Toward the definition of childhood migraine

PURPOSE OF REVIEW: The intent of this review is to provide an update on the current understanding of the diagnostic criteria, classification, pathophysiology, evaluation, and management of pediatric migraine. RECENT FINDINGS: The International Headache Society has recently revised its diagnostic criteria and classification system in the 2004 International Criteria for Headache Disorders. These new criteria have incorporated many developmentally sensitive changes that will allow broader application in children and adolescents. Appreciation of the new classification system requires understanding of current views of the pathophysiology of migraine. Migraine is now viewed as an inherited disorder with a primary neuronal initiation of a cascade of neurochemical processes culminating in a spreading wave of cortical neuronal depolarization and regional oligemia. The evaluation of a child with headache begins with a thorough medical history and complete physical and neurologic examination. One of the key questions for the bedside clinician is when to perform further diagnostic studies. Extensive review concludes that the role of further ancillary diagnostic studies, specifically EEG and neuroimaging, is limited. The management of pediatric migraine requires a balance of biobehavioral measures coupled with agents for acute treatment and, if needed, daily preventive medicines. The pharmacologic management of pediatric migraine has been subjected to thorough review, and controlled data unfortunately are limited. The most rigorously studied agents for the acute treatment of migraine are ibuprofen, acetaminophen, and sumatriptan nasal spray, all of which have shown safety and efficacy in controlled trials. For preventive or prophylactic treatment in the population of children and adolescents with frequent, disabling migraine, flunarizine (not available in the United States) is the most efficacious agent, but encouraging data are emerging regarding the use of several antiepileptic agents such as topiramate, disodium valproate, levetiracetam, the antihistamine cyproheptadine, and the antidepressant amitriptyline. SUMMARY: Recent literature has reshaped the definition, evaluation, and management of pediatric migraine.     

Toward a definition of childhood dystonia

PURPOSE OF REVIEW: The purpose of this review is to summarize recent progress toward providing a consistent, sensitive, specific, and useful definition of dystonia as it presents in childhood. RECENT FINDINGS: An NIH-funded consensus group published a definition of childhood dystonia in January of 2003. Recent work has attempted to identify quantitative methods for diagnosis and measurement of childhood dystonia. Techniques include biomechanical, kinematic, and surface EMG measurements that show promise for providing specific and sensitive measures of childhood dystonia. SUMMARY: The results of current research efforts will be useful for verifying and modifying definitions of dystonia to provide consistent and measurable terms for including children in research trials and selecting appropriate interventions for clinical treatment.     

Toward the definition of cerebral arteriopathies of childhood

PURPOSE OF REVIEW: To facilitate and standardize the diagnosis of cerebrovascular conditions in childhood, particularly in the field of arterial ischemic diseases. RECENT FINDINGS: Progress in diagnostic techniques in the past decade have led to newly established etiologies for childhood stroke, most of which represent some form of vascular pathology. These advances must be integrated into a modern nomenclature system with revised definitions of stroke and arterial wall diseases-arteriopathies-in childhood. SUMMARY: This nomenclature system is intended to facilitate and enhance clinical research in childhood stroke, particularly multicenter collaborative studies.     

Plasmapheresis in childhood acute disseminated encephalomyelitis

Accepted modes of therapy in acute disseminated encephalomyelitis include intravenous methylprednisolone, intravenous immunoglobulin or a combination of both. Effectiveness of plasmapheresis has been demonstrated by many case reports. We used plasmapheresis to treat steroid non-responsive acute disseminated encephalomyelitis in two children. There was complete clinical and radiological recovery in both the cases.     

Prognostic factors in childhood acute encephalitis

We have studied the prognostic factors in 462 children, from 1 month to 16 years old, with acute encephalitis. Death occurred in 2.8% patients, 6.7% were severely damaged and 90.5% were cured with no or only minor sequelae. The risk of death or severe damage in patients less than 1 year of age was 5.0-fold (95% confidence limits, 2.2 to 11.6; P less than 0.001) greater than that of older children. When compared with those children whose level of consciousness had been normal before admission, children who had been disoriented before admission had a 3.9-fold (1.1 to 14.3, P less than 0.05) risk and those who had been unconscious had a 25.4-fold (7.3 to 88.1, P less than 0.001) greater risk of death or severe damage. The risk of death or severe damage in patients with herpes simplex virus encephalitis was 11.7-fold (3.8 to 35.8, P less than 0.001) and in patients with Mycoplasma pneumoniae encephalitis it was 7.0-fold (2.6 to 18.7, P less than 0.001) that of other children. All patients with none of the above mentioned risk factors were cured without any major sequelae. We conclude that specific attention should be paid to the youngest patients, especially to those with an impaired level of consciousness, and all available measures should be focused on early detection of herpes simplex virus or M. pneumoniae infection.     

急性播散性脑脊髓炎与多发性硬化的诊断及鉴别诊断

目的 根据急性播散性脑脊髓炎（ＡＤＥＭ）和多发性硬化（ＭＳ）临床及实验室检查特点,探讨二者的诊断和鉴别诊断。方法 制定较严格的诊断标准,对符合标准的３４例ＡＤＭ和１７例ＭＳ的临床表现及实验室检查分析比较。结果 ＡＤＥＭ３４例,男１９例,女１５例;ＭＳ１７例,男７例,女１０例。ＡＤＥＭ与ＭＳ起病发热（６４．７％;２９．４％）;头痛（５８．８％;２３．５％）;意识障碍（６４．７％;５．９％）,其中昏迷     

Herpes simplex encephalitis in childhood

This is a report on diagnostic and therapeutic experience in 6 patients aged 3 weeks to 6.3 years suffering from herpes simplex encephalitis. In 2 patients, a 3-week-old newborn and a 1.3-year-old boy, acyclovir-therapy started at days 8 and 17 respectively, following the demonstration of hemorrhagic necrosis in the brain by cranial CT-scan and IgM-specific HSV-antibodies in the blood. A 6.3-year-old girl was treated with acyclovir at day 10 of her illness, when cCT showed hemorrhagic necrosis in the brain. It was not before the 21st day, that diagnosis of HSE could be confirmed serologically. She suffered a relapse of encephalitis 5 weeks later. In a 3-month-old boy, treated with acyclovir at day 4 of his illness, IgM-specific HSV-antibodies were found already at day 4. His clinical course was complicated by subdural effusion. These 4 children survived with severe neurologic sequelae. Another 2 patients, a 5- and 7.5-month-old boy respectively, survived without apparent defect. In both cases vesicles upon the tongue appeared in the beginning of illness. Acyclovir-therapy started at day 7, diagnosis being confirmed serologically later. In our experience HSE should be suspected in children suffering from fever, drowsiness and focal or secondarily generalizing seizures. In these cases antiviral therapy should not depend on serologic findings.     

The prognosis of encephalitis in childhood

Follow-up examination of 95 former patients who had been suffering from encephalitis in infancy were performed. The coincidence of disturbance of consciousness, pathological-EEG and neurological irritation- and deficiency symptoms proved to be an unfavourable prognosis. These patients are especially handicapped in their concentration and motorial performances. Only 50% of the group with a severe course of the disease achieved a complete vocational training.     

Toward a definition of neglect in young children

This study examined the relationship between child experiences identified conceptually as "neglectful" prior to age 4 and child outcomes at age 4. This was done using measures from two sites collected as part of LONGSCAN. Child needs were included within categories of physical and psychological safety and security. Problems with residence safety or cleanliness and untreated behavioral problems predicted child impairments in language. CPS reports of failure to provide shelter predicted impairments in several developmental outcomes. A stimulating home environment predicted less impairment in cognitive development. Multiple changes in residence predicted externalizing behavior problems. Exposure to verbally aggressive discipline predicted more behavioral problems overall. Conversely, some indicators (such as caregiver transitions and lack of medical care) predicted less developmental impairment or fewer behavior problems in certain domains. The approach supports a conceptualization of neglect based on child developmental needs. Implications for practice and future research are discussed.     

Recurrent acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating condition, which is usually monophasic. Recurrent ADEM is a much less characterized entity and its differentiation from multiple sclerosis (MS) poses a diagnostic challenge. We report a seven year old girl with recurrence of ADEM after 19 months and discuss the diagnostic issues involved.     

Autoimmune hemolytic anemia complicating disseminated childhood tuberculosis

An 8-year-old girl presented with severe autoimmune hemolytic anemia (AIHA) in association with mediastinal widening. Biopsy of mediastinal lymph node confirmed the diagnosis of tuberculosis. A diagnosis of disseminated tuberculosis in association with AIHA was made, and the patient was treated with steroids and antitubercular therapy. This is the first report case of AIHA in association with childhood tuberculosis; we also discuss other reported cases of AIHA in association with adult tuberculosis in English literature