Kiddie Brains

24 01 2013

I was fortunate enough during my neurology rotation to spend some quality time in child neurology, which I found much more enjoyable than adult neuro.  Says the one going into pediatrics, right?  It’s not just working with kids that made it so much more enjoyable, it was a combination of the schedule, the variety, the people, and even the illnesses themselves.

The attending was this fantastic Indian doctor who had gone to medical school in India, residency training in England, then moved his practice to the U.S.  All of the relocation resulted in a fantastic accent which, truth be told, took me a solid 3 days to be able to understand.  Unfortunately, most of his patients either had been there for too short a time, or else were not so good at discerning accents.  On several occasions, I wound up having to ‘translate’ for the patients.

Those of you who live or work with somebody who speaks with a thick accent probably know what I mean; you can understand, but the people on the receiving end often cock their heads to the side in confusion.  I had the added dimension of that person being an attending (read: my superior), so in order to avoid being rude I had to try to balance the translating with making it not look like I was translating.

I still don’t know whether I pulled that one off or not.

Another particularly entertaining characteristic stemmed from the sheer number of articles that he had published in the course of his career.  Each time the doc began to teach a new topic, he would start out speaking quickly, pause, say “Wait, let me pull the article,” turn to the computer, and then Google his name plus the name of the disease he was looking up.  Every time.  I was both impressed and entertained.

Adult neurology sees a lot of progressive neurological illnesses, things like Alzheimer’s, stroke, Parkinson’s, and multiple sclerosis.  For all of these, there are treatments, but no cure.  If a patient had a stroke 2 days ago, all the physician can do is wish them luck and send them to physical therapy.  Meds can help Parkinson’s for a little while, but the effect current of Alzheimer’s treatments are minimal at best.  With kids, it’s different.  Most of them have either seizures or headaches, both of which improve to the point of cure as they grow up.

From what I saw, the adult neurological issues tended to worsen over time, while the pediatric issues tended to improve, even with minimal treatment.

However, there were parents that were reluctant to commit to treatment.  These were generally parents with children who had headaches, which is no big deal because once a tumor was ruled out, a headache won’t kill you.  They can, however, really impact important factors for the kid’s future, like school performance and behavior.

One set of parents I remember particularly well had a 6-year-old little boy, I’ll call him Rusty (not his real name), who came in for dozens of episodes of ‘staring spells’ every day.  The diagnosis of absence, or ‘petit mal,’ seizures was clear from the history his parents gave, but just to be sure the doc ordered an EEG to confirm the diagnosis.  After the EEG was over and it was confirmed that Rusty had epilepsy, he and his parents were brought back to the clinic to discuss treating the seizures.  The conversation was going as expected until the neurologist mentioned drugs.  Then the mom looked at the dad, who looked at the mom, who looked at Rusty playing with a plastic puzzle on the floor.  And she looked at me and said no.

“We don’t want to give him any medications, they just have so many side effects.  As his parents, we don’t want to give him anything that will risk his health in the future,” said the mom.

“His seizures aren’t even the serious kind,” said the dad.

So the neurologist, as any concerned physician would, explained to both of them that yes, medications have risks, but so do long-term, frequent seizures.  There’s a risk of lagging school performance as well as impaired social relationships, but worse, there’s always a risk of permanent brain damage, or that the little seizures could generalize into much more severe grand mal seizures and even lead to death.  That is an extreme example, but it has been known to happen.  As scary as the media and all-natural-guru parents on the internet blogs make the medications out to be, forcing your kid to live with long-term seizure activity is the worse option to me.

It’s not as if non-pharmaceuticals shouldn’t be used for epilepsy.  The ketogenic diet is a very effective treatment for a lot of kiddos with severe seizures that have failed 5 or 6 of medicine’s best drug treatment, sending 1/3 of the kids into permanent remission.  But Rusty had a very common type of childhood seizures that could have been easily treated with a very minimal risk of side effects, and a microscopically small chance of a serious side effect.

I was also trying to figure out, for the duration of the conversation, why on earth the parents would bring their seizing child into the neurology clinic if not for him to receive treatment.

In the end, the parents scheduled a follow-up appointment for the following week so they would have time to ‘do some research,’ and we offered up the names of websites that are full of sound medical information.  I never saw them again, and don’t know what they decided to do.  When the child grows older, though, he will likely ask his parents about their choices only if something goes wrong in the course of treatment.  If it was a side effect of the medication bad enough to put him in the hospital (like Stevens-Johnsons), he will ask, “Why did this happen?”  If he has a grand mal seizure after no intervention, he will ask, “Why did this happen?”

I’m not a parent and can’t even pretend to understand the gravity of making choices every day that impact your kid for the rest of his or her life, but looking at those situations, I know which answer I’d rather give.  You can either tell your kid that the rash was something bad that happened because you were trying to help him get better, or you could tell him he’s sicker now because you didn’t try to make him well before.




2 responses

25 01 2013
Rachael Coons

I babysat a little boy who had a form of epilepsy that was very hard to control that appeared when he was 2 (the summer I babysat for the family). A combination of the Ketogenic diet and whatever drugs he’s on have had him seizure free for 3 years now if i remember correctly. But having seen how much his development was impacted from the, quite literally, dozens of seizures he was having a day while his family and doctors struggled to figure out how to control it makes me seriously question these parent’s decision to not do anything (if they did as you suspect). Most of this little boy’s seizures were the same type as this boys with myoclonic seizures as well if I remember correctly. I don’t understand how parents could think that any form of seizure is not “the serious kind.”

26 01 2013

It’s very sad how people with access to the internet and an opinion on “nature is best” often over-ride very sound advice from the medical community. To make it worse when they offer up such intellegent passages such as “hundreds of years ago people didn’t take (insert medicine / food / common everyday item) and they lived better, healthier and longer lives.”

Please did you forget that this was the same generation that if they cut their finger on a tin can they could end up dead?That people in general did not live as long and their lives were pretty rubbish. Being a parent today is like being back in middle school, you get bullied by people who have more facebook friends than you because you choose to go the standard route, you choose to put your faith into a well creditied, scientific and researched route versus some well meaning yahoo with a megaphone.

So, what do you think?

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