Encefalopatía hiponatrémica como consecuencia de la utilización de fluidos hiposódicos. ¿Pudo haberse evitado en este caso? / Hyponatremic encephalopathy resulting from the use of hyponatremic fluids. Could it have been avoided in this case?

La hiponatremia dilucional yatrogénica es una entidad clínica infradiagnosticada y evitable, que puede tener consecuencias mortales, como el edema cerebral agudo. La administración de fluidos intravenosos hiposódicos de mantenimiento, según la pauta clásica de Holliday y Segar, es un factor determinante para la aparición de dicha entidad o para el agravamiento de las formas leves de hiponatremia, sobre todo en los pacientes pediátricos tras cirugía o ingresados por patologías agudas, cuyo riñón es incapaz de excretar agua libre por un exceso de hormona antidiurética (ADH). Los fluidos isonatrémicos pueden prevenir la aparición de la citada hiponatremia y sus temibles complicaciones. Presentamos un caso de evolución satisfactoria, con objeto de concienciar al personal sanitario de la necesidad de abandonar los fluidos hiposódicos y utilizar como fluidos de mantenimiento aquellos con un contenido de sodio más próximo al del plasma (AU)

The dilutional and iatrogenic hyponatremia is an underdiagnosed and avoidable situation, that can result in a life threatening condition, such as cerebral edema. The intravenous administration of hyponatremic fluids, as a maintenance fluid therapy according to Holliday & Segar, has been related with this entity or the worsening of mild hyponatremia in acute ill pediatric patients and also postoperative pediatric patients. These patient's kidneys are unable of excrete free water because of an excess of antidiuretic hormone (ADH) effect. Best evidence at the present time says that isonatremic maintenance fluids can prevent hyponatremia and its health threatening consequences. We report a case of successful development and deeply insist on the necessary changes that paediatricians must do on using intravenous isotonic saline solutions instead of hyponatremic fluids (AU)

[Attention deficit hyperactivity disorder therapy update: extended-release methylphenidate]. / Actualización terapéutica en el trastorno por déficit de atención e hiperactividad: metilfenidato de liberacion prolongada.

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is a very common condition in neuropaediatric practice and the most widely used medication is methylphenidate (MPT). We discuss the comorbid disorders, diagnosis, aetiopathology and neurochemical bases, and we also stress the importance of pharmacological action on the dopaminergic and noradrenergic pathways, and the problems and benefits of the different formulations of MPT. AIMS: Since extended-release MPT by means of the OROS technique has only recently been commercialised in Spain, we conducted a comparative analysis of immediate-release MPT and extended-release MPT in a series of 93 patients in order to determine which of them is preferable, to evaluate the reasons why this is so, and to analyse the shortcomings and advantages of the two drugs. PATIENTS AND METHODS: We present a study of 93 patients between 6 and 18 years old. Once an initial treatment had been established, changing over to extended-release MPT was proposed. We analysed compliance, effectiveness, safety, the preferences of the family and the degree of control over afternoon symptoms with the new treatment. RESULTS AND CONCLUSIONS: Most of the patients began treatment with immediate-release MPT or other medication. Changing to extended-release MPT brought about greater satisfaction with the control of afternoon symptoms and an improvement in the degree of compliance with respect to the initial treatment with immediate-release MPT or other drugs.

[The contribution of the cerebellum to cognitive processes]. / Contribución del cerebelo a los procesos cognitivos.

INTRODUCTION: Apart from its functions involving control over movement, the cerebellum is also related to learning motor sequences and, according to the experimental and clinical evidence we will examine, to cognitive and learning processes that do not exclusively involve motor activity. DEVELOPMENT: The cerebrocerebellar connections act as a vehicle for the afferent information from the sensory-motor cortex, prefrontal cortex, the frontal regions responsible for (expressive) language, parietal cortex, superior colliculus and superior temporal cortex, returning efferences to similar areas that are responsible for attention, visuospatial perception, memory and the regulation of executive and emotional functions. It plays a role in the preparation and anticipation of motor responses, according to sequences experienced previously depending on the information received from the surroundings, thus anticipating the physiological state for carrying out perceptual motor or cognitive tasks. A number of experimental neuroimaging studies, as well as the discovery of a new cell in the neuronal population of the cerebellum, relate the cerebellum to cognitive processing. CONCLUSIONS: Clinical observation of patients with cerebellar lesion or dysfunction, which are related to a deficit in the cognitive functions, suggests a model with which to understand these mechanisms. Long-lasting depression is considered to be the learning mechanism in the cerebellum and is intimately related to the mechanisms involved in neuronal plasticity and in memory.

[Attention deficit hyperactivity disorder and epilepsy]. / Trastorno por déficit de atención e hiperactividad y epilepsia.

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is currently one of the morbid clinical pictures in childhood and adolescence that is most frequently diagnosed in the Neuropaediatric clinic. DEVELOPMENT: ADHD is sometimes associated to other important neurological problems, such as behavioural disorders, tics or headaches, and may occasionally be related to epilepsy, although in this particular case the epileptic syndromes often involve disorders affecting behaviour and attention. Due to the frequent association of these disorders (epilepsy and ADHD) it is wise to perform an electroencephalographic study in patients who visit because of symptoms of disattention. Likewise, the neuropsychological assessment of epileptic children must not be neglected. We analyse the therapeutic options regarding the use of stimulants when both disorders coexist and we endorse the association of antiepileptic and psychostimulant drugs when necessary.

Trastorno por déficit de atención e hiperactividad y epilepsia / Attention deficit hyperactivity disorder and epilepsy

Introducción. El trastorno por déficit de atención e hiperactividad (TDAH) constituye hoy en día uno de los cuadros mórbidos de la edad infantil y adolescencia más frecuentemente diagnosticados en la consulta de Neuropediatría. Desarrollo. El TDAH se asocia en ocasiones a otros problemas neurológicos de importancia, como los trastornos de conducta, tics, cefaleas y, en ocasiones, puede relacionarse con epilepsia, con la particularidad de que los síndromes epilépticos conllevan en muchos casos alteraciones de la conducta y la atención. Debido a la frecuente asociación de estos trastornos, epilepsia y TDAH, es oportuno realizar un estudio electroencefalográfico en los pacientes que consultan por síntomas disatencionales, del mismo modo que no debemos olvidar la valoración neuropsicológica de los niños epilépticos. Se analizan las opciones terapéuticas en relación con el uso de los estimulantes cuando coexisten ambos trastornos, y se valida la asociación de antiepilépticos y psicoestimulantes cuando se precisen (AU)

Introduction. Attention deficit hyperactivity disorder (ADHD) is currently one of the morbid clinical pictures in childhood and adolescence that is most frequently diagnosed in the Neuropaediatric clinic. Development. ADHD is sometimes associated to other important neurological problems, such as behavioural disorders, tics or headaches, and may occasionally be related to epilepsy, although in this particular case the epileptic syndromes often involve disorders affecting behaviour and attention. Due to the frequent association of these disorders (epilepsy and ADHD) it is wise to perform an electroencephalographic study in patients who visit because of symptoms of disattention. Likewise, the neuropsychological assessment of epileptic children must not be neglected. We analyse the therapeutic options regarding the use of stimulants when both disorders coexist and we endorse the association of antiepileptic and psychostimulant drugs when necessary (AU)

[The neuropaediatric and pathogenic clinical bases of autistic spectrum disorder]. / Bases clinicas neuropediatricas y patogenicas del trastorno del espectro autista.

INTRODUCTION: The dimension of the autistic spectrum embraces a considerable degree of clinical complexity which is, in turn, an expression of the numerous systems involved in the functioning of the central nervous system. Every day different biological factors are revealed which put in doubt other factors that, in a more objective way, appear to be involved in a particular aetiology. DEVELOPMENT AND CONCLUSIONS: It is clear that exactly what causes autistic spectrum disorder is still unknown and it may be useful to analyse cases with a known aetiology and correlate them with other similar cases, as it is likely to be this association between findings and studies in the future that will probably enable us to better define the bases and the underlying causes of the complex and manifold origin of the autistic spectrum. This will enable a more efficient therapeutic approach to be developed, which, when all is said and done, is what is primarily sought in the management of children with autistic spectrum disorder.

[Functional neuronal plasticity]. / Plasticidad neuronal funcional.

INTRODUCTION: Thanks to the contributions made by neuroscientific research and the clinical evidence regarding the functional recovery of the central nervous system in the different motor, cognitive, linguistic and sensory spheres, we now know more about how the brain is built and its modifications. This recovery is possible due to the plasticity of the brain, its capacity to reorganise itself and to modify functions in order to adapt to both external and internal changes. This capacity is inherent to brain cells and allows cortical circuits to be repaired, integrates other cortical areas to carry out modified functions and responds to different disorders. It depends on genetic, neuronal and neurochemical factors and its limits can be manipulated through clinical and pharmacological intervention. DEVELOPMENT: The brain's capacity to adapt itself to changes is crucial in the development of the nervous system and has important repercussions on learning. The neuroanatomical, neurochemical and functional changes that take place during the reorganisation made possible by plasticity will facilitate the recovery acquisition of the functions involved (adaptive plasticity) and may hinder the development of others (maladaptive plasticity). This variability of the possible responses is related to the chronology of the lesion, the site that is affected, the state of the substrata that can take on the function and the type of function that is altered. The mechanisms responsible for facilitating this plasticity are different at any given time (fast and late plasticity), depending on the function that is altered, with expansion of the somatotopic representations in the motor cortex adjacent to the damage, interhemispherical transfer of language or crossed plasticity in the auditory or visual function. The neuropsychological pathology can appear linked to the lesion or secondary to a maladaptive plasticity. CONCLUSIONS: Advancing in our knowledge of the intrinsic mechanisms of brain plasticity and synaptic regulation will lead us to understand the recovery of damaged or lost functions in the brains of children with special needs, and thus allow us to implement favourable clinical and pharmacological interventions.

Bases clínicas neuropediátricas y patogénicas del trastorno del espectro autista / The neuropaediatrci and pathogenic clinical bases of autistic spectrum disorder

Introducción. La dimensión del espectro autista abarca una complejidad clínica considerable que es, a su vez, expresión de la multitud de sistemas implicados en el funcionamiento del sistema nervioso central; cada día se evidencian distintos factores biológicos que ponen en discusión los factores que, de una forma más objetiva, parecen implicados en una etiología definida. Conclusiones. Es evidente que todavía no se conocen con precisión las causas determinantes del espectro autista y posiblemente sea útil analizar los casos con una etiología conocida y correlacionarlos con otros similares, siendo esta asociación de hallazgos y los estudios futuros los que probablemente permitan definir mejor las bases y el substrato del origen complejo y múltiple del espectro autista. Ello posibilitará un acercamiento terapéutico mas eficaz, que, en definitiva, es el anhelo primordial para el abordaje de los niños con espectro autista (AU)

Introduction. The dimension of the autistic spectrum embraces a considerable degree of clinical complexity which is, in turn, an expression of the numerous systems involved in the functioning of the central nervous system. Every day different biological factors are revealed which put in doubt other factors that, in a more objective way, appear to be involved in a particular aetiology. Conclusions. It is clear that exactly what causes autistic spectrum disorder is still unknown and it may be useful to analyse cases with a known aetiology and correlate them with other similar cases, as it is likely to be this association between findings and studies in the future that will probably enable us to better define the bases and the underlying causes of the complex and manifold origin of the autistic spectrum. This will enable a more efficient therapeutic approach to be developed, which, when all is said and done, is what is primarily sought in the management of children with autistic spectrum disorder (AU)

[Adopted children: risk factors and neuropsychological problems]. / Niños adoptados: factores de riesgo y problemática neuropsicológica.

In recent years there has been a striking increase in the number of transnational adoptions in our country, which follows the trend already observed in other developed European countries. Major contributing factors to this phenomenon have been the improvements in socioeconomic conditions in our country, the drop in the birth rate, with the corresponding decrease in the number of children available for adoption, and the disappearance of orphanages. This growing demand can be met by developing countries, in which the birth rate is still high and there are only limited chances of being able to maintain offspring. The children that are adopted come mainly from countries in Central and South America, Eastern Europe and Asia. Pathologies that can be expected in adopted children include general paediatric conditions, especially infections (which are often autochthonous ailments in their own country) and malnutrition, as well as neuropsychological and developmental disorders, such as psychomotor retardation, conduct and behavioural disorders, which sometimes stem from conflicts arising in the process of adaptation, communication problems, which occasionally reflect an autistic like disorder, and the problems deriving from the circumstances that condition the donation of the child for adoption (perinatal pathology, maternal drug addiction and withdrawal symptoms, maternal psychopathology.). The pathology, history and prognosis of the adopted child depend on several different factors that act in an accumulative fashion. The country of origin plays a decisive role in the type of pathology, according to the level of the health care system that exists there, the existence of adoption programmes that are regulated by law, etc. The child's age at adoption marks the difference in the optimisation of their development, if they have early access to a stable family unit. Having stayed in institutions and the length of time spent there is a risk factor for presenting a neuropsychological pathology. On many occasions the scarce information available about the child's medical history makes it more difficult to anticipate the appearance of certain problems. The existence of social risk factors in the biological families is a conditioning factor in increased morbidity. We describe a short series of adopted patients who were attended in our Neuropaediatric clinic, and we analyse the above mentioned conditioning variables and the most frequent pathologies.

Niños adoptados: factores de riesgo y problemática neuropsicológica / Adopted children: risk factors and neuropsychological problems

En los últimos años hemos asistido a un incremento llamativo en el número de adopciones transnacionales en nuestro país, que sigue las tendencias ya existentes en otros países desarrollados europeos. A este fenómeno ha contribuido la mejora en las condiciones socioeconómicas de nuestro país, el descenso de la natalidad, con una disminución en la oferta de niños en adopción, y la desaparición de los orfanatos. Esta demanda creciente tiene salida en los países en vías de desarrollo, en los que la natalidad es todavía elevada y las posibilidades de mantener a la descendencia muy limitadas. Los niños adoptados son originarios, principalmente, de países pertenecientes a Centroamérica, América de sur, Europa del este y Asia. La patología esperable en el niño adoptado comprende tanto problemas pediátricos generales, entre los que destacan las infecciones -amenudo autóctonas del país de origen- y la desnutrición, como trastornos neuropsicológicos y de desarrollo, como el retraso psicomotor, los trastornos de comportamiento y conducta -que en ocasionesresponden a conflictos adaptativos-, los problemas de comunicación -en ocasiones como expresión de un trastorno de características autistas- y los problemas derivados de las circunstancias que condicionaron la donación del niño en adopción (patología perinatal, drogadicción materna y síndrome de abstinencia, psicopatía materna, etc.). La patología, evolución y pronóstico del niño adoptado dependen de diversos factores que actúan de forma sumatoria. El país de origen es determinante del tipo de patología, en función del desarrollo del sistema sanitario, la existencia de programas de adopción regulados, etc. La edad del niño en el momento de su adopción marca la diferencia en la optimización de su desarrollo, si tiene acceso temprano a un núcleo familiar estable. La estancia previa en instituciones y su duración es un factor de riesgo para presentar patología neuropsicológica. La escasa información disponible en muchas ocasiones acerca de los antecedentes hace más difícil el anticiparse a la aparición de determinados problemas. Por último, la existencia de factores de riesgo social de las familias biológicas condiciona mayor morbilidad. Describimos una serie corta de pacientes adoptados atendidos en nuestra consulta de neuropediatría y analizamos las variables condicionantes citadas y las patologías más frecuentes (AU)

In recent years there has been a striking increase in the number of transnational adoptions in our country, which follows the trend already observed in other developed European countries. Major contributing factors to this phenomenon have been the improvements in socioeconomic conditions in our country, the drop in the birth rate, with the corresponding decrease in the number of children available for adoption, and the disappearance of orphanages. This growing demand can be met by developing countries, in which the birth rate is still high and there are only limited chances of being able to maintain offspring. The children that are adopted come mainly from countries in Central and South America, Eastern Europe and Asia. Pathologies that can be expected in adopted children include general paediatric conditions, especially infections (which are often autochthonous ailments in their own country) and malnutrition, as well as neuropsychological and developmental disorders, such as psychomotor retardation, conduct and behavioural disorders, which sometimes stem from conflicts arising in the process of adaptation, communication problems, which occasionally reflect an autistic-like disorder, and the problems deriving from the circumstances that condition the donation of the child for adoption (perinatal pathology, maternal drug-addiction and withdrawal symptoms, maternal psychopathology...). The pathology, history and prognosis of the adopted child depend on several different factors that act in an accumulative fashion. The country of origin plays a decisive role in the type of pathology, according to the level of the health care system that exists there, the existence of adoption programmes that are regulated by law, etc. The child’s age at adoption marks the difference in the optimisation of their development, if they have early access to a stable family unit. Having stayed in institutions and the length of time spent there is a risk factor for presenting a neuropsychological pathology. On many occasions the scarce information available about the child’s medical history makes it more difficult to anticipate the appearance of certain problems. The existence of social risk factors in the biological families is a conditioning factor in increased morbidity. We describe a short series of adopted patients who were attended in our Neuropaediatric clinic, and we analyse the above-mentioned conditioning variables and the most frequent pathologies (AU)