Recommendations

The Australia and New Zealand Child Neurology Society

The Australia and New Zealand Child Neurology Society (ANZCNS) is a collaborative group of medical professionals working in the field of paediatric neurology or in allied neurosciences who are working to advance the science of paediatric neurology and advocate for improved care for young people with neurological disorders.

2.
Do not routinely perform computed tomography (CT) scanning of children presenting with new onset seizures.

Do not routinely perform computed tomography (CT) scanning of children presenting with new onset seizures

The yield from neuroimaging of children presenting with new onset afebrile seizures is typically low, with one study finding that it led to a change in clinical management for only four percent of patients. As there are already a well-tested set of indicators for determining the likelihood of intracranial abnormalities in children with new onset unprovoked seizures, a combination of clinical history, examination, and electroencephalograph (where relevant) should first be used to determine whether the condition warrants neuroimaging.

Clinical indicators for intracranial abnormalities, which are likely to change initial patient management, include (i) a focal seizure in children aged less than three years, (ii) abnormal neurological examination, (iii) Todd’s post-ictal paresis, or (iv) presence of a condition predisposing to seizures.

In children where an intracranial abnormality is considered likely, and neuroimaging is indicated, magnetic resonance imaging (MRI) is recommended over computed tomography (CT) because (i) there is superior anatomic resolution and characterisation of pathologic processes from using MRI, and (ii) there is radiation exposure and escalated future cancer risk associated with CT.

Supporting evidence
  • Aprahamian N, Harper MB, Prabhu SP, et al. Pediatric first time non-febrile seizure with focal manifestations: is emergent imaging indicated? Seizure 2014; 23(9):740-5.
  • Dayan PS, Lillis K, Bennett J, et al. Interobserver agreement in the assessment of clinical findings in children with first unprovoked seizures. Pediatrics 2011; 127(5).
  • Gaillard WD, Chiron C, Cross JH, et al. Guidelines for imaging infants and children with recent-onset epilepsy. Epilepsia 2009; 50(9):2147-53.
  • Kuzniecky RI. Neuroimaging of epilepsy: therapeutic implications. NeuroRx 2005; 2(2):384-93.
  • Malviya S, Voepel-Lewis T, Eldevik OP, et al. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth 2000; 84(6):743-8.
  • Matthews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346:f2360.
  • Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380:499–505.
  • Sharma S, Riviello JJ, Harper MB, et al. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatrics 2003; 111(1):1-5.
How this list was made How this list was made

Following deliberations, the ANZCNS Board determined to investigate the evidence for nine priority recommendations regarding low-value clinical practices in paediatric neurology. An evidence review was developed for these recommendations and served as the basis for an online survey sent to all ANZCNS members asking respondents if they agreed, disagreed or were unsure if these recommendations were evidence based, undertaken in significant numbers, and important in terms of reducing patient harm and unnecessary healthcare expenditure. Based on survey responses, each of the nine was assigned a score and ranked accordingly. Based on this information and a final evidence review, these top 5 recommendations were chosen.


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