Hydrocephalic syndrome in infants treatment. Hydrocephalic syndrome in a child under one year old - clinical symptoms. Symptoms in adults

Increased intracranial pressure has other names: intracranial hypertension, hypertensive syndrome or hydrocephalic syndrome. In adults, the treatment of this condition is due to many factors and can be quite a complicated process.

Before treating, you need not only to make a diagnosis, but also to describe one of the links in a variety of neurological diseases.

The general “diagnosis” of hydrocephalic syndrome is sinned mainly by domestic medicine, and in most cases this diagnosis is unfounded. Real idiopathic or benign intracranial hypertension occurs no more than 1-2 cases per 100 thousand people. Everything else that is diagnosed as ICP is one of the links in diseases such as brain tumors, neurological infections, severe traumatic brain injuries, hereditary rare diseases, intracranial hemorrhage.

Hydrocephalic syndrome in adults. Treatment. Diagnostics.

In most adults, it is easy to identify signs and prescribe proper treatment. The signs of the disease are:

impaired vision and movement of the eyeballs, strabismus;
severe headaches;
impaired consciousness (from mild stupor to coma);
nausea, vomiting, usually associated with food intake, most often in the morning;
convulsions and mental disorders.

It should be noted that each of the listed symptoms identified separately is not evidence of ICP.

You also need to know that it is possible to correctly assess the state of ICP only during a craniotomy or with the help of a lumbar puncture, however, the accuracy will be less.

The specifics of the treatment of hydrocephalic syndrome in adults

A rather serious and difficult-to-diagnose condition is hydrocephalic syndrome in adults. Its treatment depends on the causes of the disease. For example, when such operations are performed in which the cerebrospinal fluid is removed from the cavity cranium, and in the presence of a tumor, it is produced complete removal. Also applies special treatment with neuroinfections, when antibiotics are found.

It should be noted that drug treatment is only a temporary measure for acute situation when diagnosed with hydrocephalic syndrome in adults. The treatment for this condition is without fail takes place in a hospital under strict supervision.

It is important to know that none of the conditions of hydrocephalic syndrome in a mature person is treated with:

herbs;
homeopathic remedies;
vitamins;
acupuncture;
massage;
nootropic drugs ("Piracetam", "Pikamilon", "Nootropil", "Pantogam", etc.);
vascular preparations ("Cinnarizine", a nicotinic acid, Cavinton, etc.);

It is also incorrect to prescribe treatment with any diuretic drugs. As a rule, this treatment is directed to a non-existent disease. For healthy person this treatment threatens side effects from the drugs used, but will not help if the hydrocephalic syndrome in adults is really diagnosed.

ICP is not treated with "quack" methods - this will only lead to what will be missed right time, complete loss of vision and partial loss of intelligence is possible.

Each age has its own reasons for development. this disease. Intrauterine hydrocephalus develops due to genetic abnormalities, malformations of the central nervous system, infections transmitted from the mother. Acquired pathology in children appears as a result of:

tumors in the tissues of the brain or spinal cord;
injuries acquired during labor activity;
hemorrhages.

How the disease manifests itself

Features of symptoms are associated with the form of the disease (congenital or acquired). In infants, the first type of disease is more common, and in older children, the second. Acquired pathology is more often a complication after head injuries (external or closed fractures) or diseases affecting the work of higher nervous system(VNS).

Hydrocephalic syndrome in newborns

Every baby in the womb accumulates a lot of fluid in the brain during the sixth month of development. This is due to the fact that the ventricles of the brain are wider in the fetus. Before childbirth, when the cerebrospinal fluid is completely gone, they should narrow and return to normal. If this does not happen, then doctors make a diagnosis of HHS. Hydrocephalic syndrome in infants manifests itself depending on the genesis of the pathology.

If HHS is the result of hypertension, then bulging of the eyes or Graefe's symptom (lag of the upper eyelid from eyeball). Signs of the syndrome in newborns, which are a consequence of hydrocephalus:

bad dream;
long and frequent crying;
irritability, anxiety;
drowsiness, low activity;
accelerated head enlargement;
thinning of the bones;
change in the proportions of the skull;
oculomotor disorders (strabismus, paresis);
inability to hold the head on their own;
lack of closure of the fontanel;
muscle hypertonicity.

For children under one year old

Infants under one year of age (preterm infants under 2 years of age) are diagnosed with HHS based on symptoms. The very first sign is a monthly increase in head circumference by 1-2 cm. Hydrocephalic syndrome in a child up to a year old is manifested as follows:

tremor upper limbs;
dizziness;
abnormal increase in head circumference;
pallor of the skin;
divergence of the sutures of the skull;
weak muscle tone lower extremities;
reduced reflexes: grasping, supporting, crawling, walking, swallowing;
lethargy, increased drowsiness, passivity.

In older children

Pathological process in older children, it makes itself felt with tinnitus, temporary disorientation in space, impaired gait. They sleep restlessly, often startle in their sleep. Violations in emotional sphere range from neurasthenia and causeless euphoria to apathy. Sometimes there are psychoses with delusions or hallucinations. With severe hypertension, it is possible aggressive behavior. Other signs of HGS.

Babies are often diagnosed with hydrocephalic syndrome. In fact, hydrocephalic syndrome in infants is not so common. What is this pathology, and what does it threaten? What are its features?

At a subsequent examination, the hydrocephalic syndrome in a child may not be confirmed. Even if the diagnosis is confirmed, do not be afraid. The main thing is to have information and follow all the recommendations of the doctor.

Hydrocephalic syndrome in adults has its own characteristics. It is provoked not by congenital, but by acquired pathologies of brain nutrition.

Peculiarities

All signs of hydrocephalic syndrome are associated with the fact that an excessive amount accumulates in the head. cerebrospinal fluid. It should be there, but volume matters. With an excess of liquor, it begins to compress the brain tissue, causing a disruption in their functioning.

Fluid in the brain accumulates during development in the womb. Normally, before the birth of a child, its amount decreases. If this does not happen, the baby may lag behind in development and will suffer from high intracranial pressure.

Parents should not panic if such a diagnosis is confirmed. We'll fix everything. Correction is possible, especially if the baby is not yet six months old. The main thing is not to delay the treatment and strictly follow all the recommendations.

Hypertensive syndrome in newborns can provoke an increase in intracranial pressure, but this is not an independent diagnosis. This is a symptom. He appears, then retreats for a while. Such jumps can cause emotional stress, exercise stress and even eating. It is not necessary to treat ICP in this case. It is dangerous only with advanced hydrocephalus.

It is important to determine the origin of HGS in each case. For correction, massage is used in combination with drug treatment(do not confuse with the mentioned syndrome).

Development mechanism

Hypertension syndrome in adults, newborns and children develop in different ways. In the womb, the child grows rapidly, the system that feeds the brain is rapidly developing. At first, it feeds only through the blood, then, as it develops, the liquor also joins. By the end of fetal development, not only blood, but also spinal nutrition should be formed.

Each of us in the sixth month of development in the womb had quite a lot of fluid in the head. This is due to the fact that the ventricles of the brain in the fetus are wider. Then they should narrow, and before childbirth come to a normal state. Then the liquor is completely gone from the head.

If this did not happen or the process slowed down, a diagnosis of "hypertensive syndrome in infants" is made.

Do not confuse hypertensive hydrocephalic syndrome with hydrocephalus. These are two different diagnoses. The latter has more serious consequences and develop differently.

Kinds

HHS can develop not only in infants. It may appear on:

newborns;
children;
adults.

The reasons

There may be several reasons for this pathology in newborns. Most often it is:

infections;
complications during pregnancy;
brain damage;
prematurity;
anomalies in the development of the brain;
long stay without water (12 hours or more);
chronic diseases (mothers);
birth trauma.

The diagnosis of "hypertensive hydrocephalic syndrome" is usually made only in the countries of the former USSR. Russia is no exception. In the West, it is considered a manifestation of some pathologies of the brain.

During pregnancy, it is important to take all tests and monitor general blood counts. An analysis for toxoplasmosis will help prevent a crisis and identify the problem in time.

Acquired Causes:

hematoma, abscess, tumor, brain cysts;
foreign bodies;
fragments of bones that fell into the brain during a skull fracture;
intracranial hypertension;
infections;
metabolic disorder;
osteochondrosis of the cervical region;
disorders after a stroke.

These causes can indirectly affect the drainage of fluid from the brain area. The disease itself manifests itself in different ways - from mild form to heavy. Symptoms are especially pronounced if the disease is not treated.

Toxoplasmosis can provoke not only hydrocephalic syndrome. It leads to serious disorders of the central nervous system. Manifestations will not keep you waiting. The most dangerous is encephalopathy. it pathological condition brain that dies nerve cells, occur dystrophic changes. Brain functions are seriously impaired.

Hypoxia, prematurity (deep), infections can disrupt the normal development of the fetus.

For the crumbs, the birth itself is also extremely dangerous. Despite the fact that this natural process, it often leads to complications and injuries. Childbirth can cause hemorrhages, trauma, hypoxia. It can even happen outdoor open or closed fracture, dislocation. All these reasons can provoke a serious imbalance between the process of production and absorption of CSF. But it is he, along with blood, that nourishes the brain. Here it is important to subcompensate the load.

Sometimes after birth, the baby has a residual syndrome. These are changes in the tissues and functions of the brain due to their mechanical injury.

Symptoms

It is very difficult to determine visually, these are the symptoms of the syndrome or the behavior of the baby. Pathology manifests itself in different ways. The nature of the manifestations depends on the form, degree of the disease, its cause. However, there are still signs that can be symptoms of HHS:

irritability;
anxiety;
the child has poor sleep;
frequent and long cry of the baby;
lethargy;
low activity;
drowsiness.

The severity of symptoms depends on the genesis of the disease. Many of them are the result of hypertension. Children with HHS may have bulging eyes, Greffe's sign (between upper eyelid and a noticeable white streak forms in the pupil).

With severe development, the upper eyelid may half close the eye (symptom of the "setting sun"). These children may develop strabismus, they throw back their heads. Muscle tone can be both reduced and abnormally increased. This is especially evident in the muscles of the legs. The child can walk on tiptoe. Such symptoms should alert. It is necessary to immediately show the child to the pediatrician, and he, if necessary, will already refer him to a pediatric neurologist. Therapy must be comprehensive.

In children with this syndrome, reflexes (walking, crawling, grasping) are reduced. Such movement disorders often accompany HGS. Hypertensive anomalies are often observed.

These symptoms also occur with other pathologies, for example, with perinatal encephalopathy(PEP). It often becomes the result of prolonged intrauterine hypoxia (oxygen deficiency).

PEP is the result of a violation of the processes of intrauterine development. At the same time, the child can recover, but long-term developmental classes are needed.

It is important to exclude other diseases. When PEP is strictly not allowed to prescribe diuretics. They can cause heart problems and interfere with neuroreflex processes. But with HHS, hypertension, they are indicated.

Mandatory symptom of HHS - pathological changes baby's head circumference. She's growing too fast. For a month, 1.5 cm or more can be added. In this case, the sutures of the skull can swell, the very shape of the head changes.

Some have naturally large heads. it genetic feature rather than a symptom of a pathology. That is why it is important to do an ultrasound, and not guess based on tactile and visual examination. If one of the parents has a large head, then the baby's big head is not a pathology.

HHS does not appear in newborns either. In older children, HHS is often associated with infection or trauma. Typical symptoms:

headache often (pain throbbing, bursting or aching, more often happens in the morning). Localization - forehead, temples, superciliary arches;
nausea, vomiting;
the child hardly lowers his head or raises his eyes;
dizziness;
can see double, and consciousness is disturbed;
sometimes there are convulsions and even coma.

During a painful attack, the child may turn pale, he is lethargic, feels general weakness. He is disturbed by a loud sound, the light seems bright.

Features of diagnostics

Hypertension-hydrocephalic syndrome is very insidious. It is not so easy to diagnose, especially on early stage. Only a pediatric neuropathologist can establish the correct diagnosis. He will determine the degree of pathology, its causes, changes in the tissue structure of the brain. At the same time, it is based on ultrasound data of the head. As they say, by eye, such a diagnosis will not work, although many pediatricians sin with this. At the first signs of nervousness, poor sleep, suspicion of increased intracranial pressure, doctors are in a hurry to voice the diagnosis of hydrocephalic syndrome.

By the way, in 95% of cases such an intuitive diagnosis is not confirmed again. It often turns out that this is not a disease, but the behavior of a particular child. If the diagnosis is confirmed, often the disease has a moderate manifestation.

Even instrumental methods are not always helpful in making a diagnosis. When it comes to babies, it is important to monitor the dynamics of an increase in head circumference, to check reflexes.

The following methods are also used:

the condition of the vessels of the fundus is analyzed;
neurosonography is performed;
sometimes a puncture is made in the lumbar region in order to analyze the pressure of the cerebrospinal fluid (this method is considered the most reliable);
CT scan;
nuclear magnetic resonance.

If the diagnosis is confirmed

If ultrasound and neurosonography confirmed HHS, you will need to:

treat crumbs with medication;
regularly visit a massage therapist;
postpone scheduled vaccinations.

Not to be underestimated healing power massage. A competent massage therapist can work wonders. It is indispensable in the treatment of HGS. Replacement therapy is also important. It compensates for the insufficient output of cerebrospinal fluid. It is important to treat not the symptoms, for example, high intracranial pressure, impaired muscle tone, poor sleep, but the cause. Specific methods of treatment should be selected by a neurologist - a child or an adult.

Treatment

The neurologist selects the correct treatment regimen. In severe cases, the help of a neurosurgeon may be required. Often an ophthalmologist is involved. He analyzes how full the vessels of the fundus are, whether they are spasmodic, etc. Treat such patients in neurological departments or centers.

We treat a newborn

Folk methods will not help here. Unqualified treatment can lead to disastrous consequences. Babies up to 6 months are treated on an outpatient basis. The following activities will be required:

Diacarb treatment. This is a diuretic. It reduces the production of liquor. Enhances fluid excretion.
Use of nootropics. These drugs stimulate the blood supply to the brain (Actovegin, Piracetam, Asparkam).
Treatment sedatives(Tazepam, Diazepam).
A professional massage is a must.

Hypertension syndrome, also known as hydrocephalic syndrome, is a specific pathological condition in which cerebrospinal fluid is produced in an increased amount. This fluid, medically called cerebrospinal fluid, usually accumulates within meninges and in small amounts in the ventricles of the brain.

Western doctors most often attribute this disease to one of the types of pathologies from the development of the brain. Despite this, hydrocephalus is considered in most cases to be a syndrome.

A distinctive feature of the disease is that often hypertension-hydrocephalic syndrome, as one of the diagnoses, is set incorrectly, and this happens in almost 98% of cases. The situation can be explained by the fact that this pathology is very rare in humans.

Varieties of the disease

Hypertension syndrome is classified depending on the age of the patient.

Therefore, this disease exists only in three forms:

in newborns;
in children;
in adults.

In most cases, the syndrome manifests itself in newborns due to congenital causes . As for children or adults, the disease is acquired.

But each of these groups has its own factors that directly affect the appearance of the disease.

Causes of the syndrome in newborns

Hypertensive hydrocephalic syndrome has many possible causes appearance in newborns, and here are the main ones:

The occurrence of complications during pregnancy, often provoked by infectious or viral diseases.
Fetal hypoxia.
Deviations in the work of the cardiovascular system.
Damage to the fetus during childbirth, which is mechanical in nature.
Retardation of intrauterine development.
Traumatic brain injuries that can be inflicted on a child both during pregnancy and directly during childbirth.
Anomalies in the development of the fetus.
Births that occur prematurely or late.
Fetal dehydration that lasts more than 12 hours.
chronic diseases future mother.

Causes of the acquired syndrome

Hypertensive syndrome in children, as in adults, is acquired. Often the result of its appearance or even a concomitant diagnosis is cerebral palsy.

Before establishing this diagnosis, it is necessary to know what hypertension syndrome is and how it manifests itself. Its symptoms include two conditions at once, which occur both with hypertension and with hydrocephalus.

Hypertension is an increased intracranial pressure, and - a deviation in the form of an increase in the amount of fluid (liquor) within the brain.

The main symptoms of hypertension in newborns are:

poor reaction to the breast and refusal to feed;
moaning and crying for no reason;
a noticeable decrease in muscle tone;
lack of a pronounced swallowing reflex;
tremor or leg cramps;
eye changes - swelling of apples, strabismus, the presence of a white stripe between the pupil and the upper eyelid, the iris hidden behind the lower eyelid;
tension in the fontanel;
dynamic increase in head diameter, which reaches 1 cm per month.

The hypertensive-hydrocephalic syndrome in children manifests itself a little differently:

strong morning headache;
nausea and urge to vomit;
complicated lifting of the eyes and pain that occurs when turning the head;
pale skin and constant weakness leading to dizziness;
muscle pain and deviations in the functions of the vestibular apparatus;
fear of bright lights and too loud noises;
reduced memory, concentration and thought process.

Hypertension syndrome manifests itself in adults in almost the same way as in children. In addition to the above symptoms, this group of people is characterized by deterioration visual function and consciousness, sharp headaches and the urge to vomit, which as a result leads to the appearance of convulsions. Very rarely, a coma can occur.

Diagnosis of the disease

Determining the syndrome is very difficult, and making a diagnosis with a full guarantee of its probability is an impossible task. The congenital syndrome is determined by the correct functioning of the reflexes, as well as the size of the head circumference. To confirm or detect its presence in children or adults, an examination is carried out eye vessels, tomography, ultrasound, as well as puncture of the cerebrospinal fluid.

Symptom management in newborns and children

Liquor-hypertension syndrome requires a special treatment regimen, which differs for different groups sick.

Newborns should see and be treated by a neurologist until they are one year old. If there are special indications, this period may be extended. Depending on the severity of the disease, as well as its manifestations, the specialist must draw up the necessary treatment.

It may include those drugs whose action is aimed at removing excess cerebrospinal fluid. They are Triampur, Glycerol, etc. Also in this case, it is necessary to prescribe funds that provide vascular tone - for example, Aescusan.

Often the cause of the syndrome is a violation of the nervous system. Despite the prescribed treatment, in order to prevent and restore young parents, it is necessary to provide the child with correct mode sleep and nutrition, frequent walks on fresh air, lack of irritants and infections. If the treatment and all recommendations are followed, already after 6 months, normalization of intracranial pressure can be observed, which in the future will not deviate from the norm.

Older children should receive a consultation with a pediatric neurologist at least twice a year, during which the fundus is measured and an X-ray of the skull is prescribed. After a traumatic brain injury or in the presence of inflammatory processes in the brain or its membranes, observation and treatment in a dispensary is necessary.

Treatment methods for adults

Treatment of adults is also extremely important, since a neglected disease can become a threat not only to health, but also to life. Action high pressure over a long period does not allow the brain to function properly, which leads to a decrease in intellectual abilities and even dysfunction of the nervous regulation in relation to internal organs. Often the result is a hormonal imbalance.

Treatment of hypertension in adults includes the use of diuretics, which contributes to the activation of CSF secretion, as well as its absorption. This therapy is carried out in several courses, and in complicated forms, drugs should be taken every week. If the disease is mild, then treatment without the use of medicines is possible.

However, for this you need to follow a few recommendations:

normalize the drinking regime;
perform a set of special gymnastic exercises that help lower intracranial pressure;
get rid of excess head venous bed with the help of osteopathy or manual therapy.

Very rarely, hypertension becomes a serious threat to human health.. In such a case, it is necessary to surgical intervention. This operation involves the implantation of shunts, with the help of which the CSF will be removed from the brain. The result of this will be a gradual decrease in the manifestations of the symptoms of the disease and, as a result, getting rid of it completely.

Timely contact with a specialist is always right decision when the first signs of illness appear. If treatment is started on time, the disease will not have the opportunity to acquire a chronic or severe form.

Hydrocephalic syndrome in infants is a disease in which there is an increase in the ventricles of the brain and accumulates a large number of cerebrospinal fluid. Among obvious signs the enlarged head of the child stands out. With hydrocephalic syndrome, the baby may develop brain atrophy. High intracranial pressure leads to swelling of the fontanel and frequent anxiety of the baby. The diagnosis of the disease is based on the results of the examination, ultrasound, CT and MRI. We will tell you more about what it is and how to treat it.

Symptoms of hydrocephalic syndrome

Hydrocephalus can appear in children and adults of any age category. In most cases, hydrocephalic syndrome occurs in children. When the liquor (cerebrospinal fluid) began to collect before the fusion of the bones of the skull, the child's head increases significantly in size, the skull begins to deform, which is visually very noticeable.

Along with this, atrophy or cessation of tissue development is noted. hemisphere. In this regard, the intracranial pressure in the child does not rise very high. With a prolonged course of the disease, normotensive hydrocephalus is formed, in which the ventricles are large and dilated, brain atrophy is more pronounced.

External hydrocephalus with a gradual development in a child is characterized by atrophy that progresses. Due to a conduction disorder, the baby develops movement disorders.

Also typical symptoms are visual impairment, and sometimes endocrine disorders. Increased intracranial pressure leads to cerebral ischemia. The baby has disorders at the level of intelligence and psyche. The skin on the head becomes thinner, the bones of the skull become thinner with an increase in the gaps between them. The fontanelles of such a child are constantly tense and are in an expanded state, the pulsation is completely absent. With gentle tapping of the baby's head, you can hear the sound of an empty vessel.

In this disease, there is a violation motor function eyeball. In such a child, the gaze is directed downward, strabismus develops, which can ultimately lead to total loss vision.
Over time, newborns with hydrocephalic syndrome manifest:

violation of statics and coordination of movements;
inability to sit, stand and hold the head.

Further, the baby experiences a strong decrease in intelligence, behavioral symptoms change, irritability, excitability, and an indifferent attitude towards others appear. From neurological symptoms observed:

headache;
drowsiness;
decreased vision;
piercing cry.

puffiness optic nerve occurs gradually after intracranial pressure begins to rise. It also affects the appearance of the following symptoms:

slow information processing;
premature puberty;
problems with concentration and memory.

The consequences of hypertensive-hydrocephalic syndrome in a child can be expressed as:

weakness in arms and legs;
complete loss of vision and hearing;
disturbed metabolism;
non-standard temperatures.

There is also a risk lethal outcome. But in the case when the operation is performed on time, the patient is on the mend, therefore, there is a chance for recovery. After shunting, the disease ceases to cause concern. If symptoms of hydrocephalic syndrome do not appear within 3 months, the shunt is completely removed.

Diagnostics

If there is a suspicion of hydrocephalic syndrome, first of all, the circumference of the head is measured in the child. Other body parameters are also measured and compared with the indicator healthy child. One study is not considered reliable for establishing a diagnosis, because an increase in head volume may be a consequence of rickets or some individual structure of the baby. Measurements must be taken multiple times. If the volume of the head grows, then there is a possibility of hydrocephalic syndrome.

When examining a sick child, methods such as echoencephalography and neurosonography are used. As an indicator of the norm, a slightly increased or slowed down speed of the cerebrospinal fluid (cerebrospinal fluid) is considered. A slight change in the parameters of the ventricle of the brain. All signs of the disease should be examined several times. Also, when diagnosing, a lumbar puncture is performed to measure fluid pressure in the spinal cord.

Treatment of hydrocephalic syndrome in a child

The method of treatment will completely depend on the causes of the onset of the disease and the intensity of the development of the hydrocephalic syndrome. If necessary, pathogenic or symptomatic therapy is practiced, the main goal of which is the elimination of intracranial pressure. Conservative treatment in this disease is ineffective, but it can be applied to initial stage or as dehydration therapy.

the basis of all effective methods considered a surgical procedure. It is used in the absence of inflammation of the meninges or in the case of progression of the syndrome. The operation consists of forming a path through which CSF is able to be removed to one of the parts of the body, where it can be utilized.

In the case of an open hydrocephalic syndrome, it is necessary to constantly remove excess cerebrospinal fluid from the cranial cavity. Bypass can be applied to connect the lumbar cistern and the abdominal cavity.

To date, the most acceptable is the shunting of the cavity lateral ventricle with utilization of CSF into the cavity of the right atrium. Over a long distance, the shunt is carried out under skin. Shunting is done for children with progressive hydrocephalic syndrome. With any type of shunting, there is a possibility infectious complication Therefore, examinations are periodically carried out using ultrasound and computed tomography.

Complications in the treatment of hydrocephalic syndrome

After shunting, some complications may appear in the form of:

hyperdrainage state;
shunt occlusion at different levels;
seizures of epilepsy;
shunt infection with further development some diseases, etc.

To date, with occlusive hydrocephalus, to restore the patency of the cerebrospinal fluid, endoscopic surgery. Shunt removal is very rare.

Preventive measures for hydrocephalic syndrome
If a child has infections such as syphilis, meningitis, encephalitis, after treatment preventive actions should be directed towards them. It is also desirable to exclude stress and overwork from the child's life. In case of suspicious behavior of a child, seek advice from a pediatrician, neurologist, surgeon, neonatologist.