Abstracts

A key feature of optimal health care delivery is the dissemination of comprehensive [ldquo]best practice[rdquo] models that are readily applicable to the average clinician[rsquo]s practice. However, in pediatric epilepsy care the evidence base for [ldquo]best practice[rdquo] standards is largely uncharacterized. Our objective was to analyze the evidence for elements of pediatric epilepsy care including: behavioral/ psychosocial issues, cognitive issues, use and monitoring of antiepileptic drugs (AEDs), and diagnostic issues. We searched medical databases and reference lists of seminal review articles published in English between 1980 and 2003. We selected primary data studies for children with a principal diagnosis of epilepsy. Three neurologists reviewed and rated eligible studies for evidence quality using classification criteria adopted by the American Academy of Neurology. Searches yielded 733 eligible studies which were reviewed and classified. Of these, 31 (4%) articles were rated as highest quality (Class I), 191 articles each were rated Class II and III, and the remaining articles were rated Class IV. There was consistent Class I and II evidence recommending a waiting period before treatment initiation and identified evidence-based risk factors that indicate early treatment is necessary. Established recommendations based on substantial Class II evidence supports discontinuation at twelve or twenty-four months seizure-free; specifying seizure types, syndromes, and other necessary factors for consideration in decision making. Notably, five Class I and 51 Class II (13% of all studies) articles addressed cognitive and behavioral problems; all supported screening at diagnosis. Cognitive correlates included seizure type, syndrome classification, and pre-existing status, but not AED use. Evidence on AED side effects, monitoring, and factors influencing diagnostic testing or specialist referral was limited in breadth, and lacked sufficient consistent Class I and II evidence. Despite the vast literature regarding the diagnosis and management of pediatric epilepsy, few data meet rigorous standards of study design or analysis for evidence-based practices. This study identified gaps where additional studies are necessary. Support for some elements of care may lead to recommendations for practice that are not currently part of the primary management of pediatric epilepsy. (Supported by a cooperative agreement from the Centers for Disease Control and Prevention through the Association of American Medical Colleges, grant number U36/CCU319276-02-3, AAMC ID number MM-0531-03/03. Publication and report contents are solely the responsibility of the authors and do not necessarily represent the official views of the AAMC or the CDC.)