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Current management in child neurology, 2nd edn
  1. Richard O Robinson

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    Edited by Bernard L Maria (Pp 562, US$74.95). Published by BC Decker Inc, Hamilton, 2002. ISBN 155009162X

    Management includes assessment, diagnosis, and treatment. What emerges therefore is a book of clinical paediatric neurology—not a book on treatment in paediatric neurology. It is divided into outpatient and inpatient conditions and priority within these areas is apportioned by incidence. The top four outpatient neurological conditions presenting to paediatricians in Florida are attention deficit hyperactivity disorder (ADHD), seizures and epilepsy, developmental delay, and headache. The top four discharge diagnoses from hospital on the other hand are enteroviral meningitis, epilepsy, hyperkinetic syndrome (which the author explains by the presence of comorbid conditions requiring hospital treatment), and concussion.

    The aim of this book is to provide “primary care physicians, neurologists and house staff with factual information on how to treat children with the most common disorders of the nervous system”.

    There are some surprising omissions including spinal dysraphism. Movement disorders generally get short shrift. Of the 550 pages, cerebral palsy gets five (biomechanics gets five lines, prevention of secondary deformity is ignored), although there are a further eight on spasticity. There is nothing on chorea or dystonic syndromes—the latter omission is particularly surprising in view of the treatment implications.

    In these days of economic scrutiny the evidence base for treatment recommendations should be referenced but is not for cerebral palsy, language disorders, or learning disability.

    One hundred and nine authors contributed to this book. That so many have been induced to contribute may be because few provide more than seven pages. Thus, the most extensively treated topic is that of epilepsy with 86 pages from 13 separate authors. This leads to redundancy (treatment with antiepileptic drugs in most chapters but especially those on first choice antiepileptic drugs and recurrent seizures) and surprising omissions. A diagnostic approach to Lennox-Gastaut syndrome and progressive myoclonic epilepsies would have been useful. Nowhere are the implications of the genetics of familial epilepsies described. Genetic counselling generally is mentioned only in the chapters on neurofibromatosis and tuberous sclerosis. The concept of channelopathies is absent throughout.

    The target audience for this book see a lot of headaches; hence, 46 pages and seven authors. Again, redundancy and gaps. No one mentions taking the blood pressure of a child with headache. Neuroimaging is thought unnecessary unless there are abnormal neurological signs. A slightly more sensible discussion is found on 491 in the inpatient chapter dealing with acute headache.

    Prominent also is ADHD with 26 pages and five authors, reflecting the American referral patterns described above. Another curious (to the European paediatric neurologist) area of practice is outlined in the chapter “Is my child ready for school?” (by which is meant for normal school since all American children are entitled to education). At the end of four pages, which include a list 14 tests—seven of which require special training and at least five of which seem specifically designed to address the question—it is concluded that “the paediatrician or family physician can assess school readiness using a thorough, careful medical history and physical examination”!

    In contrast there are five pages on inborn areas of metabolism and eight on neurodegenerative disorders. Both tend to give lists of conditions but not the screening tests including DNA analysis for those conditions. Statements such as the value of increased cerebrospinal fluid lactate are of limited value unless normal concentrations are given. Curiously phenylketonuria is not mentioned. Half a page is given to treatment of inborn errors. Enzyme replacement is not mentioned under the neurodegenerative conditions. While these conditions are individually rare, their collective burden is considerable. Many, particularly the inborn errors, are both treatable and susceptible to prenatal diagnosis. Similar comments may be made for the hereditary neuropathies (eight pages) and muscular dystrophies and myopathies (eight pages). Muscle histology gets five lines.

    Some omissions may be considered dangerous. Meningoencephalitis is not mentioned as a cause of neonatal fits, optic neuritis as a cause of visual loss, and dystrophia myotonica as a cause of neonatal hypotonia. Step 2 in the treatment of status epilepticus is to give fosphenytoin. But what if the child is already on phenytoin? Step 3 has the child on either a midazolam or a pentobarbitone infusion achieving burst suppression pattern on electroencephalography—but no advice is provided on what to do if either of these drugs fails or, if they succeed, what to do next.

    No doubt there are areas the American physician will find useful—particularly, for example, the chapters on the economics of the health care system in the United States and advice on practice business management. Nevertheless, I think that this book sits uneasily between the needs of the general paediatrician and the needs of the neurologist. For the former there is more information—or not enough in a useable form—than is useful and for the latter the text is just not up to the standard already provided elsewhere. With the book is provided a CD-ROM, which has the text plus links to child neurology websites and the National Library of Medicine. Those who purchase this book are advised to avail themselves fully of these facilities.

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