About The Practice

Serving Texas Children's Concerns about Neurology, Epilepsy Developmental & Sleep Disorders. Advanced spasticity management.

The Houston Area ( Bellaire Katy Sugar Land Richmond Missouri City Cypress The Woodlands Lake Jackson)

The Greater San Antonio Area ( New Braunfels Seguin Central Texas)

Dr Joshua Rotenberg. Board Certified in Neurology with Special Qualifications in Child Neurology.

Dr. Rotenberg has added subspecialty board certification in epilepsy AND sleep disorders (American Board of Psychiatry & Neurology-Child Neurology).

Member - American Epilepsy Society

Member - American Academy of Cerebral Palsy & Developmental Medicine

Texas Medical & Sleep Specialists - Children & Adults Welcome. WWW.TXMSS.COM 713-464-4107

Monday, October 20, 2014

Seizures after Vaccine are Not due to the Vaccine...it might be worse.

Etiologies for Seizures Around the Time of Vaccination found in 65%!!

Its important to have an expedited evaluation by an epilepsy specialist. JR

Post-immunization epilepsy likely not related to vaccine: study

Reuters: HealthSeptember 17, 2014
(Reuters Health) - Children who start having seizures soon after a vaccination and go on to develop epilepsy usually turn out to have an underlying cause of the seizure disorder, according to a new study published in Pediatrics.
"It's reassuring to hear that with follow-up testing, the vast majority of these cases can be identified as coming from a different cause," Dr. Shannon MacDonald told Reuters Health.
In the days after receiving a vaccine, compared to other times, children are two to five times more likely to have a febrile seizure, according to the authors of the new study.
"When a child has its first seizure shortly after a vaccination, and continues to have seizures thereafter, parents may think the vaccination has caused the epilepsy. However, in our study the majority of children who developed epilepsy after a vaccination, had a genetic or structural cause of the epilepsy," Dr. Nienke Verbeek, a clinical geneticist at University Medical Centre Utrecht in The Netherlands, told Reuters Health.
"In these children, the vaccination should only be considered a trigger for the first seizure that thereby unmasks the child’s underlying susceptibility for epilepsy," Verbeek added.
Roughly one in every 100 healthy, normally developing children will develop epilepsy after a febrile seizure, according to NINDS, but children with certain conditions, including cerebral palsy and developmental delay, are at greater risk.
To better understand the relationship between febrile seizures and epilepsy, the researchers looked at nearly a thousand children who had a first seizure within several days of being vaccinated. Twenty-six of the children were later diagnosed with epilepsy, and the researchers were able to follow up with 23 of them.
Eight of the children had Dravet syndrome, a rare genetic condition in which seizures may be brought on by fever, infectious disease, or vaccination. Three of the children had developmental delays and structural brain defects that could cause epilepsy. Four other children had gene mutations that could cause epilepsy, brain malformations, or a family history of the disease.
"Although no underlying cause was detected in one-third of children with epilepsy with vaccination-related onset, a genetic basis of epilepsy in these children is still possible: genetic analyses were incomplete, some children had positive family histories for seizures, and molecular defects underlying many genetically determined epilepsies have yet to be discovered," Verbeek and her colleagues write.
"For parents it is important to understand that a genetic cause (a so called DNA-mutation) for epilepsy cannot be induced by vaccinations," Verbeek told Reuters Health. " These mutations are already present in the child before it is born. They may have been transmitted by one of the parents, but more commonly have occurred spontaneously around the time of conception."
The findings “provide a pretty strong case that this was not caused by the vaccination,” Dr. Jorn Olsen told Reuters Health in a telephone interview.
SOURCE: Pediatrics, online September 15, 2014.
OBJECTIVES: This study was an assessment of the incidence, course, and etiology of epilepsy with vaccination-related seizure onset in a population-based cohort of children.
METHODS: The medical data of 990 children with seizures after vaccination in the first 2 years of life, reported to the National Institute for Public Health and Environment in the Netherlands in 1997 through 2006, were reviewed. Follow-up data were obtained of children who were subsequently diagnosed with epilepsy and had had seizure onset within 24 hours after administration of an inactivated vaccine or 5 to 12 days after a live attenuated vaccine.
RESULTS: Follow-up was available for 23 of 26 children (median age: 10.6 years) with epilepsy onset after vaccination. Twelve children developed epileptic encephalopathy, 8 had benign epilepsy, and 3 had encephalopathy before seizure onset. Underlying causes were identified in 15 children (65%) and included SCN1A–related Dravet syndrome (formerly severe myoclonic epilepsy of infancy) or genetic epilepsy with febrile seizures plus syndrome (n = 8 and n= 1, respectively), a protocadherin 19 mutation, a 1qter microdeletion, neuronal migration disorders (n = 2), and other monogenic familial epilepsy (n= 2).
CONCLUSIONS: Our results suggest that in most cases, genetic or structural defects are the underlying cause of epilepsy with onset after vaccination, including both cases with preexistent encephalopathy or benign epilepsy with good outcome. These results have significant added value in counseling of parents of children with vaccination-related first seizures, and they might help to support public faith in vaccination programs.

Sunday, October 19, 2014

The impact of migraines on the whole family

This article discusses the impact that migraine headaches have on the entire family.

Most Migraine sufferers will tell you that their migraines are worsened by stress. Stress can come from a number of sources, but the ones that seem to be on the top of the list are school, or work, and family. Though all three are tremendously significant, it is infinitely easier to change a classroom, school or even job than it is to change one’s family.
Whether it be marital discord, money concerns, or parent – teen conflict, families issues have a tremendous impact on the migraineur and ignoring this is likely to result in less than successful migraine therapy.
On the flip side, having a supportive, understanding family can be an enormous help to the migraine sufferer…to an extent. Unfortunately, we find that very often with our adolescent patients, the parents are too focused on the migraine; so called “helicopter parents” who are hovering over their teen with repeated inquiries about their pain. In my clinic I had one parent ask her 16 year old son how he was feeling 4 times in a 15 minute visit. This kind of attention only serves to increase the focus on a problem that we are trying to minimize.
Often, having the whole family involved in the therapeutic process is the answer. It may mean scheduling visits at a time that spouses or parents are available, and it may involve family counseling. People often find the prospect of family counseling threatening. It really should not be viewed as such. Seldom do people take classes on being a spouse or a parent before having to be one. Processes that seem right and become family habit sometimes are detrimental in ways not obvious to those involved.
Making the effort to work on sources of family stress and how the family responds to them; learning to be supportive without being overbearing can be the key to improving the life not only of the migraineur, but the whole family.

Read more here

A parent's thoughts on concussions can hinder treatment and recovery

A study shows that a parent's misconceptions about concussions and treatment hinders treatment and recovery.

With football season in full swing, there's no shortage of talk about young players -- from high school down to the pee wee levels -- suffering from concussions. Yet many parents may lack knowledge about this mild traumatic brain injury, according to two studies to be presented Oct. 10 at a pre-conference symposium on pediatric sports medicine at the American Academy of Pediatrics (AAP) National Conference & Exhibition in San Diego.
Nearly 175,000 children are treated in U.S. emergency rooms each year for concussions due to sports-related activities, according to the Centers for Disease Control and Prevention. Parental knowledge of the signs and symptoms of concussion and recognizing that this is a brain injury is important to ensure children are diagnosed in a timely manner and get appropriate treatment.
Two separate studies looked at parents' knowledge of concussion and common misconceptions. They will be presented as part of the Peds21 symposium, "1, 2, 3, Go! Sports in the World of Pediatrics -- Playing it Safe and Making it Fun!" in the San Diego Convention Center.
For the first abstract, titled "Parental Knowledge of Concussion," 511 parents of children ages 5-18 years who sought care at a pediatric emergency department within two weeks of their child suffering a head injury filled out a 24-item survey. They were asked questions about their demographics, their child's head injury, and general questions related to their knowledge of concussion and its treatment.
Results showed about half of parents correctly identified a concussion as a brain injury that could lead to symptoms such as headache or difficulty concentrating. No parental demographics (age, sex, education or prior history of sports participation) significantly predicted parents' knowledge about concussions.
The survey also indicated that almost all parents (92 percent) were aware that they should stop their child from playing and see a physician if they suspected a concussion. Yet only 26 percent were aware of guidelines on when their child could return to sports and school work.
"Our study showed that the vast majority of parents knew what to do if they suspected a concussion in their child and in most cases understood the clinical importance of this injury as a brain injury," said lead author Kirstin D. Weerdenburg, MD, FAAP, pediatric emergency medicine fellow at Hospital for Sick Children, Toronto, Ontario, Canada.
"The study also highlights that a physician visit shortly after the injury is important to confirm the diagnosis for parents and to inform parents of return to play/learn guidelines to ensure a proper recovery and prevent a second concussion while the brain is still healing," Dr. Weerdenburg said.
The authors of the second abstract, "Parental Misconceptions Regarding Sports-Related Concussion," also surveyed parents to assess their knowledge of concussions. The online survey was completed by two groups -- 214 parents whose children were evaluated at a sports medicine clinic for musculoskeletal or mild traumatic brain injuries (group 1) and 250 parents of students at a local private school (group 2).
The survey included questions that gauged their knowledge of and attitudes about concussions as well as demographic information.
The majority of parents in both groups did well overall but had several misconceptions:
  • About 70 percent in group 1 and 49 percent in group 2 incorrectly believed that brain imaging (CT/MRI scans) can be used to diagnose concussion.
  • About 55 percent in group 1 and 52 percent in group 2 did not know that "bell ringer or ding" is synonymous with concussion.
  • Reduced breathing rate was incorrectly identified as a symptom by 25 percent and 29 percent, respectively.
  • Difficulty speaking was incorrectly identified as a symptom by 75 percent and 79 percent, respectively.
"Our study highlights the fact that many parents are still in need of education regarding concussion identification and post-injury evaluation. Even those highly educated parents were prone to misconceptions," said senior author Tracy Zaslow, MD, FAAP, medical director of the sports medicine and concussion program at Children's Orthopaedic Center, Children's Hospital Los Angeles. "False perceptions such as the ones pinpointed by our study may impact when medical care is sought after concussion and lead to less than optimal home care."
Read more here

Insomnia in older adults affects sleep quality

A study showed that older adults who have insomnia have their sleep quality affected, but not their sleep duration.

Reports of insomnia are common among the elderly, but a new study finds that sleep problems may stem from the quality of rest and other health concerns more than the overall amount of sleep that patients get.
An estimated 30 percent of adults report having some symptoms of insomnia, which includes difficulty falling asleep, staying asleep or waking up too early and then not feeling well rested during the daytime. Prior studies suggest that nearly half of older adults report at least one insomnia symptom and that lack of restorative sleep might be linked to heart disease, falls, and declines in cognitive and daytime functioning.
The new study found discrepancies between self-reported insomnia and outcomes recorded on a sleep-monitoring device. Older adults' perception of sleep does not always match what's actually happening when a more objective assessment is used to monitor sleep patterns and behaviors.
A study, published online by Journals of Gerontology: Medical Sciences, used data from 727 participants in the National Social Life, Health and Aging Project who were randomly invited to participate in an "Activity and Sleep Study." The activity and sleep study had two components: a self-administered sleep booklet, which included questions about the person's sleep experience, (e.g., "how often do you feel really rested when you wake up in the morning?") and 72-hours of wrist actigraphy, which is a wristwatch-like sensor that monitors sleep patterns and movements.
An author on the study, Linda Waite, the University of Chicago Lucy Flower Professor in Urban Sociology and the director of the Center on Aging at NORC at UChicago, said the researchers wanted to objectively evaluate several aspects of older adults' sleep characteristics, which is why they used the actigraphs in addition to the survey questions.
"Older adults may complain of waking up too early and not feeling rested despite accumulating substantial hours of sleep," Waite said.
The actigraph measurements showed that most of the older adults got sufficient amounts of sleep.
Even though reported sleep problems are common among older individuals, according to the survey only about 13 percent of older adults in the study said that they rarely or never feel rested when waking up in the morning. About 12 percent reported often having trouble falling asleep, 30 percent indicated they regularly had problems with waking up during the night and 13 percent reported problems with waking up too early and not being able to fall asleep again most of the time.
The actigraph provided data that showed the average duration of sleep period among the study participants was 7.9 hours and the average total sleep time was 7.25 hours. Waite said this indicates that the majority of older adults are getting the recommended amount of sleep and usually not having common sleep problems.
One other unexpected finding for the researchers was that respondents who reported waking up more frequently during the night had more total sleep time. "This suggests that a question about feeling rested may tap into other aspects of older adults' everyday health or psychological experience," said Waite.
"Our findings suggest that reports of what seem like specific sleep problems from survey questions may be more accurately viewed as indicators of general problems or dissatisfaction with sleep that may be due to other issues in their lives affecting their overall well-being. These survey questions and actigraphy may measure different aspects of sleep experience."
Read more here

When to go to the hospital for a migraine

This article explains when it is appropriate to go to the hospital for a migraine headache.

Headache is one of the most common reasons for an emergency room visit. Some people go due chronic headache or Migraine problems that do not go away with treatment, and in other cases, headache is a symptom of another medical problem.
The best reason for an ER visit is for unusual symptoms that are new to you. You may seek attention to make sure there is no chance of another problem such as aneurysm or meningitis. A severe headache that starts very suddenly (within a second or two) can mean another disorder such as stroke. New symptoms such as a fever, weakness, vision loss or double vision, or confusion are some of most concerning symptoms. If you have a new symptom and serious, life-threatening medical problems such as liver, heart or kidney disease, are pregnant, or have a disorder which affects your immune system such as HIV infection, an ER visit may be more essential.
For many patients, an ER visit for headache or Migraine happens after a long period of severe headache lasting days or weeks. After long time of experiencing severe headache, you may reach the "last straw" and no longer be able to deal with the problem. ER doctors are not specialists in headache and Migraine, and their goals are to make sure there is no serious life-threatening problem and help reduce suffering. Different ER doctors have different ways to treat acute headache and Migraine: there is no universal protocol for emergency treatment of headache disorders.
When going to the ER, be sure to mention:
  • your symptoms, including any that are new or unusual for you;
  • any medications you have taken, especially in the last few days; and
  • if you have had good results from a particular medication regimen, that can be helpful to the ER.
Often ER doctors will want to order tests such as a CT scan of the head or spinal tap to make sure there is no bleeding in the brain, large stroke or meningitis. If you are having your typical severe headache or Migraine, and no new symptoms, the chance these tests will be helpful are extremely low and you have the right to refuse them. (See 5 Things Migraine and Headache Patients and Doctors Should Question.)
The majority of persons coming to an ER for severe headache or Migraine do not get lasting results from the medications given in the ER, so having a good long-term plan and relationship with an outpatient doctor who treats your headache disorder is very important. If you have even occasional long-lasting headaches or Migraines, a good preventive plan is very important, and you should have at least one rescue medication to prevent future ER visits.
Read more here

Five common sleep myths

This article busts five common myths about sleep.

Good sleep is a cornerstone of good health. Yet misunderstandings about sleep – and lack thereof – are common. Here experts shine a light on five popular myths about sleep.

1. Older people don't need as much sleep as they used to.

Older woman in bed alseep
Fact: The amount of sleep adults need remains fairly stable from about age 20 onwards.
You've probably heard you'll need less sleep as you age. So when older people spend hours awake in the middle of night or wake before the sun comes up, it's often accepted as a normal part of ageing.
But while some aspects of sleep do change as you age, the amount of sleep you need remains fairly constant, says Professor David Hillman, chair of the Sleep Health Foundation.
"If people notice a change in their sleep requirements as they get older, such as spending longer in bed for less benefit, and waking up unrefreshed despite getting the same amount of sleep that used to refresh them, then that implies there's something wrong with sleep itself," he says. In this case, he advises seeing a sleep specialist who can help to diagnose any possible sleep disorder and once these are identified and treated, older adults can feel years younger.
You are also more likely to experience advanced sleep phase syndrome as you get older, which means you get sleepier earlier in the evening, Hillman says. So while you may still be sleeping for eight hours, you might find yourself awake before the birds.
Also, while your body is programmed to sleep at night, some of us find ourselves feeling sleepy in the afternoon. Given that older adults are less likely to be at work, they sometimes have an afternoon nap. But napping in the afternoon, especially later in the afternoon, will affect how well you sleep at night.

2. You can die from lack of sleep.

Man lying in bed looking worried
Fact: Possibly, but it's more likely due to an increased risk of accidental death.
While sleep is important to human health, there's no good evidence to show being sleep deprived has direct and profoundly deadly effects on your body, says Sydney sleep researcher Dr Nathaniel Marshall. But it can impair your judgement in potentially fatal ways.
"People are just more likely to do stupid things and put themselves in life threatening situations when they've not been sleeping," Marshall says.
American high school student Randy Gardner, who stayed awake for 11 days, is regarded as the record holder for the longest period going without sleep. He did not use stimulants, but rather kept himself awake by doing things he found fun, like playing basketball, Marshall says.
At the conclusion of the attempt, Gardner's health seemed good; he was able to speak, play games and do limited mental tasks. When he finally slept, he did so for just 14 hours and 40 minutes, awoke naturally, stayed awake 24 hours, then slept a normal eight hours.
"This kid showed that you can stay awake a long time and it's not fatal. I mean I'm not recommending it – he was a special case and he had experts supervising him – but it's not fatal. He just slept for 14 hours."
However Marshall points out the effect of Gardner's experience on his health was not examined in any detail in the experiment.

3. If you're not a morning person, you never will be.

Man yawning under the covers in bed
Fact: Your internal 'body clock' is not rigidly fixed but is influenced by your sleep routine.
Feel like you'd rather die than get up when your alarm goes off in the mornings?
The time we feel sleepy and the time we wake up is influenced to a large extent by an internal clock in the brain that varies from person to person. It's true that some of us are more 'early to bed and early to rise' people than others. But despite what many of us think, our internal body clocks are not rigidly fixed, says Sydney sleep physician and researcher Dr Keith Wong. They are partly determined by our genes but also by our sleep routine, he says.
If you want to become more of a 'morning person', he advises changing the time you get up, rather than the time you go to sleep, as this will have the most impact. Try pushing back your wake time a small amount each day and expose yourself to bright light soon after waking, to 'reset' your clock's 'programmed' wake time. (Daylight is best, as even the natural light on a cloudy morning is brighter than most artificial light.) Go to bed when you feel sleepy, and avoid bright light in the evening before bed. Once your body clock is set to your new routine, you'll need to stick to a regular schedule to maintain it.
If you cannot go to sleep until very late at night and lifestyle change doesn't help, you may have a condition known as Delayed Sleep Phase Syndrome, where the internal clock does not work properly. More complex treatment from a sleep specialist may be needed to treat this.

4. People who get up early are healthier.

Woman sleeping in bed
Fact: Getting enough sleep is more important than the time you get up.
Getting up early has a lot going for it. The world tends to be quieter and less crowded, and the first rays of daylight can be golden and beautiful. But there's nothing inherently healthier about being an early riser, says Sydney sleep physician and researcher Dr Keith Wong.
A 1998 study of more than 1200 adults published in the British Medical Journal could find no health advantages in the 'early to bed, early to rise' habit. So if you're not someone who wants or needs to get up early, don't feel compelled to do so, Wong says.
But while when you sleep is not important, how much you sleep is. Not getting enough sleep can impair your reaction time, problem solving ability, mood and immune system. And it might lead to long term health problems, such as heart disease and diabetes.
Being an early riser could have health advantages if it means you're less likely to be forced to undersleep to fit in with the schedule you are expected to keep, for example, the hours you work or study. A standard nine to five business day for instance is more suited to someone who tends to wake when the sun comes up than someone who likes to sleep until mid morning or later. But being a late riser is probably better if you are a musician or chef who needs to work until later at night and still wants to be sure to get enough zeds.

5. Counting sheep will help you fall asleep.

Woman in bed looking at an alarm clock
Fact: Mental imagery can help induce sleep but the task has to be something you find pleasant and relaxing.
Counting sheep has long been touted as a way of combating insomnia; references to the practice in literature date back more than 150 years. But whether it works has never been tested in scientific studies.
It's known though mental imagery can help bring on sleep by serving as a distraction from stressful thoughts, says Sydney sleep psychologist Dianne Richards. But what works for some may not work for others. It needs to be something you find pleasant and relaxing and her experience is that many people find counting tasks somewhat stressful. Her hunch is that other methods will have broader appeal.
The idea behind distraction strategies is to stop your mind worrying, planning or problem solving as these are activities that lead to production of the stress hormone cortisol and interfere with sleep.
But if the alternative task you give your brain is too boring, or it simply doesn't appeal, you won't stick with it and your mind will drift back to the thoughts that produce cortisol.
"Ultimately, the task you choose has to be effective for you," she says.
Read more here

ADHD affects school performance as early as 2nd grade

A study claims that ADHD can negatively affect a child's performance in school as early as the 2nd grade.

Attention-deficit/hyperactivity disorder can harm a child's academic performance and social skills as early as the second grade, a new Australian study contends.
Children between 6 and 8 years old who were tested and scored high for ADHD symptoms were more likely to get lower grades in elementary school and have trouble fitting in with other kids, compared with children without ADHD, the study authors reported.
Kids with ADHD also were more likely to have other mental health or developmental disorders, including anxiety, depression and autism, according to the study.
"Already at this stage, which is relatively young, it's very clear the children have important functional problems in every domain we registered," said study lead author Dr. Daryl Efron, a developmental-behavioral pediatrician with the Royal Children's Hospital Melbourne. "On every measure, we found the kids with ADHD were performing far poorer than the control children."
The researchers also said they discovered that about 80 percent of the young children with ADHD symptoms had not been diagnosed with the disorder, a finding called "striking" by Dr. David Fassler, a clinical professor of psychiatry at the University of Vermont College of Medicine.
"For this reason, I would fully agree with the authors' conclusion that the results of the study underscore the need for earlier recognition and treatment of ADHD in young children," Fassler said.
The study, published online Sept. 29 in the journal Pediatrics, is one of the first reports from the Children's Attention Project, a long-term examination of ADHD funded by the Australian government.
The researchers tested nearly 400 children between 6 and 8 years of age at 43 Melbourne schools, identifying 179 with ADHD and another 212 without ADHD who will serve as a "control group." These children will be observed throughout their academic careers.
By the second grade, the children with ADHD were already struggling. They were more likely to score below-average in reading and mathematics, and more likely to have problems connecting socially with their peers, the researchers said.
For example, 33 percent of kids with ADHD were reading below average and 46 percent had math skills below average. For non-ADHD kids, only about 6 percent were reading below average and nearly 15 percent had below-average math skills, the researchers found.
And the ADHD children were more likely to have other mental health or developmental problems -- such as anxiety, obsessive-compulsive disorder, depression, mania and autism, said Efron, who's also a senior lecturer at the University of Melbourne.
"Some people think it's only when kids get older you can pick up these comorbidities [overlapping health issues]. But we've shown you can pick them up at this early stage if you are looking for them," he said.
What's more, these problems seem to accumulate in some kids with ADHD, with 30 percent having two such impairments and 24 percent having three. By comparison, about 6 percent of non-ADHD kids had two such impairments, and about 1 percent had three, according to the study.
The investigators found that boys and girls with ADHD were equally impaired by the disorder.
"There hasn't been that much research into girls with ADHD, so we don't know that much," Efron said. "When we do see girls, in my experience, they are as impaired as the boys. But it is a novel research finding."
In another study published in the same issue of Pediatrics, researchers presented disappointing results for a drug that some had hoped would ease the insomnia experienced by many children with ADHD.
The drug, eszopiclone, failed to help children aged 6 to 17 with their ADHD-related insomnia. Both low and high doses of the drug proved ineffective, the researchers found.
Read more here