Category Archives: Pediatrics

Pediatrics

Reviewing the 2023 RSV season and an outlook on 2024 – Contemporary Pediatrics

In this video interview, Tina Tan, MD, FAAP, FIDSA, FPIDS, editor in chief, Contemporary Pediatrics, professor of pediatrics, Feinberg School of Medicine, Northwestern University, pediatric infectious diseases attending, Ann & Robert H. Lurie Children's Hospital of Chicago, recaps 2023 with regard to respiratory syncytial virus (RSV).

Tan breaks down the severity of the RSV season in 2023, how newly FDA approved preventive tools have changed the treatment landscape, and what could be in store for 2024.

Interview transcript (edited for clarity):

Contemporary Pediatrics:

Hello and thanks for watching. I'm Joshua Fitch, editor of Contemporary Pediatrics. Today I'm joined by Dr. Tina Tan, editor in chief of Contemporary Pediatrics and a pediatric infectious disease attending at Ann and Robert H. Lurie Children's Hospital in Chicago. Dr. Tan, thank you for being here. First, let's talk about what a year it's been when it comes to RSV. Going back to about a year ago, when it was a very difficult RSV season, can you take us back and recap that a little bit, and really the urgent need for some some new treatment for this obviously, very young population?

Tina Tan, MD, FAAP, FIDSA, FPIDS:

Yeah, absolutely. So RSV causes annual epidemics, but last year, what we were noticing is that there wasn't just 1 epidemic, but there were actually several surges of RSV that occurred out of its normal season. So RSV normally occurs between October and March here in the United States and for reasons that are still not understood, we actually had several surges last year with 1 surge actually occurring during the summer. But it was the fall surge, which started earlier, that really was incredible, because we also were having surges of influenza, as well as COVIDa nd what that ended up doing was it overwhelmed the pediatric health care system so that there really were few to no hospital beds that were available at any given time. There were children that actually had to be transported either by ambulance or helicopter to other states in order to be treated and hospitalized for complications that they were having from RSV. It really did point out the fact that we did not have any way of preventing RSV disease, and that we really needed to have other tools in order to decrease the amount of severe RSV that we were seeing that was placing kids and infants in the hospital.

Contemporary Pediatrics:

Thank you Dr. Tan, of course, like you just mentioned, that harsh of an RSV season then turned into those new tools and vaccines to prevent the disease, including nirsevimab approved in July 2023 and Pfizer's maternal vaccine approved in August. Obviously, this was an exciting time looking back, can you kind of discuss what these approvals meant at that time, and really still mean now for RSV disease?

Tan:

That was fantastic news, because it really put other tools in our toolbox that we could use to prevent the severe complications that were being seen with RSV, especially in the younger infants under 6 months of age. And not only were we able to give a monoclonal antibody to the infants under 8 months of age, but we also were able to vaccinate pregnant women between 32 and 36 weeks so that they would be able to pass antibody on to their babies during a time when the baby would be at greatest risk for having complications should they get RSV, so it was really fantastic news that we had 2 different tools available that could decrease the amount of severe RSV disease that was being seen.

Contemporary Pediatrics:

To quickly follow up on that, you explained it from the health care professional standpoint. In your day-to-day, talk about kind of a sense of relief, if there was one from the parents standpoint, as they were the ones also dealing with their child having RSV disease, the cause for concern. Can you touch on that, what you've seen and what kind of relief these these approvals have brought?

Tan:

When nirsevimab was first approved, there were parents that were literally calling and clamoring to try and get the vaccines for their babies or the monoclonal antibody for their babies. Talking to some of my ob-gyn colleagues, there were women that were asking for RSV vaccine because they understood, because many of them had other children that this could be a potentially severe infection that their younger baby could get, and so they were actually asking the ob-gyn for the vaccine. So, I think that the word has gotten out that we do have something that can prevent hospitalization and other complications in these very young babies.

Contemporary Pediatrics:

You mentioned the word getting out. Well, recently following the approvals, the next question heading into September and October was availability, mainly with nirsevimab as it turned out. In October, the CDC recommended it'd be prioritized for the highest risk infants, amid some limited availability. Can you talk about some of the rollout challenges you've noticed, and availability now that we're into the RSV season and the winter months?

Tan:

It really has been a challenge for individuals to get an adequate supply of nirsevimab. Nobody has an adequate supply. People are prioritizing their 100 mg doses, which is recommended for infants that are 5 kilos and greater in weight to those infants that are under 6 months of age, infants that have underlying conditions, and infants that are Alaskan Native, American Indian infants, because we know that these are infants that are at the greatest risk for complication, should they get RSV.

Contemporary Pediatrics:

Is that kind of an unprecedented situation to where here's the brand new tool we've been talking about for so long, but now, how do we get it to everyone? Have we seen this before on such a large nationwide scale.

Tan:

We've seen this before, in some of the severe influenza seasons, where individuals were not able to get enough influenza vaccine to vaccinate their patients. So it's not unheard of that this happened and I think what probably occurred is that there was an underestimation of the demand that would happen once the product was released.

Contemporary Pediatrics:

Thank you, Dr. Tan. Lastly, we've kind of reviewed start of 2023 to now, looking ahead in your opinion, where do you think we stand when it comes to these preventative treatments? What trends have you noticed this RSV season, and if you can speak to any national trends as well, that'd be great, as we close out 2023 and really look into 2024's winter months.

Tan:

Right now we are starting to see a surge in RSV in many different areas of the country. It still remains to be seen how effective the limited amount of nirsevimab being given and maternal immunization being uptaken will have in terms of impacting the amount of severe RSV disease that we're seeing. My hope is that there is going to be some impact it might not have been as great as we would have liked to seen, but I would hope that there would be some impact with the use of the nirsevimab available and the maternal vaccination on the amount of severe RSV disease that may occur.

Contemporary Pediatrics:

Dr. Tan thank you so much for speaking with us.

Tan:

My pleasure.

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Reviewing the 2023 RSV season and an outlook on 2024 - Contemporary Pediatrics

Pediatrics

Predictive Factors for Insulin Resistance in Pediatric Obesity: A Comprehensive Analysis – Physician’s Weekly

The following is a summary of Predicting Insulin Resistance in a Pediatric Population With Obesity, published in the December 2023 issue of Pediatrics by Arajo, et al.

Insulin resistance (IR) affects overweight and obese kids and teens, and its important to catch it early to avoid long-term problems. For a study, researchers sought to find factors that can be used to predict IR and create a multivariate model that could do this correctly. They did a cross-sectional study of demographic, clinical, and biochemical data from a group of patients who went to a specialized Pediatric Nutrition Unit in Portugal over 20 years. To identify IR, they made multivariate regression models.

People who took part were randomly split into two groups: a model group that worked on building predictive models and a confirmation group that checked the studys results against the model. Results: 1423 people between the ages of 3 and 17 took part in their study. They were randomly split into two groups: the model group (n = 879) and the evaluation group (n = 544). The predictive models, which used demographic and clinical factors that were not used in other models, were good at telling the difference [area under the curve (AUC): 0.8340.868; sensitivity: 77.0%83.7%; specificity: 77.0%78.7%] and had high negative predictive values (88.9%91.6%).

Adding fasting glucose or triglycerides/HDL cholesterol index to the models based on clinical factors did not make them better at diagnosing, but adding fasting insulin seemed to make the model better at telling the difference (AUC: 0.996). During the evaluation, the model that considered demographic and clinical factors along with insulin had a high accuracy rate for detecting IR (AUC: 0.978) and consistently high negative predictive values (90%96.3%) for all models. Conclusion: Models based on demographic and clinical factors can help find kids and teens who are moderately or highly likely to have IR and would benefit from a fasting insulin test.

Source: journals.lww.com/jpgn/abstract/2023/12000/predicting_insulin_resistance_in_a_pediatric.19.aspx

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Predictive Factors for Insulin Resistance in Pediatric Obesity: A Comprehensive Analysis - Physician's Weekly

Pediatrics

Locals partner to open pediatric clinic in Brookhaven – Daily Leader – Dailyleader

Published 2:58 pm Thursday, December 28, 2023

BROOKHAVEN Ole Brook Kids Pediatric Clinic Co-owners Kayla Thurman and Amber Martin hope to serve the community with their new business. Both are certified nurse practitioners. Martin has 24 years of pediatric experience and Thurman has 11 years of pediatric experience.

The new pediatric clinic will open at 301-C US51 S, hopefully, by the end of January. The location can be found on Dr. Louie Wilkins Drive just south of Walgreens.

For the last four or five years, Thurman and Martin have shared a small office space and worked closely together. Thurman said she saw ways to help the local community and an opportunity to fill a need for a purely pediatric clinic in Brookhaven. She shared her idea with Martin and they went in together to open up the practice.

We would see so many patients who didnt have any other places to go but didnt need an emergency room or adult urgent care. We are pediatric trained and will offer something new, Thurman said. In the last year, it just came up. It was a God thing. It fell in place perfectly. We needed a physician to partner with us and my preacher recommended someone I used to know. Every piece has been put together. It is a huge leap of faith. Now our idea and dream is a reality.

Ole Brook Kids will be located in a former dentist office. Renovations have been mostly cosmetic and the once red brick exterior was painted now snow white. Martin said the building is owned by Hunter Posey who happened to have the perfect space for them. It all fell into place.

The clinic will treat fevers, coughs, acute illnesses, minor injuries and simple wound repairs. Their mission statement states they understand illness and injuries dont always happen between 8 a.m. to 5 p.m. and will work to provide care outside of those hours. Martin said they plan to be open with longer hours during the week and be open from 10 a.m. to 2 p.m. on Saturday and 1 p.m. to 4 p.m. on Sunday. Wellness visits, sports physicals and vaccinations will also be offered by the clinic.

Thurman and Martin have practiced in Brookhaven long enough that Martin is confident they will have a client base to start.

The connections we have made have been remarkable. It has fallen in place. This is a community that is well connected with people excited to be a part of a small business, Martin said. We felt led. The support in the few things we have put out there has been humbling and amazing. We care about our patients and look to our work as service.

Thurman said they plan to be Big enough to serve you and small enough to know you.

Careers of service

Thurman received her bachelors of science in nursing from the University of Mississippi Medical Center in 2012 and started her career in the Pediatric Intensive Care Unit at UMMC. She earned her masters of science in nursing from the University of Alabama Birmingham as a pediatric nurse practitioner in 2015. She is originally from Monticello.

Her career took her to Blair E. Batson Childrens hospital to work in the Pediatric Emergency Department. Thurmans husband is Dillon Thurman and they have three children Kinley, John Luke and Fisher Thurman. She is an active member of Grace Life Church in Brookhaven. Outside of nursing, she enjoys watching her childrens activities and spending time with family.

Thurmans interest in pediatrics began in middle school. She said in high school as soon as she got her drivers license she would drive up to Jackson to volunteer at the childrens hospital.

Working with kids you take care of the whole family. You have a fulfillment and get to watch them grow. You are with them a while, Thurman said. I wanted to come back home and serve my own community. I had a dream of opening up my own clinic. I presented the idea to Martin and she said yes so here we are. We are trusting God and His will. He has worked it all out.

One of the reasons she enjoys working with pediatrics is due to the resilience of kids. They tend to bounce back faster and children offer a challenge because they do not always fit the box.

Martin graduated with a bachelors of science in nursing from the University of Southern Mississippi in 1999. She began her career working in the Neonatal Intensive Care Unit at UMMC. In 2012, Martin continued her education and earned a masters of science in nursing from the University of South Alabama. She is originally from Gulfport.

She is married to Brad Martin. Their children are Makayla, Mallory and Maddox. All three children have kept Martin busy with local activities and sports. They are active members of Calvary Baptist Church.

Outside of nursing, Martin serves as an adjunct teacher for the Mississippi College nursing program. She teaches courses in registered nursing, the bachelors of science in nursing and masters of science in nursing programs. Her time at UMMC prepared her for pediatric medicine.

I always wanted to be a nurse and loved neonatal care. It all led to pediatrics. When my husband was in school in Georgia I worked at a hospital there. They encouraged me to go back to school to do this and I have loved it ever since, Martin said. It has been about connections with people. One door opens and then you step through it. You see children a lot. I had always thought about having my own pediatric clinic. It brings back your passion when you have ownership of it.

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Locals partner to open pediatric clinic in Brookhaven - Daily Leader - Dailyleader

Pediatrics

Infants Pay the Price When Parents Battle Food Insecurity and Benefits Red Tape – Research Horizons – Research Horizons

Study led by Chidiogo Anyigbo, MD, MPH and colleagues at Cincinnati Childrens documents early signs of emotional and behavioral disruption in households under stress, reinforcing the need to assure stable access to healthy nutrition from day one.

Taking on the parenting duties to support a newborn child is stressful enough when everything goes well.

But when parents living in under-resourced conditions also must battle government red tape to stay enrolled in important food benefit programs, the stress measurably affects their babies emotional and behavioral health, according to research published Dec. 26, 2023, in JAMA Pediatrics.

Given the importance of the first year of life to overall brain development, addressing disruptions to food security is a problem that requires rapid intervention, according to lead author Chidiogo Anyigbo, MD, MPH, a clinician and researcher with the Division of General and Community Pediatrics at Cincinnati Childrens.

A number of studies have associated household food insecurity with poor pediatric mental health outcomes including depression, externalizing and internalizing behaviors, and hyperactivity, Anyigbo says. But those studies have focused almost exclusively on children aged nine months and older. To our knowledge this is the first study to document the association between household food insecurity and problems accessing nutrition benefits programs and behavioral challenges during the first six months. This finding is important because at this stage of child development, every month matters, and early intervention can have lifelong benefits.

The American Academy of Pediatrics provides many recommendations for preventative screening for a childs physical and mental health. While pediatricians can use blood tests, scanners and other tools to learn many things about an infants health, understanding how their environments influence mental health is no simple task.

This study used two measurement tools routinely administered during primary care pediatric well visits to identify populations of infants at early risk of behavioral challenges due to factors such as impact of food insecurity or public benefits programs. Overall, the study analyzed data from more than 1,500 infants, 90% of whom lived with families receiving or qualified to receive public health insurance (Medicaid).

The researchers started with a screening tool that assesses health-related social needs (HRSNs) before the age of 4 months. They compared that information to another standard tool called the Baby Pediatric Symptom Checklist (BPSC), which is given at age 6 months.

The HRSN data reveals a constellation of problems that under-resourced families can face, including challenges meeting basic needs for food, housing, and safety. But in this study, researchers found a particular correlation between reports of food insecurity and difficulties maintaining benefits, and infant behaviors measured in more detail at age 6 months.

Overall, about 26% of the families studied reported babies exhibiting unusual amounts of behavioral dysfunction such as inflexibility, difficulty with routines, and irritability. The more problems reported in the HRSN data, the more problems were found later in the BPSC data.

Specifically, when two or more problems appeared on the HRSN screening, children were twice as likely to exhibit behavior concerns on their BPSC screening test that were serious enough to prompt clinical review, Anyigbo says.

We already know that food insecurity can increase emotional distress, increase aggravation, and weaken the attachment between parent and child, Anyigbo says. Now with screening tools that can detect these concerns at an early age, we have an opportunity to intervene.

Pediatricians and primary care clinics have near-universal access to infants and are well-positioned to help connect families to food pantries and community food banks. They also can help families connect with parent support programs, services to assist with insurance coverage, and programs such as the Supplemental Nutrition Assistance Program (SNAP) and the Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Anyigbo has already begun working on an online platform and QR code project to help more families who speak a variety of languages navigate the hassles of qualifying for food benefits through the WIC program. Read more about the $326,000 grant awarded for that project.

The idea that these kinds of support systems are needed isnt especially new, Anyigbo says. What is new is that the evidence indicating how vital it is for healthy infant behavioral development to address food insecurity right away. Challenges accessing public nutrition benefits such as WIC may further compound the deleterious effects of food insecurity on infant behavioral functioning. This is particularly relevant given ongoing calls for Congress to act to fully fund the WIC program.

In addition to Anyigbo, Cincinnati Childrens co-authors included Chunyan Liu, MS, Shelley Ehrlich, MD, ScD, MPH, Allison Reyner, MS; Robert Ammerman, PhD; and Robert Kahn, MD, MPH.

Funding sources for the study include the National Center for Advancing Translational Sciences (KL2TR001426) and a Young Investigator Award from the Academic Pediatric Association.

A six-year study led by experts at Cincinnati Childrenspublished Oct. 16, 2023,inJAMA Pediatricsfound alarming evidence of unhealthy behavioral trajectories starting as early as age 2 among families affected by low income and other social stressors.

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Infants Pay the Price When Parents Battle Food Insecurity and Benefits Red Tape - Research Horizons - Research Horizons

Pediatrics

RSV Roundtable: Addressing the senior population – Contemporary Pediatrics

Welcome to the fourth episode of our 5-episode series; respiratory syncytial virus (RSV) Roundtable, a collaborative project fromContemporary Pediatrics,Contagion, andContemporary OB/GYN.

This series discusses several aspects of RSV including incidence rates, vaccines, and immunizations.

In this episode, our panel evaluates challenges in providing RSV vaccination to the senior population, including the lack of a "one size fits all" recommendation and risk factors such as heart failure that are more common in this population.

Our panel of clinicians includes:

This series will release a new episode every Friday through January 5, 2024.

For a full list of already published episodes, click here.

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RSV Roundtable: Addressing the senior population - Contemporary Pediatrics

Pediatrics

Rehabilitation Following Above-Knee Amputation in a Pediatric Osteosarcoma Patient: A Case Report – Cureus

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Rehabilitation Following Above-Knee Amputation in a Pediatric Osteosarcoma Patient: A Case Report - Cureus

Pediatrics

Campbell chair of Pediatrics talks with WRAL about flu, respiratory illness – News | Campbell University – Campbell University News

Dr. Lori Langdon, chair of Pediatrics at the Campbell University School of Osteopathic Medicine, spoke with WRAL this week after the death of a Wilson girl who developed myocarditis after she was infected with the flu, WRAL reports.

Langdon also offered parents advice on when to see a doctor or to seek emergency care. She told the Raleigh station that its important to closely monitor children when theyre sick, particularly for fever and dehydration.

The height of the fever or number doesnt scare us. It scares us how they are handling the fever, said Langdon, who has more than 25 years experience in pediatric medicine. Really push fluids. I dont want you to be concerned if they are not eating solid foods.

Respiratory infections are now prevalent, she told WRAL.

Our top reason for seeking a higher level of care is if there is difficulty breathing, Langdon said. We are getting slammed with RSV right now.

Seek emergency care if a child is struggling to breathe, Langdon told WRAL.

If their belly muscles are working in and out to help them breathe, shoulders bobbing, head bobbing all are bad signs of respiratory distress, and they should be seen even if its the weekend, even if its the middle of the night, Langdon said.

Langdon also has nearly 1,000 subscribers on her YouTube channel, where she offers medical advice to children and parents.

Seasonal influenza activity is elevated in most parts of the country, with the Southeast, South-central, and West Coast areas of the country reporting the highest levels of activity, the Centers for Disease Control and Prevention reports, as of Dec. 15.

More than 7,000 people were admitted to hospitals over the past week. Nationally, 14 children this season have died of the flu, the CDC reports.

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Campbell chair of Pediatrics talks with WRAL about flu, respiratory illness - News | Campbell University - Campbell University News

Pediatrics

Democrats eye appropriations to protect pediatrician training – Roll Call

Corrected 3:46 p.m. | House Republicansattempting to tie the reauthorization of a critical pediatrician training program to efforts to limit gender-affirming care for transgender children acknowledge those efforts will collapse. Now lawmakers are lookingto fund the program as-is through the appropriations process.

Federal authorization for the Childrens Hospitals Graduate Medical Education Program, which trains more than half of pediatric specialists and almost half of general pediatricians nationwide, lapsed on Sept. 30.

Earlier this year, the Republican-led House Energy and Commerce Committee approved a reauthorization bill that bars any federal funds from going to hospitals that provide gender-affirming care. That provision was a nonstarter for Democrats, who wanted to see a clean reauthorization of the physician training program.

Both sides have refused to budge, and without congressional investment, hospitals might be forced to make cuts to fund their next classes of fellows and residents.

But in a last-minute bid to prevent more pediatrician shortages, some lawmakers hope to appropriate dollars for the Childrens Hospitals Graduate Medical Education program through the fiscal 2024 Labor-Health and Human Services-Education funding bill.

There are no actual consequences to not reauthorizing the program and just appropriating funding, a Senate Democratic aide said, unless lawmakers want to make changes to the program. Funding the training program through the appropriations process would sidestep GOP attempts to tie the training program to an anti-trans policy.

The Labor-HHS-Education funding deadline this year is Feb. 2, thanks to an unusual two-pronged approachthe Hill is taking to appropriations this year. So far the House has passed seven of its 12 appropriations bills, but the health funding bill is not on that list.

The proposed House Labor-HHS funding bill includes $400 million for the program, a $15 million boost above the 2023 enacted level but it includes the gender-affirming care restrictions. The Senate bill proposes $385 million flat fundingwithout restrictions.

The focus right now is ensuring the appropriations is as robust as possible to make sure the funding continues, a Childrens Hospital Association spokesperson said. The group is hopeful the gender-affirming care provisions will be stripped out in conference.

Rep. Kim Schrier, D-Wash., a pediatrician who led Democrats attempt to get a clean reauthorization of the program through the House, said shes hopeful this plan will get funds to childrens hospitals in the next year, though shes disappointed the usually bipartisan program has devolved to this.

Congress cannot afford to cut funding at a time when the US desperately needs to be training the next generation of pediatricians and pediatric subspecialists, Schrier said in a statement.

The standoff comes as pediatric hospitals face workforce shortages among physicians and nurses and many childrens hospitals have been forced to rely on temporary staffing agencies to fill workforce gaps, according to the Childrens Hospital Association.

Its become more difficult to fill pediatric residency positions in recent years, and several pediatric specialties are seeing 20 to 40 percent fewer applicants, according to the American Academy of Pediatrics.

The Childrens Hospitals Graduate Medical Education program is, at its core, a workforce program and has historically been a bipartisan, feel-good issue. In 2018 Texas Republican Michael C. Burgess co-led the reauthorization.

But House Republicans are making gender-affirming care a hallmark social issue of this Congress. So far theyve added riders to seven of 12 government funding bills to limit access to hormone therapy, surgery and other, similar care.

Most of the bills have little chance of passing the Democrat-controlled Senate, but thats not the point for conservatives, who want to amplify the issue ahead of the 2024 election.

This is the issue of our time. This is the hill were going to die on, Rep. Daniel Crenshaw, R-Texas, who led the legislative push in committee to tie pediatric physician training to gender-affirming care bans, said of gender-affirming care during a summer legislative hearing on his bill.

But asked this week whether hed hold up the appropriations process over the policy rider, Crenshaw, who is still advocating for his legislation with riders blocking gender-affirming care, acknowledged the House needs to get a bill to the floor.

Im weighing my options as the funding process moves, he said.

This story has been corrected to reflect the correct date the Labor-HHS-Education spending bill expires.

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Democrats eye appropriations to protect pediatrician training - Roll Call

Pediatrics

Discussing epilepsy’s initial signs and treatments in the pediatric population – Contemporary Pediatrics

In this Contemporary Pediatrics interview, William Gallentine, DO, clinical professor of neurology, interim chief, Pediatric Neurology, Stanford Medicine Children's Health, discusses what to look for when suspecting epilepsy in children, who to refer to, and how to break down seizures to worried parents.

Interview transcript (edited for clarity):

Contemporary Pediatrics:

What signs can the general pediatrician look for suspecting epilepsy?

William Gallentine, DO:

So seizures really are behaviors that occur whenever we have abnormal electrical discharges occurring within the brain. They can occur within many areas and depending on where those seizures are coming from, oftentimes, the behaviors that you can see in association with those can vary quite dramatically. Because of that, seizures can have a varied appearance in terms of how they may look.

The appearance of them, sometimes the child can be confused, and not behaving appropriately with repetitive type of movements on one side of the body. Other times, they actually may be more what people more traditionally think of as kind of generalized convulsions where the entire body may stiff and, and shake. Those are things that seizures that are more readily recognized by providers, and are not quite as subtle, and the ones that oftentimes quickly become presented to emergency departments, and brought in as acute level of care. So depending upon the nature of the seizure, oftentimes they may be determined to be seizures easier.

A hallmark of things that would kind of highlight them being seizures, would be seizures oftentimes look the same. So they have the same appearance when they occur. If they are occurring in the same area of the brain, that same area of the brain is involved, oftentimes, you'll have this appearance, that will look the same over and over again. So if you're having repetitive behaviors, that kind of look the same for short periods of time, that's kind of the hallmark of seizures.

The other things that you can also kind of look to are the events that occur out of sleep, that are also repetitive, can oftentimes be a clue that this could be something that's potentially related to epilepsy.

Contemporary Pediatrics:

Who should a child be seeing once epilepsy is suspected after a primary visit?

Gallentine:

Making sure that they're seeing an epilepsy provider, someone with it with expertise in that area, and that certainly could be a child neurologist or an epilepsy specialist. The majority of children that we take care of seizures can be well controlled with our typical anti-seizure medications, and really can go about their normal lives and do all the things that we wished for them to do.

But there is a smaller subset of patients that make up about 20% or 30% of patients with epilepsy, that the seizures become very difficult to control and are resistant to the medications. In those scenarios, even if they are seeing a child neurologist, if they haven't been seen at a tertiary medical center with expertise in epilepsy, it's really important to advocate for the patient being evaluated in a program like that, because there are different types of therapies, there are different approaches in the centers that we'll be taking will be very aggressive in terms of trying to get the seizures under better control.

That may be with further medications, but oftentimes that may be going a different route with our treatments. That may be including surgical interventions, where we're actually trying to render a patient seizure-free by doing a specific surgery to eliminate epileptic focus, that may actually be offering dietary therapies where we're using specific things like ketogenic diet to try to help control seizures, or it could even be implanting nerve stimulators, where were actually putting in stimulators, either on the periphery, or actually even into the brain that may help decrease the frequency and improve overall seizures.

All this is extraordinarily important, because we know that the longer children go with very difficult to control seizures, the worse their outcomes ultimately are. This could have an impact on their overall cognition, and their overall long term potential within their lives to do the things that they ultimately want to do.

Contemporary Pediatrics:

What can the general pediatrician do during initial visits to not only help the child, but also reassure the parents?

Gallentine:

The big thing is one, recognize that this is a very scary situation. These are some of the most scary situations that parents can go through and so sort of recognizing that our property yes, this can be very scary, but the reality of it is, that the majority of children who are having a seizure, once the seizure is over, the emergency is over. In the acute period, and that period with the seizures occur, really the sole job is this kind of support the child, make sure that the child is safe. In that scenario, [it] is recommend basic seizure first aid. One, look at your watch so you know how long the seizure is lasting, and then two, just making sure the patient is safe.

Most seizures in most individuals are only going to last 1 to 2 minutes in duration and following that, like I said, the emergency is over. Where the bigger problem comes, is when the seizure lasts more than 5 minutes, then the likelihood of that seizure ending on its own without medical intervention really begins to drop off. Oftentimes, you're going to require a medication to actually get that to seizure to stop. That's a scenario where one, activating 911, if the seizure is clearly going to be a prolonged seizure, and number two, hopefully those patients will have rescue medications. Medications that have been either provided by their primary care doctor, at the emergency department, or if they've already seen a neurologist in that particular setting, and administering a rescue medication at that 5-minute mark, really trying to avoid prolonged seizures.

Seizures that last more than 30 minutes, which then potentially result in injury to the brain. Usually, a lot of the time is spent on that initial visit with a first time or second time seizure patient. One, trying to have the parents understand kind of what's an emergency and what is not. And realizing that in most circumstances, the seizures are going to be brief. They're going to get through them, and really, we just want to make sure that things are safe. We don't want [the child] putting things into their mouths, we want to roll them in a rescue position so that they're safe. But really, just getting them through that and then supporting them. So that's kind of the acute portion of that. And then the next question that's always on the mind, of all the families was 'why is this happening?' And in that situation, it's going to come down to their evaluation in terms of what's the underlying cause. In most circumstances that evaluation is going to be led by the neurologist. So getting them in with those appointments, getting them in to see the neurologist and kind of move forward with those evaluations can be very helpful in expediting those things.

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Discussing epilepsy's initial signs and treatments in the pediatric population - Contemporary Pediatrics