Strokes in newborns are as common as in adults. Recognition and early intervention is critical to minimizing the damage. Children’s Mercy is one of fewer than 10 pediatric stroke centers nationally, and the region’s first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children.
In this podcast Mukta Sharma, MD, pediatric hematologist/oncologists, discusses the warnings signs and causes of stroke and how early intervention affect the rest of a child’s life.
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The Importance of FAST Action for Infant and Pediatric Stroke
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Learn more about Mukta Sharma, MD
Mukta Sharma, MD
Mukta Sharma, MD, FAAP, MPH, is one of co-leaders for the comprehensive pediatric stroke center and services at Children’s Mercy Kansas City and Assistant Professor of Pediatrics at the University of Missouri-Kansas City. Dr. Sharma received her medical degree from Government Medical College and Hospital, Nagpur University, India. She completed a residency in Pediatrics at Kansas University Medical Center and a fellowship in Pediatric Hematology Oncology at Children’s Mercy Kansas City. Dr. Sharma is board certified in Pediatrics and Pediatric Hematology/Oncology.Learn more about Mukta Sharma, MD
Transcription:
The Importance of FAST Action for Infant and Pediatric Stroke
Dr. Michael Smith (Host): I'm Dr. Mike. This is Pediatrics in Practice. The topic is the importance of fast action for infant and pediatric stroke. My guest is Dr. Mukta Sharma. Dr. Sharma is a co-leader for the comprehensive pediatric stroke center and services at Children’s Mercy Cancer City and assistant professor of pediatrics at the University of Missouri Kansas City. Welcome to the show.
Dr. Mukta Sharma, FAAP, MPH (Guest): Thank you so much for having me today.
Dr. Smith: Let's start off. How common is a stroke in newborns?
Dr. Sharma: Stroke in children and newborns is uncommon but not as rare as once thought. Risk of stroke, I would say for live births, is about one in 4,000, and for older children, about 10 out of 100,000 children per year get a stroke. I think a common pediatric condition people are aware of is brain tumors as one of the most common cancers in children. Stroke in children is as common as brain tumors in children.
Dr. Smith: You said something interesting, that it's more common than what we originally thought, so in the past where doctors just misdiagnose a stroke in infants?
Dr. Sharma: Yes. Stroke overall, the incidents in children, has what you call a bimodal curve. Highest incidents of stroke in children is actually infants and children, what we call bimodal stroke around birth up to one month. I think over the last decade a lot of numbers that we’re hearing about how common stroke is coming from raises awareness and increases the ability to diagnose based on technology and neuroimaging and modalities that have become available. I think that’s leading to recognition that stroke is much more common than we thought previously.
Dr. Smith: What are some of the more common causes of stroke in a newborn?
Dr. Sharma: When we talk about stroke and when we say newborns, I'm going to refer to newborn children because causes of stroke are different around perinatal and prenatal newborn babies compared to older children. For now, what's available in research, for a large part, we do not know why stroke happens in newborn babies during the perinatal period. There are various mechanisms that have been proposed including traveling of the clot from the placenta to fetal circulation and the clot traveling to the brain. This can happen before delivery period of right around the time of birth, and babies can present with symptoms like seizures who was feeding, respiratory issues, so the symptoms can be non-specific compared to stroke symptoms we see in children and adults where commonly presenting symptoms can include but called in the past criteria, for example, the facial drooping, the arm weakness, and the slurring of speech. Compared to that, newborn babies, their symptoms can be non-specific when we talk about symptoms of stroke and neonates or babies compared to older children and adults.
Dr. Smith: Which of course makes it tough to diagnose in that, but we are recognizing it better now. We're recognizing these warning signs and were able to then implement an action plan faster. Is that why we’re diagnosing it more, we’re seeing the numbers go up, but we’re addressing it quicker?
Dr. Sharma: That’s correct. Based on the American Stroke Association guidelines for managing stroke in children, it’s hard to prevent because we don’t know a lot as to why stroke happens in babies, but the focus is based on promptly recognizing and diagnosing the stroke so that we can take steps to reduce the odds of stroke recurrence and helping children as they go through the different development phases to be able to recover and be able to regain potential to the fullest possibility.
Dr. Smith: I know that Children’s Mercy is one of maybe 10 or so national centers with a pediatric stroke clinic. Tell us a little bit about the stroke clinic at Children’s Mercy.
Dr. Sharma: It is a new development and we have a newborn baby on the horizon as far as a stroke program goes, so there has been a lot of background work that's been hospital-wide involving a lot of subspecialist support and other services – an emergency department, our transport service, our intensive care services involving radiology services and of course hematology in terms of management of clots and bleeding problems, stroke neurologists, Dr. Roha Khalid and our rehab team. It really feels like it has been mobilizing a village to line up services here at Children’s Mercy to be able to care for children with strokes. We are very excited to have started our multidisciplinary stroke clinic. We had our first clinic in September and it was just overwhelming to see responsive families wherein one afternoon, they could see all these different subspecialists get therapy evaluations for their children all under one roof, one umbrella, and all subspecialists in the same room. I've been thrilled with all the background work that has happened, and now our clinic has started here at Children's Mercy.
Dr. Smith: That’s interesting. When a patient comes to the clinic with the family, they stay in one room, so the idea is you guys come to the patient to that room and they can see everybody at once. That’s how it works?
Dr. Sharma: That’s correct. Our comprehensive team in our clinic includes myself and Dr.Khalid, our stroke neurologist, so we tag team to see patients together and then it’s followed by our rehab team, which is Dr. Vadivelu accompanied by neuropsychologists and OT and PT. It’s a variety of specialists as these children are able to see in one visit compared to going to different clinics throughout the hospital.
Dr. Smith: How are patients referred to the clinic?
Dr. Sharma: A lot of referrals are at this point coming from within our hospital and that is because when strokes happen, children are presenting to the emergency departments or it’s being diagnosed in the nursery or neonatal ICU we have at the hospital that the time of discharge based on children that have complexed needs and it is important to know that almost four out of five children can have long-term lifelong deficits from stroke, from the injury they have. Every minute of a stroke, about two million neurons of brain cells, are being damaged and we know the brain cells do not regrow, so the goal is towards limiting injury. For patients that are more complex and need to see different subspecialists, they are the ones that are referred to us through the clinic. For some children that have had the workup done, we were talking earlier about risk factors such as stroke in children, and some of them include congenital heart disease, abnormalities with the blood cells, sickle cell disease, so there are conditions we know that increases risk of stroke in children. Based on what the underlying need is and needs to see different subspecialists, that’s how they're referred to the stroke clinic, otherwise, for example, the therapy needs are more frequent, then we’ll go and see the rehab team on a more frequent basis and then come back to the comprehensive clinic to have a visit with all the providers.
Dr. Smith: With this comprehensive approach to the early intervention, the rehabilitation that occurs, what kind of outcomes are you experiencing with these patients?
Dr. Sharma: We have known that brains in children have higher neural plasticity and have the ability to recover and develop new learning pathways, and I think that the earlier we intervene, the better outcomes we see. Over the years, having taken care of kids with stroke, it is amazing to me that as we have lined up services for early recognition, early referral to services, I have babies with newborn strokes like we had talked about earlier, their symptoms can be non-specific and they're really not presenting with weakness per se around all times, but they will develop a neglect of one side, losing development milestones and these will typically present between 8 to 12 months of age. There's a big gap. These babies can go home and then they're developing those symptoms of weakness, and we are seeing again and again in our clinic, and in our experience, that the earlier these babies are diagnosed around birth time and referred to therapy, the better outcomes they have. We do not know, even with the same pattern of brain injuries, lack of blood flow even from a clot or a bleed – the brain lesions may look similar on MRI scans or neuroimaging, but the symptoms can still be different. It can be from mild to very severe for a similar looking injury and we do not know why, but what we’re experiencing is starting them early in therapy really helps change their long-time outcome in terms of better outcomes.
Dr. Smith: That’s the key. Early intervention; that’s exactly what you guys are able to do. I know you're teaching that out to the community physicians as well to recognize those warnings signs. Thank you for the work that you're doing at Children’s Mercy and thank you for coming on this show today. You're listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, go to childrensmercy.org. That’s childrensmercy.org. I'm Dr. Michael Smith. Thanks for listening.
The Importance of FAST Action for Infant and Pediatric Stroke
Dr. Michael Smith (Host): I'm Dr. Mike. This is Pediatrics in Practice. The topic is the importance of fast action for infant and pediatric stroke. My guest is Dr. Mukta Sharma. Dr. Sharma is a co-leader for the comprehensive pediatric stroke center and services at Children’s Mercy Cancer City and assistant professor of pediatrics at the University of Missouri Kansas City. Welcome to the show.
Dr. Mukta Sharma, FAAP, MPH (Guest): Thank you so much for having me today.
Dr. Smith: Let's start off. How common is a stroke in newborns?
Dr. Sharma: Stroke in children and newborns is uncommon but not as rare as once thought. Risk of stroke, I would say for live births, is about one in 4,000, and for older children, about 10 out of 100,000 children per year get a stroke. I think a common pediatric condition people are aware of is brain tumors as one of the most common cancers in children. Stroke in children is as common as brain tumors in children.
Dr. Smith: You said something interesting, that it's more common than what we originally thought, so in the past where doctors just misdiagnose a stroke in infants?
Dr. Sharma: Yes. Stroke overall, the incidents in children, has what you call a bimodal curve. Highest incidents of stroke in children is actually infants and children, what we call bimodal stroke around birth up to one month. I think over the last decade a lot of numbers that we’re hearing about how common stroke is coming from raises awareness and increases the ability to diagnose based on technology and neuroimaging and modalities that have become available. I think that’s leading to recognition that stroke is much more common than we thought previously.
Dr. Smith: What are some of the more common causes of stroke in a newborn?
Dr. Sharma: When we talk about stroke and when we say newborns, I'm going to refer to newborn children because causes of stroke are different around perinatal and prenatal newborn babies compared to older children. For now, what's available in research, for a large part, we do not know why stroke happens in newborn babies during the perinatal period. There are various mechanisms that have been proposed including traveling of the clot from the placenta to fetal circulation and the clot traveling to the brain. This can happen before delivery period of right around the time of birth, and babies can present with symptoms like seizures who was feeding, respiratory issues, so the symptoms can be non-specific compared to stroke symptoms we see in children and adults where commonly presenting symptoms can include but called in the past criteria, for example, the facial drooping, the arm weakness, and the slurring of speech. Compared to that, newborn babies, their symptoms can be non-specific when we talk about symptoms of stroke and neonates or babies compared to older children and adults.
Dr. Smith: Which of course makes it tough to diagnose in that, but we are recognizing it better now. We're recognizing these warning signs and were able to then implement an action plan faster. Is that why we’re diagnosing it more, we’re seeing the numbers go up, but we’re addressing it quicker?
Dr. Sharma: That’s correct. Based on the American Stroke Association guidelines for managing stroke in children, it’s hard to prevent because we don’t know a lot as to why stroke happens in babies, but the focus is based on promptly recognizing and diagnosing the stroke so that we can take steps to reduce the odds of stroke recurrence and helping children as they go through the different development phases to be able to recover and be able to regain potential to the fullest possibility.
Dr. Smith: I know that Children’s Mercy is one of maybe 10 or so national centers with a pediatric stroke clinic. Tell us a little bit about the stroke clinic at Children’s Mercy.
Dr. Sharma: It is a new development and we have a newborn baby on the horizon as far as a stroke program goes, so there has been a lot of background work that's been hospital-wide involving a lot of subspecialist support and other services – an emergency department, our transport service, our intensive care services involving radiology services and of course hematology in terms of management of clots and bleeding problems, stroke neurologists, Dr. Roha Khalid and our rehab team. It really feels like it has been mobilizing a village to line up services here at Children’s Mercy to be able to care for children with strokes. We are very excited to have started our multidisciplinary stroke clinic. We had our first clinic in September and it was just overwhelming to see responsive families wherein one afternoon, they could see all these different subspecialists get therapy evaluations for their children all under one roof, one umbrella, and all subspecialists in the same room. I've been thrilled with all the background work that has happened, and now our clinic has started here at Children's Mercy.
Dr. Smith: That’s interesting. When a patient comes to the clinic with the family, they stay in one room, so the idea is you guys come to the patient to that room and they can see everybody at once. That’s how it works?
Dr. Sharma: That’s correct. Our comprehensive team in our clinic includes myself and Dr.Khalid, our stroke neurologist, so we tag team to see patients together and then it’s followed by our rehab team, which is Dr. Vadivelu accompanied by neuropsychologists and OT and PT. It’s a variety of specialists as these children are able to see in one visit compared to going to different clinics throughout the hospital.
Dr. Smith: How are patients referred to the clinic?
Dr. Sharma: A lot of referrals are at this point coming from within our hospital and that is because when strokes happen, children are presenting to the emergency departments or it’s being diagnosed in the nursery or neonatal ICU we have at the hospital that the time of discharge based on children that have complexed needs and it is important to know that almost four out of five children can have long-term lifelong deficits from stroke, from the injury they have. Every minute of a stroke, about two million neurons of brain cells, are being damaged and we know the brain cells do not regrow, so the goal is towards limiting injury. For patients that are more complex and need to see different subspecialists, they are the ones that are referred to us through the clinic. For some children that have had the workup done, we were talking earlier about risk factors such as stroke in children, and some of them include congenital heart disease, abnormalities with the blood cells, sickle cell disease, so there are conditions we know that increases risk of stroke in children. Based on what the underlying need is and needs to see different subspecialists, that’s how they're referred to the stroke clinic, otherwise, for example, the therapy needs are more frequent, then we’ll go and see the rehab team on a more frequent basis and then come back to the comprehensive clinic to have a visit with all the providers.
Dr. Smith: With this comprehensive approach to the early intervention, the rehabilitation that occurs, what kind of outcomes are you experiencing with these patients?
Dr. Sharma: We have known that brains in children have higher neural plasticity and have the ability to recover and develop new learning pathways, and I think that the earlier we intervene, the better outcomes we see. Over the years, having taken care of kids with stroke, it is amazing to me that as we have lined up services for early recognition, early referral to services, I have babies with newborn strokes like we had talked about earlier, their symptoms can be non-specific and they're really not presenting with weakness per se around all times, but they will develop a neglect of one side, losing development milestones and these will typically present between 8 to 12 months of age. There's a big gap. These babies can go home and then they're developing those symptoms of weakness, and we are seeing again and again in our clinic, and in our experience, that the earlier these babies are diagnosed around birth time and referred to therapy, the better outcomes they have. We do not know, even with the same pattern of brain injuries, lack of blood flow even from a clot or a bleed – the brain lesions may look similar on MRI scans or neuroimaging, but the symptoms can still be different. It can be from mild to very severe for a similar looking injury and we do not know why, but what we’re experiencing is starting them early in therapy really helps change their long-time outcome in terms of better outcomes.
Dr. Smith: That’s the key. Early intervention; that’s exactly what you guys are able to do. I know you're teaching that out to the community physicians as well to recognize those warnings signs. Thank you for the work that you're doing at Children’s Mercy and thank you for coming on this show today. You're listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, go to childrensmercy.org. That’s childrensmercy.org. I'm Dr. Michael Smith. Thanks for listening.