Sri Lanka PG selection exam paediatrics neurology topics syllabus 2024 2025

https://pgim.cmb.ac.lk/examination-circulars

Nelson textbook pediatrics 22nd edition neurology topics seizure epilepsy classification management

ls -la /home/daytona/workspace/ && ls /home/daytona/skills/docx/

mkdir -p /home/daytona/workspace/neurology-notes && node -e "require('docx'); co…

~/neurology-notes/generate.js

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// ═══════════════════════════════════════════════════════════════════════════
//  CONTENT
// ═══════════════════════════════════════════════════════════════════════════

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// ── COVER / TITLE ──────────────────────────────────────────────────────────
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    children: [new TextRun({ text: "MD Paediatrics PG Selection Examination", size: 26, color: "555555", italics: true })],
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    children: [new TextRun({ text: "PGIM – University of Colombo, Sri Lanka", size: 24, color: "777777", italics: true })],
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    children: [new TextRun({ text: "Based on: Nelson's Textbook of Paediatrics (21st/22nd Ed) • Harriet Lane Handbook (23rd Ed)", size: 22, color: "888888" })],
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// ═══════════════════════════════════════════════════════════════════════════
// 1. NEUROLOGICAL EXAMINATION
// ═══════════════════════════════════════════════════════════════════════════
children.push(h1("1. NEUROLOGICAL EXAMINATION IN CHILDREN"));

children.push(h2("1.1 Neonatal Neurological Examination"));
children.push(p("Gestational age-dependent findings are normal – preterm infants have a physiologically hypotonic state."));
children.push(h3("Primitive Reflexes – Normal Disappearance Ages"));
children.push(makeTable(
  ["Reflex", "Disappears By"],
  [
    ["Moro reflex", "4–6 months"],
    ["Palmar grasp", "3–4 months"],
    ["Plantar grasp", "9–12 months"],
    ["Rooting", "3–4 months"],
    ["ATNR (fencer reflex)", "4–6 months"],
    ["Parachute response", "Appears 8–9 months; persists"],
  ]
));

children.push(h3("Key Developmental Motor Milestones"));
children.push(makeTable(
  ["Age", "Gross Motor", "Fine Motor"],
  [
    ["2 months", "Lifts head 45° prone", "Hands unfisted"],
    ["4 months", "Lifts head 90°, rolls front to back", "Reaches, midline hand play"],
    ["6 months", "Sits with support, rolls both ways", "Transfers hand to hand"],
    ["9 months", "Pulls to stand, cruises", "Inferior pincer grasp"],
    ["12 months", "Walks with support", "Fine pincer grasp"],
    ["18 months", "Walks independently, runs", "Stacks 2–3 cubes"],
    ["2 years", "Runs, up stairs (both feet per step)", "Stacks 6 cubes, circular scribble"],
  ]
));
children.push(h3("Motor Delay Red Flags"));
children.push(bullet("Not sitting by 9 months"));
children.push(bullet("Not walking by 18 months"));
children.push(bullet("Hand dominance before 18 months (suggests contralateral weakness)"));
children.push(bullet("Loss/regression of motor skills at any age (always serious)"));

// ═══════════════════════════════════════════════════════════════════════════
// 2. SEIZURES & EPILEPSY
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("2. SEIZURES AND EPILEPSY"));

children.push(h2("2.1 ILAE 2017 Seizure Classification"));
children.push(makeTable(
  ["Focal Onset", "Generalised Onset", "Unknown Onset"],
  [
    ["Aware (= old 'simple partial')", "Tonic-clonic", "Tonic-clonic"],
    ["Impaired awareness (= old 'complex partial')", "Absence", "Epileptic spasms"],
    ["Focal to bilateral tonic-clonic", "Myoclonic", "Unknown"],
    ["", "Tonic", ""],
    ["", "Atonic ('drop attacks')", ""],
    ["", "Clonic", ""],
  ]
));

children.push(h2("2.2 Causes of Seizures by Age"));
children.push(makeTable(
  ["Age", "Common Causes"],
  [
    ["Neonates (0–28 days)", "HIE, hypoglycaemia, hypocalcaemia, hypomagnesaemia, ICH, CNS infection, IEM, pyridoxine deficiency, brain malformation"],
    ["1 month – 2 years", "Febrile seizures, infantile spasms, meningitis, metabolic, trauma (NAI)"],
    ["2–6 years", "Febrile seizures, idiopathic epilepsy, trauma, CNS infection"],
    ["School age", "Idiopathic epilepsy (CAE, BECTS), trauma, CNS tumour"],
    ["Adolescence", "JME, trauma, drug-related, vasculitis"],
  ]
));

children.push(h2("2.3 Febrile Seizures ★ HIGH YIELD"));
children.push(h3("Simple Febrile Seizure"));
children.push(bullet("Age 6–60 months"));
children.push(bullet("Generalised, tonic-clonic"));
children.push(bullet("Duration < 15 minutes"));
children.push(bullet("Does NOT recur within 24 hours"));
children.push(bullet("No post-ictal focal deficit"));
children.push(p("**Management:** Identify and treat source of fever. No EEG, neuroimaging, or bloodwork required if: well-appearing, fully immunised, normal neuro exam, no meningeal signs."));

children.push(h3("Complex Febrile Seizure – any of:"));
children.push(bullet("Focal onset"));
children.push(bullet("Duration > 15 minutes"));
children.push(bullet("Recurs within 24 hours"));

children.push(h3("LP Indications After Febrile Seizure"));
children.push(makeTable(
  ["Age", "Recommendation"],
  [
    ["< 12 months", "Strongly consider"],
    ["12–18 months", "Consider"],
    ["> 18 months", "Only if meningism/concerning features"],
    ["Any age + prior antibiotics", "Always perform (may mask meningitis)"],
  ]
));

children.push(h3("Recurrence Risk"));
children.push(bullet("30–40% overall recurrence risk"));
children.push(bullet("Risk factors: age < 12 months, FH of FS, low-grade fever, short duration before seizure"));
children.push(bullet("Risk of epilepsy: simple FS ~1–2%; complex FS 4–15%"));

children.push(h2("2.4 Epilepsy Syndromes ★ HIGH YIELD"));

children.push(h3("Neonatal Syndromes"));
children.push(makeTable(
  ["Syndrome", "Onset", "EEG", "Treatment", "Prognosis"],
  [
    ["Benign neonatal seizures\n('fifth day fits')", "Day 4–6", "Theta pointu alternant", "Self-limiting", "Excellent"],
    ["Early myoclonic encephalopathy (EME)", "1st month", "Burst-suppression", "Variable", "Poor"],
    ["Ohtahara syndrome (EIEE)", "First 3 months", "Burst-suppression", "Variable", "Poor, often fatal"],
  ]
));

children.push(h3("Infantile Syndromes"));
children.push(h4("West Syndrome (Infantile Spasms) ★★"));
children.push(bullet("Age: 4–8 months (peak 6 months)"));
children.push(bullet("Triad: epileptic spasms + hypsarrhythmia + developmental regression"));
children.push(bullet("Spasms: sudden bilateral tonic contraction (flexion > extension), in clusters on waking"));
children.push(bullet("Causes: structural (TSC, Down, HIE, lissencephaly), metabolic, unknown"));
children.push(bullet("**Treatment:** ACTH (1st line most centres); Vigabatrin (1st line in tuberous sclerosis)"));
children.push(bullet("Prognosis: ~90% have intellectual disability; may evolve to Lennox-Gastaut"));
children.push(bullet("Investigations: MRI brain, metabolic screen, chromosomes, urine organic acids"));

children.push(h4("Dravet Syndrome ★★"));
children.push(bullet("SCN1A gene mutation (Nav1.1 sodium channel)"));
children.push(bullet("Fever-triggered prolonged hemiclonic seizures in 1st year → polymorphic seizures"));
children.push(bullet("**AVOID sodium channel blockers:** carbamazepine, phenytoin, lamotrigine – WORSEN seizures"));
children.push(bullet("Treatment: valproate + clobazam; add-on: topiramate, stiripentol, cannabidiol (Epidiolex), fenfluramine"));

children.push(h3("Childhood Syndromes"));
children.push(makeTable(
  ["Syndrome", "Age", "Seizure Type", "EEG", "Treatment"],
  [
    ["Childhood Absence Epilepsy (CAE)", "4–10 yrs", "Absence 5–30 sec, abrupt onset/offset", "3 Hz generalised spike-wave", "Ethosuximide (1st line), valproate, lamotrigine"],
    ["BECTS (Rolandic epilepsy)", "3–13 yrs", "Nocturnal facial twitching, drooling, 2° generalisation", "Centrotemporal spikes, sleep-activated", "Often nil; levetiracetam, oxcarbazepine"],
    ["Lennox-Gastaut (LGS)", "1–7 yrs", "Tonic, atonic, atypical absence; status common", "Slow spike-wave < 2.5 Hz", "Valproate + clobazam; add rufinamide, lamotrigine"],
  ]
));

children.push(h4("Childhood Absence Epilepsy – Key Points"));
children.push(bullet("Absence ≠ complex partial: no aura, no post-ictal confusion, abrupt onset/offset"));
children.push(bullet("Hyperventilation for 3 minutes in clinic precipitates typical absence"));
children.push(bullet("Ethosuximide = drug of choice (best evidence, fewest side effects)"));
children.push(bullet("~65–70% achieve remission by adolescence; 10% develop JME"));

children.push(h4("BECTS – Key Points"));
children.push(bullet("Most common childhood epilepsy syndrome"));
children.push(bullet("Nocturnal oro-facial-pharyngeal: drooling, guttural sounds, facial twitching; child remains conscious"));
children.push(bullet("Normal development and intelligence; self-limiting – remission in >95% by age 15–16"));

children.push(h3("Adolescent Syndromes"));
children.push(h4("Juvenile Myoclonic Epilepsy (JME) ★★"));
children.push(bullet("Age 12–18 years; seizure types: myoclonic jerks (morning) + GTCS + absence"));
children.push(bullet("EEG: 4–6 Hz generalised polyspike-wave"));
children.push(bullet("Triggers: sleep deprivation, alcohol, photic stimulation"));
children.push(bullet("Often misdiagnosed – patient 'drops things in the morning'"));
children.push(bullet("**Lifelong treatment usually required** (high relapse rate if stopped)"));
children.push(bullet("1st line: valproate; avoid in girls (teratogenic) → use levetiracetam or lamotrigine"));

children.push(h2("2.5 Status Epilepticus ★ EXAM ESSENTIAL"));
children.push(p("**Definition:** Seizure lasting > 5 minutes OR 2 seizures without return to baseline consciousness."));
children.push(h3("Management Protocol"));
children.push(makeTable(
  ["Phase", "Time", "Actions"],
  [
    ["Phase 0", "0–5 min", "ABCs, O2, IV/IO access, BGL check, place in recovery position"],
    [{text:"Phase 1 – Benzodiazepines", bold:true}, "5–20 min", "Lorazepam IV 0.05–0.1 mg/kg (preferred) OR Diazepam IV 0.2–0.3 mg/kg OR rectal 0.5 mg/kg OR Midazolam IM 0.1–0.2 mg/kg (no IV). Repeat once after 5 min if no response."],
    [{text:"Phase 2 – 2nd-line agents", bold:true}, "20–40 min", "Levetiracetam IV 20–60 mg/kg (preferred) OR Valproate IV 20–40 mg/kg OR Fosphenytoin IV 20 mg/kg PE OR Phenobarbital IV 20 mg/kg"],
    [{text:"Phase 3 – Refractory SE", bold:true}, "> 40 min", "RSI + ICU. Midazolam infusion 0.1–2 mg/kg/hr. Pentobarbital infusion. Consider: pyridoxine 100 mg IV if < 2 years (rule out pyridoxine-dependent epilepsy)"],
  ]
));

children.push(h2("2.6 Anti-Seizure Medications (ASMs) Summary"));
children.push(makeTable(
  ["Drug", "Seizure Type", "Key Side Effects", "Notes"],
  [
    ["Phenobarbital", "Focal, generalised", "Sedation, cognitive impairment, hyperactivity", "1st line neonate; hepatic enzyme inducer"],
    ["Carbamazepine", "Focal, GTCS", "Hyponatraemia, diplopia, rash (SJS – HLA-B*1502)", "Worsens absence, myoclonic, Dravet"],
    ["Valproate", "All types", "Weight gain, hair loss, hepatotoxicity, teratogenicity (NTD)", "Drug of choice many generalised syndromes; avoid in women of childbearing age"],
    ["Ethosuximide", "Absence ONLY", "GI upset, headache, hiccups", "1st line childhood absence"],
    ["Levetiracetam", "Focal, generalised", "Behavioural: irritability, aggression", "Wide safety profile; IV formulation available"],
    ["Lamotrigine", "Focal, generalised, absence", "Rash (SJS risk – titrate SLOWLY)", "Avoid rapid titration; interaction with valproate"],
    ["Topiramate", "Focal, generalised", "Cognitive slowing, kidney stones, weight loss, glaucoma", "'Dope-a-max'; metabolic acidosis; migraine prophylaxis"],
    ["Vigabatrin", "Infantile spasms, focal", "Visual field defects (irreversible), sedation", "1st line TSC + West syndrome"],
    ["ACTH", "West syndrome", "Hypertension, infection, adrenal suppression", "40–60 IU/day; monitor BP"],
    ["Clobazam", "Adjunctive (Dravet, LGS)", "Sedation, tolerance", "1,5-benzodiazepine; less sedating"],
    ["Fenfluramine", "Dravet syndrome", "Cardiac valvulopathy (monitor with echo)", "Newer agent; significant efficacy in Dravet"],
  ]
));
children.push(p("⚠️ **HLA-B*1502 (Asian populations – including Sri Lanka):** Screen BEFORE starting carbamazepine, oxcarbazepine, phenytoin, or lamotrigine. Positive = high risk of Stevens-Johnson Syndrome / toxic epidermal necrolysis.", {color:"C00000"}));

// ═══════════════════════════════════════════════════════════════════════════
// 3. HEADACHE
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("3. HEADACHE"));

children.push(h2("3.1 Red Flags ("SNOOP" Mnemonic)"));
children.push(makeTable(
  ["Letter", "Red Flag"],
  [
    ["S", "Systemic symptoms (fever, weight loss) / Secondary risk factors (immunosuppression, malignancy)"],
    ["N", "Neurological signs or symptoms (focal deficit, papilloedema, meningism)"],
    ["O", "Onset: thunderclap (worst-ever, sudden-onset headache)"],
    ["O", "Older age of onset / Wakes from sleep / Progressive pattern"],
    ["P", "Prior headache history change / Postural component"],
  ]
));

children.push(h2("3.2 Migraine in Children"));
children.push(h3("ICHD-3 Diagnostic Criteria (modified for children)"));
children.push(bullet("≥5 attacks lasting 2–72 hours (may be shorter in children)"));
children.push(bullet("≥2 of: unilateral (may be bilateral in children), pulsating quality, moderate-severe, aggravated by physical activity"));
children.push(bullet("≥1 of: nausea/vomiting OR photophobia AND phonophobia"));
children.push(bullet("Migraine with aura: reversible visual/sensory/motor/speech symptoms, 5–60 minutes before headache"));

children.push(h3("Abortive Treatment"));
children.push(bullet("**1st line:** NSAIDs – ibuprofen 10 mg/kg"));
children.push(bullet("**2nd line:** Triptans – sumatriptan nasal spray (≥12 yrs), rizatriptan (≥6 yrs), almotriptan (≥12 yrs)"));
children.push(bullet("Antiemetics: ondansetron, metoclopramide"));
children.push(bullet("Avoid opioids"));

children.push(h3("Migraine Prophylaxis (Harriet Lane Table)"));
children.push(makeTable(
  ["Drug", "Adverse Effects", "Comorbidities to Consider"],
  [
    ["Topiramate", "Cognitive slowing, weight loss, kidney stones, paresthesia", "Obesity, epilepsy"],
    ["Valproate", "Hepatotoxicity, weight gain, teratogenicity", "Bipolar disorder, epilepsy"],
    ["Amitriptyline", "Sedation, constipation, weight gain (Black box: suicidal thoughts)", "Depression, insomnia"],
    ["Propranolol", "Hypotension, bronchospasm, masks hypoglycaemia", "Hypertension"],
    ["Cyproheptadine", "Sedation, increased appetite, hepatitis", "Seasonal allergies, poor appetite (young children)"],
    ["Riboflavin / Magnesium / CoQ10", "Low side-effect profile; limited paediatric data", "Poor nutritional intake"],
  ]
));
children.push(p("Anti-CGRP agents: approved in adults (2018); no paediatric studies yet."));

children.push(h2("3.3 Paediatric Migraine Variants"));
children.push(bullet("**Abdominal migraine:** Recurrent periumbilical pain 1–72 hours + nausea; no headache; treat as migraine"));
children.push(bullet("**Cyclic vomiting syndrome:** Stereotyped vomiting episodes; treat with ondansetron, amitriptyline"));

// ═══════════════════════════════════════════════════════════════════════════
// 4. CNS INFECTIONS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("4. CENTRAL NERVOUS SYSTEM INFECTIONS"));

children.push(h2("4.1 Bacterial Meningitis"));
children.push(h3("Organisms by Age"));
children.push(makeTable(
  ["Age", "Common Organisms"],
  [
    ["Neonates", "Group B Streptococcus, E. coli, Listeria monocytogenes, Klebsiella"],
    ["1–3 months", "GBS, E. coli, Listeria + Strep. pneumoniae, N. meningitidis"],
    ["3 months – 5 years", "Strep. pneumoniae (most common), N. meningitidis, Hib (unvaccinated)"],
    ["> 5 years", "Strep. pneumoniae, N. meningitidis"],
  ]
));

children.push(h3("CSF Analysis in Meningitis"));
children.push(makeTable(
  ["Parameter", "Bacterial", "Viral", "TB", "Fungal"],
  [
    ["Appearance", "Turbid/purulent", "Clear", "Clear/xanthochromic", "Clear"],
    ["WBC", "> 1000 (PMN)", "10–500 (lymph)", "10–500 (lymph)", "10–500 (lymph)"],
    ["Protein", "High (> 1 g/L)", "Normal/mild", "Very high", "Elevated"],
    ["Glucose (CSF:serum)", "< 0.4 (low)", "Normal (> 0.6)", "Very low (< 0.3)", "Low"],
    ["Gram stain/Special", "Positive ~80%", "Negative", "ZN stain", "India ink (Cryptococcus)"],
  ]
));

children.push(h3("Management"));
children.push(bullet("**Empirical antibiotics IMMEDIATELY** – do NOT delay for LP if: shocked, papilloedema, or focal signs"));
children.push(bullet("Ceftriaxone 100 mg/kg/day IV (max 4 g/day) + ampicillin if < 3 months (Listeria coverage)"));
children.push(bullet("**Dexamethasone** 0.15 mg/kg IV 6-hourly × 4 days – give BEFORE or WITH 1st antibiotic dose (reduces hearing loss, neurological sequelae in pneumococcal meningitis)"));
children.push(bullet("Fluid management: isotonic fluids; maintain euvolaemia (fluid restriction is OLD teaching)"));
children.push(bullet("All patients need formal audiology (hearing loss = most common long-term complication)"));

children.push(h3("Meningococcal Disease – Key Points"));
children.push(bullet("Non-blanching petechial/purpuric rash = emergency (meningococcaemia)"));
children.push(bullet("Waterhouse-Friderichsen syndrome: bilateral adrenal haemorrhage + DIC + shock"));
children.push(bullet("Treatment: benzylpenicillin IV; ceftriaxone if penicillin allergy"));
children.push(bullet("Prophylaxis for close contacts: rifampicin 2 days, OR ciprofloxacin single dose, OR ceftriaxone IM"));

children.push(h2("4.2 HSV Encephalitis ★★"));
children.push(bullet("Temporal lobe involvement: personality change, memory disturbance, temporal lobe seizures"));
children.push(bullet("EEG: PLEDs (periodic lateralising epileptiform discharges) in temporal region"));
children.push(bullet("MRI: temporal lobe signal change on FLAIR/DWI"));
children.push(bullet("CSF: HSV PCR (gold standard)"));
children.push(bullet("**Treatment: Acyclovir IV 10–15 mg/kg/dose 8-hourly × 14–21 days – START EMPIRICALLY**"));

children.push(h2("4.3 Tuberculous Meningitis (TBM)"));
children.push(h3("Clinical Stages"));
children.push(makeTable(
  ["Stage", "Features"],
  [
    ["Stage 1 (Alert)", "Non-specific: fever, malaise, headache, irritability"],
    ["Stage 2 (Lethargic)", "Meningism + CN palsies (VI and III most common) + mild confusion"],
    ["Stage 3 (Coma)", "Obtundation, seizures, coma, hemiplegia"],
  ]
));
children.push(bullet("MRI: basal exudate + hydrocephalus + basal ganglia infarcts (characteristic triad)"));
children.push(bullet("Treatment: RHEZ × 2 months + RH × 7–10 months (total 9–12 months)"));
children.push(bullet("Add steroids (prednisolone/dexamethasone) – reduce mortality and neurological disability"));

children.push(h2("4.4 Autoimmune Encephalitis (NMDAR) ★★"));
children.push(bullet("Anti-NMDA receptor encephalitis (anti-NR1 antibody)"));
children.push(bullet("Young women/girls; may be associated with ovarian teratoma"));
children.push(bullet("Stages: prodrome → psychiatric symptoms → seizures → orofacial dyskinesias → decreased consciousness → autonomic instability"));
children.push(bullet("MRI often normal; antibodies in serum AND CSF"));
children.push(bullet("Treatment: tumour removal (if present) + IV methylprednisolone → IVIG → rituximab/cyclophosphamide"));

// ═══════════════════════════════════════════════════════════════════════════
// 5. CEREBRAL PALSY
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("5. CEREBRAL PALSY"));

children.push(p("**Definition:** Permanent, non-progressive disorders of movement and posture attributed to disturbances in fetal/infant brain development."));
children.push(p("**Epidemiology:** 2–3 per 1,000 live births"));

children.push(h2("5.1 Classification"));
children.push(makeTable(
  ["Type", "Tone", "Distribution", "Pathology"],
  [
    ["Spastic (~80%)", "Increased (clasp-knife, clonus)", "Diplegia / Quadriplegia / Hemiplegia", "PVL (preterm), cortical/subcortical injury (term)"],
    ["Dyskinetic (~10%)", "Variable (lead-pipe or candle-wax)", "Generalised", "Basal ganglia injury (hyperbilirubinaemia, perinatal asphyxia)"],
    ["Ataxic (~5–10%)", "Decreased", "Generalised", "Cerebellar pathology"],
    ["Hypotonic", "Decreased", "Generalised/axial", "Diffuse cortical/cerebellar dysfunction"],
  ]
));
children.push(p("**PVL (Periventricular Leukomalacia):** Premature infants < 32 weeks. White matter injury in watershed zones → spastic diplegia (legs > arms, as leg fibres are closest to ventricles)."));

children.push(h2("5.2 Clinical Features"));
children.push(bullet("Delayed motor milestones + abnormal tone + persistent primitive reflexes > 6 months"));
children.push(bullet("Hand dominance before 18 months → investigate for contralateral hemiplegia"));
children.push(p("**Comorbidities:** Epilepsy (30–50%), intellectual disability, vision and hearing problems, speech/language delay, feeding difficulties, orthopaedic problems"));

children.push(h2("5.3 GMFCS (Gross Motor Function Classification System)"));
children.push(makeTable(
  ["Level", "Functional Ability"],
  [
    ["I", "Walks without limitations"],
    ["II", "Walks with limitations"],
    ["III", "Walks using handheld mobility device"],
    ["IV", "Self-mobility limited; uses power wheelchair"],
    ["V", "Self-mobility severely limited even with assistive technology"],
  ]
));

children.push(h2("5.4 Management"));
children.push(bullet("**Multidisciplinary:** physiotherapy, occupational therapy, speech therapy, orthotics"));
children.push(bullet("**Spasticity:** Botulinum toxin A (focal), oral baclofen, intrathecal baclofen pump, selective dorsal rhizotomy"));
children.push(bullet("**Orthopaedic:** hip surveillance, scoliosis management"));
children.push(bullet("Treat associated epilepsy, vision/hearing problems, nutrition"));

// ═══════════════════════════════════════════════════════════════════════════
// 6. NEURODEVELOPMENTAL DISORDERS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("6. NEURODEVELOPMENTAL DISORDERS"));

children.push(h2("6.1 Intellectual Disability (ID)"));
children.push(p("**Definition:** IQ < 70 + impairment in adaptive functioning + onset < 18 years"));
children.push(makeTable(
  ["Severity", "IQ Range", "Functional Ability"],
  [
    ["Mild", "50–70", "Can usually read; live semi-independently"],
    ["Moderate", "35–50", "Functional literacy with support"],
    ["Severe", "20–35", "Limited self-care"],
    ["Profound", "< 20", "Requires full care"],
  ]
));
children.push(p("**Investigations:** Chromosomal microarray (preferred over karyotype), fragile X (boys), metabolic screen, TFTs, TORCH serology, MRI brain."));
children.push(p("**Key causes:** Down syndrome (most common chromosomal), Fragile X (most common INHERITED – CGG repeat in FMR1 gene), PKU (treatable), hypothyroidism (treatable)"));

children.push(h2("6.2 Autism Spectrum Disorder (ASD)"));
children.push(h3("DSM-5 Criteria"));
children.push(bullet("Persistent deficits in social communication and interaction across contexts"));
children.push(bullet("Restricted, repetitive patterns of behaviour, interests, or activities"));
children.push(bullet("Symptoms present in early developmental period"));
children.push(bullet("Causes significant functional impairment"));

children.push(h3("Red Flags ★★"));
children.push(makeTable(
  ["Age", "Red Flag"],
  [
    ["2 months", "No social smile"],
    ["12 months", "No babbling, no pointing, no social gestures"],
    ["16 months", "No single words"],
    ["24 months", "No two-word phrases"],
    ["Any age", "ANY regression of language or social skills"],
  ]
));
children.push(p("**Screening:** M-CHAT (Modified Checklist for Autism in Toddlers) – used at 16–30 months."));
children.push(p("**Comorbidities:** Epilepsy (25–30%), ADHD, anxiety, intellectual disability."));
children.push(p("**Management:** Early intensive behavioural therapy (ABA), speech therapy, OT, special education. Risperidone/aripiprazole for irritability/aggression."));

children.push(h2("6.3 ADHD"));
children.push(p("**DSM-5:** ≥6 symptoms of inattention AND/OR hyperactivity-impulsivity; onset < 12 years; present in ≥2 settings; impairs functioning."));
children.push(h3("Management"));
children.push(makeTable(
  ["Age", "1st Line", "2nd Line"],
  [
    ["< 6 years", "Parent training / behavioural therapy", "Medication only if severe"],
    ["≥ 6 years", "Stimulants (methylphenidate, amphetamines)", "Atomoxetine (SNRI), guanfacine, clonidine"],
  ]
));
children.push(p("**Methylphenidate:** 0.3–1 mg/kg/day; side effects: appetite suppression, insomnia, growth concerns (monitor height/weight)."));
children.push(p("**Atomoxetine:** Useful if substance abuse risk, tics, or anxiety; takes 4–6 weeks for full effect."));

// ═══════════════════════════════════════════════════════════════════════════
// 7. RAISED ICP & HYDROCEPHALUS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("7. INCREASED INTRACRANIAL PRESSURE (ICP)"));

children.push(h2("7.1 Clinical Features"));
children.push(h3("Infants (open fontanelle)"));
children.push(bullet("Bulging fontanelle, rapid head circumference increase (> 2 cm/week)"));
children.push(bullet("Engorged scalp veins, setting-sun sign (Parinaud sign = dorsal midbrain compression by hydrocephalus)"));

children.push(h3("Older Children"));
children.push(bullet("Headache: morning, wakes from sleep, worse with Valsalva"));
children.push(bullet("Vomiting: projectile, without nausea"));
children.push(bullet("Diplopia: CN VI palsy – false localising sign"));
children.push(bullet("Papilloedema"));
children.push(bullet("**Cushing's triad (LATE, OMINOUS):** bradycardia + hypertension + irregular breathing"));

children.push(h2("7.2 Hydrocephalus"));
children.push(makeTable(
  ["Type", "Mechanism", "Examples"],
  [
    ["Obstructive (non-communicating)", "Block in CSF flow pathway", "Aqueduct stenosis, posterior fossa tumour, vein of Galen malformation"],
    ["Communicating", "Impaired CSF reabsorption", "Post-meningitis, subarachnoid haemorrhage, choroid plexus tumour"],
  ]
));
children.push(bullet("**Investigations:** Head USS (infants); CT (emergency); MRI (gold standard)"));
children.push(bullet("**VP shunt:** Most common treatment"));
children.push(bullet("**ETV (Endoscopic Third Ventriculostomy):** Suitable for aqueduct stenosis in older children; avoids shunt"));

children.push(h2("7.3 Pseudotumour Cerebri (IIH)"));
children.push(bullet("Raised ICP, no structural cause, normal CSF composition"));
children.push(bullet("Associations: obesity, vitamin A toxicity, tetracycline, OCP, steroid withdrawal"));
children.push(bullet("Symptoms: headache, pulsatile tinnitus, visual obscurations, diplopia"));
children.push(bullet("Treatment: acetazolamide, weight loss; serial LP; optic nerve sheath fenestration (if vision threatened)"));

// ═══════════════════════════════════════════════════════════════════════════
// 8. BRAIN TUMOURS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("8. BRAIN TUMOURS IN CHILDREN"));

children.push(p("**70% of childhood brain tumours are infratentorial** (posterior fossa)."));
children.push(p("**Clinical triad of posterior fossa tumour:** (1) Raised ICP, (2) Cerebellar signs (ataxia, nystagmus, dysmetria), (3) CN palsies"));

children.push(h2("8.1 Infratentorial Tumours ★★"));
children.push(makeTable(
  ["Tumour", "Age", "Key Features", "Treatment"],
  [
    ["Medulloblastoma", "5–14 years", "4th ventricle → obstructive hydrocephalus; 'drop metastases' down spinal cord; desmoplastic variant has better prognosis", "Surgery + craniospinal RT + chemotherapy"],
    ["Cerebellar astrocytoma (pilocytic)", "5–15 years", "Cystic + mural nodule; benign; excellent prognosis", "Surgery alone often curative"],
    ["Ependymoma", "< 5 years", "4th ventricle floor; high recurrence", "Surgery + local RT"],
    ["DIPG (brainstem glioma)", "5–9 years", "Diffuse intrinsic pontine glioma; CN palsies + long tract signs + ataxia; H3K27M mutation; VERY POOR prognosis", "Radiation (palliative only); no effective chemotherapy"],
  ]
));

children.push(h2("8.2 Supratentorial Tumours"));
children.push(makeTable(
  ["Tumour", "Key Features"],
  [
    ["Optic pathway glioma", "Associated with NF-1 (50%); visual loss, proptosis"],
    ["Craniopharyngioma", "Suprasellar; bitemporal hemianopia, hypothalamic dysfunction, DI; calcification on CT; Rathke pouch origin"],
    ["Glioblastoma (GBM)", "High grade; very poor prognosis"],
  ]
));

// ═══════════════════════════════════════════════════════════════════════════
// 9. NEUROMUSCULAR DISORDERS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("9. NEUROMUSCULAR DISORDERS"));

children.push(h2("9.1 Approach to the Floppy Infant"));
children.push(makeTable(
  ["Feature", "Central (UMN)", "Peripheral (LMN/Muscle)"],
  [
    ["Tone", "Decreased", "Decreased"],
    ["Power", "Relatively preserved", "Markedly decreased"],
    ["Reflexes", "Normal or increased", "Decreased or absent"],
    ["Alertness", "Decreased (encephalopathic)", "Alert – 'bright eyes'"],
    ["Facial weakness", "Usually absent", "Present (NMJ, myopathy)"],
  ]
));

children.push(h2("9.2 Spinal Muscular Atrophy (SMA) ★★"));
children.push(p("**Genetics:** SMN1 gene deletion (chromosome 5q); most common genetic cause of infant mortality."));
children.push(makeTable(
  ["Type", "Onset", "Maximum Function", "Survival"],
  [
    ["Type 1 (Werdnig-Hoffmann)", "< 6 months", "Never sits", "< 2 years (without treatment)"],
    ["Type 2", "7–18 months", "Sits but never walks", "Reduced (respiratory complications)"],
    ["Type 3 (Kugelberg-Welander)", "> 18 months", "Walks", "Near normal"],
    ["Type 4", "Adult onset", "Walks", "Normal"],
  ]
));
children.push(p("**SMA Type 1 features:** Profound hypotonia, areflexia, paradoxical breathing (intercostal weak, diaphragm spared), **ALERT and bright eyes**, tongue fasciculations, NO sensory loss."));
children.push(h3("Disease-Modifying Treatments ★★"));
children.push(makeTable(
  ["Drug", "Route", "Indication", "Notes"],
  [
    ["Nusinersen (Spinraza)", "Intrathecal injection", "All types; approved", "Antisense oligonucleotide; disease-modifying"],
    ["Onasemnogene abeparvovec (Zolgensma)", "IV, single dose", "< 2 years, < 21 kg", "Gene therapy; potentially curative"],
    ["Risdiplam (Evrysdi)", "Oral", "All ages", "SMN2 splicing modifier"],
  ]
));

children.push(h2("9.3 Duchenne Muscular Dystrophy (DMD) ★★"));
children.push(bullet("**Genetics:** X-linked recessive; dystrophin gene (Xp21); most common frame-shift deletion"));
children.push(bullet("**Incidence:** 1/3,500 male births"));
children.push(bullet("**Clinical:** Proximal muscle weakness age 3–5 years; **Gowers sign**; **calf pseudohypertrophy**"));
children.push(bullet("**CK:** Markedly elevated (50–100× normal)"));
children.push(bullet("**Cardiac:** Dilated cardiomyopathy by adolescence (monitor with echo + ECG)"));
children.push(bullet("**Cognitive:** 1/3 have some intellectual impairment (non-progressive)"));
children.push(bullet("**Diagnosis:** EMG (myopathic), muscle biopsy (absent dystrophin), genetic testing"));
children.push(h3("Treatment"));
children.push(makeTable(
  ["Treatment", "Purpose"],
  [
    ["Deflazacort / prednisolone", "Slow progression, extend ambulation (started once plateau reached ~5–6 yrs)"],
    ["ACE inhibitor + beta-blocker", "Cardiomyopathy management"],
    ["Eteplirsen (exon 51 skip)", "Exon-skipping therapy (~13% patients with specific deletion)"],
    ["Ataluren", "Stop codon readthrough mutations (~10–15%)"],
    ["Physiotherapy + orthotics", "Prevent contractures, maintain function"],
  ]
));

children.push(h2("9.4 Myasthenia Gravis (MG)"));
children.push(bullet("Autoimmune NMJ disorder; anti-AChR antibodies (~85% generalised MG)"));
children.push(bullet("Features: fatigable ptosis + ophthalmoplegia + bulbar weakness; worsens with activity, improves with rest"));
children.push(bullet("**Ice pack test:** Ice on closed ptotic eye × 2 min → improves ptosis"));
children.push(bullet("**Repetitive nerve stimulation:** ≥10% decremental response at 3 Hz"));
children.push(bullet("CT chest: thymic hyperplasia or thymoma"));
children.push(makeTable(
  ["Treatment", "Notes"],
  [
    ["Pyridostigmine", "Symptomatic (anticholinesterase)"],
    ["Prednisolone", "Immunosuppression"],
    ["Azathioprine / mycophenolate", "Steroid-sparing"],
    ["Thymectomy", "AChR+ patients; evidence from MGTX trial"],
    ["Plasma exchange / IVIG", "Myasthenic crisis"],
  ]
));
children.push(p("**Neonatal transient MG:** Passive transfer of maternal anti-AChR antibodies; resolves in 2–8 weeks."));

children.push(h2("9.5 Guillain-Barré Syndrome (GBS)"));
children.push(bullet("Acute inflammatory demyelinating polyradiculoneuropathy"));
children.push(bullet("Post-infectious: Campylobacter jejuni, CMV, EBV, Mycoplasma, COVID-19"));
children.push(bullet("**Ascending flaccid paralysis + areflexia** + mild sensory symptoms; autonomic instability (main cause of death)"));
children.push(bullet("**CSF:** Elevated protein + normal WBC = albuminocytological dissociation (after 1 week)"));
children.push(bullet("**NCS/EMG:** Reduced conduction velocity, prolonged latencies (demyelinating pattern)"));
children.push(bullet("**Treatment:** IVIG 2 g/kg over 2–5 days OR plasma exchange; **steroids NOT effective**"));
children.push(p("**Miller Fisher Syndrome (MFS):** Ataxia + ophthalmoplegia + areflexia; anti-GQ1b antibody; benign prognosis."));

// ═══════════════════════════════════════════════════════════════════════════
// 10. MOVEMENT DISORDERS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("10. MOVEMENT DISORDERS"));

children.push(h2("10.1 Tics and Tourette Syndrome"));
children.push(bullet("**Tourette syndrome:** ≥2 motor tics + ≥1 vocal tic; present > 1 year; onset < 18 years"));
children.push(bullet("**Comorbidities:** ADHD (60%), OCD (40%), anxiety"));
children.push(bullet("Treatment: psychoeducation first; CBIT (comprehensive behavioural intervention); clonidine, guanfacine; haloperidol, aripiprazole, fluphenazine for severe tics"));

children.push(h2("10.2 Sydenham's Chorea (Rheumatic Chorea)"));
children.push(bullet("Post-streptococcal (Group A beta-haemolytic Streptococcus) – part of rheumatic fever"));
children.push(bullet("**Involuntary, purposeless, non-rhythmic movements; 'milkmaid's grip'**; emotional lability, hypotonia, dysarthria"));
children.push(bullet("May occur weeks to months after streptococcal infection (ASOT may be normal by then)"));
children.push(bullet("Always check: echocardiogram for associated carditis"));
children.push(bullet("Treatment: **Penicillin prophylaxis** (secondary prevention); haloperidol or valproate for chorea"));

children.push(h2("10.3 Acute Cerebellar Ataxia"));
children.push(bullet("Most common cause in children: **post-infectious (varicella most common)**"));
children.push(bullet("Other causes: drug toxicity (phenytoin, CBZ), posterior fossa tumour, stroke, MS"));
children.push(bullet("Investigation: MRI brain; metabolic screen if recurrent"));
children.push(p("**Friedreich's Ataxia:** Progressive; GAA repeat in frataxin gene; spinocerebellar degeneration + peripheral neuropathy + hypertrophic cardiomyopathy; pes cavus; onset < 25 years."));

// ═══════════════════════════════════════════════════════════════════════════
// 11. NEUROCUTANEOUS SYNDROMES
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("11. NEUROCUTANEOUS SYNDROMES (PHAKOMATOSES)"));

children.push(h2("11.1 Neurofibromatosis Type 1 (NF1)"));
children.push(p("**Genetics:** Autosomal dominant; NF1 gene (chromosome 17q) – encodes neurofibromin (tumour suppressor). Diagnosis: ≥2 of 7 criteria:"));
children.push(makeTable(
  ["#", "Criterion"],
  [
    ["1", "≥6 café-au-lait spots (> 5 mm prepubertal, > 15 mm postpubertal)"],
    ["2", "≥2 neurofibromas OR 1 plexiform neurofibroma"],
    ["3", "Axillary or inguinal freckling (Crowe's sign)"],
    ["4", "Optic glioma"],
    ["5", "≥2 Lisch nodules (iris hamartomas)"],
    ["6", "Sphenoid wing dysplasia or cortical thinning of long bone"],
    ["7", "First-degree relative with NF1"],
  ]
));

children.push(h2("11.2 Neurofibromatosis Type 2 (NF2)"));
children.push(bullet("**Bilateral acoustic neuromas (vestibular schwannomas)** – pathognomonic"));
children.push(bullet("Also: meningiomas, ependymomas, cortical lens opacities"));
children.push(bullet("NF2 gene (chromosome 22) – encodes merlin"));

children.push(h2("11.3 Tuberous Sclerosis Complex (TSC) ★★"));
children.push(p("**Genetics:** TSC1 (hamartin, chr 9) or TSC2 (tuberin, chr 16); autosomal dominant; de novo mutations common."));
children.push(h3("Key Skin Features (Exam Favourite)"));
children.push(makeTable(
  ["Lesion", "Notes"],
  [
    ["Hypomelanotic macules (ash-leaf spots)", "Earliest finding; best seen with Wood's lamp"],
    ["Facial angiofibromas ('adenoma sebaceum')", "Appear after age 2–5"],
    ["Shagreen patches", "Lumbar/gluteal region; cobblestone texture"],
    ["Ungual/periungual fibromas", "Appear in adolescence"],
    ["Confetti lesions", "Multiple tiny hypopigmented macules"],
  ]
));
children.push(p("**Neurological:** Epilepsy (80–90%); often begins as infantile spasms – treat with **vigabatrin** (1st line). Intellectual disability, ASD."));
children.push(p("**Other organs:** Cardiac rhabdomyomas (fetal/neonatal), renal angiomyolipomas, pulmonary LAM, SEGA (subependymal giant cell astrocytoma – monitor with MRI)."));

children.push(h2("11.4 Sturge-Weber Syndrome"));
children.push(bullet("Port-wine stain (V1 trigeminal distribution) + ipsilateral leptomeningeal angioma"));
children.push(bullet("CT: 'tram-track' (tramline) calcification (gyral)"));
children.push(bullet("Complications: refractory epilepsy, hemiparesis, glaucoma"));
children.push(bullet("Non-hereditary (somatic GNAQ mutation)"));

// ═══════════════════════════════════════════════════════════════════════════
// 12. STROKE
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("12. STROKE IN CHILDREN"));

children.push(h2("12.1 Ischaemic Stroke – Risk Factors"));
children.push(makeTable(
  ["Category", "Examples"],
  [
    ["Cardiac", "Congenital heart disease (most common in neonates/infants)"],
    ["Haematological", "Sickle cell disease (risk 300× normal; most common in older children), coagulopathies (Factor V Leiden, protein C/S deficiency, APLA)"],
    ["Arteriopathy", "Moyamoya, arterial dissection, vasculitis"],
    ["Metabolic", "MELAS, homocystinuria"],
  ]
));
children.push(bullet("**Presentation:** Acute hemiplegia (most common), focal seizures, speech disturbance"));
children.push(bullet("**Investigations:** MRI DWI (gold standard acutely), MRA, echo, thrombophilia screen, sickle cell screen"));
children.push(bullet("**Sickle cell:** Exchange transfusion (acute); chronic transfusion programme (secondary prevention)"));

children.push(h2("12.2 Haemorrhagic Stroke"));
children.push(bullet("AVMs (arteriovenous malformations) = most common cause of intracranial haemorrhage in children"));
children.push(bullet("Presentation: sudden severe headache, seizures, focal deficit"));

// ═══════════════════════════════════════════════════════════════════════════
// 13. NEUROLOGY OF THE NEWBORN
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("13. NEUROLOGY OF THE NEWBORN"));

children.push(h2("13.1 Hypoxic-Ischaemic Encephalopathy (HIE)"));
children.push(h3("Sarnat Classification"));
children.push(makeTable(
  ["Grade", "Consciousness", "Tone", "Seizures", "EEG", "Prognosis"],
  [
    ["Mild (I)", "Hyperalert, irritable", "Normal/hypertonicity", "None", "Normal", "Excellent"],
    ["Moderate (II)", "Lethargic, obtunded", "Hypotonia", "Common", "Low voltage delta/theta", "Variable"],
    ["Severe (III)", "Stupor/coma", "Flaccid", "Frequent/status", "Burst suppression or flat", "Poor"],
  ]
));

children.push(h3("Therapeutic Hypothermia ★★ EXAM ESSENTIAL"));
children.push(p("**Eligibility criteria (ALL of the following):**"));
children.push(bullet("GA ≥ 36 weeks"));
children.push(bullet("At least ONE of: Apgar ≤ 5 at 10 min; resuscitation > 10 min; pH < 7.0; base deficit ≥ 16; or clinical encephalopathy (Sarnat ≥ 2)"));
children.push(p("**Protocol:**"));
children.push(bullet("Target: 33–34°C core temperature for **72 hours**, then slow rewarming over 6 hours"));
children.push(bullet("Must start **within 6 hours** of birth"));
children.push(bullet("Reduces death or disability by ~25–30%"));

children.push(h2("13.2 Neonatal Seizures"));
children.push(makeTable(
  ["Type", "Features"],
  [
    ["Subtle (most common in preterm)", "Ocular deviation, bicycling, apnoea, blinking"],
    ["Clonic (most common in term)", "Rhythmic jerking; often focal"],
    ["Tonic", "Sustained posturing; brainstem release in severe HIE"],
    ["Myoclonic", "Rapid brief jerks; ominous if generalised"],
  ]
));
children.push(bullet("**Investigations:** BGL, electrolytes (Ca, Mg, Na), blood culture/LP, metabolic screen, EEG (most sensitive), cranial USS/MRI"));
children.push(bullet("**Treatment:** Phenobarbital 20 mg/kg load (1st line); levetiracetam increasingly used; pyridoxine 100 mg IV if refractory (< 2 years)"));

// ═══════════════════════════════════════════════════════════════════════════
// 14. NEURAL TUBE DEFECTS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("14. SPINAL CORD AND NEURAL TUBE DEFECTS"));

children.push(p("**Prevention:** Folic acid 400 mcg/day periconceptionally (4–5 mg/day if prior NTD, on antiepileptics, obesity, or diabetes)"));
children.push(makeTable(
  ["Defect", "Description", "Features"],
  [
    ["Spina bifida occulta", "Vertebral defect, no sac, skin intact", "Usually asymptomatic; tuft of hair, dimple, or lipoma may mark site"],
    ["Meningocele", "CSF-filled sac; cord not involved", "Usually no neurological deficit"],
    ["Myelomeningocele", "Cord/nerve roots in sac", "Lower limb paralysis, bowel/bladder dysfunction; hydrocephalus (Chiari II association)"],
    ["Anencephaly", "Absence of cranial vault", "Incompatible with sustained life"],
  ]
));
children.push(p("**Chiari II malformation:** Always associated with myelomeningocele; downward herniation of cerebellar tonsils; may cause hydrocephalus, lower CN palsies, respiratory difficulties."));

// ═══════════════════════════════════════════════════════════════════════════
// 15. NEUROLOGICAL INVESTIGATIONS
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("15. NEUROLOGICAL INVESTIGATIONS"));

children.push(h2("15.1 EEG Patterns – HIGH YIELD TABLE ★★"));
children.push(makeTable(
  ["EEG Pattern", "Associated Condition"],
  [
    ["3 Hz generalised spike-wave", "Childhood absence epilepsy"],
    ["Hypsarrhythmia", "West syndrome (infantile spasms)"],
    ["Slow spike-wave (< 2.5 Hz)", "Lennox-Gastaut syndrome"],
    ["Centrotemporal spikes (sleep-activated)", "BECTS / Rolandic epilepsy"],
    ["Burst-suppression", "Neonatal encephalopathy; Ohtahara syndrome"],
    ["PLEDs (periodic lateralising epileptiform discharges)", "HSV encephalitis; stroke"],
    ["4–6 Hz polyspike-wave", "Juvenile myoclonic epilepsy (JME)"],
    ["Photo-paroxysmal response", "JME; photosensitive epilepsy"],
    ["Theta pointu alternant", "Benign neonatal seizures ('fifth day fits')"],
  ]
));

children.push(h2("15.2 Neuroimaging Indications (Urgent CT/MRI)"));
children.push(bullet("Papilloedema"));
children.push(bullet("Focal neurological deficit"));
children.push(bullet("Seizure with Todd's palsy"));
children.push(bullet("New-onset headache + ataxia"));
children.push(bullet("Depressed consciousness"));
children.push(bullet("Focal seizure in immunocompromised child"));

children.push(h2("15.3 Key MRI Sequences"));
children.push(makeTable(
  ["Sequence", "Best For"],
  [
    ["DWI (diffusion-weighted)", "Acute ischaemia (bright within minutes of onset)"],
    ["FLAIR", "Inflammation, demyelination, encephalitis"],
    ["T1 + gadolinium", "Tumours, abscess, meningeal enhancement"],
    ["MRS (spectroscopy)", "Metabolic disorders, tumour characterisation"],
    ["MRA", "Vascular anomalies, moyamoya, AVM"],
  ]
));

// ═══════════════════════════════════════════════════════════════════════════
// 16. DEMYELINATING DISEASES
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("16. DEMYELINATING DISEASES"));

children.push(h2("16.1 Paediatric Multiple Sclerosis"));
children.push(bullet("< 5% of MS cases present in childhood; female:male 1:1 prepubertal, 3:1 adolescence"));
children.push(bullet("**McDonald criteria:** Dissemination in space AND time"));
children.push(bullet("**Optic neuritis:** Painful visual loss, RAPD (relative afferent pupillary defect), unilateral"));
children.push(bullet("MRI: periventricular white matter lesions – **'Dawson fingers'** (perpendicular to corpus callosum)"));
children.push(bullet("CSF: oligoclonal bands, elevated IgG index"));
children.push(bullet("Acute treatment: methylprednisolone IV; DMTs: interferon-beta, glatiramer, natalizumab, ocrelizumab"));

children.push(h2("16.2 ADEM (Acute Disseminated Encephalomyelitis)"));
children.push(bullet("Post-infectious or post-vaccination; multifocal demyelination"));
children.push(bullet("**Encephalopathy + multifocal neurological deficits** (distinguishes from MS)"));
children.push(bullet("MRI: widespread, bilateral, asymmetric white matter lesions + cortical/deep grey matter involvement"));
children.push(bullet("Treatment: high-dose IV methylprednisolone; IVIG or plasma exchange if refractory"));
children.push(bullet("Usually monophasic; good prognosis"));

// ═══════════════════════════════════════════════════════════════════════════
// 17. QUICK REFERENCE TABLE
// ═══════════════════════════════════════════════════════════════════════════
children.push(pageBreak(), h1("17. QUICK REFERENCE – HIGH-YIELD EXAM FACTS ★★★"));

children.push(makeTable(
  ["Topic", "Key Point"],
  [
    [{text:"Febrile seizure", bold:true}, "No LP if > 18 months, simple FS, well, fully immunised, no meningism"],
    [{text:"Infantile spasms EEG", bold:true}, "Hypsarrhythmia"],
    [{text:"West syndrome treatment", bold:true}, "ACTH (1st line); vigabatrin if tuberous sclerosis"],
    [{text:"Dravet treatment", bold:true}, "Valproate + clobazam; AVOID sodium channel blockers"],
    [{text:"Childhood absence EEG", bold:true}, "3 Hz generalised spike-wave; precipitated by hyperventilation"],
    [{text:"BECTS", bold:true}, "Most common childhood epilepsy syndrome; self-limiting"],
    [{text:"JME", bold:true}, "Lifelong treatment usually needed; avoid valproate in girls"],
    [{text:"Status epilepticus 1st line", bold:true}, "Lorazepam IV or midazolam IM"],
    [{text:"Status epilepticus 2nd line", bold:true}, "Levetiracetam IV, valproate IV, or fosphenytoin"],
    [{text:"SMA Type 1", bold:true}, "Never sits; bright eyes; SMN1 deletion; nusinersen/gene therapy"],
    [{text:"DMD", bold:true}, "Xp21; CK very high; Gowers sign; calf pseudohypertrophy; deflazacort"],
    [{text:"GBS CSF", bold:true}, "Albuminocytological dissociation (high protein, normal WBC)"],
    [{text:"GBS treatment", bold:true}, "IVIG or plasma exchange; steroids NOT effective"],
    [{text:"NF1 diagnosis", bold:true}, "≥2 of 7 criteria; ≥6 café-au-lait spots most common feature"],
    [{text:"TSC skin", bold:true}, "Ash-leaf spots (earliest, Wood's lamp), angiofibromas, shagreen patch"],
    [{text:"HIE hypothermia", bold:true}, "GA ≥36 wks; start within 6 hrs; 33–34°C × 72 hrs"],
    [{text:"TBM stages", bold:true}, "Alert → CN palsy + meningism → coma"],
    [{text:"NMDAR encephalitis", bold:true}, "Psychiatric → seizures → orofacial dyskinesias; anti-NR1 antibody"],
    [{text:"Medulloblastoma", bold:true}, "Most common malignant paediatric brain tumour; 4th ventricle; drop mets"],
    [{text:"Cerebellar astrocytoma", bold:true}, "Cystic + mural nodule; pilocytic; excellent prognosis"],
    [{text:"DIPG", bold:true}, "H3K27M mutation; pons; no effective chemo; very poor prognosis"],
    [{text:"Craniopharyngioma", bold:true}, "Suprasellar calcification; bitemporal hemianopia; hypothalamic dysfunction"],
    [{text:"HLA-B*1502 (Asian/Sri Lanka)", bold:true}, "Screen before CBZ, phenytoin, lamotrigine – high risk SJS/TEN"],
    [{text:"Pseudotumour cerebri", bold:true}, "Obesity, vit A, tetracycline; treat with acetazolamide + weight loss"],
    [{text:"Sydenham's chorea", bold:true}, "Post-strep; milkmaid's grip; penicillin prophylaxis; echo for carditis"],
    [{text:"Parachute reflex", bold:true}, "Appears 8–9 months; persists (protective reflex)"],
    [{text:"Setting-sun sign", bold:true}, "Parinaud sign = dorsal midbrain compression by hydrocephalus"],
    [{text:"Neonatal myasthenia", bold:true}, "Passive maternal anti-AChR transfer; resolves 2–8 weeks"],
    [{text:"Folic acid dose NTD prevention", bold:true}, "400 mcg/day standard; 4–5 mg/day if high risk"],
    [{text:"Sickle cell stroke", bold:true}, "Exchange transfusion acute; chronic transfusion for secondary prevention"],
  ]
));

// ── footer note ──────────────────────────────────────────────────────────
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// ═══════════════════════════════════════════════════════════════════════════
// BUILD DOCUMENT
// ═══════════════════════════════════════════════════════════════════════════
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cd /home/daytona/workspace/neurology-notes && node generate.js 2>&1

~/neurology-notes/generate.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/neurology-notes/generate.js'

cd /home/daytona/workspace/neurology-notes && node generate.js 2>&1

python /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/worksp…

ls -lh /home/daytona/workspace/neurology-notes/Paediatric_Neurology_PG_Exam_Note…