Alicia Callejo-Black, MD, describes the neuropediatrician’s potential to enhance care access for patients with certain childhood neurological issues. Offering a useful breakdown of case types, Callejo-Black discusses common symptoms that a neuropediatrician can investigate and address – often sparing families the waiting times associated with referrals to pediatric neurology. Helping providers know when to reassure parents versus recommending a workup, she explains how to identify and classify febrile seizures, how to recognize infantile spasms, what to understand about tics, and which movement abnormalities in infancy are likely benign. For pediatricians interested in deepening their neurological expertise, she provides information on the one-of-a-kind fellowship available through the UCSF Neuropediatrician Program.
Good afternoon, everyone. Thank you for joining today. Um, the talk today is called Pearls from a Neuropediatrician, um, and you might think to yourself, what is a neuropediatrician? because it's a new position that we are, um, uh, designing, um, and have created. And so I'll talk about that today. Um, again, I'm Alicia Callejola, a pediatrician here at UCSF, one of the co-founders of the UCSF neuropediatrician programs, um, and it's inaugural fellow. So, for our um agenda, um, we're going to again talk about this role, um, talk about some common uh neurological cases and management that we can do as general pediatricians, um, and then when to refer to neurology. And then I'll finish up the talk about how to refer to UCSF. Um, my goal today is to cover some common conditions that you can take care of as a pediatrician, um, and then when neurology, uh, referral is indicated, um, by a neuropediatrician. So, what is this role? Um, this is a board certified pediatrician who has completed advanced training in pediatric neurology. It's a one-year long fellowship. Um, they provide general pediatric care, um, but are also uniquely positioned to guide families through concerns of the nervous system. Um, this is a, uh, program that is available through our pediatric Brain Center, which is, um, our outpatient, um, neurology Center here at UCSF. Traineess learn how to diagnose and manage, um, common pediatric neurological conditions such as concussions, developmental delays, migraines, and other headaches, ticks and febrile seizures, to name a few. And we collaborate closely with pediatric neurologists when additional expertise or testing is needed. So why see a neuropediatrician? Um, they can be an excellent first point of contact for pediatric patients with common neurological conditions. Um, it allows for shorter wait times to be seen for specialized care. Um, this individual, um, has this unique mixture of both generalized and specialized training, um, and so it provides this holistic management in, um, an approach to taking care of, um, these types of patients, and multiple providers are involved in their care, including board certified pediatric neurologists. Um, so I'm gonna go through a couple of cases, um, and holding in mind that there's a couple of points that I want to, um, uh, talk about with each case, um, namely, why this is important for us to know as general pediatricians, um, what to do, sort of to manage within the scope of your own practice, when to refer to neurology, and what to do in the meantime before they're seen by a specialist. So for our first case, this is a 2 year old with seizure-like activity. They presented to the emergency department after a concerning episode at home. He was sitting in his high chair, and he had a whole body convulsion, um, without vocality. Um, 911 was called and after emergency medical services arrived, he was back to his baseline, so no treatment was given on route to the emergency department. There, he was found to have a temperature of 103 °F and was flu A positive. He had accompanying um URI symptoms such as cough and congestion. Um, again, because he was back to baseline by the time that he was brought to the hospital, there were no, um, uh, concerning features on his examination and no focal findings. Um, he had a normal neurological exam, um, that the doctors performed in the emergency department at that time, and he was discharged home, uh, with a plan for follow-up in clinic. So in your clinic, he's well appearing, um, as expected for a toddler of his age, he's running around the room. Um, there's nothing significant in his past medical history, and he's been hitting all expected developmental milestones including walking and running, using utensils and speaking in two word sentences. Parents are concerned, they wanna know, is there a repeat seizure or what to do about it, and if this means that their child will have epilepsy. Um, so this is something that a lot of us have taken care of, um, in our clinics. Um, these are febrile seizures. Um, we're gonna talk about the definition, um, that a febrile seizure is a convulsion that's associated with the fever, which we define as greater than 100.4 °F or 388. Degrees Celsius in a child that's older than 6 months and younger than 60 months, which is 5 years. And it has to be um uh defined within the absence of any sort of provoking cause, whether it's CNS infection, metabolic abnormalities, or head trauma. Um, etiology, um, uh, is multifactorial. We know, um, oftentimes due to a genetic predisposition, there will be a positive family history, um, in our pediatric patients that have febrile seizures. Um, and then, um, uh, pediatric patients are more susceptible in the setting of, uh, multiple factors including developmental immaturity, um, and underdeveloped inhibitory network, um, enhanced neuronal excitability, and then Um, these neuroinflammatory, uh, cytokine activity that, um, are associated with the fever itself. So when we're thinking about febrile seizures, uh, we wanna classify them. And it's important to make this classification because it informs management and prognosis. Um, so we define a simple febrile seizure as a seizure that is generalized, um, meaning that we're not seeing any focal, um, findings to it, like one arm is, uh, rhythmically shaking or eye deviation. Um, it's less than 15 minutes with a mean duration around 3 to 4, um, and it doesn't repeat in a 24 hour period. Uh, for a complex febrile seizure, it's, uh, can either be focal, um, to meet this, um, definition, um, prolonged, greater than 15 minutes, um, or multiple can occur within a 24 hour period. So, why do we want to know about this, um, as general pediatricians? Um, so it's one of the more common neurological conditions in children and it's the most common form of childhood convulsions. Um, so many of us have seen, if not, we'll see this in our practice. It occurs in 2 to 4% of children under 5 years of age in the United States. Um, and it's important to understand ongoing management and when, when to consider other diagnoses or refer as appropriate. So for acute management, this of course, is um not something that we're gonna be doing in our clinic practice, but it's important to um discuss knowing what happens when our patients uh present to the emergency department. Um, and really, this is more so if a patient is having ongoing seizure, um, not sort of the seizure that's resolved by the time that they're seen. And so that would be that emergency rescue therapy or fast-acting benzodiazepines, um, an additional anti-seizure medication if persistent after the initial therapy with phosphenytoin being our first line. And then if there are any concerning features like vocality or it's prolonged past that fifteen-minute mark, then um neuroimaging and EEG would be obtained. This is gonna be really our bread and butter as PCPs and thinking about um management ongoing of a patient, um who's presenting to us after their first febrile seizure. And it's gonna come down to education and reassurance. Um, starting off with the discussion of the benign nature with the family that, um, febrile seizures in of themselves do not cause brain injury. Um, so if there are any changing, um, features of their exam or new neurodevelopmental, um, uh, concerns, then that would warrant, um, referral. Um, talking about the natural course of the condition that, um, this is something that our children essentially grow out of because of the maturation of their nervous system. Um, there had been previous guidelines recommending cooling baths and around the clock antipyretics. I know that's something certainly that I had learned during residency, but Um, recent studies have shown that there have, uh, there has not been any um decreased risk of, uh, subsequent um febrile seizures afterwards or with the, with, with these types of um treatments. Um, there's also oftentimes a question about whether or not we would start an anti-seizure medication. Um, and, uh, most often the benefit does not outweigh the side effects. Um, in select cases, um, if there is an increased underlying risk factors such as a recurrence or if there were concerning features, then it could be a case by case. But this would certainly be something that would be done under specialist care. Um, some things, of course, would be if it was a prolonged seizure, focal features, if there are any subsequent neurodevelopmental or prior neuro developmental abnormalities, and then if there are any concerning findings on neuroimaging or neuro testing. Um, again, uh, this is a treatment that sometimes we will see in our patients that have recurrent, prolonged seizures or a high risk of recurrence. And then sometimes with their parents that have a lot of anxiety, they might feel a lot more comfortable having a medication like this, um, available. And it's usually initiated by a neurologist, whether it's um the emergency. department, um, or after they've seen a specialist with ongoing management by our PCP. I've talked with a lot of my colleagues who have um refilled these prescriptions, um, or, um, weight-based, um, them, uh, for a child as they grow. Um, and so this is just a table to show kind of what our current recommended therapies are, um, for rescue treatment. So, this is a big question that a lot of parents have and something that um we need to be able to communicate with our families. Um, they wanna know about the risk of recurrence, um, which is around 30 to 35% with either a simple or complex febrile seizure. And it's important to note that a complex feature increases the risk of repeat complex febrile seizures, but not of recurrence independently. Um, of those who have a recurrence after a simple febrile seizure, uh, 50% will have a single recurrence and 50% will have more than one. there is no significant effect on cognition, um, excluding, of course, children who had had developmental differences noted prior, and who, and those who developed subsequent afebrile seizures after that first, um, initial febrile seizure. Um, when we're thinking about recurrence risk, um, it's also going to be slightly higher with, um, those who had a febrile seizure later on, such in the 18 to 24 month period. If there's a positive family history, um, or a shorter duration of fever or lower peak temperature indicating a higher susceptibility. Um, and then, this is, of course, the other big question that our families have with the risk of epilepsy. And so, we have to think about is the baseline that between the ages of 0 to 10, we have about a 0.5 to 1% risk of epilepsy, um, that increases to 1 to 2% with a simple febrile seizure, and then 5-fold to 5 to 10% with a complex febrile seizure or any subsequent abnormal, or any abnormal developmental history or family history of epilepsy. Um, one cohort study with around 180 subjects did find that the risk of epilepsy was about highest of 5 years and then decreased over time. And it's also important to note that these numbers are just with that initial um episode and that any subsequent seizures, even simple febrile seizures can increase the risk of subsequent development of epilepsy, um, sort of in a compact, compounding um manner. I don't have the numbers of those specifics, but it is, it does increase that risk, um, with each episode. So when to refer to pediatric neurology. Um, so there are a couple of reasons. Um, for complex febrile seizures, um, I think, uh, we've discussed that it's, uh, um, a good thing to have a specialist involved in, uh, patient's care, um, with the type of, um, febrile seizure like that. And then especially if there are persistent neurological deficits or failure to return to baseline. Um, again, emphasizing that these seizures themselves do not cause brain injury and so anything that's abnormal, whether it's development or regression of developmental milestones should prompt a higher level of concern in that referral. Um, if there are any pre-existing neurological or developmental abnormalities or again onset afterwards, um, if there was a prior, uh, afebrile. Seizure, um, which I imagine if that had occurred, they would already be established. But sometimes when you see a patient with a febrile seizure, parents say, oh by the way, this is very similar to an episode we saw before and he wasn't sick at that time. So that would again then prompt that referral to be seen. And then finally, if seizures are very difficult to control or recurring frequently, then um it's also appropriate to refer to a specialist at that time. And in the meantime, um, families are probably wondering what can we do to keep our, our kids safe. And so that's gonna be, um, counseling on general safety and seizure first aid. Um, knowing that, um, this, if we've only had, um, febrile seizures or seizure saving of something that's provoking, that oftentimes, um, you know, being aware of, um, the possibility of a repeat episode with our next febrile illness. Um, I think that uh it can be a shared decision making as far as around the clock antipyretics at that time, um, as long as they're dosing them and using them appropriately, um, at least for uh fever control. But again, it hasn't been shown to decrease the risk of recurrence. Um, if seizure-like activity is, um, noted, we want to place the child on A cleared floor, on their side and with head cushioned and nothing in the mouth and not restrained. Um, and then, of course, calling 911 for a seizure that's lasting longer than 5 minutes, um, or if they had a rescue medication, um, that was prescribed prior, it's not aborting the seizure. If there's any respiratory compromise or slow return to baseline. OK. So now we're gonna move on to case two. this is a 5 week old with some concerning movements. Um, they were first noted when the patient was around 2 weeks of age. Um, and there's a couple of different movements that the, um, parents are asking about today. One is a rhythmic shaking of both arms, um, that they noticed when it seems like they're startled and especially when lying down. Um, there is a second movement, that's small rhythmic, um, uh, movements of the extremities, especially arms when upset or crying. And then finally, the third movement is this beat-like movement of the feet when sleeping. Um, parents have gently laid a hand on the limbs when these movements occurred and have noted that they do stop when they place a little bit of pressure. Um, this infant, um, is previously healthy, no significant, um, past medical history or birth trauma. Um, they had a newborn screening that was negative, um, and they've been meeting all expected milestones including moving all of their limbs symmetrically, briefly lifting their head when prone, opening their fists and alerting to sound and focusing on faces. Um, on your exam today, There are no concerning focal findings, no dysmorphic features, um, and when you look at their growth parameters, they've been growing as expected, um, with, uh, head circumference tracking along like the 20th percentile, but everything is as expected for their growth and development at this time. Um, so, uh, you know, this is something that we will follow very closely with our patients. This is why we have such frequent episodes, uh, or such frequent, um, uh, clinic sessions with our, our infants to follow, um, their normal development. Um, uh, we know that, uh, when, uh, infants are born, that their nervous system is immature with ongoing myelination until 2 years of age, um, and that we follow their clinical exam very closely because it shows us how the brain and nervous system is developing. Um, our exam starts off with making sure we're seeing symmetry of involuntary movements and the expected newborn reflexes, and then we pay attention to the normal development of voluntary movements as they arise, as well as the extinguishment of the um newborn reflex reflexes as we're expecting them to um no longer be present. Um, so, our newborn reflexes are mediated by subcortical and spinal pathways that are active due to an immaturity of the descending inhibitory control from higher brain centers, um, and they're critical for, um, Uh, feeding, such as the sucker rooting reflexes for protection from harm and, uh, like moro or cough reflex and for initial motor coordination, such as grasp or the stepping reflex. Um, we expect them to, uh, be present, um, when born and then, uh, uh, extinguished by a certain time, and then there are other reflexes such as the tonic neck reflex that we See, um, present, um, and then extinguished by the time the infant is ready to roll. Um, there are certain exam findings that can be normal within the first several months of life and then disappear. Some of those can be more brisk reflexes, um, like a patellar reflex, um, or, um, upgoing toes, which is our positive Babinski reflex, um, or clonus, where a few beats of, um, um, uh, movement can be seen of extension movement can be seen at the ankle. Um, we consider these normals if they're not uh accompanied by other, um, abnormal features such as, um, higher tone, um, and, and as well as the infant is hitting all of their expected development, uh, milestones. So, why is this important for us to know and why do we want to know about some of the um movements that we see um in infancy? It can be one of the most common concerns discussed during um our well baby visits. Um, we are the first point of contact and can provide reassurance or initiate investigation as indicated. And knowing normal and abnormal empowers us, um, and empowers our parents as well too. So today, I'm gonna cover a couple of benign movements of infancy, um, uh, some that you may be very familiar with just because of how common they are, and then a few that, um, are less common and would, um, definitely uh warrant a referral to be seen by a specialist. Um, yeah. So the first one is jitteriness or jittering. Um, and this is something that we, uh, very frequently see in the neonatal period. Um, it's these high frequency low amplitude movements, um, of the extremities. Um, and it's usually precipitated by some sort of stimulus. So when we see this in the The newborn period, we will check the glucose, um, or if we have high enough concern electrolytes such as calcium to make sure that there is not an um abnormality in a level that is, uh, precipitating, um, this movement. Um, and when we flex the affected limb, it stops the movement. Um, it's onset, um, uh, right after birth and then typically subsides by 7 to 9 months of age, um, but can actually persist up to 12 months, and again, is not concerning if not accompanied by any other features such as developmental delays or abnormal exam findings. Or shuddering. These are gonna be brief bursts of a rapid tremor, oftentimes seen in the head and the arms, like a shiver movement, um, can be triggered by excitement or other emotional stimuli. Um, usually onset within the first year of life, um, between 4 to 14 months. Um, I saw, I read maybe like an average mean around like 8 months, um, and can resolve over several months. Um. Next, we have our myoclonic disorders, um, which, um, you know, in the name themselves, um, can be benign as long as we have a normal exam. Um, for, um, our benign neonatal sleep myoclonus, that's gonna be a jerking that we see during, uh, quiet sleep that can cluster. Um, usually occurring in the upper limbs, but can, uh, be seen in other parts of, um, uh, their body. And if we are able to capture, um, an EEG during these episodes, we wouldn't see any, um, epileptic form, um, or concerning activity. Um, usually resolves by about 6 months. Um, Compared to our benign myoclonus of early infancy, um, these are movements that are occurring during wakeful time, um, can resemble, um, a diagnosis of infantile spasms, which I'll talk about a little bit later on. But if we were again able to capture these um episodes, EEG would be normal. Um, their consciousness is not affected during episodes and the development is normal and usually resolved over a few years' time. Um, some sources have actually classified shattering attacks, which is the, um, movement I talked about prior as being along the same spectrum as the benign myoclonus of early infancy as well. Um, the next is self-stimulating gratification behaviors. Um, this is also can be quite common, uh, onset in young childhood. Between 3 months and up to 5 years. Um, it can be misdiagnosed or we can be concerned for seizures with them, or, um, concerned for possible abuse as well too. Um, Uh, it's very situational in that you can, um, uh, see behaviors, um, that are classic for, um, this type of behavior. And the mainstay of treatment is reassurance, um, and education for families. And eventually for children when they're developmentally able to understand, um, that these behaviors, that there's an appropriate time and place for them. Um, this was something that actually, uh, one of the neurologists I've been working with had said that she's done before, and I've never seen this, but, uh, considering a referral to OT, um, for sensory alternatives, if it's a persistent behavior even with kind of initial, um, attempts at management. And then, um, these are just some other um types of benign movements that can be seen. Um, but because of their rarity, it is appropriate to um send to a specialist for evaluation. Um, there, uh, is spasm Newton's, which is going to be a slow head tremor along a horizontal plane. Um, you can see associated nystagmus, which is the eye movements with it, um, and can start in infancy and last for several months. Um, and we have a normal non Uh, focal exam in between episodes. There's transient idiopathic dystonia of infancy, which can be an abnormal posturing, uh, of upper limb or trunk usually presenting before 5 months of age, um, and can persist for a year or so after. Um, and we usually have, again, a normal exam in between episodes. Um, there are the paroxysmal, um, disorders, uh, whether it's the upgaze deviation or torticollis. Um, for both of these, uh, you can have normal exams in between, but you can also have some abnormal exams, um, whether it's, uh, some cognitive impairment or some motor delay or balance issues. Um, And so, uh, that's something that again would warrant investigation. So, we can talk about what to do in the meantime within our clinic, um, especially depending on the type of, of movement that's seen. Um, and so for a tremor, uh, again, we talked about whether or not there's something that precipitated or something that could be a treatable cause. We wanna do electrolyte levels, renal and hepatic function testing. Um, can consider a vitamin B12 deficiency or congenital hyperthyroidism if present, if persistent. Um, we wanna monitor our development and our exam closely. Are they meeting milestones as expected? Um, and then are we having normal rise and fall of our newborn and infant reflexes? Um, one thing to consider for our, um, uh, infants with torticollis is uh, whether or not it might be an issue of, um, a tightened muscle referral to physical therapy versus an eye alignment issue and they're actually turning their neck, um, uh, to sort of keep um their view, um, more aligned and it could be a referral to ophthalmology, um, to consider. So, when do we refer patients like this to pediatric neurology? Um, uh, a referral to neurology is helpful to classify movements and manage evaluation. Um, if there are any, there, there's anything concerning about the movements, um, such that they, um, might be, um, uh, concerning for seizures. So there's stereotypes, meaning they're the same every time. Um, they're clustering, uh, there's an arrest of attention, but that's difficult in some of our patients to determine or a loss of tone. Um, and if the movements are unable to be suppressed. Um, if there's any change in development that's associated with these movements, um, if they are increasing frequency, you're seeing an associated color change or the infants seem to be bothered by the movements, and then again, if these movements are not um extinguishing by an expected time. Um, it's always great to have parents take a video, especially for your, um, knowledge and for the specialists who may see them. Um, and so that's something that we recommend doing as long as, you know, the patient is safe while they're taking that video. And then, um, just as a, a general rule of thumb, um, movements that tend to have an external context, say it's a gratification behavior and it's always occurring in the high chair when they're sitting up, are generally benign as long as they're following these other um rules as well. Um, one of the things that we wanna make sure that we're not missing is infantile spasms, um, just because this is a very age-specific convulsive disorder, and a lot of the, um, benign movements that I mentioned before are mimics, and the only way to tell the difference is going to be that EEG, um. So, uh, this, uh, these types of movements present, um, within the 4 to 7 month range. They're gonna be symmetric contractions, of flexor and extensor muscles and clustering over several minutes. Um, again, we wanna capture the movements themselves and then any interectal, um, activity where we have the pathonemonic hips arrhythmia. that we see with this type of condition. Um, and then if that EEG finding is found, then this, um, child would undergo further workup, um, including neuroimaging, metabolic, and genetic studies. Um, and so this is something that I know many pediatricians have in the back of their mind when parents bring concerns about movements. So, when we've made the referral and we're waiting for them to be seen, um, we had talked about seizure first aid. So that's something to make sure that we're discussing as well and then went to seek emergency care. If you had sent any lab studies or referrals to other specialists, just making sure that they're getting um uh connected with those, um, and that we're following up any results. And then finally, if you feel like based on videos that you've seen or description, if you are concerned enough, it is good to send a patient to the emergency department for expedited workup. Um, uh, if it, it's really, it feels very or looks very, um, consistent with, um, that type of movement and especially if there's any developmental concerns or delay, uh, accompanying, um, those movements as well. Um, the overnight EEG is gonna be a gold standard for evaluation of infantile spasms. Um, if you are, um, less sure and it's a little bit borderline, um, sharing a video and then, um, having an urgent referral to neurology for an expedited outpatient EEG is also an option and it really just depends on your degree of suspicion and the videos that you're seeing. OK, great. So for our last case today, I'm going to talk about a 10 year old, um, also with some involuntary movements. Um, these were first noted when he was 4 years old. Um, they are sudden movements of his arm and nodding of his head. Uh, he does feel an urge prior to the onset of the movement. Um, not all the time, but when you ask him directly, he says, yes, I think I know when they're coming on. And he feels uncomfortable if he suppresses it, but there's no pain associated with the movement itself. He has become self-conscious about it and feels that it interrupts his day to day activity. Um, there's no significant birth history for him. His development has been as expected. He was diagnosed with ADHD at 8 years of age, um, which is managed with Adderall extended release on weekdays, and he's been doing very well with that and, um, no concerns at school at this time. Um, there is a positive family history of OCD, um, and, uh, when you examine him, you do catch those intermittent movements, including jerking of his shoulders and arms and turning and nodding of his head. Otherwise, from your exam, there's nothing focal or concerning that you have found. Um, and you don't hear any vocalizations during this time. He's able to speak fluidly without interruption. Um, so this is something that we have probably all seen as well, um, which is a tick, um, which, by definition is a repeated individually recognizable or intermittent movement or movement fragments or utterances that are almost always briefly suppressible and associated with an awareness of the urge to perform the movement. Um, they are non-rhythmic, um, and regarding this pre-monetary urge, um, I was reading that it's, um, much more prevalent in adults with this condition that up to 90% report that urge prior, um, just because it's sort of the developmental stage and their awareness, it's only reported more in like 20 to 30% of, of, um, of our younger, um, patients with this condition. Um, so that's just, uh, sort of an interesting, uh, distinction based on, um, their age. Um, it's ego dystonic, meaning that it's experienced as unwanted. Um, and it often onsets, um, between the ages of 4 to 6 when we're seeing it in our pediatric populations. Uh, it's due to a dysregulation of, um, the motor control pathway. So, for ticks, we also characterize them to sort of give us an understanding of how to help the patient and also prognosis. Um, it can either be simple, meaning it's involving one body region, either motor or vocal. And then, um, complex, meaning multiple body parts or complex movements. Um, you can either have eopraxia or eolalia where you are imitating another's movements or words, or coopraxia or coprolalia where you have socially inappropriate gestures or words. Um, we differentiate based on the duration that a patient has, um, had these, um, symptoms for and then the type of tick that we're seeing. Uh, provisional versus chronic, and then motor vocal or a combination. Um, and so a provisional tic disorder, which used to be called transient tic disorder, presents before age 18. It's lasting less than a year, um, waxing and waning its presentation, but does spontaneously resolve in weeks to months after onset of these, um, movements. Um, for chronic disorder, it's also present before 18, uh, age 18, but it's lasting longer than 1 year. Um, and then for Tourette's syndrome, that's gonna be a chronic tic disorder with two or more motor tics, plus one or more vocal tic. Um, and what's important to note is that for, um, this type of tick disorder that most resolve into late puberty, so anywhere from 3/4 to 80% of patients have resolution. And for ticks that persist into adulthood, um, they're often less severe, um, and disabling than they were in childhood. Um, Tourette.org can be a great resource for us as practitioners, for families, patients, and for schools as well. Um, so why do we want to know about tic disorders as a general pediatrician? It's a common condition. Studies have shown that 6 to 18% of children can have motor tics in their life. Um, and it's important to recognize this condition and differentiate it from other movement disorders or possible seizures to support family and initiate appropriate referrals or treatment. Um, it can, uh, be comorbid with other conditions such as ADHD and OCD. So those should be identified and treatment, um, initiated as indicated. Um, one thing to differentiate is a tick versus a stereotopy. So stereotopy is another type of movement. It's a repetitive, simple movement that can also be voluntarily suppressed. It's onset usually a little bit earlier than ticks, more um before the age of 3, can be triggered by heightened emotions, excitement, or boredom. Um, it doesn't interfere with your daily activity, um, and can be stopped with distraction, but sometimes it's soothing or release. And so it's actually felt as ego syntonic, um, to the individual. And, uh, as we know, it can be seen in neurotypical children or, um, those with autism or other neurodevelopmental conditions. So when we're thinking about treatment and management of ticks, um, usually it's reassurance, if not it's causing any type of distress. Um, if it is disruptive, then the focus is on a reduction of severity and frequency, um, and improving overall quality of life. And so the mainstay of therapy of treatment is going to be behavioral cognitive therapy. And tickHelper.com is, um, uh, one way that we can help um connect our patients with this type of therapy. Um, however, it can be hard to access. Um, I think, I think that there are, um, uh, fewer therapists probably than, um, you know, is, uh, needed for patients that have this type of, of movement disorder. And so they may need help on how to, um, either, um, uh, access the therapy or give them resources to sort of complete some of the therapy, um, on their own. Um, and then another thing to consider would be a 504 plan for patients, um, so that they can continue to have support in the school setting. If we are initi initiating pharmacotherapy, um, our first tier is gonna be alpha 2 agonists like lonidine or gumicine, and our tier two, which are typical and atypical neuroleptics are, are, um, most likely gonna be um initiated under specialist care. So we recommend referral to pediatric neurology when the ticks are disruptive, severe, having rapid progression or causing pain or injury. And then also consider if they're refractory to the first line treatments that you've initiated in your practice. Um, you can also consider a referral if uh the diagnosis is uncertain due to atypical features, if you want to rule out seizures, um, or if there are comorbidities complicating management, and they often can be co-managed with psychiatry as well. OK, great. So, um, I'd like to share a slide, um, to, uh, give you information on how to refer to UCSF, um, pediatric neurology. Um, this is our access center line and this is the number that, um, you can use to refer to any specialist, um, but it's relevant, of course, to this talk today. Um, so I will leave that up there, and then I've been told that these slides will be made available, so you have access to that as well too. Um, I also want to give you information on how to learn more about our, um, UCSF neuropediatrician program if you have any interest in applying to be a fellow. Um, our program director is Doctor Bethany Johnson Kerner, who's a wonderful PDS neurologist here at UCSF, um, and she, um, has made herself available, um, for any follow-up questions. Um, eligible candidates are pediatricians who have received training through an ECGME accredited residency and are, um, board certified or board eligible in general ped pediatrics. Um, I have shared, um, this bottom link here, uh, a Um, are, um, patient facing, um, uh, educational page from UCSF about, um, neuropediatricians. So that's something that, um, you can review yourself or share with families. These are my references, and that is the end of my talk. Um, so thank you again so much for joining today.
