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Epilepsy Update · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit depending on our topic or podcast.
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Today I'm so honored because joining me here in the podcast studio is Dr.
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Daniel Lapid. Dr. Lapid, thank you so much for being here in the podcast studio.
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No problem, Holly. Thank you for inviting me. You're one of the newest members
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of our neurology team here at the University of Texas Health Science Center.
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Yes. Welcome. Thank you. Thank you. I'm excited to be here.
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You completed your fellowship in Houston at Texas Children's.
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And then before that, you were at Wake Forest for your residency and then in El Paso Medical School.
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El Paso is great for my medical training. They required us to learn some Spanish
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in the first two years, and so that was good.
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But I wanted to see what was outside of Texas, so I went to North Carolina and
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had a great training there.
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I just wanted to come back to Texas after my five years, so I came back to Houston
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for my epilepsy fellowship.
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You are a husband and father, and your wife will soon have your second baby.
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Be i'll say being a pediatric neurologist first has
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effect has impacted me as being a father i'm just
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a little more cautious about them doing
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things but then also i'm
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a little like whenever whenever if she's doing something weird or a little off
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i'm a little hyper acute but then i have to back back off and like no no this
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is all normal she's she there's nothing going on but in terms of you're talking
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about your two-year-old daughter of course Because it's easy to worry.
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Exactly. Exactly. You start worrying, you start thinking about all these things
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and like normal parents do.
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But just with the knowledge that I have as a neurologist.
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But having my daughter has also shed some light in how parents feel whenever
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they bring their children to see me or to the hospital.
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And I feel a little more sympathetic to what's going on and I feel like I'm
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more understanding than I was before I was a father. So that's definitely helped.
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I feel like it's helped with the care that I provide. And that,
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yeah, being parents, that really changes us.
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There's no way to really know how much it will change you. Exactly.
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You mentioned when you take your daughter to see a pediatrician or a specialist,
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you really gravitate to clinicians who talk to you as the parent and the child
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and how important that communication is. Yes.
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As I've gone from city to city, we've had a couple of different pediatricians
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and or like even urgent care.
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It just, pediatricians that like to hear what we have to say or just check in
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with my wife and I, that I feel like, oh, they care about us.
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I don't want to come back to see them, but the pediatricians,
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and I know they're really busy.
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Nothing, I have nothing Nothing against them, but some of the ones that just,
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you know, take 10 minutes and just kind of speed in and out because the baby's
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not really going to say too much.
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They're like, I won't see them as, or they're like, maybe we'll find someone else.
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But we think we found a good pediatrician here in town, so we're hopeful. fall.
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That's great. And it is so important, that relationship and the communication.
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And it means so much when the provider can sit down, take the time, talk to you eye to eye.
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So let's talk about what's new in neurology in the field of pediatric epilepsy,
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responsive Responsive Neurostimulation, or RNS.
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It's an old device in that they've been FDA approved since 2013.
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They started implanting in adults since 2009, but more in the maybe last two
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to three years, it's been more in pediatric patients.
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And so it's been done plenty in the adults, but in pediatric cases, it's more recent.
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And I don't want to say that I'm a professional or anything in this area,
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but just maybe an area of interest, the neurostimulation, neuromodulation.
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And so probably the pediatricians are more familiar with the VNS,
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the vagal nerve stimulator.
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But the RNS has been more approved for and found to be useful in the focal epilepsies.
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But there's some ongoing trials and some case reports now where it may be helpful
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in even the generalized epilepsies.
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And so just for the pediatricians to be aware of, if they have patients that
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have seizures and are seeing an epi-opthologist and they bring up an RNS.
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It is a device that's implanted into the brain with the little battery in the skull,
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and then it's covered with a layer of skin done by the neurosurgeon.
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It can be implanted in different areas of the brain where the seizures are coming from.
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What it does is it is able to detect the patient's own seizure signature pattern,
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and then after it detects, then it can treat.
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And so, really fascinating use of technology.
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You may hear patients, they have a magnet. It's not like the VNS magnet where it can stop a seizure.
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It's just more to help detect and store, I guess, the patient's seizures.
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And so whenever they see the epilatologist in follow-up, we're able to see how
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many seizures they had in a month and if it's getting better,
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if it's getting worse, or maybe if we need to make some modifications to the treatment.
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But it's been shown to be very effective in the pediatric population.
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And so it's very exciting.
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And I just want pediatricians to be aware of these new device,
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neurostimulation devices to help with seizures.
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That sounds like it could be really great for some patients.
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Can you tell us a little bit more about how it works? Yes.
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So it's similar to, and maybe pediatricians, or maybe the people in the community
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are familiar with electrodes that go into the thalamus for deep brain stimulation,
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and those have been, can treat movement disorders.
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And actually, some DBS has been shown to be helpful in some.
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Epilepsy cases as well. But anyways, there's these tiny electrodes,
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very tiny electrodes, that are implanted into certain locations in the brain.
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Then it can detect the seizure, just like an intracranial electrode during an invasive study.
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And then it'll take it and then it'll send a current.
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The implanted device will send a current and will kind of modulate or stop the seizure.
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So it does use like, it's kind of, it stimulates their shocks,
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but the patient's illness, they shouldn't be feeling anything.
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So it doesn't hurt. No, it doesn't hurt, no.
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Most of the epipathologists should be familiar with it.
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Maybe some older ones may not be as, maybe, or when I say older,
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I meant more further away from training.
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They may be less experienced are less familiar, but they should still be familiar.
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What's nice is the company has these, what they call, RNS engineers,
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and they can also help with making some tweaks.
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But if it doesn't come up in the course of, if your patient's intractable,
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has difficult to control seizures, is on three or four or five different medications,
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it is something to bring up if it hasn't been brought up.
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So the other day, my son said it was during lunch and one of his classmates
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had a seizure and the ambulance came.
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He was describing what happened and my heart went out to this teenager.
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Being a teenager is already hard and with that on top of it,
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is this something that is right for all different ages?
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It depends on how comfortable the neurosurgeon is with implanting the device.
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But in Houston, we were doing it in the school-age kids.
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Probably not good for babies or toddlers, but once they reach school age,
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they may need some modifications in the future. So you're an epileptologist.
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You went into this challenging, complicated field to make a difference in this puzzle piece.
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It can often be incredibly hard to get to the bottom of what's causing something
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and find an effective treatment.
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It's tricky because a lot of these patients, well, sometimes you may not even
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know they're having seizures or they have seizure disorder.
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But when they do, they can be definitely affected both psychologically and emotionally,
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and then they get stressed, and there's just a stigma with seizures and the word epilepsy.
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But if they're able to find a good treatment, and I hope that I can help these
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patients and families finding that right treatment for them. They're very grateful.
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That's one of the reasons I went into the field of epilepsy.
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That's amazing. Is that usually what happens if a seizure happens at school, an ambulance?
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Yeah, it's definitely scary. And even in the hospital, whenever I see a seizure,
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I'm like, oh, it just makes everyone uneasy.
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If patients already have the diagnosis of seizures, they don't always need to
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get the ambulance involved, especially if they have a seizure action plan.
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So it's important that all families with seizures disorders should have a seizure
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action plan for their school.
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Many times, if it's a first-time seizure in a child at school,
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then the ambulance will probably be involved.
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Let's cover when is a seizure an urgent thing. Dr.
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Gross was on the show recently, and he was saying anything other than a febrile
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seizure should be seen by a neurologist.
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And then if it's in a baby, then that is something that needs to be seen urgently.
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Definitely agree. I definitely agree with what Dr. Gross said.
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Febrile seizures don't always need to be evaluated by us, but can definitely
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be run by us if there's just any sort of confusion.
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But seizures that need to be seen urgently are the febrile seizures.
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I agree. They don't always need to be evaluated by us.
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But if there's any sort of concern or confusion, then definitely send them our way or run it by us.
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And any first-time seizure, there's not necessarily an urgency to them to be evaluated.
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But just put in the referral and we'll definitely, and if you can,
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order an EEG. But we can also do that as well.
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And we can evaluate. But the super, what we consider, what I would consider
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a neurologic emergency or urgency is infantile spasms.
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And so just to give our viewpoint or what we think about from the epilepsy standpoint
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or neurology standpoint is that it's important to get them treated sooner rather
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than later just to help with developmental issues or delay or aggression and down the road.
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And this is for infantile spasms?
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And seizures in a baby, or are they one and the same, or is it totally different?
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Yeah, that's a good question. That's a good question, Holly.
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So infantile spasms are a type of seizures, but not necessarily,
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not all seizures in a baby are infantile spasms.
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And so babies can have regular familial seizures or other causes of seizures,
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but spasms are a type of seizure.
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I guess the full name is infantile epileptic spasm syndrome, IESS.
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But that's a special type of seizures or unique type of seizures where there
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are kind of very quick movements that can cluster.
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And typically happens in the onset would be around maybe four to seven months,
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but typically happens less than a year of age.
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If it's less than four months, then I'm less likely to think infantile spasms.
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I guess normally what I think is six months of age.
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And so for the pediatricians that aren't aware,
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normally some classical findings or things that you would see in presentation
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is happening either as they're waking up from sleep,
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so So like a nap or in the morning or sometimes as they're falling asleep and
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then they happen in clusters,
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just this, these quick jerks or flexion or extension kind of movements and that
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maybe one to five seconds lasting over course of 30 seconds to a minute.
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And then afterwards they're kind of, the baby's kind of fussy,
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cries and then, and then in between clusters, they could be okay.
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And then if they're caught early enough, then ideally there wouldn't be any
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sort of delay or aggression and developmental delay or aggression.
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But sometimes the movements are weird. The parents don't think too much,
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aren't thinking too much about it.
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And so they present to the pediatrician a little late and then they may have
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plateaued in their development or maybe there's some regression in language
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or they're not rolling as much as they were.
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But at that point, we still want to treat sooner rather than later and so feel
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free to send to to send us and see if you can send call us see if you can see
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them in clinic or just send them to emergency room,
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of course for our listeners out of the san antonio area contact your pediatric
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neurologist who you normally see what about so if a baby is kind of freezing
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and staring so tell us what does that What does that usually mean?
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Is that a seizure or could that be a spasm? Or if it doesn't involve other body parts, it's not?
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So if the baby's kind of staring off, it could be multiple different things,
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both seizure and not seizure, but...
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If you feel like the staring off is maybe a little longer than it should be
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for their age or if they're not reacting to like a loud noise or stimulation,
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then definitely is more concerning for seizure.
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But they can just be tired or inattentive as well.
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But that is not typical of infantile spasms.
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Still should be worked up and we'll probably need an EEG to capture these episodes.
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But would not be considered a spasm.
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Before we talk about a case, is there anything else you want to say,
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Daniel, about infantile spasms? It sounds like it can be pretty scary.
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It is definitely worrisome to the family, and we can talk more about prognosis.
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So in terms of the causes of the infantile spasms,
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they can be either idiopathic or we're not exactly sure why they have infantile spasms,
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or there may be some sort of underlying genetic or structural cause such as
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tuberous sclerosis or just other sort of inborn errors in metabolism or other genetic causes.
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But I would say typically if it's idiopathic and we treat early enough and their
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EEG improves, then prognosis is fairly good.
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If they find a genetic cause or some sort structural issue, then the prognosis
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is not as optimal, but could still be treated, just may take a couple more medications
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or may have longer-lasting effects.
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Is it something that a child could grow out of? It's definitely something a
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child could grow out of, especially if it's what they classify as idiopathic.
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But sometimes the infantile spasms can, or if it's deemed West syndrome,
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them, sometimes they can transition or progress to a Lennox-Gastaut.
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So kind of scary in that case.
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And you always hate to tell that to the parents.
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Sometimes they just need to hear what could the outcomes be.
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Take a case yes a five-month-old healthy boy is
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brought to his pediatrician by his parents for a one week
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of abnormal movements described as sudden
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flexion of his stomach and bringing in
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his arms with each distinct episode lasting only one second but occurring about
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every 30 seconds over a period of about five minutes between each episode he
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would be fussy mom feels like she has noticed these episodes more as he's waking
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up from a nap. He hasn't had any recent illnesses.
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He's been meeting his milestones and already meeting his six-month milestones,
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rolling from stomach to back, sitting with support.
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The neurological exam is normal.
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If the physician feels like it's really just the movements are concerning but developing well,
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then maybe they just need to discuss with the neurologist to see,
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hey, is this something we need to send in?
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And I would agree. I think I'd send them to the hospital just to capture these abnormal movements.
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The movements definitely sound suspicious for infantile spasms.
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It's comforting to know that the baby's been meeting his milestones.
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So maybe it's just been caught early. Go ahead. The EEG while awake appears
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to have a normal background, but sleep started to show some background disorganization.
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As he woke up from the following morning, there were a few episodes captured
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consistent with infantile spasms.
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EEG is important in terms of capturing these episodes because it can show that
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there's classical signatures we can see whenever a patient has impetile spasms.
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And then probably what many physicians are familiar with or have heard of is
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this term hypsarrhythmia, which is
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a description of the EEG background and disorganized background. ground.
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And typically if it's seen, if the EEG is done early in the course of the infantile
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spasms, then there may not be any hypsarrhythmia.
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And so it's important to do these overnight studies in order to capture sleep
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because hypsarrhythmia first pops up in sleep.
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And so if the baby, if we just do normal 30 minute, one hour study and baby
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doesn't sleep, then we may not capture And there's no episodes that we may not capture anything.
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And many residents are familiar, like if you admit someone and you hook them
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with EEG and nothing will happen that first day.
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And so if you don't capture any
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episodes, EEG is awake, then it's tough to really say what was going on.
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But if you capture sleep and there's hip arrhythmia, then that's very concerning
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for infantile spasms. And then if you're able to capture an episode as well,
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that's a sign of infantile spasms.
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But sometimes, just from the neurologist's point of view, some pediatricians
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may hear from the parents or from a discharge summary.
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EG was normal, no seizures captured, come back in a couple weeks.
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And that's because, like I had mentioned earlier, the hip shiridmia is not typically seen early on.
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And so it may need to come back in two to three weeks to do another overnight
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study to see if the background's changed or if we can capture more episodes
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and see if they're consistent with infantile spasms.
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And in this case, though, it's important for the patient to have an MRI and
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genetic testing? Thank you for bringing me back to the patient. Yes.
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So the patient did have some background
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disorganizations and had their infantile spasms captured on EEG.
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So, yes, in that case, it would be prudent of the team to start the patient on.
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In my training, we went with prednisolone, oral prednisolone.
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You can do steroids and either it can be prednisolone or ACTH,
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but I think most hospitals, most facilities these days go with oral prednisolone
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just because it's cheaper and easier to obtain.
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But ACTH is also another option. But yes, start treatment and you can do workup.
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And so MRI is important to look for any tuberous sclerosis or other structural
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issues and then genetic testing. But sometimes just depending on the facility,
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sometimes this can be done inpatient or outpatient.
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So as long as you get them treated early is important.
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But trying to figure out what the etiology is is also important,
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but not necessarily always done inpatient.
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And what could the genetic testing, what's an example of what that could show?
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Genetic testing could show the tuberous sclerosis or like the TSE.
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There's other genetic findings.
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Could that usually be done at the hospital or do you, is that kind of a separate
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thing where it needs to be a genetic testing?
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That can be done in the hospital or in the outpatient setting.
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They don't necessarily need a geneticist involved right away unless there's
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something that they see on the genetic testing.
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And, of course, you see patients at University Hospital where there's the new
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beautiful women's and children's tower,
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but you're on the floor in the hospital that's been around longer,
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University Hospital for Pediatric Neurology, and at UT Health San Antonio Pediatric
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Clinic on Wurzbach and Fredericksburg.
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In this case, the patient did get the steroids. Uh-huh.
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And typically we would treat for two weeks and then get a repeat EEG just to
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assess if the EEG has improved or not.
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If it has improved, which hopefully is the case, then we would start tapering the prednisolone.
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But if it hasn't improved, then, and this varies by center,
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some would add on vigabatrin, some would switch to ACTH, or add on some sort of other medication,
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or even the ketogenic diet can be helpful in refractory cases.
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And then, just like with any other diseases, whenever you start on steroids,
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it's always helpful for the pediatrician to check blood pressure and do their
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due diligence in the outpatient setting.
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Though, if it is, and feel free to call if there's any concerns for high blood pressure.
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But typically, if there's high blood pressure and they're just in their two-week
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high-dose steroids, then we would ask that you keep it on.
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But it may be a discussion where we may need to wean or taper or switch to a different medication.
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How often in that time should the patient see their pediatrician to check that blood pressure?
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Maybe just once or one just to check in on the family, see how they're doing.
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And ideally, spasms would start improving as well, but just check blood pressure.
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And if the family wants to check blood pressure at home as well,
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I'll leave that to their discretion and a pediatrician's discretion.
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So follow up blood pressure with a PCP and then follow up EEG in two weeks.
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And if there's improvement, then the patient can be weaned off medications.
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And in this case, that's what happened. Yes.
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Or if in two weeks the EEG is the same or worse, then what would you do?
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It depends on how, I guess. And it's always tricky just depending on,
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it's always patient specific.
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But let's say the patient, if the mom feels like the spasms are better,
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and then I've had this case where the spasms are better, but the EEG is worse.
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And I go, well, let's just continue on the steroids and then we'll check in another two weeks.
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If, let's say, the spasms are not better and the EEG is also not better,
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then we can just switch to ACTH or add-on.
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Or if we found a cause, maybe there's tuberous sclerosis, then we can switch
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to vigabatrin or add-on vigabatrin.
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And then typically, if it's still not getting better, we'll do the ketogenic diet.
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Do you want to talk a little bit about why the ketogenic diet can be so helpful?
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I feel like that can be a whole talk. Yes, we could do a podcast on that.
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Exactly. Do that next time.
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But ketogenic diet, there's my attending, when I was in fellowship where I learned
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about the ketogenic diet today,
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they always, they mentioned that in the Bible, there was someone who was having
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what sounded like seizures and
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they fasted and their seizures improved and so that's kind of where the.
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This like kind of ketogenic diet, like the process behind the benefits of ketogenic diet.
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It could be seen way back then, I guess you can say.
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But anyways, it may be in the past 30, 40 years, it kind of had a surge when
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this young little boy and his dad, or was having refractory seizures, his dad,
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his name was Charlie, and his dad was trying to figure out how to help his child
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and looked into the QJ diet, brought it up with a couple of different hospitals.
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And anyways, the QJ diet is just helpful because it, and it's, well, let me back up.
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QJ diet, no one's really clear on why you can help,
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but this process of using fats and not glucose for energy and maybe some sort
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of antioxidants has shown to be beneficial or or like this fasting process has
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been shown to be beneficial,
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in helping treat refractory seizures.
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And it's not all, you know, like I said, it's going to be a whole discussion,
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but they aren't always lifelong.
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Like if the patient's really improved in a year or two, then we can always discuss coming off.
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If they're like seizure-free and the patient wants to stay on or the family
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wants to stay on, then no harm in staying on.
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It just can be thought of like as another treatment or that's not necessarily
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medication, but like a therapy.
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Daniel, this has all been so interesting and I think really helpful.
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Is there anything else you want to say about infantile spasms or anything that
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you see that can be commonly missed?
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Just say, like, if any concern for infantile spasms, just feel free to send them our way.
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It's always better to make sure that they're not spasms than to miss it and
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not diagnose it and cause any developmental regression or delay down the road.
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And send that patient to the ER. Sorry, yes, to your local hospital,
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to your local neurologist.
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And then you'll see them in the hospital, of course, yeah. Yeah.
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You read to babies in the NICU, switching gears a bit. Tell me about that.
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Where was that when you did that?
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So I was in, this was at Wakeport in residency.
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I was part of this advocacy program that we had in the NICU called Books for Babies.
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And so, so it was, this started pre-pandemic when, you know,
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volunteers could sign up and they could read to babies, but then unfortunately
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the COVID pandemic hit and there was a pause to that.
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But then after, in like my last two years of residency, kind of picked back up.
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So we had high school students and medical students volunteering to read to
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babies. And then during my free time.
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Or during my downtime while I was in the hospital, I would find a baby that had,
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there was no one in the room and they were, you know, just kind of just hanging
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out and I would read to them and it was fun in a way.
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The babies need some sort of interaction if they're in, you know,
30:20
they had private rooms as well at Wake Forest.
30:23
And so if there's no one there, if they just have the mobile playing their music,
30:28
Sometimes it's good to just hear a friendly voice and be read to.
30:34
That was fun. That's awesome. It sounds like a great program,
30:37
Books for Babies. Books for Babies, yeah.
30:39
We can't start reading to the babies too early, right? Exactly,
30:43
exactly. Never too early to start reading to babies.
30:45
And even the babies at home, we can read to them.
30:50
And I'm a volunteer in the NICU at the University Hospital Women and Children's
30:55
Tower. And I know, so your second baby could be born any day now?
31:01
Any day now, yes. How are you doing and how is your wife?
31:04
Working on getting everything organized in the new baby's nook,
31:11
I guess I should say, in her corner.
31:13
Making sure all the bassinets and car seats and everything for our previous
31:20
daughter is all clean and ready and set.
31:24
And set and then we just packed our hospital bag
31:27
yesterday and so so we'll see but
31:30
we're excited my wife is she's just
31:33
ready for the baby to but in in due time whenever whenever whenever baby wants
31:38
to come out already it sounds like you don't have a lot of free time now and
31:44
i i say in this podcast like to recharge because a lot of our listeners don't
31:49
have a lot of free time this high high stress, high burnout career.
31:53
Do you want to mention anything about what you like to do? What helps you to recharge?
31:59
Moving to San Antonio has been nice in terms of it's more hilly,
32:04
hill country than Houston.
32:06
Houston, well, there's definitely some pros to Houston. There's also lots of
32:11
cons, and it's just hot and humid.
32:14
Not to say that it's not a hot and humid year, but sometimes I feel like there's a nice breeze.
32:17
So this past weekend, there was a nice breeze. We got to walk around.
32:21
They have these outdoor shops, and we live by the Rim area, and so the Rim is nice to walk around.
32:28
La Cantera is nice to walk around and there's a
32:32
nice playground slash trail area by our
32:35
by our apartment as well and so sometimes
32:39
just walking out at night when it's not too hot and it's and it's kind of cool
32:45
as has been nice San Antonio is often called a huge city but big city but a
32:51
small town feel does it feel that way yeah it definitely feels that way there's
32:56
there's lots Lots of things to do,
32:57
but it's not super crowded or there's not all these strip malls or tall buildings everywhere.
33:05
I guess there's a couple of strip malls, but from what I've seen, from what I explored.
33:10
When I lived in Houston, I worked for News 2 Houston and I produced the medical
33:14
stories during the week for News 2 Houston and then did medical reporting on the weekends.
33:20
But we never knew, headed to a story, it could take a half hour or three hours depending on traffic.
33:27
Or sometimes we'd have to cancel it because of it.
33:30
It was definitely fast-paced. And as you know, so much happening in that city.
33:35
Music.
33:37
Anything else you want to mention that we didn't cover? No, not right now.
33:42
But if I do, we can talk about it. We'll do it again. Yeah, exactly.
33:46
Okay, Dr. Daniel Lapid, epileptologist at University Hospital and the University
33:52
of Texas Health Science Center at San Antonio, thank you for being here today
33:56
on Pediatrics Now. No problem. Thank you so much, Holly.
33:58
Our sister podcast is Pediatrics Now for Parents.
34:02
It's meant to be one less thing you have to say in the exam room.
34:06
That's Pediatrics Now for Parents anywhere you get your podcasts.
34:11
That website is pediatricsnowforparents.com. Our website is pediatricsnowpodcast.com.
34:21
My email address is on there.
34:26
Please email me with questions or episode ideas. Thank you so much for listening.
34:32
I'm Holly Wayment. I'll see you next week.