Cases corner – 7 year old with unsteadiness

2nd April 2019

A 7 year old boy named James presents with his mum after falling at school. You ask him what happened, and he reports that he felt unsteady and think he tripped. He did not experience any other symptoms. He is currently asymptomatic and feels well in himself. There was no loss of consciousness or head injury. James has had an unremarkable birth history, with no past medical history of note.

You conduct a cardiovascular examination which is unremarkable. A neurological examination, demonstrates an ataxic and unsteady, which his mum confirms is new. There are no other deficits or dysfunction.

What should you do next?

  1. Organise a routine referral to the paediatric team for further evaluation
  2. Reassure Mum and advise her to bring him back for review in 2 weeks with adequate safety netting
  3. Organise an urgent referral to the paediatric team (within 48 hours)
  4. Refer the child to accident and emergency

James should be referred urgently for an appointment within 48 hours. As he is a child, he should be referred to the paediatric team. This is usually arranged by discussing the case with the on call paediatrician. In most areas of the UK, all children should be referred with the paediatric referral form, except for sarcoma pathways.

Pathologies of the brain and central nervous system can present with a huge variety of signs and symptoms. This can make it exceptionally difficult in primary care to know which symptoms qualify for an urgent referral. NICE criteria, as outlined below, is broad and vague to cover a range of presentations. This patient’s presentation was difficult to characterise, however, as a clinician the guidelines gives you the clinical discretion to refer patients you are concerned about.

The NICE guidance reports that we should:

Consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system cancer in children and young people with newly abnormal cerebellar or other central neurological function. [new 2015]