Pediatric Grand Rounds will be held throughout the academic year. The presentations are at 8:00 a.m. on Friday morning in Lied Auditorium. Registration begins at 7:30 a.m. For the next four months, due to construction, the Grand Rounds will be held in different auditoriums. The location will be specified by the date of the presentation.
Our Grand Rounds qualify for category 1 CME for physicians and 1.2 contact hours for nursing. The schedule is available on our web site, http://www2.kumc. edu/kids/cme_sched.htm. If you have any requests please contact Lisa Gilmer, the Grand Rounds Co-Coordinator, at (913) 588-5908. Everyone is welcome at these teaching conferences.
Our Pediatric Symposium - held in cooperation with the KAAP - is scheduled for May 7, 2004.
This time of year is interview time for residency applicants for both the pediatrics and the medicine/pediatrics training programs. We have outstanding applicants from our region as well as other parts of the nation. We have six pediatric and four medicine/pediatric positions and are looking forward to an excellent group of new recruits. The majority of our graduates go into practice in this region while approximately 20% of our graduates go on for further subspecialty training.
Professor and Chair
Epilepsy is defined as two or more unprovoked seizures. After a first seizure, the primary care physician must decide on an appropriate workup, and must decide whether to consult a neurologist.
If a child arrives in the emergency room (ER) actively seizing, emergent control of the seizures, with careful attention to the "ABC's" (airway, breathing and circulation), comes first. Protocols for status epilepticus start with a benzodiazepine (i.v. lorazepam or i.v. or p.r. diazepam), followed by intravenous anti-epileptic drugs and anesthesia if necessary. Once the seizures have stopped, the patient might receive a computed tomogram (CT) scan of the brain if there is a possibility of hemorrhage or a mass lesion, and a lumbar puncture for concerns about infection. During hospitalization, or after discharge, the patient will usually have an electroencephalogram (EEG), to look for interictal abnormalities indicating a risk of further seizures.
Many things can cause a seizure or mimic one, including syncope, encephalopathy due to a medical condition, toxicity, and psychiatric conditions. All of these might need to be considered. Laboratory tests in the ER should include blood (electrolytes, calcium, magnesium, CBC), urinalysis, a drug screen, and possibly a lumbar puncture (LP). Although the risk of herniation is small, a CT is usually performed before the LP. Altered consciousness can be due to an intracranial lesion, and a magnetic resonance imaging (MRI) of the brain is worth considering, even if an emergent head CT was normal.
If the episode is brief, self-limited, and the child quickly returns to baseline, he might not be seen in an emergency room, and might not be hospitalized. The evaluation can often be deferred to an outpatient setting. He will need a thorough history, physical exam and neurological exam and often an EEG.
A sleep-deprived EEG is almost always more useful than a 'routine' EEG, since some seizure activity will only show up in drowsiness or sleep. Unfortunately, a normal EEG does not rule out epilepsy (which is at least partly a clinical diagnosis). Because a standard EEG only runs about 30 minutes, a prolonged one (several hours) or extended monitoring might be indicated, especially for recurrent episodes after normal initial EEG. Although ambulatory EEGs (analogous to Holter monitoring) are available in some institutions, inpatient monitoring (recording video simultaneously with the EEG) generally provides more useful information.
Febrile seizures are diagnosed on clinical grounds. A simple febrile seizure occurs in the age range of 6 months to 6 years with a febrile illness (temperature being elevated before seizure onset or immediately after). It is brief and self-limited. The child should rapidly return to baseline neurologic exam. Any deviation from this suggests either an atypical febrile seizure (which might require a more extensive workup) or the new onset of a seizure disorder.
Whether to start an anti-epileptic drug is far from clear-cut. Most neurologists will not prescribe medication until after at least two seizures. Medication might be indicated after the first seizure in certain situations:
A child with well-controlled epilepsy should have a normal or near-normal lifestyle. As with any neurologic problem, a consultation with a pediatric neurologist might be very helpful.
(References for this article available on request).
Stacey Knobler, MD
Division Chief, Pediatric Neurology
School success is important to pediatricians. According to experts, children who are readers are less likely to experience school frustration and dropout, teen pregnancy, drug use, confrontations with the law, and ER visits, which translates into healthier, more productive life-styles.(1)
Literacy begins at birth when parents first interact with newborns. Talking, singing and reading with infants not only stimulates brain connections needed for later reading and writing competencies but also promotes bonding experiences between parent and child. When reading together provides positive experiences, young children are more likely to acquire book skills and an eagerness to learn to read.
By the time children enter kindergarten, many pre-reading skills should be evident: adequate language to communicate ideas and feelings or to solve problems; ability to sit, attend and follow directions; knowledge of the alphabet and ability to count to10; picture and story comprehension and book-handling skills; writing (scribbling, pictures) skills to express ideas and communicate; ability to discriminate sounds and rhyme words; general knowledge and cognition; and an eagerness to learn.
Yet, one in three children enters school lacking the skills necessary to begin to read and learn, placing them at significant disadvantage relative to peers. Children raised in poverty experience even higher risk, with language skills the most significant area of deficit. Fortunately, research shows that the simplest and best way to prevent reading problems is by reading to children regularly from an early age.(2) Pediatric providers are in an excellent position to counsel parents about how to promote pre-reading skills, since they see most children from birth.
Reach Out and Read (ROR) is a nationally-recognized early literacy program designed for pediatric providers to promote reading skills through anticipatory guidance during well-child visits of preschool children. Beginning at 6 months of age, each time a child visits his or her provider, advice is given about ways to enhance reading enjoyment in the home, new books are given to children to take home, and volunteers read to children and model interactive reading techniques for parents, where appropriate.
Formed in 1989 in Boston by pediatricians and educators, ROR is endorsed by the AAP and recognized in every state of the nation. Thirty-three ROR sites in Kansas City comprise Reach Out and Read Kansas City, a metro-wide coalition that provides services to 15,000-20,000 young children birth to 5 years. A Kansas state ROR coalition is currently being formed under the direction of the Kansas AAP, in cooperation with the Kansas Health Foundation.
Everyone benefits from ROR. Health providers have an easy developmental assessment and interaction tool in books, parents learn ways to foster child development, children build libraries, and everyone has an enjoyable experience. For further information about ROR Kansas City, contact Jean Harty, MD at (913) 588-2793, or www.reachoutandreadkc.org
For information about ROR Kansas, contact Chris Steege at (913) 894-5649 or www.aap-kansas.org
(1) ROT National Center
(2) National Academy of Education, 1985
Executive Director,
Reach Out and Read, Kansas City
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The University of Kansas Medical Center