Training Programme in Paediatric Neurology  (according to the EPNS Syllabus)

The definition:

Pediatric neurology (PN) deals with normal and abnormal development of central and peripheral nervous (neuromuscular) system, from the fetal period till adolescent age. It comprehends diagnostics, therapy and investigation of diseases of the nervous system.
Pediatric neurology is a unique specialization that originates from pediatrics, although in the North America and in some countries of Western Europe it develops from the field of neurology for adults.
The program of specialization/sub/specialization in PN implements itself within the tertiary education in pediatricsaccording to the decision of CESP (Confederation of European Specialists in Pediatrics) and EBP (European Board of Pediatrics) inside UEMS (European Union of Medical Specialists).

Goals of education:
• to accomplish the standardization of knowledge and skills needed for work on the tertiary level of pediatric care in the state and on the European level
• to improve the protection and therapy of children with neurologic diseases
• to achieve scientific research in PN
• to stimulate the network development of competent tertiary centers with the aim of cooperation and scientific research projects

Implementation of specialization program
Education is implemented in complete centers/ Clinics which are regularly controlled by the Quality Control Commission of the Croatian Ministry of Health and Social Care. Some centers (partial ones) can complement each other. The team and multidisciplinary approach is significant within this education.
Scientific work is not required, but it is stimulated within the program of specialization.
Subspecialistic diagnostic skills and knowledge represent the part of scientific research; these are not the part of educational program.

Each resident has his mentor/tutor. The tutor is pediatrician neurologist, a teacher with experience in the scientific research. The tutor monitors progress each year. Resident writes a diary with learned knowledge and skills. The tutor certifies diary after the testing of knowledge and skills. He evaluates the accomplishment of goals of educational program and the competency of candidate in required knowledge and skills.
National coordinator for PN mediates in communication with European commissions for education andcoordinates activities of leaders in education centers and maintains the database about centers, leaders ofcenters, tutors, teachers and candidates.

Education centers and units are defined by clinical and technical possibilities and demands with respect to modules. Director of education centre needs to be the tutor and leader of education program.
If one centre is not complete it can be complemented with the institutions near by. Education can be also implemented abroad (in Europe or outside Europe).
System of accreditation of education centers will be adopted in accordance with guidelines of UEMSE. Educationcenters will be evaluated according to the opinion of Commission of evaluation of quality according to the guidelines of UEMSE and in accordance of educational capacities and competence.
Complete education centre has to possess all required modules and submodules with at least 4 desirable modules and 2 or more tutors.
Partial education centre has to posses with more than half of obligatory modules and at least with one tutor.

Basic content of the program:
1. Earning of basic knowledge about normal and abnormal neurological functions and neurological development in children
2. Gaining the personal experience in diagnostics and therapy of pediatric neurological diseases
System 4+7+3 and >
Basic principles
Candidate becomes resident in PN by the election to the available position by the official and public competition.
Specialization is carried out at the clinical department, through the teaching which includes lectures, seminars and exercises.
Education programme is conducted through modules. Obligatory modules are the basis of the education programme. There are 4 obligatory modules. Obligatory modules are acute paediatric neurology - in duration of at least 2 years, neurology for adults (6 months)  and habilitation/rehabilitation (6 months) and child psychiatry in duration of 6 months once a week.
Each obligatory module is carried out exclusively at the accepted tertiary institution of educational type.
During the module of acute pediatric neurology resident gains the needed knowledge in the establishment of diagnosis and in the treatment of infants, children and adolescents with neurologic diseases. This part of specialization deals also with the care and therapy of children at the departments of intensive care, and care/therapy for children that require neurosurgical treatment and participation on radiological, pathologic and neurophysiologic meetings.
Module of habilitation/rehabilitation deals with learning the diagnostics and therapy of neurological diseases.
Module of neurology for adults implies staying at the department and in the outpatient clinic of tertiary neurological departments in the duration of 6 months.

Obligatory submodules:
Beside the obligatory modules there are also some obligatory submodules (7 in total). Obligatory submodules are dealing with pediatric neuroradiology, neurophysiology, neuropathology, academic module (scientific work, lectures), modules of team approach and integrated care, and finally the module of ethics and work organization (management).

Desirable modules:
Under the guidance of mentor 3 of 9 desirable modules are chosen. Inside the neuroradiology module the resident reports the neuroradiologic findings independently, under surveillance, gaining the skill of interpretation of findings.
Module of neurophysiology consists of adopting the capability of performing and interpreting EMG, EEG i EP.
Module of neuropathology consists of learning the basics in the interpretation of neuropathologic findings from different types of tissue (muscle, nerve, skin, brain, spinal cord) under the surveillance of neuropathologist.
Module of neurogenetics deals with participation in genetic counseling, gaining the skill of genetic counseling for the most frequent neurological diseases.
In the module of neurometabolic diseases, the participation in specialized departments includes dealing with the children with neurometabolic diseases, mastering diagnostic metabolic testing and diagnostics and therapy of metabolic diseases.
Module of neuropediatric intensive care deals with learning the needed skills for the work at the departments for intensive care.
Module of neonatal neurology consists of performing of neurological exams in newborns and brain US exams.
Module of neuropsychiatry deals with gaining the diagnostic and therapeutic procedures in children with the most frequent psychiatric disorders.
Module of pediatric epileptology deals with gaining the skill of diagnostics in neurophysiology and neuroradiologyand the treatment of epilepsies and epileptic syndromes including preoperative preparation for neurosurgery.
Scientific educational program enables the management of scientific research in longer period for 3-4 years according to the agreement with tutor/mentor and in accordance with established law regulations.
In the basic common program of education in pediatrics, the modules of child development or habilitation andpediatric neurology can be implemented, and these can be counted inside the 3-year-long of 6-year-long specialization.
The teaching program includes the work at the department and in the outpatient unit and dealing with active procedures during the treatment of patients in the institution approved for the purpose of education.
Entering from the neurology into the specialization in PN is possible in some countries after 2 years of specialization in neurology and 1 year of education in pediatrics.

Basic knowledge:
1st year of sub/specialization (4th year of pediatric specialization)
1.1. Basic principles of prenatal development of brain
1.2. Neonatal neurology
1.2.1. Intracranial haemorrhages
1.2.2. Neonatal seizures
1.2.3 Neonatal encephalopathies
1.2.4. Premature newborn
1.2.5. Apneas
1.3. Normal and abnormal development of infant, child and adolescent
1.4. Psychomotor retardation
1.5. Emergency states
1.5.1. Disturbances of consciousness and coma
1.5.2. Epileptic status
1.5.3. Trauma
1.5.4. Metabolic disturbances
1.5.5. Increased intracranial pressure
1.6. Epilepsy
1.6.2.Symptomatic (probably symptomatic)
1.6.3.Epileptic syndromes
1.6.4.Epileptic encephalopathy
1.6.5.Neurosurgery of epilepsy
1.7.Neuromuscular disorders
1.7.1.Syndrome of hypotonic infant
1.7.2.Acute muscle weakness
1.7.3.Congenital muscular diseases
1.7.4.Spinal muscular atrophies
1.7.5. Acquired motorneuron diseases
1.7.6.Hereditary neuropathies
1.7.7. Acquired neuropathy
1.8. Cerebral palsy
1.9. Diseases of spinal cord
1.9.1. Congenital
1.9.2. Spinocerebellar syndromes
1.9.5. Ischemia
1.10. Congenital anomaly
1.10.3. Lissencephaly
1.10.4.Migration disorders
1.10.5.Agenesis of corpus callosum
1.11. Neurocutaneous diseases
1.11.1.Tuberous sclerosis
1.11.2. Neurofibromatosis
1.11.3. Ito
1.11.4. Linear naevus sebaceus
1.11.5. Sturge Weber
1.11.6. Proteus
1.9. Neurooncology
1.10. Disturbances in the learning and communication
1.11. Congenital and acquired causes of neurologic diseases
1.12. Behaviour disturbances

1.12.1 Autism
1.12.2 Psychosis
1.12.3. Attention deficit
1.12.4. Hyperactivity syndrome
1.12.5. Learning problems

2nd year
2.1. Neurodegenerative and neurometabolic diseases
2.1.2. Disturbance of myelinization
2.1.3. Poliodystrophies
2.1.4. Diseases of deposition
2.1.5. Disturbances of intermediary metabolism
2.1.6. Speech disturbances
2.2. Movement disorders
2.2.1. Ataxia
2.2.3. Dystonia
2.2.4. Chorea
2.2.5. Myoclonus
2.2.6. Neurotic tic, stereotipias
2.3. Infectology
2.3.1. Viral meningoencephalitis
2.3.2. Bacterial meningitis
2.3.3. Parainfectious encephalitis
2.3.4. Tuberculosis meningitis
2.4. Neuroimunology
2.5. Systemic diseases accompanied by neurologic abnormalities
(acquired and congenital cardiologic, nephrologic and gastroenterologic diseases)
2.6. Brain death
2.7. Cerebrovascular diseases
2.7.1. Acute brain stroke (ischemic/haemorrhagic)
2.7.2. Vasculitis
2.7.3. Moya-Moya
2.8. Neurootology (acute and chronic disturbances of balance, congenital and acquired hearing loss)
2.9. Neuroophtalmology (papila stagnans, nistagmus, acute sight loss, disturbances of visual field, optic neuropathy)
2.10. Neurotoxicology (impact of drugs and toxins to the central and peripheral nervous system)
2.11. Neurosurgical diseases – diagnosis and treatment
2.12. Disturbances in the alimentation, gastrooesophageal reflux and neurologic diseases
2.13. Orthopedic complications and therapy of neurologic disease (scoliosis, contractures)
2.14. neurogenetics (prenatal diagnosis, DNA analysis, chromosomopathy,
2.14.1. Syndrome - Down, Angelman, Charge, Prader Wili, Osteogenesis imperfecta
2.15. Child protection- awareness of the current law, centres of social care and parental
2.16. Convention of UN about the children rights and their protection
2.17. Ethics in the research within paediatric population
2.18. Administrative procedures and management of neuropaediatric service inside the health system
2.19. Understanding the appeal procedure

3. Basic knowledge of diagnostics (1st and 2nd year of subspecialization)

3.1. Neurophysiology: EEG, EMG, EP
3.2. Tissue biopsy (muscle, nerve, skin) in the diagnostics and interpretation of basic histologic
findings (dystrophy, myositis, neuropathy)
3.3. Neurobiochemical tests (enzyme analysis, CK)
3.4. Neuroimunology (tests)
3.5. Neuroradiology
3.6. Neurometabolic tests (lactate, organic acids, aminoacids)
3.7. Evaluation of hearing and sight (VEP, BERA)
3.8. Analysis of walking

4. Basic skills and competencies

4.1. 1st year of subspecialization

4.1.1 Adequate and supportive history taking

4.1.2. Clinical examination of children of all ages  including developmental assessment

4.1.3. Comprehension, indications and contraindications, advantages and disadvantages of
neurophysiologic methods (EEG, EMG,EP), biopsy, brain and muscle US, functional methods
(PET, SPECT), brain death evaluation
4.1.4. Evaluation of clinical features and appropriate therapy
4.1.5. Coordination and team approach in the therapy of emergencies and in the complications of
multisystem neurologic diseases
4.1.6. Approach to the parents and children, competency of dealing with fatal diagnosis and poor
4.1.7. Application and knowledge about therapeutic approach to the neurologic disturbances
4.1.8. Application of antiepileptics, analgetics, steroids, immunosuppressives, antacids, antiviral
agents and antibiotics in the treatment of neurologic diseases and pain treatment

4.2, 2nd year of subpecialization
4.2.1. Therapy of behavioural disturbances
4.2.2. Principles of habilitation therapy (team approach)
4.2.3. Application of orthosis, speech aid, mechanical ventilation
4.2.4. Therapy of speech and hearing disorders
4.2.5. Basic principles of alternative therapy and possible consequences of its application
4.2.6. Principles of rehabilitation of acquired neurologic diseases (team approach)
4.2.7. Therapy of eating disorders in the chronic neurologic diseases
4.2.8. Ketogenic diet
4.2.9. Therapy and education of children with learning difficulties
4.2.10. Knowledge of methods from the other specialities and consultation of other specialties
4.2.11. Evaluation of clinical results from the literature
4.2.12. Preparation of work and oral presentation or lecture

Exam is conducted according to the regulations of Ministry of Health. Exam in the front of international commission is not required. Access to the international exam needs to be harmonized with competent state examination commission and with mentor.