Protecting the developing brain: empowering child neurologists to become more preventative.

Abstract

Child neurologists are typically located in tertiary settings. Whilst highly specialized and skilled in their field, much of their practice is based on reactive care for established and often avoidable conditions. Taking over the care of a child who has suffered a neurological ‘disaster’ can be a challenging and harrowing experience. When the neurologist enters the management arena, the neurological course for the child is often well underway and may be irreversible. A cure is a rare event, and care revolves around symptomatic relief and optimizing quality of life. On a global scale, many children referred to neurology services have suffered the sequelae of preventable conditions. Especially those who have survived the World Health Organisation's main causes of mortality in children under 5 years of age (http://apps.who.int/iris/handle/10665/82058?locale=fr). These common conditions include neonatal complications (birth asphyxia, infections, and prematurity), pneumonia, diarrhea, measles, malaria, and human immunodeficiency virus. They occur more frequently in low- and middle-income countries compared to high-income settings. The burden of disease from subsequent morbidity of these avoidable conditions is significant, especially for neurological complications.1 High-income settings have their own legacy of avoidable challenges, such as obesity and excessive screen (computer, gaming, etc.) time.2 As child neurologists, we should take an advocacy role to target conditions in a preventative rather than a reactive manner. We should engage with the caregivers at the rock-face who are in the acute situation of managing these children, and identify care pathways which either avoid complications or address them early in their course. Examples include advocating for measles vaccination. The resurgence of subacute sclerosing panencephalitis reinforces how imperative this is.3 Raising awareness of the potential implications of acute flaccid paralysis (AFP) and promoting polio vaccination is also a valuable opportunity to educate clinicians of AFP presentations, and to remind them of the importance of eradication of poliomyelitis infection. Malaria research has focused on understanding the mechanisms and optimal methods to manage complications such as cerebral malaria. Child neurologists have leading roles in these research programs. Their involvement has promoted awareness and resulted in better prevention through cost-effective and viable interventions such as malaria nets and pesticide sprays, with the result that significant reduction in the incidence of the condition has occured.1 Early recognition of epilepsy remains a challenge. Educational courses, such the Paediatric Epilepsy Training courses (initiated through the British Paediatric Neurology Association and now rolled out internationally) illustrate the power of simple teaching aids to reach a wide range of health care practitioners. Worldwide, the impact of brain cooling has dramatically reduced incidence of hypoxic-ischaemic encephalopathy; whilst low- and middle-income countries lag in this, cost-effective devices are now being introduced through collaborative projects between neonatologists and child neurologists.4 Research should be clinically applicable. Commencing with a clinical challenge and working backwards to the underlying cause is essential. Not just for the pathogenesis, but also for the health care infrastructure and operating systems that compound the resultant complications. An example of this is the Zika virus pandemic. The crisis was identified by child neurologists in Brazil, and the causal link for the congenital structural brain anomalies and the exposure to Zika virus was confirmed. Educational courses on Zika virus were organized through the International Child Neurology Association (ICNA), reaching some 3000 health practitioners to help increase their knowledge of the condition and encourage early intervention. ICNA will hold its Biennial Congress in Mumbai in November 2018. The theme of the Congress this year is Protecting the developing brain. ICNA is in the valuable position of drawing together super-specialists from diverse regions, and encouraging networking across these specialties to try and make the care we offer less reactive and more preventive.