1
Headaches • Consider a brain tumour in any child with a new, persistent* headache • Headache in isolation, unlikely to be a brain tumour • Brain tumour headaches occur at any time of day • Children aged younger than 4 years may not be able to describe a headache – observe behaviour CNS imaging required with • Persistent headache that wakes a child from sleep • Persistent headache that occurs on waking • Persistent headache in a child under 4 • Confusion or disorientation with a headache • Persistent headache with 1 or more other symptoms Common pitfalls • Failure to reassess a child with a migraine or tension headache when the headache character changes *Persistent = continuous or recurrent headache present for more than 4 weeks Nausea and vomiting • Consider a brain tumour in any child with persistent* nausea and/or vomiting • Head circumference should be measured and plotted in children under 2 with persistent vomiting CNS imaging required with • Persistent vomiting on waking (NB: exclude pregnancy where appropriate) • Persistent nausea/vomiting with 1 or more other symptom Common pitfalls • Failing to consider a CNS cause for persistent nausea and vomiting *Persistent = nausea and/or vomiting present for more than 2 weeks Visual signs and symptoms • Consider a brain tumour in any child with persistent* visual abnormality • Visual assessment requires assessment of: visual acuity eye movements pupil responses optic disc appearance visual fields (>/= 5 yrs) • Pre-school and unco-operative children should be assessed by hospital eye service within 2 weeks of referral • Parent concern alone warrants referral for visual assessment CNS imaging required with • Papilloedema • Optic atrophy • New onset nystagmus • Reduction in visual acuity not due to refractive error • Visual field reduction • Proptosis • New onset paralytic squint • Visual symptom with 1 or more other symptom Common pitfalls • Failure to fully assess vision – REFER IF NECESSARY • Failure of communication between community optometry and primary and secondary care *Persistent = visual abnormality present for more than 2 weeks Head circumference • Consider a brain tumour in any child under two years with an increasing head circumference outside the normal range in comparison to their height and weight • Careful assessment of other signs and symptoms of a brain tumour should be undertaken in these babies CNS imaging required with • Rapid rate of head circumference growth crossing centiles • Increasing head circumference with any other associated symptoms Common pitfalls • Failing to measure and monitor head circumference in a baby or young child with persistent vomiting Motor symptoms and signs • Consider a brain tumour in any child with persisting* motor abnormality • Motor assessment requires history or observation of: sitting and crawling in infants walking and running handling of small objects handwriting in school age children • Brain tumours can cause a loss or change in motor skills and this can be subtle e.g. ability to play computer games CNS imaging required with • Regression in motor skills • Focal motor weakness • Abnormal gait/co-ordination (unless local cause) • Bells palsy with NO improvement within 4 weeks • Swallowing difficulties (unless local cause) • Head tilt/torticollis (unless local cause) • Motor symptom with 1 or more other symptom Common pitfalls • Attributing abnormal gait/balance to middle ear disease with no corroborating findings • Failure to identify swallowing difficulties and aspiration as a cause of recurrent chest infections *Persistent = motor abnormality present for more than 2 weeks Growth and endocrine • Consider a brain tumour in any child with any combination of growth failure, delayed/arrested puberty and polyuria/polydipsia • Early specialist assessment if required for: precocious puberty/delayed or arrested puberty growth failure galactorrhoea primary or secondary amenorrhoea CNS imaging required with • Growth or endocrine symptom with 1 or more other symptoms Common pitfalls • Failing to consider a CNS cause in children with weight loss and vomiting • Failure to consider diabetes insipidus in children with polyuria and polydipsia Behaviour • Consider a brain tumour in any child with new onset lethargy, mood disturbance, withdrawal or disinhibition Common pitfalls • Failing to consider a physical cause for behavioural symptoms Referral from primary care • High risk of tumour – SAME DAY referral to secondary care • Lower risk* – specialist assessment within 2 weeks Imaging • High risk of tumour – URGENT CNS imaging • Lower risk* – CNS imaging within 4 weeks *Lower risk = CNS tumour in differential diagnosis, low index of suspicion Consider a brain tumour in any child presenting with • Headache • Nausea and/or vomiting • Visual symptoms and signs: reduced visual acuity and/or fields abnormal eye movements abnormal fundoscopy • Motor symptoms and signs: abnormal gait abnormal co-ordination focal motor weakness • Growth and endocrine symptoms: growth failure (weight/height) delayed, arrested or precocious puberty galactorrhoea primary/secondary amenorrhea • Increasing head circumference • Behavioural change • Diabetes insipidus • Seizures (see www.nice.org.uk/guidance/qs27) • Altered consciousness (see www.nottingham.ac.uk/paediatric-guideline/ Guidelinealgorithm.pdf) Assess these children with • History: associated symptoms, any predisposing factors • Examination of: visual system motor system height and weight head circumference (<2yrs) pubertal status IF TWO OR MORE SYMPTOMS – SCAN Assessment pitfalls • Initial symptoms of brain tumour can mimic other common illnesses • Symptoms frequently fluctuate – resolution then recurrence does not exclude a brain tumour • A normal neurological examination does not exclude a brain tumour • Language difficulties – use interpreter THE DIAGNOSIS OF BRAIN TUMOURS IN CHILDREN: A GUIDELINE FOR HEALTHCARE PROFESSIONALS This guideline has the support of the RCPCH following a rigorous assessment of the guideline development methodology and a full endorsement is expected upon completion of a full stakeholder consultation. Ask about common predisposing factors • Personal or FH of brain tumour, sarcoma, leukaemia or early onset breast cancer • Neurofibromatosis • Tuberous sclerosis • Other familial genetic syndromes HeadSmart is funded and promoted by The Brain Tumour Charity and run in partnership with the Children’s Brain Tumour Research Centre (CBTRC) and the Royal College of Paediatrics and Child Health (RCPCH). The Brain Tumour Charity Registered Charity No. 1150054 (England and Wales) SC045081 (Scotland), CBTRC Charitable Status Inland Revenue No. X15294, RCPCH Registered Charity No. 1057744 (England and Wales) SC038299 (Scotland) © 2016 The Brain Tumour Charity, CBTRC and RCPCH. headsmart.org.uk

Referral from primary care Imaging

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Page 1: Referral from primary care Imaging

Headaches• Considerabraintumourinanychildwithanew,persistent*headache

• Headacheinisolation,unlikelytobeabraintumour

• Braintumourheadachesoccuratanytimeofday

• Childrenagedyoungerthan4yearsmaynotbeabletodescribeaheadache–observebehaviour

CNS imaging required with

• Persistentheadachethatwakesachildfromsleep

• Persistentheadachethatoccursonwaking

• Persistentheadacheinachildunder4

• Confusionordisorientationwithaheadache

• Persistentheadachewith1ormoreothersymptoms

Common pitfalls

• Failuretoreassessachildwithamigraineortensionheadachewhentheheadachecharacterchanges

*Persistent = continuous or recurrent headache present for more than 4 weeks

Nausea and vomiting• Considerabraintumourinanychildwithpersistent*nauseaand/orvomiting

• Headcircumferenceshouldbemeasuredandplottedinchildrenunder2withpersistentvomiting

CNS imaging required with

• Persistentvomitingonwaking(NB:excludepregnancywhereappropriate)

• Persistentnausea/vomitingwith1ormoreothersymptom

Common pitfalls

• FailingtoconsideraCNScauseforpersistentnauseaandvomiting

*Persistent = nausea and/or vomiting present for more than 2 weeks

Visual signs and symptoms• Considerabraintumourinanychildwithpersistent*visualabnormality

• Visualassessmentrequiresassessmentof:

visualacuity

eyemovements

pupilresponses

opticdiscappearance

visualfields(>/=5yrs)

• Pre-schoolandunco-operativechildrenshouldbeassessedbyhospitaleyeservicewithin2weeksofreferral

• Parentconcernalonewarrantsreferralforvisualassessment

CNS imaging required with

• Papilloedema

• Opticatrophy

• Newonsetnystagmus

• Reductioninvisualacuitynotduetorefractiveerror

• Visualfieldreduction

• Proptosis

• Newonsetparalyticsquint

• Visualsymptomwith1ormoreothersymptom

Common pitfalls

• Failuretofullyassessvision–REFERIFNECESSARY

• Failureofcommunicationbetweencommunityoptometryandprimaryandsecondarycare

*Persistent = visual abnormality present for more than 2 weeks

Head circumference• Considerabraintumourinanychildundertwoyearswithanincreasinghead

circumferenceoutsidethenormalrangeincomparisontotheirheightandweight

• Carefulassessmentofothersignsandsymptomsofabraintumourshouldbeundertakeninthesebabies

CNS imaging required with

• Rapidrateofheadcircumferencegrowthcrossingcentiles

• Increasingheadcircumferencewithanyotherassociatedsymptoms

Common pitfalls

• Failingtomeasureandmonitorheadcircumferenceinababyoryoungchildwithpersistentvomiting

Motor symptoms and signs• Considerabraintumourinanychildwithpersisting*motorabnormality

• Motorassessmentrequireshistoryorobservationof:

sittingandcrawlingininfants

walkingandrunning

handlingofsmallobjects

handwritinginschoolagechildren

• Braintumourscancausealossorchangeinmotorskillsandthiscanbesubtlee.g.abilitytoplaycomputergames

CNS imaging required with

• Regressioninmotorskills

• Focalmotorweakness

• Abnormalgait/co-ordination(unlesslocalcause)

• BellspalsywithNOimprovementwithin4weeks

• Swallowingdifficulties(unlesslocalcause)

• Headtilt/torticollis(unlesslocalcause)

• Motorsymptomwith1ormoreothersymptom

Common pitfalls

• Attributingabnormalgait/balancetomiddleeardiseasewithnocorroboratingfindings

• Failuretoidentifyswallowingdifficultiesandaspirationasacauseofrecurrentchestinfections

*Persistent = motor abnormality present for more than 2 weeks

Growth and endocrine• Considerabraintumourinanychildwithanycombinationofgrowthfailure,

delayed/arrestedpubertyandpolyuria/polydipsia

• Earlyspecialistassessmentifrequiredfor:

precociouspuberty/delayedorarrestedpuberty

growthfailure

galactorrhoea

primaryorsecondaryamenorrhoea

CNS imaging required with

• Growthorendocrinesymptomwith1ormoreothersymptoms

Common pitfalls

• FailingtoconsideraCNScauseinchildrenwithweightlossandvomiting

• Failuretoconsiderdiabetesinsipidusinchildrenwithpolyuriaandpolydipsia

Behaviour• Considerabraintumourinanychildwithnewonsetlethargy,

mooddisturbance,withdrawalordisinhibition

Common pitfalls

• Failingtoconsideraphysicalcauseforbehaviouralsymptoms

Referral from primary care• Highriskoftumour–SAMEDAYreferraltosecondarycare

• Lowerrisk*–specialistassessmentwithin2weeks

Imaging• Highriskoftumour–URGENTCNSimaging

• Lowerrisk*–CNSimagingwithin4weeks

*Lower risk = CNS tumour in differential diagnosis, low index of suspicion

Consider a brain tumour in any child presenting with• Headache

• Nauseaand/orvomiting

• Visualsymptomsandsigns:

reducedvisualacuityand/orfields

abnormaleyemovements

abnormalfundoscopy

• Motorsymptomsandsigns:

abnormalgait

abnormalco-ordination

focalmotorweakness

• Growthandendocrinesymptoms:

growthfailure(weight/height)

delayed,arrestedorprecociouspuberty

galactorrhoea

primary/secondaryamenorrhea

• Increasingheadcircumference

• Behaviouralchange

• Diabetesinsipidus

• Seizures(seewww.nice.org.uk/guidance/qs27)

• Alteredconsciousness(seewww.nottingham.ac.uk/paediatric-guideline/Guidelinealgorithm.pdf)

Assess these children with

• History:associatedsymptoms,anypredisposingfactors

• Examinationof:

visualsystem

motorsystem

heightandweight

headcircumference(<2yrs)

pubertalstatus

IF TWO OR MORE SYMPTOMS – SCAN

Assessment pitfalls

• Initialsymptomsofbraintumourcanmimicothercommonillnesses

• Symptomsfrequentlyfluctuate–resolutionthenrecurrencedoesnotexcludeabraintumour

• Anormalneurologicalexaminationdoesnotexcludeabraintumour

• Languagedifficulties–useinterpreter

the diagnosis of brain tumours in children: a guideline for healthcare professionals

ThisguidelinehasthesupportoftheRCPCHfollowingarigorousassessmentoftheguidelinedevelopmentmethodologyandafullendorsementisexpecteduponcompletionofafullstakeholderconsultation.

Ask about common predisposing factors

• PersonalorFHofbraintumour,sarcoma,leukaemiaorearlyonsetbreastcancer

• Neurofibromatosis

• Tuberoussclerosis

• Otherfamilialgeneticsyndromes

HeadSmart is funded and promoted by The Brain Tumour Charity and run in partnership with the Children’s Brain Tumour Research Centre (CBTRC) and the Royal College of Paediatrics and Child Health (RCPCH). The Brain Tumour Charity Registered Charity No. 1150054 (England and Wales) SC045081 (Scotland), CBTRC Charitable Status Inland Revenue No. X15294, RCPCH Registered Charity No. 1057744 (England and Wales) SC038299 (Scotland) © 2016 The Brain Tumour Charity, CBTRC and RCPCH.headsmart.org.uk

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