Pediatrics: A Case-Based Review
12 March 2020
22 March 2020
05 May 2020 (online)
Kreckmann M. Pediatrics: A Case-Based Review. New York, NY: Thieme Publishers; 2019. ISBN: 978-3132053618
This case-based review manual provides a series of 85 cases of common and uncommon pediatric disorders, presented in an interactive fashion to mimic the situation in actual practice, be it the emergency department or outpatient clinic. The cases cover the entire breadth of pediatrics, forming a useful learning tool for learners exploring the field of pediatrics or preparing for board examinations. The cases are realistic and incorporate challenges unique to pediatrics such as health policy considerations affecting children, counseling families about management options and prognosis, and inclusion of disorders spanning the pediatric age range from neonates to adolescents. The book's format fosters critical thinking by emphasizing patterns of symptoms, encouraging the reader to work through the history and examination before formulating a differential diagnosis and treatment plan. The author frames each case by providing a brief history, then guides the reader through a set of directed questions that comprise both immediate next steps and long-term options. Each case is supplemented by a “Comments” section that highlights relevant information including etiology, pathogenesis, treatment, and prognosis.
Of the 85 cases, only two are directly related to epilepsy, with another 10 or so dealing with other neurologic conditions (e.g., concussion, gait abnormalities, nervous system tumors, behavioral problems). One case describes a toddler with new-onset seizure in the context of fever, with the diagnosis of simple febrile seizure. While the ensuing discussion adequately outlines some of the basic issues of febrile seizure diagnosis and management, unfortunately, several misconceptions and even erroneous statements are made. First of all, hospital admission is suggested, even for a brief simple febrile seizure. Current practice, at least in the United States, is not to admit routine cases where there is no concern for meningitis or other acute neurologic process. The author also recommends laboratory work up for all cases, including a complete blood count, which is defensible, but also sedimentation rate, blood gas analysis, and blood cultures! While these extra tests may be appropriate in some situations, most do not necessitate that extreme. The author does not clarify which children should receive an extensive work up (including electroencephalogram) and which should not. Finally, the criteria for simple febrile seizures rightly include a duration of less than 15 minutes and generalized onset, but the equally valid criterion of a single seizure within that fever is not mentioned. The author recommends treating subsequent fevers aggressively with antipyretics, not cautioning that this protocol is not based on evidence. Finally, she erroneously states that 3 to 4% of children with febrile seizures go on to develop epilepsy, not distinguishing subgroups at lesser or greater risk. It would have been optimal to also provide information as to when a febrile seizure does not have a benign prognosis but rather portends a subsequent epilepsy syndrome such as Dravet syndrome.
The second case relevant to epilepsy involved a teenage girl who lost consciousness and collapsed during a school trip. A witness described a cry, followed by facial cyanosis, fall, and tonic-clonic movements of all extremities. The author provides a reasonable differential diagnosis, concluding that the girl suffered a “grand mal” convulsion (an outdated term but certainly still used by the lay public; the author's discussion also mentions “petit mal” seizures). The recommended work up included hospital admission (appropriate) and extensive laboratory evaluation including prolactin level (inappropriate!). Otherwise, the author provides a sensible approach to the work up and management, but then, inexplicably, states that a blood and urine toxicologic examination in such a case is “not generally recommended” (in fact, that is among the most important tests in a case like this!). If it is concluded that a child requires prophylactic seizure prevention, the author suggests treatment options include carbamazepine, valproate, or phenobarbital, but there is no mention of the dozens of antiseizure medicines developed in the past two decades that are most widely prescribed in this era.
While trying to not be too critical of the author's understanding of current epilepsy nomenclature, evaluation, and treatment (she is a general pediatrician), these writings nevertheless exemplify the tremendous amount of misinformation promulgated by resources being marketed to the primary health care provider. Fortunately, in many areas of the world, specialty care is available to most accurately provide diagnosis, management, and counseling of children with seizures and epilepsy.