Paediatric Neurophysiology —
Training activity: 9

Details

Select and perform hyperventilation and photic stimulation activation procedures to include:

• Children under five
• Children over five

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Patient centred care and support
• Role of parents/guardians
• Indications and contraindications
• Local, national, international guidelines and standards
• Effective communication Informed consent
• Adverse event management procedures
• Patient safety
• Safeguarding

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to correctly selecting and performing hyperventilation (HV) and photic stimulation (PS) activation procedures, ensuring patient safety and maximising diagnostic yield for both children under and over five.
• Consider how the learning outcomes apply, specifically in relation to performing paediatric EEGs, including activation procedures, maintaining patient safety, and demonstrating effective communication to gain cooperation.
• Discuss with your training officer the specific indications and contraindications for HV and PS, and how to assess patient suitability and capacity before performing the activation.

What is your prior experience of this activity?

• Think about what you already know about the physiological basis of activation procedures and any prior experience performing HV and PS on adult or older paediatric patients.
• Consider possible challenges you might face during the activity, such as gaining adequate cooperation for HV from a child under five, accurately assessing contraindications (e.g., severe asthma or retinal pathology), or safely managing a potential photoparoxysmal response. How might you handle these challenges?
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example:
  • If a child presents with a known, complex medical history e.g., specific heart or lung condition that complicates the safe selection of HV
  • When a photoparoxysmal response is elicited during PS that requires immediate interpretation and safe termination protocols
  • If a child consistently refuses to cooperate with HV despite clear communication, requiring consultation on alternative strategies e.g., sleep deprivation/drug-induced sleep or documentation
• Acknowledge how you feel about initiating physiological and sensory stress on a child for diagnostic purposes and managing the associated safety risks.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as mastering the effective technical performance of HV (e.g., coaching breath control) and PS (e.g., managing flash frequency) tailored to the child’s age and attention span.
• Identify the specific insights you hope to gain into assessing patient suitability for activations and understanding the range of normal and abnormal EEG responses elicited by HV and PS.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of performing procedures that carry immediate, manageable physiological risks.
• Identify important information you need to consider before embarking on the activity, such as reviewing academic content on indications and contraindications for HV and PS, ensuring the patient history is definitively clear of contraindications, and clarifying the necessary safety protocols for managing activation responses.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing activation procedures (Hyperventilation/Photic Stimulation)?
• Are you encountering situations such as:
  • The child exhibits unexpected physical symptoms (e.g., severe dizziness or nausea) during hyperventilation that requires immediate termination of the procedure?
  • A highly sensitive photoparoxysmal response is elicited at a low flash frequency, challenging safety management?
  • The child’s cooperation is unexpectedly poor despite clear communication?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to patient coaching and safety monitoring to mitigate risk?
• Consider the steps you are taking in the moment, such as:
  • Immediately stopping the activation procedure and assessing the patient’s immediate response and physiological stability
  • Adjusting communication methods immediately to re-engage the child to improve cooperation or provide reassurance
• How are you feeling in that moment? For instance, are you feeling challenged in gaining or maintaining adequate compliance? Is it affecting your confidence in managing the acute safety risks associated with activation procedures?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully managing minor side effects (e.g., finger tingling) by reassuring the child? Or are you needing support because the patient has a severe adverse reaction (e.g., protracted seizure activity) necessitating emergency intervention and immediate escalation to senior medical staff?
• What are you learning as a result of the unexpected development? For example, are you gaining insight into the critical timing and judgment required for stopping activation procedures safely?

On action

What happened?

• Begin by summarising the key steps you took when selecting, explaining, and performing the activation procedures (HV and/or PS) for the child e.g., checking contraindications, demonstrating the procedure, monitoring response.
• Consider specific events, actions, or interactions which felt important, such as how you coached the child (over five) to achieve effective hyperventilation, or how you managed the safety distance and light intensity during photic stimulation.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately terminating photic stimulation when a photoparoxysmal response was elicited.
• How did you feel during this experience, e.g., did you feel acute awareness of the safety protocols or challenged by the need to maintain patient cooperation?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding safely performing activation procedures. What strengths did you demonstrate, e.g., accurate selection of the appropriate stimulation parameters? What skills and/or knowledge gaps were evident, e.g., difficulty gaining sufficient patient cooperation for hyperventilation despite clear instruction?
• Compare this experience against previous engagement with similar activities – has your practice improved in identifying the resulting EEG patterns elicited by these activations?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding whether a specific EEG change during activation constituted an abnormal response requiring further action, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to performing and interpreting activation procedures.
• What will you do differently next time you approach performing hyperventilation on a child, for instance, by proactively using a timer and a visual aid to encourage and coach consistent breathing effort?
• Do you need to practise any aspect of the activity further, such as refining your explanation of the activation procedures or key learning outcomes related to identifying features of abnormal EEGs elicited by activation?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences selecting and performing activation procedures since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent patient exhibited a photoparoxysmal response requiring immediate, safe termination forced you to re-evaluate the diligence of your pre-procedure safety checks you applied during your first attempt at performing photic stimulation.
• Considering what you understand about indications and contraindications for activation procedures, patient safety, and ensuring patient cooperation now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your activation procedure selection and performance technique based on further learning and experiences? For example, how you proactively reviewed and implemented age-specific coaching techniques to improve cooperation during hyperventilation for children over five, demonstrating you have adapted improvements based on further learning.
• Has discussing cases involving adverse patient reactions or the impact of poor communication on activation compliance with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a failed hyperventilation due to patient anxiety, refined your understanding of the critical nature of proactive communication and establishing rapport before starting activation.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent activation procedure performance experiences, contributed to your overall confidence and competence in selecting and performing activation procedures safely and effectively, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in assessing patient suitability and managing physiological changes during stimulation now enables you to confidently explain activation procedures during an OCE assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to performing activation procedures? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or Neurologist immediately when a child presents with a complex cardiac or respiratory history that complicates the safety of hyperventilation, recognising this requires specialist medical consultation regarding contraindications.
• Looking holistically at your training journey, how has this initial activation procedure experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing EEGs, practicing safely, and identifying features? For example, how this foundational experience has supported your development in understanding the clinical significance of activation procedure results for subsequent learning outcomes focused on diagnostic interpretation.

Relevant learning outcomes

#	Outcome
# 1	Outcome Identify features of normal and abnormal neonatal and paediatric EEGs, including activation procedures.
# 2	Outcome Prepare patients and environments for testing, maintaining safety and patient dignity.
# 3	Outcome Demonstrate effective and compassionate communication skills with all stakeholders, including patients and the multidisciplinary team.
# 4	Outcome Perform neonatal and paediatric EEGs, including activation procedures in a range of conditions and ages, maintaining patient safety and ensuring patient experience.