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The Whole Child: Conditions Associated with Pediatric Epilepsy

The Whole Child: Conditions Associated with Pediatric Epilepsy. Beverly Wical, MD Gillette Children’s Specialty Healthcare November, 2010. Things we think about at the beginning:. At the beginning…. Identifying cause Control of seizures. As time goes on:. Seizure control

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The Whole Child: Conditions Associated with Pediatric Epilepsy

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  1. The Whole Child: Conditions Associated with Pediatric Epilepsy Beverly Wical, MD Gillette Children’s Specialty Healthcare November, 2010

  2. Things we think about at the beginning:

  3. At the beginning… • Identifying cause • Control of seizures

  4. As time goes on: • Seizure control • Adverse effects of therapy • Associated conditions

  5. Associated conditions are associated with….? • Underlying neurologic diagnosis: what causes the epilepsy (and the other problems) • Epileptic phenomena • Seizure effects • Epileptic encephalopathy • Medication side effects

  6. Underlying neurologic diagnosis: the cause of the epilepsy: • Strongest predictor of associated conditions • Tells us “where to look” for potential problems • Gives clues about a child’s future from experiences of children with similar disorders

  7. Underlying cause: examples… • Brain injury from prematurity • Brain malformation • Infection • Stroke • Trauma • Metabolic disorder

  8. “Direct effects” • Seizure effects • Injury during a seizure • Sleepiness or headache after seizure • Epileptic encephalopathy • Epileptiform EEG abnormalities contribute to a progressive disturbance in cerebral function (ILAE)…changes in the EEG change the child’s function

  9. Medication side effects: • Very common • Often missed • The one we can most easily alter…and one caused by us. • ALL associated condtions: COULD IT BE A MEDICATION SIDE EFFECT??

  10. Associated conditions in kids with epilepsy…

  11. Associated conditions in kids with epilepsy:

  12. How to screen for associated conditions: Quality of Life… • What aspects of the child’s life present the greatest barrier to: • Best function in his/her family, work (school) and social groups? • Greatest comfort? Physically, emotionally, mentally…

  13. Cognition: thinking and learning • Intellectual ability “IQ” • Ways of thinking and learning: • Nonverbal…right hemisphere • Language based; expressive/receptive…left hemisphere • Executive functioning…frontal lobes • Memory…temporal (and frontal) lobes • Visual/spatial/motor (right hemisphere, parietal lobes)

  14. Mood • Anxiety • Depression • Irritability • Mood swings

  15. Behavior • Oppositional • Irritable • Angry • Aggressive • Too passive, “not interested” • Hyperactive • Autism spectrum disorder

  16. Sleep • Excessive daytime sleepiness • Insomnia • Sleep disordered breathing • Delayed sleep phase • Behavioral • Seizure related sleep disruption

  17. Autonomic function • “Automatic” functions • Heart rate • Breathing rate/control • Blood pressure • Body temperature (core, extremities) • Sweating • Pupillary control • Gastrointestinal function • Bladder function

  18. Food stuff… • Appetite • Weight gain or loss • Abdominal discomfort, nausea, vomiting • Feeding intolerance, delayed gastric emptying

  19. Motor impairments • Developmental coordination disorder • Low muscle tone (hypotonia) • Balance impairments • Cerebral palsy • Quadriplegia (all) • Hemiplegia (half) • Diplegia (both legs)

  20. Bone health: • Assessment for reduced bone density, risk for fractures • Related to use of certain AEDs: • Phenobarbital • Phenytoin • Carbamazepine • Valproate • Ketogenic diet • Polypharmacy • Much information on children remains unknown

  21. Bone health: risks may be additive: • Ethnicity (white, Asian) • Family hx of osteoporosis • Inability to bear weight/walk • Poor nutrition; vit D or calcium deficiency • Hyperthyroidism, hyperparathyroidism • Liver disease • Medications: steroids

  22. Bone health: • Enough vitamin D? (600 – 800 IU/d) • Enough calcium? (1000 – 1200 mg/d) • Increased risk of low bone density • Fracture risk?

  23. Sally: 10 yo girl • Focal seizures • Gasp, stiffen, turn head to R, jerking right arm • Brief episodes (all less than 2 min) • All in sleep (night time, occasional in nap)

  24. Abnormal EEG, left frontal region • Normal MRI • No other health problems identified • Seizure suspected to come from L frontal lobe

  25. Cognition Mood Behavior Sleep Autonomic Food Motor Bone health Other Sally: associated problems to screen for…

  26. Frontal lobe function: • Emotional control center • Attention • Impulse control • Judgment

  27. Frontal lobe function: • Problem solving • Mental flexibility • Can’t switch tasks back and forth • Gets “stuck” on one thing • Interpreting feedback from situation to guide one’s behavior (making someone mad, backing down verbally/walking away) • External cues to guide one’s behavior (when to sit and stand visiting a church/ forks at fancy dinner)

  28. Sally: cognition/learning: • Getting B’s and C’s in 4th grade • Struggles with attention, often cannot “stay on track,” gets frustrated easily

  29. Sally: mood, behavior: • Irritable, “moody” –worse last few months • Very anxious about social situations and “tests” at school

  30. Sally: assessment of frontal lobe function • Neuropsychology: • IQ 97 • Meets criteria for anxiety disorder • Impaired working memory, attention and impulse control. • Does not need stimulant medication. Special adaptations in class room suggested. • Psychology: • strategies to address anxiety; involvement in social skills group • Psychiatry…can be very helpful, as brain and mind in same place!

  31. Sally: Mood MEDICATION ADVERSE EFFECT? • Started new medication 4 mo ago…irritability worse! • Lamotrigine and phenytoin most mood neutral…Most AEDs can do this!! • Plan to transition to lamotrigine

  32. Sally: sleep assessment • Bed time? • Bedtime routine, sleep location? • Falls asleep ok? Insomnia? • Hours slept/night? • Restless sleeper? • Seizures disturbing sleep?

  33. Signs of sleep disordered breathing: • Snores? (loud, always, half the time?) • Struggles to breathe at night? • Ever stop breathing at night? • Hard to wake up in morning? • Breathe through mouth in day? • Headaches upon awaking? • Occasionally wet the bed? • Is over weight? • Have signs/symptoms of ADHD?

  34. Wake up unrefreshed? • Hard to wake up? • Too sleepy in the daytime?

  35. Sally’s sleep: • Often anxious at bedtime • Trouble falling asleep • Positive SDB review: • Snores most of the time • Breathes heavily in sleep • Breathes with mouth open in daytime • Often sleepy at school • Poor attention, easily distractible

  36. Sally’s sleep • Referral to pediatric sleep specialist • Large tonsils on exam! • Polysomnogram (sleep study) performed with simultaneous Video EEG • Obstructive sleep apnea • Seizure captured in sleep did not cause additional apnea, but did wake her up • Referral to ENT: tonsillectomy?

  37. Sally’s food: • Sally’s appetite is increased significantly in the last 3 months. She has gained 12 pounds. She is “hungry all the time.” • New AED started 4 mo ago

  38. Sally’s food: MEDICATION SIDE EFFECT?…gain • Oxcarbazepine (carbamazepine too) • Pregabalin (also gabapentin) • Valproate • Others… • Medication transition initiated: switch to lamotrigine beginning

  39. Sally’s food: other causes of weight gain • Obstructive sleep apnea • Anxiety/stress • Life style considerations • Family food habits • Exercise

  40. Sally’s Motor: • Always “a little clumsy” • Left handed • Slow, poor handwriting

  41. Sally’s motor: • Occupational therapy evaluation: • Slowed fine motor skills, R > L • Difficulty coordinating bilateral finger movements • Would benefit from adaptive writing tools at school; should learn keyboarding as soon as possible • Allowing her to “show what she knows” without timed writing exercises would be of benefit

  42. Changes in Sally’s care plan due to associated condition identification and management: • Cognition/learning • Attention and impulse control issues identified; school programming changed to accommodate • Mood and behavior • Anxiety disorder diagnosed; treatment with therapist and social skills group initiated • Irritability at baseline recognized as part of frontal lobe dysfunction. Worsened by current AED therapy, medication switch initiated.

  43. Sleep • Obstructive sleep apnea diagnosed; tonsillectomy resolved problem. Better sleep at night, less daytime sleepiness, less irritable, better attention. • Weight gain • Due largely to AED; medication switch initiated. Exercise program started, also reduces anxiety. • Motor • Identification of fine motor problems has led to adaptations in classroom

  44. Joey: 6 yo boy • Tonic seizures: • Stiffens all over, L body posture different than R • Focal seizures • Stop activity, change facial expression, stare, turn head and eyes to L ; ~ 30s • Secondarily generalized seizures • May or may not start with a recognizable focal seizure; stiffening and shaking of all 4 extremities

  45. Joey: • Born at 25 weeks gestation • Brain injury due to prematurity • Cerebral palsy; both legs (diplegia) and L arm/hand

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