Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.
Challenges in the Management of Seizure Disorders in Pediatric Patients
To provide physicians with current information on treatment strategies and management of seizure disorders in pediatric patients.
This activity is designed for neurologists, particularly those who treat pediatric patients with seizure disorders.
After reading this issue, the participant should be able to:
- Identify the essential components for forming an accurate diagnosis of seizure disorders in children.
- Describe the surgical, pharmaceutical, and alternative forms of treating and managing pediatric seizure disorders.
- Explain the neuropsychological and psychological impact of seizure disorders on children.
The Johns Hopkins University School of Medicine designates this continuing medical education activity for up to 3 credit hours in Category 1 of the Physician's Recognition Award of the American Medical Association. Each physician should claim only those hours of credit that he or she actually spends on the educational activity. Credits are available until the expiration date of May 31, 2003.
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. This continuing education activity was planned and produced in accordance with the ACCME Essentials and Standards for Commercial Support.
This continuing education activity was produced under the supervision of Ronald P. Lesser, MD, professor of neurology, Johns Hopkins University School of Medicine.
This program is supported by an unrestricted educational grant from Ortho-McNeil Pharmaceutical Inc.
Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.
Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.
The contents of this issue of Advanced Studies in Medicine are based on presentations and discussions from a roundtable discussion held in Aspen, Colorado, on January 26-27, 2001.
Ronald P. Lesser, MD
Johns Hopkins University School of Medicine
• Dr. Lesser reports receiving lecture support from and/or serving on the speakers' bureaus for Abbott, Novartis, Ortho-McNeil, Wallace, Parke-Davis/Warner Lambert, and Wyeth and is a consultant for Medtronic.
Blaise F.D. Bourgeois, MD
• Dr. Bourgeois reports receiving grant/lecture support from and serving as a consultant to Elan, Novartis, Ortho-McNeil, and Pfizer. He is a consultant to Swarz Pharma and has received grant/lecture support from UCB Pharma.
Michael S. Duchowny, MD
University of Miami School of Medicine
• Dr. Duchowny reports no financial or advisory relationship with any corporate organization.
Maryse Lassonde, PhD, FRSC
University of Montreal
Montreal, Quebec, Canada
• Dr. Lassonde reports no financial or advisory relationship with any corporate organization.
Lawrence Morton, MD
Medical College of Virginia
• Dr. Morton reports receiving grant/research support from Abbott, AstraZeneca, Carter Wallace, CoCensys, Elan, Eli Lilly, GlaxoWellcome, Hoechst Marion Roussell, Novartis, NPS Pharmaceuticals, Ortho-McNeil/Johnson & Johnson, Parke-Davis/Warner Lambert, Roche, Swarz Pharma, UCB Pharma, Harris, and Pharm D.
James J. Riviello, Jr., MD
Harvard Medical School
• Dr. Riviello reports serving on the speaker's bureaus for Cyberonics, Ortho-McNeil, Novartis, and Elan; as a consultant to Ortho-McNeil; and on the Neurology Board Review Course for Novartis.
Jong M. Rho, MD
University of California-Irvine
• Dr. Rho reports serving as a consultant to and on the speakers' bureaus of Elan, Ortho-McNeil, GlaxoWellcome, and Novartis.
Eileen P.G. Vining, MD
Johns Hopkins University School of Medicine
• Dr. Vining reports serving on the advisory board for Glaxo SmithKline.
Advanced Studies in Medicine makes every effort to provide the reader with full disclosure information from major contributors. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts or other very brief summaries.
Challenges in the Management of Seizure Disorders in Pediatric Patient
Ronald P. Lesser, MD; and Eileen P.G. Vining, MD
About 1 of every 100 children in the United States has chronic recurrent seizures. Most of these children with epilepsy are eventually evaluated by a child neurologist, and approximately 70% are adequately controlled by medications.
This issue of Advanced Studies in Medicine is devoted to helping clinicians manage the child who falls into the other 30% of these pediatric epilepsy cases—that is, those children who either are poorly controlled or cannot tolerate standard epilepsy drugs such as valproate, carbamazepine, and phenytoin. In recent years, a wealth of new diagnostic techniques and treatment options have emerged to assist refractory patients. However, the information base needed to formulate guidelines for their use is incomplete. For example, only a few of the newer antiepileptic drugs (AEDs) have pediatric data extensive enough to support specific recommendations for use. In fact, questions remain about the ideal use not only of newer strategies such as vagal nerve stimulation but also of "established" treatment options such as the ketogenic diet.
The goal of this program is to identify and acknowledge the lingering gaps in our current evidence base, and also to offer practicing neurologists and pediatricians some ad hoc guidelines for managing seizure disorders in young patients. It may be years before the professional societies issue formal evidence-based guidelines for management of refractory pediatric epilepsies. But practicing clinicians cannot wait for Class I evidence. The children and the families are already in our offices. And decisions need to be made today.
The review articles and edited discussions in this issue are based on a series of presentations and roundtables held in Aspen, Colorado, on January 26-27, 2001. At this meeting, topics ranging from evaluation to new medical and surgical options were considered by leaders in the field of pediatric seizures disorders. Every effort was made in the discussions and resulting publication to focus on issues of practical consequence in everyday neurology practice.
Lawrence Morton, MD, assistant professor of neurology/child neurology at the Medical College of Virginia, Richmond, opened the meeting by reviewing the standard diagnostic algorithm used by most pediatric neurologists today. He focused on how electroencephalograms (EEGs) and neuroimaging tests can be used in a cost-effective manner to predict risk of recurrence and to guide therapy.
James J. Riviello, Jr., MD, associate professor of neurology, Harvard Medical School, and senior associate in neurology at Children's Hospital, Boston, then highlighted our current understanding of status epilepticus in the pediatric patient, including classification, pathophysiology, prognostic factors, and the importance of prompt treatment with various medications.
Jong M. Rho, MD, assistant professor of pediatrics at University of California-Irvine, who reviewed the current status of the ketogenic diet in pediatric epilepsy, offered the first of 3 treatment-specific presentations. As made clear in the presentation and the subsequent discussion and comment, clinical efficacy data indicate that the high-fat, low-protein, and low-carbohydrate diet remains an option for many children—despite the mystery surrounding its exact mechanism and the difficulty of compliance with the strict regimen.
Because so many of the intractable seizure disorders of childhood are caused by cortical dysplasias, Michael S. Duchowny, MD, clinical professor of pediatric neurology, University of Miami School of Medicine, and director, EEG Laboratories and the Seizure Unit at Miami Children's Hospital, Florida, discussed how these and other developmental lesions manifest themselves, why they are so stubbornly resistant to standard therapy, and how improved imaging and surgical treatment are gradually improving outcomes.
Ronald P. Lesser, MD, professor of neurology, Johns Hopkins University School of Medicine, provided an update on the surgical treatment options available to children with epilepsy. New developments in presurgical testing with invasive EEGs and imaging techniques such as ictal single photon emission computed tomography (SPECT) have improved the ability of surgeons to remove or transect greater areas of epileptogenic tissue. New procedures such as vagal nerve stimulation, while neither a cure nor a replacement for medication, can offer many patients some added relief.
Blaise F.D. Bourgeois, MD, director, Division of Epilepsy in Clinical Neurophysiology at Children's Hospital, Boston, then offered his practical syndrome-specific recommendations for employing the rapidly expanding number of AEDs in children not responding to first-line medications. After a review of the unique pharmacokinetics and side-effect profiles of the AEDS in pediatric patients, Dr. Bourgeois presented some of the limited published efficacy data for broad-spectrum agents such as felbamate, lamotrigine, and topiramate and narrow-spectrum agents such as gabapentin. While stressing the need for more double-blind studies of these agents in specific pediatric epilepsy syndromes, he said the new agents are already playing a valuable role as second-line agents in everyday practice.
Finally, Maryse Lassonde, PhD, FRSC, professor of psychology at the University of Montreal, described how researchers are increasingly able to link specific psychological outcomes to specific types of seizure disorders in childhood. As we become more aware of the exact cognitive risks associated with specific syndromes, and as the neuropsychological testing becomes more sophisticated, our attempts at medical and surgical treatment will become more targeted.
Pursuing all potential improvements in therapy for our pediatric epilepsy patients—whether those improvements are incremental or dramatic—can be one of the most daunting and rewarding aspects of neurology practice. After all, these are the challenging patients who will grow and eventually shape a life around the consequences of our medical decisions. Limiting the frequency or duration of seizures may impact physical abilities, intellectual function, and quality of life. Today's decision can determine whether or not a teenager drives a car a decade from now.
How can you decide? It's not always clear, but our understanding of the disease process is improving and the treatment options are multiplying. The contributors to this program hope their presentations and comments provide some practical guidance to these rapidly evolving issues.