Overview
This Guidelines summary covers the presenting symptoms and diagnosis of brain tumours in children, and when to refer for specialist management.
Referral from Primary Care
- High risk of tumour—SAME DAY referral to secondary care
- Lower risk[A] —specialist assessment within 2 weeks
Imaging
- High risk of tumour—URGENT CNS imaging
- Lower risk[A] —CNS imaging within 4 weeks
Consider a Brain Tumour in Any Child Presenting With:
- Headache
- Nausea and/or vomiting
- Visual signs and symptoms:
- reduced visual acuity and/or fields
- abnormal eye movements
- abnormal fundoscopy
- Motor symptoms and signs:
- abnormal gait
- abnormal co-ordination
- focal motor weakness
- Growth and endocrine symptoms:
- growth failure (weight/height)
- delayed, arrested or precocious puberty
- galactorrhoea
- primary/secondary amenorrhea
- Increasing head circumference
- Behavioural change
- Diabetes insipidus
- Seizures (see www.nice.org.uk/guidance/qs27)
- Altered consciousness (see www.rcpch.ac.uk/system/files/protected/page/Decon%20guidelines.pdf)
Assess These Children With
- History: associated symptoms, any predisposing factors
- Examination of:
- visual system
- motor system
- height and weight
- head circumference (<2 years of age)
- pubertal status
Ask About Common Predisposing Factors
- Personal or FH of brain tumour, sarcoma, leukaemia, or early onset breast cancer
- Neurofibromatosis
- Tuberous sclerosis
- Other familial genetic syndromes
Assessment Pitfalls
- Initial symptoms of brain tumour can mimic other common illnesses
- Symptoms frequently fluctuate—resolution then recurrence does not exclude a brain tumour
- A normal neurological examination does not exclude a brain tumour
- Language difficulties—use interpreter
Headaches
- Consider a brain tumour in any child with a new, persistent[B] headache
- Headache in isolation, unlikely to be a brain tumour
- Brain tumour headaches occur at any time of day
- Children aged younger than 4 years may not be able to describe a headache—observe behaviour
CNS Imaging Required With:
- Persistent headache that wakes a child from sleep
- Persistent headache that occurs on waking
- Persistent headache in a child under 4 years of age
- Confusion or disorientation with a headache
- Persistent headache with 1 or more other symptoms
Common Pitfalls
- Failure to reassess a child with a migraine or tension headache when the headache character changes
Nausea and/or Vomiting
- Consider a brain tumour in any child with persistent[C] nausea and/or vomiting
- Head circumference should be measured and plotted in children under 2 years of age with persistent vomiting
CNS Imaging Required With:
- Persistent vomiting on waking (NB: exclude pregnancy where appropriate)
- Persistent nausea/vomiting with one or more other symptom
Common Pitfalls
- Failing to consider a CNS cause for persistent nausea and vomiting
Visual Signs and Symptoms
- Consider a brain tumour in any child with persistent[D] visual abnormality
- Visual assessment requires assessment of:
- visual acuity
- eye movements
- pupil responses
- optic disc appearance
- visual fields (≥ 5 years of age)
- Pre-school and unco-operative children should be assessed by hospital eye service within 2 weeks of referral
- Parent concern alone warrants referral for visual assessment
CNS Imaging Required With:
- Papilloedema
- Optic atrophy
- New onset nystagmus
- Reduction in visual acuity not due to refractive error
- Visual field reduction
- Proptosis
- New onset paralytic squint
- Visual symptom with 1 or more other symptom
Common Pitfalls
- Failure to fully assess vision—REFER IF NECESSARY
- Failure of communication between community optometry and primary and secondary care
Head Circumference
- Consider a brain tumour in any child under two years with an increasing head circumference outside the normal range in comparison to their height and weight
- Careful assessment of other signs and symptoms of a brain tumour should be undertaken in these babies
CNS Imaging Required With:
- Rapid rate of head circumference growth crossing centiles
- Increasing head circumference with any other associated symptoms
Common Pitfalls
- Failing to measure and monitor head circumference in a baby or young child with persistent vomiting
Motor Symptoms and Signs
- Consider a brain tumour in any child with persisting[E] motor abnormality
- Motor assessment requires history or observation of:
- sitting and crawling in infants
- walking and running
- handling of small objects
- handwriting in school age children
- Brain tumours can cause a loss or change in motor skills and this can be subtle e.g. ability to play computer games
CNS Imaging Required With:
- Regression in motor skills
- Focal motor weakness
- Abnormal gait/co-ordination (unless local cause)
- Bells palsy with NO improvement within 4 weeks
- Swallowing difficulties (unless local cause)
- Head tilt/torticollis (unless local cause)
- Motor symptom with one or more other symptom
Common Pitfalls
- Attributing abnormal gait/balance to middle ear disease with no corroborating findings
- Failure to identify swallowing difficulties and aspiration as a cause of recurrent chest infections
Growth and Endocrine
- Consider a brain tumour in any child with any combination of growth failure, delayed/arrested puberty and polyuria/polydipsia
- Early specialist assessment if required for:
- precocious puberty/delayed or arrested puberty
- growth failure
- galactorrhoea
- primary or secondary amenorrhoea
CNS Imaging Required With:
- Growth or endocrine symptom with 1 or more other symptoms
Common Pitfalls
- Failing to consider a CNS cause in children with weight loss and vomiting
- Failure to consider diabetes insipidus in children with polyuria and polydipsia
Behaviour
- Consider a brain tumour in any child with new onset lethargy, mood disturbance, withdrawal or disinhibition
Common Pitfalls
- Failing to consider a physical cause for behavioural symptoms
Presenting Symptoms of Brain Tumours by Sub-specialty
Supratentorial tumours can cause change in personality, mood or disinhibition. They can also cause symptoms of anorexia. A brain tumour needs to be considered as part of the differential diagnosis |
Psychiatry
- Anorexia
- Behavioural change
- Depression
- Psychosis
Central tumours such as optic pathway glioma are slow growing and will present with progressive visual symptoms that may present to an ophthalmologist |
Ophthalmology
- Papilloedema
- Decreased visual acuity
- Nystagmus/Parinauds
- Diplopia
- Squint
- Visual field defect
- Blindness
- Ptosis
- Proptosis
- Ocular palsies
- Ophthalmoplegia
Head tilt or torticollis can be caused by a posterior fossa tumour. These symptoms may present to ENT specialists as head tilt and torticollis have other common ENT causes |
Ear, Nose, and Throat
- Dizziness
- Vertigo
- Torticollis
- Head tilt
- Hearing loss
- Tinnitus
A young child with hydrocephalus caused by a brain tumour will have an increasing head circumference and developmental delay or regression |
Community Paediatrics
- Developmental delay
- Developmental regression
- Increasing head circumference
A child with hydrocephalus caused by a brain tumour will have persistent vomiting. In infants where the sutures are not yet fused there will be no other signs of hydrocephalus aside from macrocephaly |
Gastroenterology
- Nausea and vomiting
- Abdominal pain
- Reflux
- Failure to thrive
- Dysphagia
A supratentorial cortical tumour will present with focal neurological signs such as weakness |
Neurology
- Seizures
- Motor weakness
- CN palsies
- Ataxia/cerebellar
- Focal neurological deficits
Central tumours such as a craniopharyngioma are slow growing and will present with abnormal growth or precocious or delayed puberty. These children may also have visual symptoms |
Endocrinology
- Growth problem
- Hypo-pit/pituitary dysfunction
- Diabetes insipidus
- Precocious or delayed puberty
- Menstrual irregularities
- Galactorrhoea
- Gynaecomastia
- Cushing’s
- Obesity/weight gain
Recurrent respiratory infections can occur secondary to aspiration caused by a bulbar palsy |
Respiratory
- Recurrent chest infections
- Apnoeas
Footnotes
[A] Lower risk=CNS tumour in differential diagnosis, low index of suspicion
[B] Persistent=continuous or recurrent headache present for more than 4 weeks
[C] Persistent=nausea and/or vomiting present for more than 2 weeks
[D] Persistent=visual abnormality present for more than 2 weeks
[E] Persistent=motor abnormality present for more than 2 weeks