The Evidence behind the Practice: The Study of Neurologic Conditions in Children

1. The Evidence behind the Practice:The Study of Neurologic Conditions in Children David P. Kuter, MD, FAAFP, Family Physician Madison, Wisconsin, USA Leila A. Chenybayeva Ph.D., MPH Almaty, Kazakhstan

2. Organization Introduction Sources of Information Precepts for the Physician Symptoms, Signs, and Tests Treatments Conclusions and Recommendations Summary

3. Sources of Information Observation of patient care in many FGPs in several cities of Kazakhstan Interviews of neurologists, pediatricians, and family physicians in Kazakhstan Conference in Almaty with pediatric neurologist Reading about normal and abnormal neurologic development Examination of international neurologic literature 31 years of patient care. Following over 600 newborns through childhood Discussion with pediatric neurologists and pediatricians in USA Examination of adopted babies

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5. Frequently Diagnosed Conditions Perinatal encephalopathy Ischemic/Hypoxic encephalopathy Perinatal trauma to the central nervous system Perinatal trauma to the spinal cord Intracranial hypertension Hydrocephalus Myotonic syndrome Hypotonia

6. Newborns: Signs and Tests Shaking hands Quivering chin Large fontanel Small fontanel Ultrasound EEG

7. Infant Signs Arching back at crying Pointing toes Failure to stand Scissors position of legs Hypotonia Crying too much Spitting up

8. School-age children: Symptoms and Tests Headache Dizziness Nosebleeds Rheoencephalogram findings

9. Contrary evidence A.A. Efimova�s study, Moscow area, 2002 Children in polyclinic Neurologic diagnosis in chart Actual disease Efimova AA et al., 2002 Polyclinic A Polyclinic B 94 91 84 79 5 8

10. A.A. Efimova�s Study Conclusion: Only 10-15 % of children with a neurologic diagnosis actually have a neurologic disorder.

11. Health of Children adopted from the Former Soviet Union and Eastern Europe Children examined 56 Record shows major neurologic diagnosis 51 Perinatal encephalopathy Intracranial hypertension Perinatal trauma to central nervous system Agreed with major neurologic diagnostic standards 0 Albers L, Johnson DE, et al.. JAMA 278:922-924,1997

12. Treatments Dehydration therapy: diuretics (furosemide), panagin, Mg sulfate (i\m), sometimes mannitol (i\v) Anticonvulsive: Phenobarbitol, dilantin, benzonal Infusion therapy: aminobutyric acid, reopoliglukin, Na carbonate, glucose, ascorbic acid, cocorboxilase, hemodez Sedatives: Na bromide, radedorm, seduksen Medications to improve metabolic processes in brain: gluthamic acid, methionin, cerebrolizin Medications improving circulation in brain: vinpocetin (kavinton), cinnerazin Spasmolytic medications: dibazol ?raniocerebral hypothermia Nootropic medications: Piracetam,encefabol, kogitum, fenebut Infusions of vitamins: ?12 and others. Massage

13. Potential Dangers Electrolyte disturbance Sedation Cognitive deficit Infection, including Hepatitis B Allergy including anaphylaxis and death

14. Indirect Dangers Health system money spent for no benefit Cost to family of diagnosis and treatment Separation from family when in hospital Parents� time lost from work Psychological stress and stigma

15. Treatment of Actual Neurologic Disease Cerebral palsy Hypotonia Mental slowness Hydrocephaly Intracranial hypertension

17. Genesis of Hyperdiagnosis Isolation Limited peer review Financing issues

18. How to Respond ? ICNA: International Child Neurology Association/www.child-neuro.net Peer review for all scientific work Change funding scheme to support evidence-based care and gradually defund activities generally regarded as ineffective Apply to all specialties

19. Summary Many children given neurologic diagnosis Some of these children have no illness The difference in statistics of neurologic illness is partly due to hyperdiagnosis Hyperdiagnosis and treatment can cause harm Psychological stress and stigma To improve quality, apply evidence-base scientific method to all diagnoses and treatments. Health professionals, teaching professors must lead quality improvement through review of international literature and use of evidence-based methods.