Department of Paediatric & Adolescent Health

Paediatric Neurology Training Curriculum

Paediatric Neurology Training Curriculum 2

Contents

1. Introduction ............................................................................................................................. 3

2. Criteria for entry in Paediatric Neurology training in Malta................................................. 3

3. General requirements, duration and structure of higher specialist training ....................... 3

4. Outline of factual knowledge .................................................................................................. 6

5. Training objectives in detail .................................................................................................... 7

6. Training Programme .............................................................................................................. 10

References ..................................................................................................................................... 12

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1. Introduction 1.1 Definition

Paediatric Neurology is the medical discipline devoted to normal and abnormal development of the central nervous and peripheral neuromuscular systems from foetal life up to and including adolescence. It involves the diagnosis, treatment and research into diseases of these systems and the comprehensive management of the consequent disabilities.

1.2 Aims of training in Paediatric Neurology

To improve the care of children with neurological disorders and the support that medical services are able to give to parents/ carers associated medical professionals and other disciplines involved in child health and welfare at Mater Dei Hospital.

To establish clearly defined standards of knowledge and skill required to practice Paediatric Neurology at a tertiary level.

To ensure that the level of training and expertise in Paediatric Neurology in consistent with that of other countries in Europe.

To ensure that research is developed and encouraged within Paediatric Neurology.

To encourage the development of a European network of competent tertiary centres for Paediatric Neurology, which will allow collaborative training and research throughout Europe.

2. Criteria for entry in Paediatric Neurology training in Malta

a) Full registration with the Medical Council of Malta. b) Completion of Basic Specialist Training in Paediatrics (CCBST or equivalent). c) Success in an open call for application for the post of Higher Specialist Trainee in Paediatric

Neurology in a locally recognised institution.

3. General requirements, duration and structure of higher specialist training in Paediatric Neurology

3.1 Unless otherwise specified, any period of training referred to within this document is assumed to be full-time or part-time pro-rata. Any quoted duration of training is the minimum required (or pro-rata equivalent) for certification.

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3.2 For the purposes of completion of training:

A. Training must be undertaken within an on-call rota. B. In case the trainee is working on a ‘reduced hour’ or ‘part-time schedule’, training will be

counted on a pro-rata basis taking into consideration an adequate balance of supervised clinical training and out-of-hours duties.

C. The trainee should have out-of-office hours experience in accordance with departmental rota requirements, but not less than 45 duties per year (equivalent to 1:8).

3.3 Part time trainees will have their training recognized pro-rata; a total of 13 weeks of maternity leave throughout the entire duration of training (in addition to the normal entitlement of leave) can be recognized as part of the training period; however, any longer period of leave will not be considered as training.

3.4 The following training criteria must be satisfied for a CCST to be issued to the trainee:

A. Training undertaken must be at least 50% of full-time training with total duration of training extended pro-rata.

B. At least 50% of training must be undertaken in a training centre in Malta that is recognized by the SAC

C. The trainee shall record all stages of training and activities related to training in a log-book/e-portfolio.

3.5 All paediatric subspecialty trainees are expected to acquire dual certification. The trainee first

acquires certification in General Paediatrics after a minimum of 4 years training in General Paediatrics at the level of HST and achievement of all required competencies. Subsequently, certification in Paediatric Neurology is acquired after a further 2 years of training with achievement of all required competencies. The total duration of training in Paediatric Neurology is 4 years full time (or part time equivalent) - 2 years between year 1 and 4 (which will run concurrently with training in General Paediatrics), and year 5 and 6 (Fig 1).

(The requirements for entry into the General Paediatric register are described in another document ENDORSED BY THE SAC. This document will focus on the requirements for Paediatric Neurology.)

Figure 1. Outline of training timeline in paediatric neurology

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3.6 The trainee is expected to spend a period of overseas training of not less than 1 year and up to a maximum of two years, full-time (or part-time equivalent) in an accredited tertiary paediatric neurology centre abroad that is recognized by the MPA and SAC. This period of training can be done at any time between year 4 and year 6 of subspecialty training, provided that the trainee has already achieved a minimum of 12 months experience in the subspecialty in the local centre ,and, that the last 6 months of training (in year 6), are also done in a locally recognized institution within the Maltese territory. Training abroad will be vetted by the Postgraduate Training Coordinator/s for suitability and approved by the MPA and the SAC. This period of training will have stipulated training targets that are aimed at filling specific gaps in the training undertaken locally, and/or to further expose the trainee to the full breadth of the specialty. The trainee is to submit a detailed record of training undertaken abroad, duly signed by a mentor/s at the institution. The trainee still needs to document his/her training on the local e-portfolio by inviting the mentors or supervisors in the new training centre to complete the required accomplishment forms.

3.7 Trainees shall be involved in the care of ambulatory patients (including children’s outpatient and paediatric day care unit) and of inpatients (including paediatric wards, NPICU and management of emergencies).

3.8 Progression through subspecialty training in paediatric neurology (Year 1 through to Year 6) is dependent on satisfactory appraisal, which may include written or oral examinations, done by clinical/educational supervisors (1-2 formal assessments per year).

3.9 The trainee is expected to participate and contribute to teaching activities within the department, participate actively in local and international meetings, and contribute to the medical literature through scientific publications.

3.10 In the last year of training, the trainee is expected to sit for a Paediatric Neurology examination. Obtaining a pass in this exam is one of the prerequisites for entry into register of Paediatric Neurology.

4. Awarding of CCST in Paediatric Neurology

Entry into the specialist register in Paediatric Neurology requires all of the following:

4.1 All the criteria of the training programme/curriculum are satisfied, documentation of

training in the eportfolio is complete and the trainee passes all appraisals during the period

of training.

4.2 The bulk of the training in Paediatric Neurology (>50% of HST duration) is undertaken in a

recognised institution within the territory of the Republic of Malta.

4.3 The trainee undertakes the last 6 months of his/her training in a recognised institution within

the territory of the Republic of Malta.

4.4 The trainee passes the examination in Paediatric Neurology .

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4.5 The trainee has undertaken a period of training in a recognised tertiary centre abroad lasting

not less than 1 year and not more than 2 years duration.

4.6 The trainee shows evidence of participation in research, achieved a minimum of 1

publication in a peer reviewed journal, and contributed presentations in local and

international scientific meetings relevant to the subspecialty.

4. Outline of factual knowledge This syllabus will need to be regularly reviewed and updated. Specialist training of doctors in paediatric neurology involves several elements of which a factual syllabus can cover only parts:

a. A base of knowledge about normal and abnormal neurological function in childhood. b. Direct personal experience of the clinical assessment and management of a wide range of

paediatric neurological diseases. c. The training should take place in fully equipped departments, which are subject to regular

inspection by the national training authority. d. Training posts should be normal paid employment with a major content of supervised patient

care. e. Arrangements for obtaining widened experience in Paediatric Neurology at other hospitals

must be made within the individual training programmes where specific equipment and experience is not available at the main site of training. A minimum of one year overseas training experience in a recognized centre is mandatory.

f. There are strong psychosocial and multi-disciplinary elements to the practice of paediatric neurology. It is important that these dimensions are included in the training of paediatric neurologists.

g. A period of research is not obligatory in the training programme but is strongly encouraged. It is important that there are systems in place whereby selected trainees can engage in research.

h. Trainees are strongly encouraged to participate in various approved e-learning platforms like the European Paediatric Neurology Society (EPNS) training courses, International League against Epilepsy (ILAE), the British Paediatric Neurology Association (BPNA).

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5. Training objectives in detail 5.1 Knowledge of paediatric neurology

The level of the knowledge base of a paediatric neurologist is extensive and difficult to specify in detail but should be at least at the level of the major current textbooks of paediatric neurology:

i. Detailed information on normal and the common patterns of abnormal development.

ii. Principles of antenatal brain development, both normal and abnormal.

iii. Neonatal neurology: acute and chronic neurological illness presenting in the neonatal period.

iv. Epidemiology, aetiology, pathogenesis, pathology, clinical features, treatment and outcome measures for:

a. Neurological diseases in childhood.

b. Developmental delay, learning disability and specific learning difficulties, language and complex communication disorders.

c. Congenital and acquired disabling neurological conditions of childhood.

v. Natural history and manifestations of the common behavioural abnormalities of childhood (autistic spectrum disorders, attention deficit/hyperactivity, obsessive compulsive disorder, oppositional behaviour, depression, anxiety, adolescent psychosis and anorexia nervosa).

vi. Neurological emergencies in childhood, e.g. presenting with a coma, status epilepticus, raised intracranial pressure and paediatric emergencies presenting with neurological features, e.g. metabolic disorders, non-accidental injury.

vii. Neurosurgical diseases of childhood: theoretic and practical knowledge of the common neurosurgical disorders, their identification, investigation and management.

viii. Inter-relationship of neurological diseases with other body systems including growth and nutrition, feeding difficulties, gastro-oesophageal reflux and aspiration.

ix. Orthopaedics, orthotics and bioengineering in the clinical setting.

x. Genetic issues including taking a pedigree, recurrence risk, prenatal diagnosis, gene localisation, imprinting and the principles of molecular genetics.

5.2 Diagnostic measures

i. The ability to take good histories in a supportive fashion.

ii. Clinical examination of children of all ages including developmental assessment.

iii. Skills in clinical observation and analysis concerning normal development, play, motor performance and abnormal movements.

iv. Prenatal diagnosis as it relates to neurological disorder. v. Biochemical and neuro-metabolic investigations relevant for neurological disorder in children.

vi. Methodology of genetic and immunological investigations relevant for neurological disorders. vii. Use of tissue biopsy: interpretation of histological abnormalities. viii. Appropriate use of neuroradiology, neuropathology and clinical neurophysiology including

EEG, evoked potentials, nerve conduction studies and EMG. ix. Assessment of hearing and vision including behavioural, brainstem, auditory evoked

potentials and visual evoked potentials.

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x. Principles of gait analysis. xi. Perform tests to determine brain-stem death.

5.3 Therapy

i. Familiarity with current standard treatment plans for all forms of neurological disorder. ii. Thorough knowledge of drugs used in treatment, especially antiepileptic drugs, steroids and

other immuno-suppressants, muscle relaxants, analgesics, gastro-protective drugs, anti-bacterial and anti-viral agents and behaviour modifying drugs.

iii. Principles underlying rehabilitation of children with congenital impairments. iv. Principles of management of behaviour disorders including pharmacotherapy, counselling and

psychotherapy. v. Knowledge of aids to treatment and habilitation, hearing and vision aids, seating, mobility

aids, orthoses, communication aids, computers and ventilatory assistance etc. vi. Awareness of the range and potential consequences of unconventional and alternative

therapies. vii. Experience of rehabilitation following acquired neurological impairments. viii. Knowledge of nutritional and gastrointestinal aspects of management.

5.4 Clinical skills

i. To use relevant diagnostic measures (2.2) to interpret the patient’s clinical condition, draw relevant conclusions and engage in relevant therapy.

ii. Co-ordination of care for the critically ill child: the management of neurological emergencies and neurological aspects of multi-system neurological illness.

iii. Effective and appropriate approach to parents and children; to understand the emotions generated within children and their families by possible neurological illness and to be able to share difficult information in an appropriate fashion; to provide structured counselling at an appropriate level; to know when more skilled or different psychological help is required.

iv. Draw up a management plan taking into account continuing medical problems and attendant school, educational and psychological factors.

5.5 Multidisciplinary Care

i. Use a team approach to the management of neurological disorders and to understand its advantages and limitations.

ii. Understand methods used by occupational, speech and physiotherapists, nurses, specialist health visitors, play therapists, dieticians, clinical, educational and neuropsychologists, teachers and social workers in assessment, treatment and rehabilitation.

iii. Knowledge of methods used by other medical specialists iv. The paediatric neurologist should be able to provide consultation to other paediatric

specialties. v. Transition of care from children’s to adult services.

5.6 Technical skills

Trainees are not asked to be proficient in all these investigations but rather to be familiar with them and to understand their inherent strengths and weaknesses.

i. EEG.

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ii. EMG.

iii. Skin biopsy.

iv. Muscle biopsy.

v. Intracranial pressure monitoring/line care.

vi. Neonatal cranial ultrasound.

vii. Muscle ultrasound.

viii. Cerebral function monitoring.

5.7 Integrated care – Work with other agencies

i. Direct experience of community-based care of children with neurological impairments

ii. Knowledge of educational provision for children with neurological impairments in the country of training.

iii. Child protection: a thorough knowledge of the national legislation and experience working within that system.

iv. Social services/ benefits in the country of training.

v. Self-help and parent support groups.

5.8 Ethical issues

i. Ethical aspects of clinical Paediatric Neurology in dealing with life-long disabling, sometimes progressive conditions, including aspects of prenatal diagnosis, care and life support decisions.

ii. Ethics of research in children. Process of informed consent.

iii. Knowledge of issues governing ethics and consent for clinical trials.

iv. United Nations Convention on the rights of the child and other relevant proclamations and judgements set down in Law.

5.9 Teaching skills

i. Formal and informal teaching skills at undergraduate and postgraduate level. ii. Development of core materials to enable participation in teaching programmes on a regular

basis iii. Commitment to continuing self-education and teaching of others. iv. Maintenance of training experience portfolio.

5.10 Academic skills

i. Critical evaluation of clinical results from literature review and audit ii. Manuscript preparation iii. Oral presentation skills iv. To develop a critical approach to problem solving in clinical practice v. Support to be active in research vi. Collaborative attitude to local and national research activities.

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5.11 Management / administration

Understanding of the management skills required for the development and use of resources in the neurology unit, including budget control, contracting, strategic planning and writing a business plan.

i. Experience of the day-to-day running of a paediatric neurology service within the national medical system

ii. Knowledge and involvement in medical audit iii. The structure and function of local, specialist and national organizations. iv. Knowledge of research funding v. Understanding and implementing a leadership role in a multidisciplinary team vi. Constructive attitude to the process of decision making vii. Ability to understand clinical complaints, procedures and to respond to them effectively.

6. Training Programme The training programme contains a mix of (1) direct supervised clinical care of patients, (2) a taught programme, which contains formal lectures and seminars, (3) informal clinical and tutorial style work.

This training direct and / or indirectly covers a set of modules, each of which entails a specific area, expertise and / or skills. There are obligatory and desirable modules.

6.1 Obligatory modules

Obligatory modules are those considered essential for successful training and consist of four main modules and ten submodules.

6.1.1 Acute paediatric neurology module

The trainee works in a recognised specialist/ tertiary paediatric neurology unit(s). During this time the trainee acquires expertise in the diagnosis and management of the whole range of infants, children and adolescents with neurological disease. This includes direct involvement with the care of children in intensive care with neurological disease. This module should include the assessment and management of children undergoing neurosurgery. This training involves attendance at investigation meetings (radiology, pathology and neurophysiology), which are integral to clinical management.

6.1.2 Rehabilitation / neuro-disability module

The trainee works in a recognised paediatric neurology/ rehabilitation service, which comprises a multidisciplinary team including psychology and paramedical therapies in addition to the senior medical staff. During this time trainees acquire expertise in the diagnosis and management of the full range of paediatric neuro-disability patients of all ages.

The acute and neuro-disability modules will occupy a total of three years. The two modules may be integrated. It is envisaged that some trainees will focus on acute paediatric neurology and have two years in that area and others will focus on neuro-disability and have two years in that area reflecting their specific training needs.

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6.1.3 Adult neurology module

The trainee works in a recognised adult neurology unit with inpatient and outpatient responsibility for patients with a wide range of neurological diseases. This training will involve attendance at investigation meetings (radiology, pathology, neurophysiology). This module may be integrated with paediatric neurology modules and may include transitional clinics for older teenage patients.

6.1.4 Child psychiatry module

This module may be part-time and may be completed within basal paediatric or Paediatric Neurology training. It will consist of supervised direct clinical experience of children with psychiatric illness. This may be in a general or neuropsychiatry setting. This module may be integrated within the paediatric neurology modules.

6.1.5 Obligatory sub-modules

Ten obligatory sub-modules form part of the training programme with the purpose to achieve the aims outlined under heading 2. These are integrated within the clinical and taught aspects of the entire programme. The tutor is to certify that the aims have been achieved.

1. Paediatric neuroimaging

2. Paediatric neurophysiology

3. Academic work supervised and supported as outlined in 2.7.

4. Integrated multi-disciplinary care

5. Ethical issues

6. Neuro-genetics

7. Neuro-oncology

8. Neonatal neurology

9. Management/organisational

6.2 Desirable modules

Desirable modules are selected according to personal interest and need. Through this exercise, trainees are encouraged to acquire a greater depth of understanding of one or more of the following subjects:

1. Paediatric neuroimaging

2. Paediatric neurophysiology

3. Paediatric neuropathology

4. Neuro-genetics

5. Paediatric neuro-metabolic disease

6. Paediatric neuro-intensive care

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7. Neonatal neurology

8. Paediatric and adolescent neuropsychiatry

9. Paediatric epileptology.

6.3 Research

Trainees are encouraged to carry out research with appropriate support from local and foreign tutors. This may require extension of training time. The clinical content of this research should be recognized as part of their clinical training as agreed upon with the senior Paediatric Neurology tutor and national rules.

References

European Paediatric Neurology Training Programme Version April 2003.

Compiled by:-

Dr Stephen Attard, Dr Doriette Soler

27th September 2019