Effects and limits of acute noninvasive positive pressure ventilation in children with severe motor and intellectual disabilities with pneumonia/bronchitis.

Objective: We have frequently applied noninvasive positive pressure ventilation (NPPV) to treat acute respiratory failure in children with severe motor and intellectual disabilities. We investigated the features and causes of conditions requiring endotracheal intubation. We aimed to determine whether phlegm expulsion using appropriate breathing physiotherapy with NPPV could avoid the need for endotracheal intubation in such patients. Methods: Between December 2010 and November 2012, 21 children with 51 episodes of acute respiratory failure were placed on NPPV at our hospital. We investigated the ratio, background, and causes of conditions requiring endotracheal intubation. Results: Pneumonia and bronchitis caused 30 and 21 episodes of respiratory failure, respectively. Respiratory infection required endotracheal intubation in 8 of 30 episodes of pneumonia, and in none of the 21 episodes of bronchitis. Respiratory infections were caused by upper airway obstruction with large amounts of secretion (n=4), lower airway obstruction due to atelectasis (n=3) and a combination of both (n=1). The frequency of breathing physiotherapy was significantly higher for all patients who required assistance with active phlegm expulsion than in those who did not (p=0.006). More patients on endotracheal intubation also required phlegm aspiration compared with other patients (p=0.019). Conclusion: We applied NPPV to acute respiratory failure in children with severe motor and intellectual disabilities. This allowed 84% of them to avoid endotracheal intubation. Acute respiratory failure did not improve in any patient who required endotracheal intubation, but we also used NPPV with breathing physiotherapy and postural drainage. Assistance with phlegm expulsion is hampered in children with severe motor and intellectual disabilities due to conditions such as thoracic deformations, joint contracture and glossoptosis. We consider that assistance with phlegm expulsion using appropriate breathing physiotherapy with NPPV is very important for such patients.

[Effectiveness of continuous infusion of tizanidine (Ternelin) via a feeding tube for patients with the mixed type of tetraplegia].

OBJECTIVE: Severe muscle hypertonia in patients with the mixed type of tetraplegia may be associated with significant deterioration in the quality of life of the patients. Intermittent use of oral muscle relaxant drugs, for example, Tizanidine (Ternelin), which is a fast-acting muscle relaxant, can provide relief from the severe hypertonia in these patients, but only for short durations. METHODS: We conducted a retrospective study of the effect of continuous infusion of tizanidine via a feeding tube on the severe systemic muscle hypertonia in patients with the mixed type of tetraplegia. We mixed tizanidine with milk or other enteral nutrients and administered the mixture via a naso-duodenal tube at a constant infusion rate several hours to 5 patients with the mixed type of tetraplegia showing severe uncontrolled systemic hypertonia under intermittent treatment with oral muscle relaxant drugs. RESULTS: Significant relief from the systemic muscle hypertonia was obtained in 4 of the 5 patients with improvement of the quality of life of the patients, e. g., they could get adequate sleep. There were no serious side effects in any of the cases. CONCLUSION: We consider that continuous infusion of tizanidine via a feeding tube would be useful for the treatment of severe systemic hypertonia in patients in whom the symptom cannot be adequately controlled by intermittent use of oral muscle relaxant drugs.

[Status of children with food allergy who were prescribed an adrenaline autoinjector (epipen)].

PURPOSE: Both to evaluate the characteristics of food allergic children who were prescribed an adrenaline autoinjector and to assess whether it was used appropriately. METHODS: The characteristics of food allergic children who were prescribed an adrenaline autoinjector were investigated. Among these children, those who experienced severe anaphylaxis due to inadvertent ingestion were analyzed, as was whether and how the autoinjector was used. RESULTS: An adrenaline autoinjector was prescribed to 139 food allergic children, most often for egg, followed by milk and wheat allergies. Concomitant bronchial asthma, atopic dermatitis, and food allergies of other causes were present in 49 (35.3%), 68 (48.9%), and 102 cases (73.4%), respectively. The most frequent organ involved in anaphylaxis was the skin (94.2%), followed by the respiratory (78.5%), digestive (28.1%), and circulatory (24.8%) organs. A total of 24 cases experienced severe anaphylaxis after the prescription; however, the autoinjector was used in only six (25%) of those cases. The reasons given for lack of use included fear of use, unavailability of the autoinjector, prior improvement with use of an oral antihistamine and immediate visit to a hospital emergency department in eight, five, three and one case, respectively. CONCLUSION: These results suggest that the autoinjector is often not used appropriately after prescription. Therefore, children and their caregivers require more effective guidance on proper adrenaline autoinjector use.

Pyruvate therapy for mitochondrial DNA depletion syndrome.

BACKGROUND: Mitochondrial DNA depletion syndromes are a group of heterogeneous autosomal recessive disorders associated with a severe reduction in mitochondrial DNA in the affected tissues. Sodium pyruvate has been reported to have a therapeutic effect in mitochondrial diseases. METHODS: We analyzed the effects of 0.5g/kg of sodium pyruvate administered through a nasogastric tube in a one-year-old patient with myopathic mitochondrial DNA depletion syndrome. To evaluate the improvement, we used the Newcastle Paediatric Mitochondrial Disease Scale (NPMDS) and manual muscle testing. As the improvement of motor functions in this severely disabled infant could not be comprehensively detected by NPMDS, we also observed the infant's ability to perform several tasks such as pouting, winking, and number of times she could tap a toy xylophone with a stick. Blood lactate and pyruvate levels were also monitored. RESULTS: After one month's treatment, the NPMDS score in section IV, the domain for the quality of life, improved from 17 to13. The infant became capable of raising her forearm, lower leg and wrist against gravity. The maximum number of times she could repeat each task increased and the movements became brisker and stronger. No significant change of the blood lactate level or lactate-to-pyruvate ratio, both of which were mildly increased at the initiation of the therapy, was observed despite the clinical improvement. CONCLUSION: Sodium pyruvate administered at 0.5g/kg improved the muscle strength and the NPMDS score of an infant with myopathic mitochondrial DNA depletion syndrome. GENERAL SIGNIFICANCE: Sodium pyruvate may be effective for ameliorating the clinical manifestations of mitochondrial diseases. This article is part of a Special Issue entitled: Biochemistry of Mitochondria.

Reversible splenic lesion in a patient with Febrile Infection-Related Epilepsy Syndrome (FIRES).

Febrile infection-related epilepsy syndrome (FIRES) is a severe epileptic syndrome that manifests with refractory seizures or status epilepticus in previously healthy children after banal febrile illness. The neuroimaging findings in the acute phase of FIRES are nonspecific or normal. We report the case of a 7-year-old boy with FIRES who presented with a reversible lesion in the splenium of the corpus callosum on brain magnetic resonance imaging (MRI). The patient developed clusters of clonic seizures with a deviation of the eyes after a 3-day history of fever. A reversible splenial lesion was observed on brain MRI and, therefore, the initial diagnosis was mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). However, the intractable complex partial seizures necessitated a long-term midazolam infusion, indicating that FIRES was a more likely diagnosis than MERS. All other findings of this patient met the diagnostic criteria for FIRES. With this diagnosis, a high-dose phenobarbital was administrated, and the seizures were successfully controlled. This case indicated that FIRES should be considered even in patients with a reversible splenial lesion associated with encephalitis/encephalopathy.

Grisel syndrome as a complication of Kawasaki disease: a case report and review of the literature.

UNLABELLED: Grisel syndrome is a non-traumatic atlantoaxial subluxation and a rare complication of any inflammatory condition of the upper neck and otolaryngological procedures. Delayed diagnosis causes neurological impairment, ranging from radiculopathy to paralysis and death. Kawasaki disease is a very frequent and important acute febrile vasculitis of childhood that is seen worldwide, and upper neck involvement (cervical lymphadenopathy) is one of the common symptoms of Kawasaki disease. A case of Grisel syndrome that occurred as a complication of Kawasaki disease is reported. This is the first case report, in English, of Grisel syndrome as a complication of Kawasaki disease. CONCLUSION: Pediatricians should be aware of Grisel syndrome as a possible complication of Kawasaki disease.

[Changes in serum levels of selenium, zinc and copper in patients on a ketogenic diet using Ketonformula].

OBJECTIVE: Ketogenic diets tend to cause trace mineral deficiencies. Ketonformula is a foumula for a ketogenic diet developed by Meiji Co Ltd in Japan. No reports are available on the trace mineral deficiencies associated with a use of Ketonformula. METHODS: We monitored the serum levels of selenium, zinc and copper as well as the amount of the daily intake of these minerals before and at 6 months after the initiation of the ketogenic diet with Ketonformula in six patients with intractable epilepsy associated with severe motor and intellectual disabilities. RESULT: The median serum selenium concentration decreased from 7.0 (range, 6.5-12.3) microg/dl to 6.2 (5.4-10.9) microg/dl as a result of the 6-month-treatment with Ketonformula (p < 0.05, Wilcoxon signed-rank test). The median daily selenium intake decreased from 17.8 (15.0-27.0) microg/day at the baseline to 5.5 (5.0-22.0) microg/day after 6 months on the diet (p < 0.05). The median serum zinc concentration increased slightly (from 66.0 (46.0-84.0) microg/dl to 68.0 (46.0-71.0) microg/dl), but the difference was not significant. The median daily zinc intake, however, significantly decreased from 4.2 (3.7-6.0) mg/day to 2.2 (2.0-3.0) mg/day (p < 0.05). The median serum copper concentration also showed no significant decrease (from 134.5 (119.0-168.0) microg/dl to 126.0 (86.0-183.0) microg/dl). The median daily copper intakes, however, decreased significantly from 0.80 (0.35-1.30) mg/day to 0.30 (0.26-0.40) mg/day (p < 0.05). CONCLUSIONS: The decline of the serum selenium concentrations and daily enteral intakes of selenium, zinc, and copper after 6 months on Ketonformula suggested that patients on this ketogenic formula needs close monitoring as well as supplementation of these trace minerals.

[Efficacy, safety and tolerability of high-dose topiramate with rapid dose titration in symptomatic West syndrome].

OBJECTIVE: We investigated the efficacy, safety, and tolerability of high-dose topiramate with rapid dose titration in 12 children with symptomatic West syndrome who suffered from severe motor and intellectual disabilities. METHODS: Topiramate was introduced as add-on therapy at the daily dose of 1 mg/kg/day, followed by increments of 2 mg/kg at 3- or 4-day intervals, up to a maximum of 19 or 20 mg/kg/day. The ages at the start of topiramate therapy ranged from 5 to 22 months. Prior to the topiramate therapy, the patients had received 2 to 6 antiepileptic agents with (8 patients) or without ACTH (4 patients). RESULTS: Topiramate appeared to be effective in 8 of the 12 patients (67%); four became seizure-free;three showed greater than 90% seizure reduction; one showed greater than 50% seizure reduction. The maintenance dose was 7 to 20 mg/kg/day (mean:17.9 +/- 3.9 mg/kg/day). In 4 of these 8 patients (50%), the spasms relapsed several months after complete cessation or diminution in the frequency of the spasms following treatment with topiramate. All of the 8 topiramate-responsive patients could continue the topiramate therapy throughout this study. The duration of topiramate therapy was 7 to 42 months (median: 12.5 months). There were no severe side effects that necessitated discontinuation of topiramate, including kidney stones. CONCLUSIONS: High-dose topiramate with rapid dose titration was revealed to be effective, safe, and well-tolerated in children with symptomatic West syndrome.

[Ketogenic diet may control seizures by increasing the binding potential of the benzodiazepine receptor: a speculation from the [11C] flumazenil-PET study].

The ketogenic diet (KD) is a high-fat, low-protein, low-carbohydrate diet which is effective in the treatment of medically refractory epilepsy. Several theories have been proposed to explain the mechanism underlying the anticonvulsant efficacy of the KD, however, the precise anticonvulsant mechanism of the KD is still unknown. We speculated the mechanism underlying the effect of the KD in patients with intractable epilepsy, based on the results of the [11C] flumazenil (FMZ)-positron emission tomography (PET) study. A patient developed frontal lobe epilepsy at the age of 2 years. At the age of 4 years 11 months, she was admitted to our hospital for the initiation of a KD. At the time of admission, she had several epileptic attacks each day: frequent postural tonic seizures, hypermotor seizures, head nodding, and intermittent loss of consciousness (non-convulsive status epilepticus). MR imaging showed no abnormal signal intensity in the brain. With the KD, the seizure frequency reduced dramatically on the fifth day. Interictal [11C] FMZ-PET was performed before and 2 months after the initiation of the KD. Before the KD, the [11C] FMZ-PET images and [11C] FMZ-PET binding potential (BP) images showed extremely low accumulation of FMZ throughout the cerebral cortex. Two months after the initiation of the KD, significantly increased binding potential of [11C] FMZ was observed, implying the increased binding potential of the benzodiazepine receptors, probably due to the anticonvulsant effect of the KD. These PET findings suggested that KD may control seizures by directly or indirectly increasing the binding potential of the benzodiazepine receptors.

[Prednisolone treatment for Duchenne muscular dystrophy].

Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder and is the most common form of muscular dystrophy. Affected children develop muscle weakness in early childhood. Only steroids have been shown with evidence to improve muscle function in patients with DMD. We report the long-term effects of prednisolone treatment in patients with DMD, comparing the age at which 14 treated patients and 15 control patients lost their ability to walk. The prednisolone-treated patients were assigned to one of five regimens: 0.5 mg/kg/day given for the first 10 days of every month (n = 6), 0.75 mg/kg/day given for the first 10 days of every month (n = 3), 0.5 mg/kg on alternate days (n = 1), 0.75 mg/kg on alternate days (n = 1), or 5 mg/kg twice a week (n = 3). No significant difference in age of losing ambulation ability was observed between the treated group and the untreated group (mean age; 10 years and 6 months in both groups). However, 13 of the 14 patients showed an improvement in their activity of daily living other than ambulation in the treated group. The results of this study showed that the prednisolone treatment regimens used in this study did not prolong the period of ambulation.

[Epidemiological study of cerebral palsy in Shiga Prefecture, Japan, during 1977-2000. Part 1: incidence pattern of cerebral palsy in Shiga Prefecture with reference to birth weight and gestational age].

The prevalences of cerebral palsy (CP) among 6-year-old children in Shiga Prefecture born during 1977-2000 were compared in eight successive 3-year periods (period I-VIII) with reference to birth weight and gestational age. During the 24-year surveillance period, among 349,514 children born in Shiga Prefecture, 569 children had CP at the age of 6 years, thus the prevalence was 1.63 per 1000 live births. The prevalence increased significantly in period V compared to previous periods. There were no significant differences among period V-VIII. The proportion of CP with low birth weight and lower gestational age increased progressively, and two-thirds of CP in the period VIII had a LBW and/or preterm gestation.

[Epidemiological study of cerebral palsy in Shiga Prefecture, Japan, during 1977-2000. Part 2: etiologies and risk factors of cerebral palsy in Shiga prefecture].

Etiologies and risk factors of 569 patients with cerebral palsy (CP) in Shiga Prefecture born during 1977-2000 were investigated. The patients with CP born at preterm and at term were separately analyzed. The main etiologies or risk factors for CP in preterm children were periventricular leukomalacia (PVL, 58%), multiple births (25%) and mechanical ventilation (45%). The prevalence rates of these increased in the latter half of the study period. The main etiologies or risk factors for CP in term children were brain dysplasia (17%), fetal brain vascular disorders (15%), hypoxic ischemic encephalopathy (14%), PVL (8%) and intrauterine growth retardation (19%). The prevalence rates among etiologies did not change during the study period.

[Epidemiological study of cerebral palsy in Shiga Prefecture, Japan, during 1977-2000. Part 3: clinical features of cerebral palsy at six years of age].

Clinical features of cerebral palsy (CP), including the types of CP, severity of disability and complications were evaluated at six years of age in 569 children with CP in Shiga Prefecture born in 1977-2000. Spastic diplegia and tetraplegia accounted for the vast majority, 43% and 28%, respectively. Hemiplegia was present in 18%, dyskinetic type in 6% and ataxic type in 5% of the subject children respectively. Spastic diplegia increased and dyskinetic type decreased in the latter half of the study period. The prevalence of diplegia and tetraplegia among those born at preterm increased in the latter half of the study period. Forty-four percent of the children could walk alone at six years of age, 5% walked with a crutch, 14% crawled and 37% could not crawl. Non-walkers in preterm children with CP who were born at preterm increased in the latter half of the study period. Thirty-one percent of the children had normal intelligence, 12% were mildly retarded, 25% were moderately and 32% were severely retarded. Children with normal intelligence born at preterm decreased in the latter half of the study period. Forty-two percent of all children developed epilepsy by six years of age. Severe motor disability, severe mental retardation and epilepsy were present more frequently among children born at term than at preterm. A break in the increasing CP trend both in the prevalence and degree of disability was not recognized in Shiga Prefecture during the study period, although neonatal care markedly improved. Despite the progress and improvement of neonatal care, no decrease in the prevalence or severity of CP was observed in Shiga Prefecture during the study period.

[Sulthiame treatment for patients with intractable epilepsy].

We examined the antiepileptic effect and side effects of sulthiame in 28 patients with intractable epilepsy. The patients' ages ranged from 6 months to 34 years (mean: 8 years 7 months), and 26 of them were under 18-years-old. Nineteen patients had severe physical and mental disabilities. Sixteen patients had generalized seizures, and 12 had partial seizures. Sulthiame was administered at the dose of 50-300 mg/day (4-14 mg/kg body weight) as add-on therapy in all except one patient. Among the 28 patients, two with complex partial seizures (7%) became seizure-free. Eight patients (29%) (6 patients with generalized seizures and 2 patients with partial seizures) showed seizure reduction by > 50%. Among these 10 patients who showed positive responses, six developed tolerance within 2-5 months. Side-effects were observed in 5 patients, including enuresis, drowsiness, and drooling, none of which caused discontinuation of treatment. Therefore, we conclude that sulthiame is an effective and safe antiepileptic drug for the treatment of intractable epilepsy.

Three Japanese patients with glucose transporter type 1 deficiency syndrome.

We report three Japanese patients with glucose transporter type 1 deficiency syndrome (Glut1DS). Two patients had a normal erythrocyte 3-O-methylglucose (3OMG) uptake, one with a previously reported T295M substitution and the other with a novel 12-bp insertion at nt 1034-1035, ins CAGCAGCTGTCT. The third patient, with deficient 3OMG uptake, had a previously reported hot-spot mutation, R333W. All three patients responded to a ketogenic diet. All patients showed a significant improvement in ataxia, with blood beta-hydroxybutyrate (BOHB) levels ranging from 0.1 to 3mM. BOHB levels of at least 3mM were necessary to control seizures, and higher ketone levels are recommended to meet brain energy needs during development. FDG-PET scan, performed before and after a ketogenic diet in the R333W patient, did not change despite a clinical improvement. This clinical condition is treatable and early diagnosis is important.

[A follow up study of spastic diplegia in Shiga Prefecture--ambulatory function and career course after school age].

This study investigated the changes in ambulatory function in individuals with spastic diplegia from 6 (the age at which children start going to elementary school in Japan) to 18 years of age (the age at which children leave high school) in Shiga Prefecture. Sixty-two patients with spastic diplegia (19-28 years of age, born between 1977 and 1986) were studied. Ambulatory function at 18 years of age was compared with that at 6 years of age. Ambulatory ability tended to improve up to 9 years of age, and was maintained at its optimal level between the age of 9 and 11. In some patients, ambulatory function decreased thereafter. Of 62 patients, 43 (69%) attained unaided ambulation, and 48 (77%) could walk with or without the use of crutches by the age of 18. Those who could walk unaided at the age of 6 years (39 of 62; 63%) maintained independent ambulation at the age of 18 years, although some complained of pain and/or fatigue. Employment at 18 years of age was limited to individuals who could walk with or without crutches. Of two wheelchair-bound patients, one went on to study at the university level and the other went on to a special school. When children with spastic diplegia reached age 18, their career course correlated with the degree of mental retardation. Individuals without mental retardation were employed or went on to higher education.

Multi-institutional study on the correlation between chromosomal abnormalities and epilepsy.

While there is an abundance of literature describing the association of chromosome aberrations with epilepsy, only a few refer to the detailed features of epilepsy. It is important to investigate the associations between specific chromosome abnormalities and features of epilepsy to identify genes involved in epilepsy and treat them more effectively. We investigated the correlation between specific chromosome aberrations and epilepsy by sending questionnaires to the members of Kyoto Multi-institutional Study Group of Pediatric Neurology. Seventy-six patients were collected from 10 institutions. Chromosome abnormalities included: Down syndrome (n = 19); Angelman syndrome (n = 8); Prader-Willi syndrome (n = 4); 4p- syndrome (n = 3); 1q- syndrome (n = 2); 5p- syndrome (n = 2); Miller-Dieker syndrome (n = 2); 18q- syndrome; (n = 2); Klinefelter syndrome; (n = 2); and 32 other individual chromosomal aberrations. Overall, the severity of mental retardation correlated with the severity of epilepsy. We could abstract characteristic features of epilepsy in some syndromes. In Angelman and Prader-Willi syndromes, febrile seizures occurred frequently, the onset of epilepsy was in early childhood and seizure phenotype was multiple. Paroxysmal discharge of the occipital region and diffuse high voltage slow wave on electroencephalography were characteristic in Angelman syndrome. In Down syndrome, West syndrome and focal epilepsy were common and the prognosis of epilepsy in West syndrome with Down syndrome was good. In 4p- syndrome, febrile seizures were often seen, and unilateral or generalized clonic or tonic-clonic status epilepticus were characteristic. For the other chromosomal aberrations investigated here, the patient numbers were too small to abstract common features of epilepsy.

Cloxazolam treatment for patients with intractable epilepsy.

We examined the antiepileptic effect of cloxazolam on seizures in 23 patients with intractable epilepsy. Most of the patients had central nervous system complications, as well as frequent seizures, and were being treated with polypharmacy. Cloxazolam was administered 1 to 5 mg/day (0.05 to 0.14 mg/kg) at initiation, in two divided doses daily, and gradually increased (1 to 4 mg/day; 0.05 to 0.15 mg/kg) every month at the outpatient clinic. Plasma levels of the main active metabolite, chloro-N-desmethyldiazepam, were measured in 13 patients. Four of 23 patients (17%) became seizure-free, and nine patients (39%) manifested a good response. Both patients with generalized and partial epilepsy manifested a good response. The spectrum of cloxazolam as an antiepileptic was wide. Effective doses were 0.07 to 0.56 mg/kg, and plasma effective levels of chloro-N-desmethyldiazepam were 12.3-115.1 ng/mL. Cloxazolam may be an effective and safe antiepileptic for intractable epilepsy, and should be used as an adjunct to other antiepileptic drugs or administered after other agents.

Dichloroacetate therapy in Leigh syndrome with a mitochondrial T8993C mutation.

A 6-year-old female with Leigh syndrome associated with a T-to-C mutation at nucleotide 8993 of mitochondrial deoxyribonucleic acid (T8993C) was treated with dichloroacetate, once during the first acute deterioration after a febrile illness and another time when she demonstrated subacute regression without precipitating events. Dichloroacetate reversed the clinical course on both occasions, and diffuse lesions in the midbrain revealed on magnetic resonance imaging during the second episode disappeared completely. However, dichloroacetate could not prevent the second acute deterioration associated with a febrile illness that occurred during the second treatment. Thus dichloroacetate treatment, although limited, was effective for T8993C-associated Leigh syndrome.