain abnormality
More resistant to treatment Tonic Seizure:
1-20 second period of extensor stiffening Clonic Seizure:
Rhythmic, repetitive muscle contractions with total impairment of consciousness, of variable duration Tonic-Clonic Seizures 1. Premonitory symptoms - hours or days before seizure - NOT an aura
2. 10-30 second TONIC stage which may include:
Bowel/bladder incontinence
Upper eye deviation
3. 30-60 second CLONIC phase
4. Post-ictal phase
unarousable Myoclonic Seizure:
Sudden jerk, < 1 sec, resembles a startle Akinetic Seizure:
"drop attack" - forceful drop to the ground with immediate recovery Atonic Seizure:
Sudden loss of muscle tone - patient melts to the ground and remains limp for some time Infantile Spasms:
Quick seizures occuring in clusters,
flexor, extensor, or mixed Topics: Seizures & Epilepsy
Migraines & Headaches
Neural Tube Defect
Head Trauma
Cerebral Palsy Benign Catastrophic Frequent
Significant cognitive & psychosocial issues
Affects long-term development
May have permanent effects Status Epilepticus Life-threatening
> 30 min of continuous seizure activity OR recurrent seizures without recovery of consciousness Febrile Seizures Occur in 2-5% of US children
Most common seizure disorder in childhood
Highest occurrence between 3 months and 5 years of age
Risk of recurrence is 34%
Epilepsy occurs in 2-10% of children with febrile seizures
Treatment with AEDs is controversial
EEG & labs are not indicated if the child is otherwise healthy Treatment Epilepsy Surgery Pharmacotherapy Vagus Nerve Stimulation Ketogenic Diet See:
pp. 495-498 of text
pp. 516 -517 in Harriet Lane Handbook Usually the first course of action in treatment

Goal: Maximum seizure control with minimal or no side effects

60-70% of newly diagnosed children remain seizure free on monotherapy

30% continue to have seizures and require multiple medications A rigid high fat, low carb, low protein diet that mimics starvation 50% of children put on ketogenic diet have improved seizure control MUST be monitored by an experienced nutritionist! Approved for children over 12

Mechanism of action is unknown

Used to prevent or stop a seizure

Implantable device sends an impulse to the vagus nerve when passed over by a powerful magnet Operative morbidity is < 5%

Used when seizures are reftractory to other treatment modalities

- focal resection, most often temporal lobectomy,
- hemispherectomy
- corpus callosotomy Prognosis 30-40% of seizures will be refractory to treatment

61% of patients achieve remission
within 10 years of onset Primary Care Considerations Common Illness Management Seizures may be triggered by fever and/or illness

Recommend aggressive fever management & increased fluids

Treat early in the course of illness

Use antibiotics to manage bacterial infections If the child is vomiting & can't keep down fluids & AEDs, the child should go to the local ED for IV anti-epileptic drug administration Immunizations Special Considerations for DTaP & MMR vaccines:

For infants who have had a seizure, the pertussis vaccine should be deferred until progressive neurologic disorder is ruled out.

Encephalopathy or seizure following DTaP may be a contraindication for subsequent doses

Children with a history of seizures are more likely to have a post-MMR-vaccination seizure, but the benefits outweigh the risks

*Family history of seizures is NOT a contraindication for these immunizations*

*All other immunizations should be given per CDC schedule* Screenings *Routine vision, hearing, dental, BP, Hct, UA, and TB screenings are recommended*

Children on phenytoin need dental care no less than every 6 months due to the risk of gingival hyperplasia

Children on certain AEDs need drug-toxicity monitoring

Depending on the AED used, any or all may be indicated:
CBC with differential
Renal panel
Lipid panel
Serum glucose Psychosocial Considerations Of individuals diagnosed with epilepsy,

50% suffer from depression

15-40% are diagnosed with ADHD

13-49% have some type of anxiety disorder that is separate from the peri-ictal anxiety Research shows that parents and children have needs for information about the condition and psychosocial support more than 2 years after diagnosis & these needs, when unmet, do not decrease over time Discipline Parents often treat children with epilepsy as if he or she is sick.

Families should be reassured that they cannot make the condition worse

Families should be instructed that disciplining a child will not provoke a seizure

Parents and caregivers should discipline the child according to the same expectations of other children in the family Cognitive Dysfunction Children with epilepsy are at a higher risk for learning disabilities

Children with low-severity disorders have average school performance, while children with high-severity disorders do not show improvement in academics even when seizures improve

Some AEDs may have an effect on cognitive function

Epilepsy surgery may result in memory & language deficits Safety Considerations Mortality rate is 2-3x higher than the general population

Increased risk for accidents such as drowning, MVI, aspiration

Shower instead of bathe & should be supervised

Do not play contact sports with epilepsy

Do not climb in high places if seizures are uncontrolled Parents, family members, and all potential caregivers such as babysitters, teachers, and school-nurses should be educated about first aid for seizures Sexuality 30-70% of affected males have sexual dysfunction

Epilepsy alters sexual development in women

Incidence PCOS is higher, especially if taking valproate

Catamenial Epilepsy: seizures that occur in relation to the menstrual cycle

Some AEDs interact with OCPs

Depo-Provera is often the best choice for contraception

Teratogenesis: Women with epilepsy have a higher incidence of birth malformations, even if not on an AED Transitioning
to Adulthood Transition to independence can be difficult

PNP should assist through education, counseling, and advocacy

Research shows that earlier, slower transition from a pediatric epilepsy center to an adult epilepsy center yields better outcomes

Transition to an adult provider should be based on the patient's maturity level rather than age Migraine Treatment Headaches a common childhood ailment Occurs in:
1/3 to 1/2 of children by age 7
57-80% of those older than 15 Important Questions to Ask remember:
children under 10 have a poor sense of time and may not serve as good historians Duration Sudden recent onset is worrisome Frequency
&Triggers triggers may include:
altered caffeine intake
specific foods such as chocolate, processed meats,
aged cheeses, nuts, dairy, shellfish Quality
& Severity sharp, throbbing, pounding pain is likely a migraine

dull, constant pain is likely tension or organic assess severity by asking if activities are limited & the amount of school missed due to headaches Age of Onset have the headaches progressed over time? Management how are headaches treated at home?

what types of self-coping activities are used? Associated Symptoms may include: nausea/vomiting
visual changes
ataxia hypersomnia
food cravings
neck, shoulder, back, or abdominal pain
pallor changes in gait, personality, mentation, or behavior that occur separate from the headache are worrisome Head Trauma headache with a history of head trauma could be a sign of a subdural hematoma or a post-concussion syndrome Psychologic
Symptoms assess for depression, school stressors, and family stressors Location occipital or localized pain may indicate underlying pathology

facial pain may be sinusitis

dull periorbital discomfort indicates ocular motor dysfunction

periauricular, temporal pain may be related to TMJ Family
History most children with headaches have a positive family history of headaches Physical Examination be sure to assess the following: BP, height, weight
Neuro function
Optic fundi
Tenderness of pericranial muscles, sinuses, and TMJ
Thyroid gland
Cranial bruits imaging studies are not indicated unless there are symptoms of increased ICP Chronic Daily Low-Grade Headaches most common type of headaches in all age groups

+ history of OTC analgesic use or caffeine intake

triggered by withdrawal of caffeine or analgesics

described as throbbing, low-intensity, dull, aching; anxiety and malaise may accompany headache; usually does not interfere with daily activities

treated (sparingly) with OTC analgesics

may consider an antidepressant
for prophylaxis Cluster Headaches uncommon in children

unilateral throbbing headache, worsened by lying down; tender scalp, injected conjunctiva, tearing, ptosis

no identifiable trigger

rarely develops in childhood Migraine female:male = 3:2
+ family history
50% affected have hx of motion sickness Headache Pattern recurrent, with or without aura
(see p. 658 in Burns text)

may be described as "ice-pick" pain on the top of head

includes neuro symptoms, such as nausea/vomiting, malaise, personality changes, photophobia, phonophobia

child looks sick during headache

usually resolves after sleep

pain lasts 2-4h in young children
up to 72h in adolescents Acute Treatment Begin with APAP (fastest onset), ibuprofen (best results) or dimenhydrinate (aka Dramamine, if vomiting is the main issue)

if these are not effective, consider a 5-HTI-receptor agonist (commonly known as the "triptans")

rizatriptan (Maxalt) is approved for use in children 6-17
other triptans are approved for 18 & up - use is off-label
sumatriptan (Imitrex) has been shown safe and effective in trials

other treatment options include biofeedback and relaxation strategies Prophylactic Treatment consider prophylactic treatment when headaches cause school absence more than once monthly or if headaches occur 2-4x a month.

several classes of drugs can be effective for prophylaxis:

Antidepressants: studies show amitriptyline to be 50-80% effective
Anticonvulsants: divalproex (Depakote) or topiramate (Topomax) - reduces frequency by approx. 50%
Antiserotonergic agents: cyproheptadine (Periactin) - effective in up to 83%
Beta-blockers: propranolol, atenolol, metoprolol, nadolol - 71% achieve remission
Alpha-agonists: clonidine (Catapres)
Calcium-channel blockers: nimodipine or flunarizine* (*not available in the US) Tension Headaches occur in all ages, both sexes, and typically begins in adolescence

bilateral and diffuse,
"hat band distribution,"
may be described as feeling "tight"
does not worsen with activity
NO neuro symptoms
may last 30m, all day,
or even all week Tension Headache
Treatment Acute Treatment First line: APAP or NSAIDs

Other options: amitriptyline or tizanidine (Zanaflex) Chronic Treatment daily low-dose antidepressant

beta blockers

or anticonvulsants Adjuvant or Alternative Treatment Options massage

relaxation techniques

cold or warm compresses Primary Care Considerations the goal of treatment is to treat attacks quickly & consistently, restore ability to function, and optimize self-care abilities headaches are a major cause of school absenteeism - the PNP should help facilitate the creation of a 504 plan to help prevent the child from falling behind AKA "petit mal" seizures also known as
"grand mal" seizures Resources for Families Epilepsy Foundation of America (EFA)
www.epilepsyfoundation.org chapters in Knoxville, Nashville, and Chattanooga Monroe Carell Jr. Children's Hospital at Vanderbilt: Epilepsy Support Group meets on the 2nd Tuesday of each month
from 6-7:30pm Member Application of Nursing Theory Headache & Migraine When Traditional Prophylaxis Is Not Effective: A skilled neurologist may consider using periodic nerve blocks (bupivicaine) or intermittent Botox.

Imaging studies (MRI) may be indicated at this point. NTD & Hydrocephalus Neural Tube Defects (NTD) AKA Myelodysplasia occurs in 1 in 1500 births

linked to maternal and/or fetal folate deficiency

teratogens and maternal infections have been indicated as potential causes for NTD Folic acid supplementation before conception reduces NTD rates by 50-70% USPHS recommends that all women of childbearing age consume 400mcg of folate daily Folic acid supplementation rates are lowest in women aged 18-24 1/3 of pregnancies in the US are in women in this age group! specific teratogens include:
valproic acid, carbamazepine, cytochalasin, & calcium antagonists maternal infections include: rubella, cytomegalovirus, toxoplasmosis Types of NTD diastematomyelia Outward Clinical Findings tuft of hair
dermoid cysts

these occur
above the area of the defect treatment for neural tube defect is surgical repair of the defect Problems
& Complications &
motor & sensory alterations
(below the defect)
neurogenic bowel
neurogenic bladder
visual problems hydrocephalus seizures cognitive deficits & learning disabilities spinal
deformities results from Chiari malformation & occlusion of the 4th ventricle

85% of children with myelomeningocele will need a shunt

may be asymptomatic until after the defect is closed 15-25% of children with NTD will develop a seizure disorder most have IQ scores in average or low-average range higher than average rate of learning disabilities, especially in math scoliosis, kyphosis, or gibbus

occurs in 80-100% of children with thoracic lesions Resources for Families Spina Bifida Association of America www.sbaa.org Hydrocephalus 1 in 500 live births strong association with NTD can also result from any insult to the CNS, such as:
intraventricular hemorrhage, brain tumor, infection, or head injury Clinical Manifestations
in infants rapidly increasing head circumference
HC at birth > 95th percentile
bulging fontanelles
splitting of cranial sutures
limited upward gaze
setting-sun phenomenon: Clinical Manifestations
in infants rapidly increasing head circumference
HC at birth > 95th percentile
bulging fontanelles
splitting of cranial sutures
limited upward gaze
setting-sun phenomenon: Clinical Manifestations
in children classic presentation: rapid onset of headache that is worse in the morning, vomiting, and alterations in consciousness. sometimes accompanied by seizures. other symptoms include:
ataxia or poor coordination
developmental delays
changes in personality
inability to concentrate
irritability and/or lethargy
blurred/double vision
poor appetite
fever Treatment surgical placement of a shunting device

may be ventriculoperitoneal (VP) - most common
ventriculoatrial (VA)
ventriculopleural (more info available later in the presentation) Complications of Treatment Shunt Malfunction Shunt Infection 40-50% of shunt malfunctions occur within 1-2 years of placement
Revisions are necessary for most patients
Symptoms of incr. ICP Dangerous but somewhat rare (~8%)
Treated by removing the shunt, draining externally until CSF is sterile, then placing a new shunt Primary Care Considerations administer immunizations per schedule
refer to a pediatric ophthalmologist by 6 months for a thorough exam
Always check BP at every clinic visit - elevation of BP with widening pulse pressure is a late sign of increased ICP
Advise that these children should avoid high impact sports
Assist as needed with developing IEPs Resources for Families Hydrocephalus Association

National Hydrocephalus Foundation www.hydroassoc.org www.nhfonline.org Head Trauma head trauma involves injury to the brain and surrounding structures and tissues an important
public health issue incidence males > females

ages 0-4 and 15-19 are highest risk

brain injury = leading cause of death in people under 35

half of brain injury deaths happen in individuals 15 or younger etiology of
brain injuries Infants and toddlers: falls and physical abuse

Young children: falls, pedestrian & bicycle accidents

Adolescents: motor vehicle accidents

Concussions from sports occur at any age long term effects *length of loss of consciousness is predictive of future neurologic function* in children under 10: < 1.7 wk coma: return to full function
< 3 wk coma: borderline intelligence
< 8 wk coma: mild retardation
< 11 wk coma: severe retardation cognitive & motor development problems may result behavioral problems may occur effects of injury primary secondary contusions where the brain hits the skull
torn axons
torn corpus callosum
hemorrhage hypoxia
brain swelling
status epilepticus 5-10% of children hospitalized with head injury suffer a seizure primary care
considerations after an injury the NP can help coordinate rehabilitation

neuropsychiatric testing may be useful

families may need resources for behavioral management primary care
considerations before an injury PREVENTION is the KEY encourage helmet use, seat belts/car seats, and home safety (ie baby gates at stairs) Resources for Families Tennessee's Traumatic Brain Injury Program http://health.state.tn.us/tbi/index.htm Brain Injury Association of Tennessee www.braininjurytn.org/ Brain Injury Support Group meets 1st Tuesday of every month from 6-7:30 at Vanderbilt-Stallworth Rehabilitation Hospital Traumatic Brain Injury Caregiver Support Meeting meets 1st Tuesday of every month from 4:15-5:15 at Vanderbilt-Stallworth Rehabilitation Hospital Primary Care Considerations for children with cerebral palsy Overview 2.4 per 1000 live births

higher incidence in males

higher incidence in twins

1/2 of infants born with CP are
born preterm nonprogressive damage to the brain
and subsequent motor impairment diagnosis not given until 18-24mo - muscle/tone abnormalities may indicate a different neurodevelopmental problem Signs of CP delayed milestones
poor head control
clenched fists after 3 mo
extended Moro & atonic neck reflexes
Crossing midline before 12 months
Hand preference before 18 months
"W" sitting
"bunny hopping"
toe walking treatments of symptoms
& complications include: physical & occupational therapy
speech therapy
orthotic devices
serial casting
Botox or baclofen for spasticity Growth & Development stunted growth occurs in 25%
regular growth charts may not be appropriate.

Brooks, Day, Shavelle & Strauss created growth charts for use with CP patients - 6 sets that vary depending on the child's level of disability: 1. Walks without limitations
2. Walks with limitations
3. Walks using a hand-held mobility device
4. Self-mobility with limitations, may use powered mobility
5-NT Transported in a manual wheelchair, not tube fed
5-TF Transported in a manual wheelchair, tube fed www.lifeexpectancy.org/articles/NewGrowthCharts.shtml Immunizations Hep A should only be given if the child lives in an area of high incidence,

otherwise, the immunization schedule is followed,

with emphasis on the importance of a yearly flu shot Screenings possible vision problems include:
low visual acuity (75%)
strabismus (a majority)
homonymous hemianopsia
(in 25% of those with hemiplegia)

*see a pediatric ophthalmologist yearly*

higher rate of hearing impairment than in the general population

*regular assessment by a pediatric audiologist is recommended* Common Illness Management The child should be seen right away by the PCP if they:
have fever under 6 months of age
have fever over 38.6C (101.4F) for 3 days or more, even without other symptoms
appear acutely ill, even with undefined symptoms
have a seizure with a fever
Bowel & Bladder Problems problems with bladder control & urinary retention predispose to UTI

constipation is common due to decreased muscle tone and use of medications like baclofen

chronic constipation worsens urinary retention issues

UTIs should be managed carefully & repeated infection indicates a need for a referral to a specialist Pulmonary Problems children with CP are at a higher risk for respiratory infections

respiratory infections linger longer due to decreased ability to cough, blow nose, clear secretions

this also may cause URIs to progress into pneumonia

pneumonia is the leading cause of death in children with CP

respiratory illnesses should be managed aggressively with close followup Other Issues skin breakdown & decubitus ulcers are an issue for kids with poor mobility and/or AFOs

80% have speech impairments

20-40% have seizures

3 in 10 have severe learning disabilities

1 in 9 has autistic tendencies Know the Signs of
Baclofen Withdrawal: itchy skin
decreased BP
blurred vision
dizziness, faintness, lightheadedness
increased sweating, flushing
unusual tiredness/weakness
increased muscle spasms
hallucinations baclofen withdrawal can be fatal! Modeling & Role-Modeling:
a theory and paradigm for nursing Helen Erickson,
Evelyn Tomlin,
Mary Ann Swain This theory draws
from the work done by:

Erik Erikson
(Stages of Psychosocial Development)

Jean Piaget
(Cognitive Theory of Development)

Abraham Maslow
(Hierarchy of Needs)

Hans Selye
(General Adaptation Syndrome & other work with stress)

Important Concepts Holism: people are more than the sum of their parts

Affiliated-Individuation: all people have an instinctual drive to be dependent on support systems while also maintaining a sense of independence

Model of the World: a person's perspective of his environment

Adaptation Potential: ability to cope with a stressor

Stress: a response to a stimuli, can have positive or negative effects

Nursing Roles facilitation: help client identify and develop personal strengths

nurturance: gently support and encourage

unconditional acceptance: use empathy to fully accept person as worthy Goals of
Intervention build trust through nurse-client relationship, empathy, and affirmation

promote positive orientation by facilitating the ability to project self into a positive future

promote control by asking the client what they need and how you can help

affirm and promote strengths by commenting on small strengths

set mutual, health-directed goals and involve client in care how this fits in to the
care of a child with a
chronic neurologic condition: These patients require highly individualized care, and have many complications and comorbidities.

these patients are not "average patients", therefore "typical treatments" are not enough

MRM allows us to see things from the patient's perception and tailor our interventions to a
context that will be useful to the
child & family. References Ashwal, S., Russman, B. S., Blasco, P. A., Miller, G., Sandler, A., Shevell, M., & Stevenson, R. (2004). Practice parameter: Diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology, 62(2), 851-853.
Blair, J. L. (2010). Epilepsy Seizure Disorders. In P. J. Allen, J. A. Vessey & N. A. Schapiro (Eds.), Primary care of the child with a chronic condition (5th ed., pp. 486-513). St. Louis, MO: Mosby.
Blosser, C. G., & Reider-Demer, M. (2009). Headaches. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr & C. G. Blosser (Eds.), Pediatric primary care (4th ed., pp. 655-663). St. Louis, MO: Elsevier.
Brooks, J., Day, S. M., Shavelle, R. M., & Strauss, D. J. (2011). Low weight, morbidity, and mortality in children with cerebral palsy: New clinical growth charts. Pediatrics, 128(2), e299-e307
Cooper, S. (2012). Neurology. In M. M. Tschudy & K. M. Arcara (Eds.), The harriet lane handbook (19th ed., pp. 504-523). Philadelphia, PA: Mosby.
Duffy, L. V. (2012). Hydrocephalus. In P. J. Allen, J. A. Vessey & N. A. Schapiro (Eds.), Primary care of the child with a chronic condition (5th ed., pp. 546-558). St. Louis, MO: Mosby.
Erickson, H. C., Tomlin, E. M., & Swain, M. A. P. (1983). Modeling and role-modeling: A theory and paradigm for nursing. Englewood Cliffs, NJ: Prentice-Hall.
Hirtz, D., Berg, A., Bettis, D., Camfield, C., Camfield, P., Crumrine, P., . . . Shinnar, S. (2003). Practice parameter: Treatment of the child with a first unprovoked seizure: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology, 60(2), 166-175.
Ho, T. W., Pearlman, E., Lewis, D., Hamalainen, M., Connor, K., Michelson, D., . . . Hewitt, D. J. (2012). Efficacy and tolerability of rizatriptan in pediatric migraineurs: Results from a randomized, double-blind, placebo-controlled trial using a novel adaptive enrichment design. Cephalagia, 32(10), 750-765.
Jurasek, L., Ray, L., & Quigley, D. (2010). Development and implementation of an adolescent epilepsy transition clinic. Journal of Neuroscience Nursing, 42(4), 181-187.
Kroner-Herwig, B., & Gassmann, J. (2012). Headache disorders in children and adolescents: Their association with psychological, behavioral, and socio-environmental factors. Headache, E-pub ahead of print. doi: 10.1111/j.1526-4610.2012.02210.x.
Langlois, J. A., Rutland-Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury: A brief overview. Journal of Head Trauma and Rehabilitation, 21(5), 375-378.
Lazzaretti, C. C., & Pearson, C. (2012). Myelodysplasia. In P. J. Allen, J. A. Vessey & N. A. Schapiro (Eds.), Primary care of the child with a chronic condition (5th ed., pp. 671-685). St. Louis, MO: Mosby.
Lewis, D., Ashwal, A., Hershey, A., Hirtz, D., Yonker, M., & Silberstein, S. (2004). Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology, 63(12), 2215-2224.
Mayo Foundation for Medical Education and Research. (2012). Baclofen (Intrathecal Roue): Precautions. Retrieved September 14, 2012, from http://www.mayoclinic.com/health/drug-information/DR600213/DSECTION=precautions-
Shore, C. P., Buelow, J. M., Austin, J. K., & Johnson, C. S. (2009). Continuing psychosocial care needs in children with new-onset epilepsy and their parents. Journal of Neuroscience Nursing, 41(5), 244-249.
Strauss, D. J., Shavelle, R. M., & Brooks, J. (2011). New growth charts. The Life Expectancy Project. Retrieved September 14, 2012, from http://www.lifeexpectancy.org/articles/NewGrowthCharts.shtml

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