Houston Area Pediatric Specialists

Independent pediatric specialists aim to serve our community. We want to share news and analysis regarding our specialties and our practices.

Friday, August 27, 2010

Absence Epilepsy - Which medication is best?

Big news from the New England Journal on absence epilepsy - ethosuximide is more effective than valproate or lamotrigine in Childhood Absence Epilepsy. Dr. Josh Rotenberg


2010 Mar 4;362(9):790-9.

Ethosuximide, valproic acid, and lamotrigine in childhood absence epilepsy.

Glauser TA, Cnaan A, Shinnar S, Hirtz DG, Dlugos D, Masur D, Clark PO, Capparelli EV, Adamson PC; Childhood Absence Epilepsy Study Group.

Collaborators (157)

Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital, 3333 Burnet Ave., MLC 2015, Cincinnati, OH 45229, USA. tracy.glauser@cchmc.org

Comment in:


BACKGROUND: Childhood absence epilepsy, the most common pediatric epilepsy syndrome, is usually treated with ethosuximide, valproic acid, or lamotrigine. The most efficacious and tolerable initial empirical treatment has not been defined.

METHODS: In a double-blind, randomized, controlled clinical trial, we compared the efficacy, tolerability, and neuropsychological effects of ethosuximide, valproic acid, and lamotrigine in children with newly diagnosed childhood absence epilepsy. Drug doses were incrementally increased until the child was free of seizures, the maximal allowable or highest tolerable dose was reached, or a criterion indicating treatment failure was met. The primary outcome was freedom from treatment failure after 16 weeks of therapy; the secondary outcome was attentional dysfunction. Differential drug effects were determined by means of pairwise comparisons.

RESULTS: The 453 children who were randomly assigned to treatment with ethosuximide (156), lamotrigine (149), or valproic acid (148) were similar with respect to their demographic characteristics. After 16 weeks of therapy, the freedom-from-failure rates for ethosuximide and valproic acid were similar (53% and 58%, respectively; odds ratio with valproic acid vs. ethosuximide, 1.26; 95% confidence interval [CI], 0.80 to 1.98; P=0.35) and were higher than the rate for lamotrigine (29%; odds ratio with ethosuximide vs. lamotrigine, 2.66; 95% CI, 1.65 to 4.28; odds ratio with valproic acid vs. lamotrigine, 3.34; 95% CI, 2.06 to 5.42; P<0.001 p="">

CONCLUSIONS: Ethosuximide and valproic acid are more effective than lamotrigine in the treatment of childhood absence epilepsy. Ethosuximide is associated with fewer adverse attentional effects.

How can families prepare for a sleep study for a child?

How can families prepare for a pediatric sleep study? Here is a nice site.
Make sure that you are going to a center specializing in children. It makes a difference in the data collection, analysis, diagnosis and treatment. My protocol (learned from doing EEG's all the time) adds some developmentally sensitive elements and gets 92% success with kids.
Josh Rotenberg MD

Getting A Sleep Study
Ask the Sleep Expert
Dr. Rafael Pelayo, MDStanford Sleep Disorders Clinic, Stanford, CA


I recommend that kids and parents make it a fun night, since typically the parent will be sleeping in the room with the child. They can wear matching pajamas, order take out food, and stay up as late as they like. This helps take the pressure off the child falling asleep since the sleep study is to find out what happens during sleep. The children typically sleep better than the parents do.
I also tell children the same rules apply in the sleep clinic as in their home; if they’re able to jump on the bed at home they can do it here. I encourage them to bring anything from home— except their pets—to make them feel comfortable, such as pillows, blankets, and sheets. We also make sure the clinic is very child-appropriate with video games, magazines, and telephones for the child to call home if they want to.

Symptoms of a seizure can be subtle...

Symptoms of a seizure can be subtle...

Symptoms of a Seizure

A seizure is usually defined as a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain, in particular the outside rim of the brain called the cortex. Below you will find some of the symptoms people with epilepsy may experience before, during and after a seizure. Seizures can take on many different forms and seizures affect different people in different ways. It is not implied that every person with seizures will experience every symptom described below.

Seizures have a beginning, middle, and end

When an individual is aware of the beginning, it may be thought of as a warning or aura. On the other hand, an individual may not be aware of the beginning and therefore have no warning.
Sometimes, the warning or aura is not followed by any other symptoms. It may be considered a simple partial seizure by the doctor.

The middle of the seizure may take several different forms. For people who have warnings, the aura may simply continue or it may turn into a complex partial seizure or a convulsion. For those who do not have a warning, the seizure may continue as a complex partial seizure or it may evolve into a convulsion.

The end to a seizure represents a transition from the seizure back to the individual’s normal state. This period is referred to as the “post-ictal period” (an ictus is a seizure) and signifies the recovery period for the brain. It may last from seconds to minutes to hours, depending on several factors including which part(s) of the brain were affected by the seizure and whether the individual was on anti-seizure medication. If a person has a complex partial seizure or a convulsion, their level of awareness gradually improves during the post-ictal period, much like a person waking up from anesthesia after an operation. There are other symptoms that occur during the post-ictal period and are detailed below.

Please note: Below is only a partial list, some people may experience other symptoms not listed below. These lists are meant to help patients communicate with their physicians.

Early seizure symptoms (warnings)

Deja vu
Jamais vu
Visual loss or blurring
Racing thoughts
Stomach feelings
Strange feelings
Tingling feeling

Pleasant feeling


No warning: Sometimes seizures come with no warning

Seizure symptoms

Black out
Electric Shock Feeling
Loss of consciousness
Spacing out
Out of body experience
Visual loss or blurring


Chewing movements
Difficulty talking
Eyelid fluttering
Eyes rolling up
Falling down
Foot stomping
Hand waving
Inability to move
Lip smacking
Making sounds
Teeth clenching/grinding
Tongue biting
Twitching movements
Breathing difficulty
Heart racing

After-seizure symptoms (post-ictal)

Memory loss
Writing difficulty

Depression and sadness

Difficulty talking
Urge to urinate/defecate

If you or someone you know has the symptoms listed above -- you are not alone.

Adapated from: Schachter SC, editor. Brainstorms: epilepsy in our words. New York: Raven Press; 1993; and Schachter SC, editor.The brainstorms companion: epilepsy in our view. New York: Raven Press; 1995..

Night-time wakings in your baby? Thinking about "crying it out"? Trying the Ferber method? Think again! ...Dr. Rotenberg

Coddle or let the kid cry? New research awakens the sleep-training debate !

There is perhaps no parenting decision that tugs on the heartstrings as strongly as whether to let a baby cry him- or herself to sleep.

At one end of the spectrum are parents who use some form of “cry-it-out” method to teach their baby to sleep through the night. The method is characterized by periods of letting a baby cry – from a few minutes to more than an hour – without picking him or her up. At the other end are the “no-cry” types who consider letting a baby cry for any length of time to be cruel and unusual punishment.

“ "I don’t want to diss sleep-training programs per se, but the way we construed emotional availability is that an emotionally available parent is not a parent who is going to abandon a child at night and let the child cry it out.””

Stuck in the middle are a lot of exhausted parents hoping to make the right choice – especially since sleep deprivation in infants has been linked to behavioural and cognitive problems, not to mention its effects on mom and dad.

New research on infant sleep appears to deal a blow to those in the cry-it-out camp. Penn State researcher Douglas Teti examined the role of emotional availability on infant sleep and found that regardless of a family’s night-time routine, infants with parents who were responsive and warm had fewer night wakings and an easier time drifting off. In his study, which involved infrared cameras placed in families’ bedrooms and nurseries, a lapse of more than a minute resulted in a lower emotional availability score.


Link to the abstract ...


J Fam Psychol. 2010 Jun;24(3):307-15.
Maternal emotional availability at bedtime predicts infant sleep quality.
Teti DM, Kim BR, Mayer G, Countermine M.
Human Development and Family Studies, The Pennsylvania State University, S-211 Henderson Building, University Park, PA 16802, USA. dmt16@psu.edu
In the present study, linkages were examined between parental behaviors (maternal practices) at bedtime, emotional availability of mothering at bedtime, and infant sleep quality in a cross-sectional sample of families with infants between 1 and 24 months of age. Observations of maternal behaviors and maternal emotional availability were conducted independently by 2 sets of trained observers who were blind to data being coded by the other. With infant age statistically controlled, specific maternal behaviors at bedtime were unrelated to infant sleep disruptions at bedtime and during the night. By contrast, emotional availability of mothering at bedtime was significantly and inversely related to infant sleep disruption, and, although these links were stronger for younger infants, they were significant for older infants as well. Maternal emotional availability was also inversely linked with mothers' ratings of whether their infants had sleep difficulties. These findings demonstrate that parents' emotional availability at bedtimes may be as important, if not more important, than bedtime practices in predicting infant sleep quality. Results support the theoretical premise that parents' emotional availability to children in sleep contexts promotes feelings of safety and security and, as a result, better-regulated child sleep.
PMID: 20545404 [PubMed - in process]

Wednesday, August 25, 2010

Pesticide Exposure in the Womb Increases ADHD Risk

Exposure to pesticides while in the womb may increase the odds that a child will have attention deficit hyperactivity disorder, according to researchers at the University of California-Berkeley School of Public Health. Combine that with research published in May in Pediatrics finding that children exposed to pesticides were more likely to have ADHD, and it's enough to make parents wonder how to reduce their family's exposure to pesticides.


Sunday, August 22, 2010

Pediatric Insomnia in ADHD Clinical Study - Enrolling Patients

Pediatric Insomnia in ADHD Study - Mulitcenter Study
Study summary:A randomized, placebo-controlled, double-blind, fixed-dose study of the efficacy and safety of Eszopicolone (Lunesta) in children 6-11, adolescents 12-17 with attention deficit/hyperactivity disorder- associated insomnia.
Qualified participants must:• Have documented ADHD-associated insomnia, defined as the subject or subject's parental guardian reports difficulty with sleep latency greater than 30 min
• Have daytime functional impairment as a result of sleep problems
• Have tried behavioral intervention for sleep problems
• Be able to stay over night in a sleep lab for testing


Insomnia before school? Think delayed sleep phase...

From Dr. Rotenberg...

Delayed Sleep Phase Syndrome

What is delayed sleep phase disorder?

Delayed sleep phase disorder is a sleep disorder in which the person’s sleep-wake cycle (internal clock) is delayed by 2 or more hours. Basically, because of the shift in the internal clock by two or more hours, the ability to fall asleep is also postponed. For example, rather than falling asleep at 10 PM and waking at 7 AM, an adolescent with delayed sleep phase disorder will not fall asleep until 12 or 1 AM and then has great difficulty awakening at 7 AM for school or work. If the child or adolescent is allowed to sleep until late in the morning, he will feel rested and can function well. Most children and adolescents with delayed sleep phase disorder describe themselves as “night owls” and usually feel and function their best in the evening and nighttime hours. They usually get much less sleep on weekdays compared to weekends or holidays....