Australia and New Zealand Child Neurology Society

The Australia and New Zealand Child Neurology Society (ANZCNS) is a collaborative group of medical professionals working in the field of paediatric neurology or in allied neurosciences who are working to advance the science of paediatric neurology and advocate for improved care for young people with neurological disorders.

1. Do not routinely perform electroencephalographs (EEGs) for children presenting with febrile seizures

Febrile seizures are seizures associated with fever, but without evidence of central nervous system infection. There is no evidence that epileptiform discharges (i.e. distinctive electroencephalograph patterns associated with epileptic disorders) in children with febrile seizures have any diagnostic or prognostic implications.

For instance, even among otherwise neurodevelopmentally normal children with a first complex febrile seizure (febrile seizures which are prolonged or occur multiple times within 24 hours or are confined to one side of the body) these EEG patterns are a poor predictor for epilepsy. Therefore, an EEG test should not be a routine investigation for these and other patients presenting with febrile seizures.

Supporting Evidence
  • Harini C, Nagarajan E, Kimia AA, et al. Utility of initial EEG in first complex febrile seizure. Epilepsy Behav. 2015;52(Pt A):200-4.
  • Kuturec M, Emoto SE, Sofijanov N, et al. Febrile seizures: is the EEG a useful predictor of recurrences? Clin Pediatr (Phila). 1997;36(1):31-6..
  • Sadleir LG, Scheffer IE. Febrile seizures. BMJ. 2007 10;334(7588):307-11.
  • Shah PB, James S, Elayaraja S. EEG for children with complex febrile seizures. Cochrane Database Syst Rev. 2015 8;(12):CD009196.

2. Do not routinely perform computed tomography (CT) scanning of children presenting with new onset seizures

The yield from neuroimaging of children presenting with new onset afebrile seizures is typically low, with one study finding that it led to a change in clinical management for only four percent of patients. As there are already a well-tested set of indicators for determining the likelihood of intracranial abnormalities in children with new onset unprovoked seizures, a combination of clinical history, examination, and electroencephalograph (where relevant) should first be used to determine whether the condition warrants neuroimaging.

Clinical indicators for intracranial abnormalities, which are likely to change initial patient management, include (i) a focal seizure in children aged less than three years, (ii) abnormal neurological examination, (iii) Todd’s post-ictal paresis, or (iv) presence of a condition predisposing to seizures.

In children where an intracranial abnormality is considered likely, and neuroimaging is indicated, magnetic resonance imaging (MRI) is recommended over computed tomography (CT) because (i) there is superior anatomic resolution and characterisation of pathologic processes from using MRI, and (ii) there is radiation exposure and escalated future cancer risk associated with CT.

Supporting Evidence
  • Aprahamian N, Harper MB, Prabhu SP, Monuteaux MC, Sadiq Z, Torres A, Kimia AA. Pediatric first time non-febrile seizure with focal manifestations: is emergent imaging indicated?. Seizure. 2014;23(9):740-5.
  • Dayan PS, Lillis K, Bennett J, et al. Interobserver Agreement in the Assessment of Clinical Findings in Children With First Unprovoked Seizures. Pediatrics 2011, 127(5).
  • Gaillard WD, Chiron C, Cross JH, Harvey AS, Kuzniecky R, Hertz-Pannier L, Vezina LG, ILAE, Committee for Neuroimaging, Subcommittee for Pediatric. Guidelines for imaging infants and children with recent-onset epilepsy. Epilepsia. 2009;50(9):2147-53
  • Kuzniecky RI. Neuroimaging of Epilepsy: Therapeutic Implications. NeuroRx. 2005;2(2):384-393.
  • Malviya S, Voepel-Lewis T, Eldevik OP, Rockwell DT, Wong JH, Tait AR. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth. 2000 Jun;84(6):743-8
  • Matthews JD, Forsythe AV, Brady Z. et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013;346:f2360.
  • Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380: 499–505.
  • Sharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatrics. 2003;111(1):1-5.

3. Do not routinely undertake repeat blood level monitoring of antiepileptic drug (AED) treatments

The serum concentration of an antiepileptic drug (AED) varies markedly between patients taking the same dosage because of differences in people’s ability to absorb, distribute, metabolise and excrete drugs. The utility of drug blood level monitoring assumes that plasma drug level correlates better with clinical response or side effects than with dosage, or provides better information than clinical review of the patient. However, evidence from a major randomised controlled trial suggests that repeat blood level monitoring of AED treatments has no discernible impact on patient outcomes in terms of remissions from seizures or incidence of adverse effects. Other studies have also shown that there is no definitive correlation between a patient’s AED blood level and clinical efficacy.

Specific exceptions where targeted AED blood level assessment can be useful include their use in assessing compliance, titrating AEDs in complex polypharmacy regimens, or adjusting for altered AED metabolism in disease states, puberty, or pregnancy.

Supporting Evidence
  • Harini C, Nagarajan E, Kimia AA, et al. Utility of initial EEG in first complex febrile seizure. Epilepsy Behav. 2015;52(Pt A):200-4.
  • Kozer E, Scolnik D, Agamata WM, et al. Utility of antiepileptic drug monitoring in the pediatric emergency department. Ther Drug Monit. 2003;25(1):17-21.
  • Louis, Monitoring Antiepileptic Drugs: A Level-Headed Approach, Curr Neuropharmacol. 2009; 7(2): 115–119.
  • Naik GS, Kodagali R, Mathew BS, et al. Therapeutic Drug Monitoring of Levetiracetam and Lamotrigine: Is There a Need? Ther Drug Monit. 2015;37(4):437-44.
  • Tomson T, Dahl ML, Kimland E. Therapeutic monitoring of antiepileptic drugs for epilepsy. Cochrane Database Syst Rev. 2007 24;(1):CD002216.

4. Do not routinely undertake neuroimaging for new onset primary headache without first examining for neurological abnormality

Most headaches are attributable to benign conditions. Studies suggest that the yield of neuroimaging findings in children with headache that actually change patient management is no higher than 2.5 per cent. This supports the practice of selective imaging of paediatric headache patients with clinical presentation suspicious for intracranial abnormality.

Moreover, the routine use of neuroimaging may lead to the discovery of incidental benign abnormalities, which may cause undue alarm, and headaches may be wrongfully attributed to these incidental findings. For instance, a retrospective study revealed benign neuroimaging abnormalities in approximately 20 per cent of paediatric headache patients who underwent neuroimaging.

Neuroimaging on a routine basis is therefore not indicated in children with new onset primary headaches and a normal neurological examination. It should be reserved for a selected group of children whose history and/or physical examination suggest serious intracranial pathologies.

Supporting Evidence
  • Alexiou GA, Argyropoulou MI. Neuroimaging in childhood headache: a systematic review. Pediatr Radiol (2013) 43:777–784.
  • Clarke CE, Edwards J, Nicholl DJ, Sivaguru A. Imaging results in a consecutive series of 530 new patients in the Birmingham Headache Service. J Neurol. 2010 Aug;257(8):1274-8. doi: 10.1007/s00415-010-5506-7. Epub 2010 Mar 3.
  • Schwedt et al, “Benign” imaging abnormalities in children and adolescents with headache. Headache. 2006; 46(3):387-98.

5. Do not routinely perform electroencephalographs (EEGs) for children presenting with syncope (fainting)

Studies have found that the incidence of epileptiform discharges (i.e. distinctive EEG patterns associated with epileptic disorders) in patients with syncope is roughly similar to its incidence among healthy subjects, and that therefore EEG has very low diagnostic yield among these patients. Moreover, clinical criteria have been formulated that can differentiate syncope from seizures with very high sensitivity and specificity. Thus, guidelines recommend that an EEG should not be performed if syncope is the most likely cause of the transient loss of consciousness.

Supporting Evidence
  • Abubakr A, Wambacq I. The diagnostic value of EEGs in patients with syncope. Epilepsy & Behavior. 6(3):433-4, 2005.
  • Dantas FG, Cavalcanti AP, Rodrigues Maciel BD, et al. The role of EEG in patients with syncope. Journal of Clinical Neurophysiology. 29(1):55-7, 2012.
  • Linzer M, Yang EH, Estes NA, III et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997; 126(12):989‐996.
  • Poliquin-Lasnier L, Moore FG. EEG in suspected syncope: do EEGs ordered by neurologists give a higher yield? Can J Neurol Sci. 2009 ;36(6):769-73.
  • Sheldon et al, Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002; 40(1):142‐148.
  • Moya, Angel et al. 2009. “Guidelines for the Diagnosis and Management of Syncope (Version 2009).” European Heart Journal 30(21):2631–71.

 

How was this list created?

Following deliberations, the ANZCNS Board determined to investigate the evidence for nine priority recommendations regarding low-value clinical practices in paediatric neurology. An evidence review was developed for these recommendations and served as the basis for an online survey sent to all ANZCNS members asking respondents if they agreed, disagreed or were unsure if these recommendations were evidence based, undertaken in significant numbers, and important in terms of reducing patient harm and unnecessary healthcare expenditure.  Based on survey responses, each of the nine was assigned a score and ranked accordingly. Based on this information and a final evidence review, these top-5 recommendations were chosen.

Launched April 2018