You are on page 1of 11

DOI: 10.1542/peds.

2010-1371
; originally published online January 23, 2012; 2012;129;256 Pediatrics
Shirley A. Russ, Kandyce Larson and Neal Halfon
A National Profile of Childhood Epilepsy and Seizure Disorder

http://pediatrics.aappublications.org/content/129/2/256.full.html
located on the World Wide Web at:
The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2012 by the American Academy
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1948. PEDIATRICS is owned,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
A National Prole of Childhood Epilepsy and Seizure
Disorder
WHATS KNOWN ON THIS SUBJECT: Epilepsy/seizure disorder is
known to be associated with a range of mental health and
neurodevelopmental comorbidities, based on clinical studies, and
on population studies largely conducted outside the United States.
WHAT THIS STUDY ADDS: In a nationally representative sample of
US children, estimated prevalence of reported lifetime epilepsy/
seizure disorder was 1%, and of current epilepsy/seizure disorder
was 6.3/1000. Developmental, mental health, and physical
comorbidities are common, warranting enhanced surveillance,
and an integrated service approach.
abstract
OBJECTIVE: To determine sociodemographics, patterns of comorbidity,
and function of US children with reported epilepsy/seizure disorder.
METHODS: Bivariate and multivariable cross-sectional analysis of data
from the National Survey of Childrens Health (2007) on 91 605 children
ages birth to 17 years, including 977 children reported by their
parents to have been diagnosed with epilepsy/seizure disorder.
RESULTS: Estimated lifetime prevalence of epilepsy/seizure disorder
was 10.2/1000 (95% condence interval [CI]: 8.711.8) or 1%, and of
current reported epilepsy/seizure disorder was 6.3/1000 (95% CI: 4.9
7.8). Epilepsy/seizure disorder prevalence was higher in lower-income
families and in older, male children. Children with current reported
epilepsy/seizure disorder were signicantly more likely than those
never diagnosed to experience depression (8% vs 2%), anxiety (17%
vs 3%), attention-decit/hyperactivity disorder (23% vs 6%), conduct
problems (16% vs 3%), developmental delay (51% vs 3%), autism/
autism spectrum disorder (16% vs 1%), and headaches (14% vs
5%) (all P , .05). They had greater risk of limitation in ability to
do things (relative risk: 9.22; 95% CI: 7.5611.24), repeating a school
grade (relative risk: 2.59; CI: 1.524.40), poorer social competence and
greater parent aggravation, and were at increased risk of having
unmet medical and mental health needs. Children with prior but
not current seizures largely had intermediate risk.
CONCLUSIONS: In a nationally representative sample, children with seiz-
ures were at increased risk for mental health, developmental, and phys-
ical comorbidities, increasing needs for care coordination and specialized
services. Children with reported prior but not current seizures need fur-
ther study to establish reasons for their higher than expected levels of
reported functional limitations. Pediatrics 2012;129:256264
AUTHORS: Shirley A. Russ, MD, MPH,
a,b
Kandyce Larson, PhD,
b,c
and Neal Halfon, MD, MPH
b,c,d
a
Department of Academic Primary Care Pediatrics, Cedars-Sinai
Medical Center, Los Angeles, California;
b
University of California
Los Angeles Center for Healthier Children, Families, and
Communities, Los Angeles, California; and
c
Department of
Pediatrics, David Geffen School of Medicine, and
d
Department of
Health Services, School of Public Health, and Department of
Public Policy, School of Public Affairs, University of California Los
Angeles, Los Angeles, California
KEY WORDS
epilepsy, seizure disorder, children
ABBREVIATIONS
ADHDattention-decit/hyperactivity disorder
ASDautism spectrum disorder
CIcondence interval
MADDSPMetropolitan Atlanta Developmental Disabilities Sur-
veillance Program
NSCHNational Survey of Childrens Health
RRrelative risk
www.pediatrics.org/cgi/doi/10.1542/peds.2010-1371
doi:10.1542/peds.2010-1371
Accepted for publication Oct 13, 2011
Address correspondence to Shirley A. Russ, MD, MPH, University
of California Los Angeles Center for Healthier Children, Families,
and Communities, 10990 Wilshire Blvd, Suite 900, Los Angeles, CA
90024. E-mail: shirlyruss@aol.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
256 RUSS et al
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
Epilepsy/seizure disorder is the most
common childhood neurologic con-
dition,
1
and a major public health
concern.
2
Children diagnosed with
epilepsy face considerable chal-
lenges. The seizures themselves, es-
pecially when poorly controlled, may
be disabling and interfere with the
childs ability to learn, whereas sec-
ondary inuences, such as stigma
and lack of knowledge about the
condition can negatively affect social
and psychological function.
35
In addi-
tion, children with epilepsy frequently
exhibit comorbidities that affect de-
velopmental progress and emotional
health, including attention-decit/
hyperactivity disorder (ADHD),
68
learn-
ing disabilities,
911
depression, and
anxiety.
1,1216
Knowledge of the epide-
miology of childhood epilepsy and of
current functioning of children with
this condition will help inform the
development of systems of care that
move beyond a narrow focus on seizure
control to address implications of the
condition for the childs social, emo-
tional, and developmental well-being.
3
Most studies of childhood epilepsy in
the United States have been conducted
on subjects recruited fromgeneral and
specialist medical settings, so may be
biased toward inclusion of children
with the most complex clinical pic-
tures.
17
Population-based studies, with
subjects recruited from nonmedical
community-based settings have gen-
erally been based on local samples,
2
with limited ability to examine a wide
range of potential comorbidities and
functional attributes, or have been
conducted outside the United States.
18
Identifying and characterizing the full
range of comorbidities in people with
epilepsy has been identied as a Na-
tional Institute of Neurologic Disorders
and Stroke Epilepsy Research Bench-
mark.
19
To address this gap in knowl-
edge, we used data from the 2007
National Survey of Childrens Health
(NSCH) to estimate the prevalence of
reported epilepsy/seizure disorder for
US children, and to examine comor-
bid mental health/developmental dis-
orders, physical health conditions, and
child and family functioning. To our
knowledge, this is the rst national
study to estimate prevalence of repor-
ted epilepsy/seizure disorder in US
children and to examine patterns of
reported comorbidity.
METHODS
Sample
The 2007 NSCH was conducted as
a module of the State and Local Area
Integrated Telephone Survey by the
National Center for Health Statistics.
The study used a stratied random-
digit-dial sampling design to achieve
a nationally representative sample of
91 642 parents of children 0 to 17 years
of age. One child was randomly se-
lected from each household and inter-
views were conducted with the parent
or guardian who knew most about the
childs health and health care. Inter-
views lasting 30 minutes were con-
ducted in English and Spanish. The
overall weighted response rate was
51.2% (American Association of Public
Opinion Rate 4).
The sample for this study included 91
605 children ages birth to 17 with
nonmissing data on the question
about lifetime epilepsy/seizure dis-
order. There is some variability in the
nal study sample for each different
comorbid condition/functioning in-
dicator owing to missing data, and
because certain measures were not
relevant and/or not asked for infants
or very young children. Questions
about learning disability were asked
only of children ages 3 to 17 years,
questions about severe headaches
were asked only of children ages 6 to
17 years, and questions about oral
health problems were asked only of
children ages 1 to 17 years. Height/
weight data were restricted to chil-
dren ages 10 and older because of
concerns about the validity of par-
ent report for younger ages.
20
School
functioning and social competence
were measured only for children ages
6 to 17. Questions about mental health
treatment were asked only of children
older than 24 months, and special ed-
ucation services only of children aged 6
to 17 years.
To produce population-based estimates,
data records for each interview were
assigned a sampling weight. NSCH
sampling weights adjust for strati-
cation by geographic area and vari-
ous forms of nonresponse, including
poststratication to match population
control totals on key demographic
variables obtained from Census Bu-
reau data. Further details on the de-
signandoperationof NSCHarereported
elsewhere.
20
This study was granted
exempt status by the University of
California Los Angeles Institutional Re-
view Board.
Measures
Lifetime Epilepsy or Seizure Disorder
Parents were asked if a doctor or
health care provider ever told them
that their childhad epilepsy or seizure
disorder, and if so, if their child cur-
rently had epilepsy or seizure disor-
der. Children were categorized as
never diagnosed with epilepsy/
seizure disorder, currently diagnosed,
or previously but not currently
diagnosed.
Mental Health and Developmental
Indicators
Children were identied as having
comorbid mental health/developmental
disorders if the parent reported that the
child currently had depression, anxiety,
attention-decit disorder/ADHD, con-
duct problems, learning disability, de-
velopmental delay, or autism/autism
spectrum disorder (ASD).
ARTICLE
PEDIATRICS Volume 129, Number 2, February 2012 257
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
Physical Health Indicators
Measures of physical health included
parent report of a child currently hav-
ing a hearing or vision problem and
currently having asthma. Additional
measures included a health care pro-
vider telling the parent the child had
migraine headaches in the past year;
hay fever/respiratory allergy, food/
digestive allergy, or eczema/skin al-
lergy; and 3 or more ear infections.
Obesity was dened as a BMI in the 95th
percentile and above according to
Centers for Disease Control and Pre-
vention growth charts.
20
Oral health
problems were assessed by parent
report of whether the child had
decayed teeth or cavities, broken
teeth, or bleeding gums in the past 6
months.
Functional Health Indicators
Parents reported an activity restriction
(yes/no) if the child was limited or
prevented in any way in his/her ability
to do the things most children of the
same age can do. School functioning
was assessed by parent report of
whether the child had ever repeated
a grade, and contact in the past year by
the school about problems. Social
competence was measured by parent
ratings of how often the child shows
respect for teachers and neighbors;
gets along well with other children;
tries to understand others feelings;
and tries to resolve conicts with
classmates, family, and friends. Items
were summed to create a composite
following criteria established by pre-
vious research
21
; scores ,12 on the
16-point scale identied children with
low social competence. The Aggrava-
tion in Parenting scale
22
measures
stress in parenting through 3 items
where parents rate how often the child
was much harder to care for than
other children; does things that really
bothers them; and how often they felt
angry with him or her. Items were
summed to create a scale ranging from
0 to 12, and scores above 6 (corre-
sponding with an answer of some-
times for each item) identied parents
with high aggravation.
Service Use and Access Indicators
Parents reported whether their child
received preventive medical care at
least 1 time in the past 12 months, and
mental health treatment or counseling.
Children ages 6 to 17 years were
coded as receiving special education if
parents reported an Individualized Ed-
ucational Program (IEP). Children were
codedas havinganunmet healthneedif
their parent reported that during the
past 12 months, the child needed health
care but care was delayed or not re-
ceived. The medical home variable was
constructed by researchers at the Child
and Adolescent Health Measurement
Initiative.
23
The following criteria must
be met for presence of a medical home:
(1) having a personal doctor or nurse,
(2) having a usual place for sick/well
care, (3) presence of family-centered
care, (4) no trouble obtaining needed
referrals, and (5) receipt of needed
care coordination.
Study Covariates
Study covariates included household
incomeinrelationtothefederal poverty
level, family structure, race/ethnicity,
highest parent education, child age in
years, andchildgender. Missingdataon
household income were imputed fol-
lowing routines from National Center
for Health Statistics.
20
Analysis
All statistical analyses were per-
formedusingStata(version11.0; Stata
Corp, College Station, TX). Survey es-
timation procedures were applied and
the Taylor-series linearization method
adjusted the standard errors for the
complex survey design. We present
prevalence estimates for comorbid
conditions, functioning, and service
use by epilepsy/seizure disorder sta-
tus (never diagnosed, current epilepsy/
seizure disorder, previously diagnosed).
Bivariate associations were examined
using x
2
tests with post hoc pairwise
comparisons between selected catego-
ries. Regression models added controls
for sociodemographics. Relative risks
were estimated using generalized linear
models with a Poisson distribution and
log link.
24
RESULTS
Prevalence and
Sociodemographics of Epilepsy/
Seizure Disorder
The estimated lifetime prevalence of
epilepsy/seizure disorder was 10.2 per
1000 (95% condence interval [CI]: 8.7
11.8), or 1%, and current epilepsy/
seizure disorder was 6.3 per 1000
(95% CI: 4.97.8), or 0.6%. After ad-
justment for sociodemographics, life-
time epilepsy/seizure disorder was
more common in children from fami-
lies with income ,100% federal pov-
erty level (relative risk [RR]: 1.95; CI:
1.163.27) (Table 1). There was no re-
lationship between childhood epilepsy
and family structure, race/ethnicity, or
parent educational level. Prevalence of
lifetime epilepsy/seizure disorder (and
also current epilepsy, data not shown)
increased with age. Epilepsy/seizure
disorder was more common in boys
(RR: 1.38; CI: 1.031.84).
Epilepsy/Seizure Disorder
Comorbidity
Compared with children never di-
agnosed, children with current
epilepsy/seizure disorder were more
likely to experience mental health and
developmental comorbidities (Table 2).
Depression (8% vs 2%), anxiety (17% vs
3%), ADHD (23% vs 6%), conduct prob-
lems (16% vs 3%), learning disability
(56% vs 7%), developmental delay (51%
vs 3%), and autism/ASD (16% vs 1%)
were all signicantly more likely in
258 RUSS et al
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
children with current epilepsy (P ,
.05). Each of these conditions was also
reported more frequently in children
with previously but not currently di-
agnosed epilepsy/seizure disorder (eg,
depression [7% vs 2%], developmental
delay [17% vs 3%], autism/ASD [7% vs
1%]).
Compared with children never di-
agnosed, childrenwithcurrent epilepsy/
seizure disorder were more likely to
experience a range of physical health
comorbidities including hearing or vi-
sion problems (22% vs 2%), asthma
(18% vs 9%), headaches (14% vs 5%),
allergies (43% vs 26%), ear infections
(11% vs 6%), and poor oral health
(Table 3). Children with a former
epilepsy/seizure disorder diagnosis also
had elevated risks. Epilepsy/seizure dis-
order status was not associated with
obesity.
Epilepsy/Seizure Disorder and
Function
Compared with children never di-
agnosed, childrenwithcurrent epilepsy/
seizure disorder were more likely to
have limited activity (RR: 9.22; CI: 7.56
11.24), grade repetition (RR: 2.59; CI:
1.524.42), school problems (RR: 1.63;
CI: 1.262.10), low social competence
(RR: 2.16; CI: 1.612.90), and high levels
of parent aggravation (RR: 2.46; CI:
1.543.93) after adjustment for socio-
demographics (Table 4). Children pre-
viously but not currently diagnosed
with epilepsy/seizure disorder also
had greater risks of poorer function
across all domains, in each case with
an intermediate level of risk (eg, ac-
tivity limitation [RR: 2.92; CI: 2.144.00],
grade repetition [RR: 1.55; CI: 1.05
2.27], high parent aggravation [RR:
2.19; CI: 1.443.32]).
Epilepsy/Seizure Disorder and
Service Use and Access
Comparedwithchildrenneverdiagnosed,
children with current epilepsy/seizure
disorder were more likely to access
mental healthtreatment (RR: 3.07; CI: 2.25
4.20) and special education services (RR:
6.39; CI: 5.447.50) (Table 5). They were
reported to be as likely to attend pre-
ventive health visits as children never
diagnosed, less likely to report receiving
care in a medical home (RR 0.72; CI: 0.54
0.96), and more likely to report unmet
needs for care coordination, medical
care, and mental health services. Chil-
dren with a former epilepsy/seizure dis-
order diagnosis also had elevated unmet
care coordination needs.
DISCUSSION
The estimated lifetime prevalence
of epilepsy/seizure disorder among
TABLE 1 Sociodemographic Correlates of Lifetime Epilepsy /Seizure Disorder
Child Ever Diagnosed with Epilepsy/Seizure Disorder
No. in Sample
(Unweighted)
No. Ever Diagnosed
(Unweighted)
Weighted Prevalence per 1000 95% CI per 1000 Adjusted
RR
95% CI
Total 91 605 977 10.2 8.711.8
Former diagnosis 451 3.9 3.34.6
Current diagnosis 526 6.3 4.97.8
Household income
,100% FPL 10 956 170 12.8 9.617.1 1.95 1.163.27
100% 199% FPL 15 575 226 12.5 9.815.9 1.79 1.202.65
200% 299% FPL 16 531 183 12.4 7.620.2 1.51 0.802.85
300% 399% FPL 14 215 111 5.9 4.38.1 0.78 0.511.17
400% FPL or greater 34 328 287 7.7 6.010.0 base
Family structure
Two biological/ adoptive parents 70 595 669 9.1 7.411.2 base
Single mother 14 722 217 13.6 10.717.2 1.22 0.861.73
Other 5741 86 13.6 9.818.7 1.20 0.801.80
Race/Ethnicity
White 61 352 633 10.9 8.813.5 base
African American 8869 108 10.6 7.814.3 0.72 0.511.03
Hispanic 11 520 121 8.9 6.212.9 0.68 0.431.06
Multiracial/Other 8320 95 8.2 4.913.4 0.75 0.441.27
Highest parent education
HS diploma 20 811 309 11.7 9.614.1 1.03 0.731.45
More than HS 69 703 658 9.5 7.711.8 base
Child age, y
05 27 555 204 6.3 4.98.3 base
611 27 781 303 10.3 8.212.8 1.62 1.132.31
1217 36 269 470 14.0 10.818.2 2.26 1.543.33
Child gender
Male 47 513 508 11.8 9.414.9 1.38 1.031.84
Female 43 983 469 8.6 7.210.3 base
FPL, federal poverty level.
ARTICLE
PEDIATRICS Volume 129, Number 2, February 2012 259
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
children in the United States in 2007
was 10.2 per 1000 (1%). Prevalence of
current epilepsy/seizure disorder
was 6.3 per 1000, corresponding to
just over 450 000 children ages birth
to 17 years nationwide. Children with
current seizures are at increased risk
for mental health, developmental, and
physical comorbidities, as well as
functional disabilities. They are less
likely to receive care in a medical
home, and are at increased risk for
having unmet needs for medical and
mental health services. Children re-
ported to have previous but not cur-
rent epilepsy/seizure disorder also
had more reported comorbidities and
functional limitations, but at lower
levels than children with active seizure
disorders.
Direct comparison with other preva-
lence studies is hampered by different
methods of case ascertainment, study
samples (local versus national), case
denitions, and cohort ages. These
estimates are slightly higher than the
6.0 to 7.7 per 1000 lifetime prevalence of
TABLE 2 Mental Health and Developmental Indicators
Depression
(n = 81 860)
Anxiety
(n = 81 857)
ADHD
(n = 81 664)
Conduct
(n = 81 884)
Learning
Disability
(n = 77 731)
Developmental
Delay
(n = 81 794)
Autism
(n = 81 852)
Never diagnosed with
epilepsy/seizure disorder
No. cases 1598 2519 5294 2247 5417 2117 830
Weighted prevalence
(95% CI)
1.9 (1.72.2) 2.7 (2.53.0) 6.2 (5.96.7) 3.2 (2.93.5) 7.3 (6.97.8) 2.8 (2.63.1) 0.9 (0.81.1)
Current epilepsy/seizure
disorder
No. cases 49 95 127 90 286 249 65
Weighted prevalence
(95% CI)
8.4 (4.315.7) 17.4 (10.228.1) 23.1 (15.333.3) 15.6 (9.624.4) 56 (44.666.9) 50.5 (39.161.9) 15.5 (8.526.4)
Relative risk adjusted
a
(95% CI)
3.43 (1.966.00) 5.26 (3.268.50) 2.92 (2.014.25) 3.83 (2.376.20) 6.73 (5.478.29) 16.37 (12.7720.99) 15.55 (8.6727.90)
Former epilepsy/seizure
disorder
No. cases 35 49 70 41 119 77 25
Weighted prevalence
(95% CI)
7.3 (4.311.9) 8.9 (5.813.4) 15.6 (9.923.6) 8 (4.912.9) 26.2 (20.033.5) 17.1 (12.123.6) 6.8 (3.512.8)
Relative risk adjusted
a
(95% CI)
2.93 (1.744.93) 2.6 (1.694.01) 1.57 (1.102.24) 1.99 (1.233.20) 3.05 (2.324.01) 5.42 (3.847.65) 7.02 (3.7813.06)
a
Models include controls for household income, family structure, race/ethnicity, parent education, child age, and gender.
TABLE 3 Physical Health Indicators
Hearing/Vision
(n = 91 410)
Asthma
(n = 91 378)
Headaches
(n = 63 996)
Allergies
(n = 91 341)
Ear Infections
(n = 91 547)
Obesity
(n = 44 083)
Oral Health
Problems
(n = 86 465)
Never diagnosed with
epilepsy/seizure disorder
No. cases 2025 7765 3457 25 429 5265 5918 17 627
Weighted prevalence
(95% CI)
2.4 (2.12.6) 9 (8.59.4) 5.2 (4.85.6)
26.4 (25.727.1)
6.2 (5.86.6) 16.3 (15.417.3) 22.8 (22.123.6)
Current epilepsy/seizure
disorder
No. cases 102 96 66 197 70 66 151
Weighted prevalence
(95% CI)
22.2 (12.037.5) 18.2 (12.126.3) 13.9 (8.022.8) 43.1 (34.052.7) 10.5 (7.115.1) 16.3 (10.225.0) 31.7 (22.642.5)
Relative risk adjusted
a
(95% CI)
7.96 (4.5214.02) 1.8 (1.262.57) 2.33 (1.383.94) 1.63 (1.322.02) 1.99 (1.362.89) 0.96 (0.631.46) 1.35 (0.981.85)
Former epilepsy/seizure
disorder
No. Cases 45 58 51 170 54 52 120
Weighted prevalence
(95% CI)
11 (7.216.5) 13.6 (9.219.6) 19.1 (12.128.9) 38.3 (30.746.5) 14.8 (9.223.0) 24.8 (16.435.5) 25.4 (18.433.9)
Relative risk adjusted
a
(95% CI)
3.92 (2.506.15) 1.35 (0.931.98) 2.76 (1.913.97) 1.35 (1.111.65) 2.08 (1.393.11) 1.29 (0.891.87) 0.91 (0.681.21)
a
Models include controls for household income, family structure, race/ethnicity, parent education, child age, and gender.
260 RUSS et al
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
childhood epilepsy among 10-year-olds
from the 1995 Metropolitan Atlanta
Developmental DisabilitiesSurveillance
Program (MADDSP),
2
and prevalences
reported from other developed coun-
tries, possibly reecting a broader case
denition.
2532
Consistent with prior
studies, epilepsy was more prevalent in
boys,
2
and in lower-income families,
3335
yet there were no differences based
on race/ethnicity or household educa-
tional level. The prevalence of current
epilepsy/seizure disorder was higher in
older age cohorts. Lack of data on age of
onset of seizures precluded separation
of incident cases, expected to decrease
with age,
36,37
from prevalent cases in
each age group.
Our study reports the most compre-
hensive analysis to date of comorbid-
ities in a nationally representative
sample of US children with epilepsy.
Compared with MADDSP (1995), which
reported 35% prevalence of any of 4
comorbid developmental disabilities
(mental retardation, cerebral palsy,
visual or hearing impairment) among
children with lifetime epilepsy,
2
we
observed a 50% prevalence of de-
velopmental delay and 56% prevalence
of learning disabilities among children
with current epilepsy/seizure disorder.
Rates of learning disability among
children with epilepsy have varied in
the literature from 25% to 76%,
10,11,38
depending on case denitions and
populations studied. Consistent with
prior studies, we also observed a
strong association between epilepsy
and autism/ASD, and a weaker asso-
ciation with ADHD, suggesting a need
for investigation of potential common
genetic and environmental etiologic
factors.
3941
Observed associations with
depression and anxiety are consistent
TABLE 4 Functional Health Indicators
Activity Limitation
(n = 91 492)
Repeated Grade
(n = 63 944)
School Problems
(n = 62 062)
Low Social Competence
(n = 63 553)
High Parent Aggravation
(n = 91 011)
Never diagnosed with
epilepsy/seizure disorder
No. cases 4932 5386 17 840 11 606 4141
Weighted prevalence (95% CI) 5.8 (5.46.2) 10.4 (9.811.0) 30.3 (29.431.3) 20.0 (19.220.8) 5.9 (5.46.3)
Current epilepsy/seizure disorder
No. cases 309 93 224 179 99
Weighted prevalence (95% CI) 63.0 (52.572.5) 31.2 (17.948.5) 52.2 (38.265.9) 46.8 (33.360.8) 16.1 (10.124.6)
Relative risk adjusted
a
(95% CI) 9.22 (7.5611.24) 2.59 (1.524.42) 1.63 (1.262.10) 2.16 (1.612.90) 2.46 (1.543.93)
Former epilepsy/seizure disorder
No. cases 100 61 155 113 49
Weighted prevalence (95% CI) 22.8 (16.231.0) 17.6 (12.124.9) 41.2 (33.149.8) 38.5 (29.847.9) 14.9 (9.722.2)
Relative risk adjusted
a
(95% CI) 2.92 (2.144.00) 1.55 (1.052.27) 1.26 (1.021.57) 1.67 (1.312.13) 2.19 (1.443.32)
a
Models include controls for household income, family structure, race/ethnicity, parent education, child age, and gender.
TABLE 5 Service Use and Access
Preventive
Health Visit
(n = 90 784)
Mental Health
Treatment
(n = 81 860)
Special Education
Services
(n = 63 795)
Care in a
Medical Home
(n = 88 034)
Unmet Care
Coordination
Need (n = 91 447)
Unmet Medical
Care Need
(n = 91 487)
Unmet Mental
Health Need
(n = 91 487)
Never diagnosed with
epilepsy/seizure disorder
No. cases 78 749 6982 6625 54 197 3792 2686 751
Weighted prevalence
(95% CI)
88.5 (88.089.0) 7.9 (7.58.4) 10.6 (10.011.2) 57.7 (56.958.6) 5.5 (5.16.0) 3.5 (3.23.9) 0.8 (0.71.0)
Current epilepsy/seizure
disorder
No. cases 485 147 285 181 106 55 23
Weighted prevalence
(95% CI)
92 (81.996.7) 27.7 (19.438.0) 74.8 (65.582.3) 39.7 (28.152.5) 18.8 (12.327.5) 18.2 (8.434.9) 8.1 (3.119.6)
Relative risk adjusted
a
(95% CI)
1.06 (0.981.15) 3.07 (2.254.20) 6.39 (5.447.50) 0.72 (0.540.96) 3.34 (2.175.14) 4.91 (2.2910.51) 7.24 (3.1316.71)
Former epilepsy/seizure
disorder
No. cases 403 79 124 207 46 27 10
Weighted prevalence
(95% CI)
88.5 (88.089.0) 15.2 (10.721.2) 30.6 (23.338.9) 40.7 (33.148.7) 14.3 (9.221.6) 5 (2.98.6) 1.5 (0.73.2)
Relative risk adjusted
a
(95% CI)
1.04 (0.981.10) 1.58 (1.132.20) 2.62 (2.043.37) 0.78 (0.650.93) 2.31 (1.503.57) 1.32 (0.752.31) 1.33 (0.583.03)
a
Models include controls for household income, family structure, race/ethnicity, parent education, child age, and gender.
ARTICLE
PEDIATRICS Volume 129, Number 2, February 2012 261
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
with current literature.
1,1214,16,42
Quali-
tative studies show parents of chil-
dren with epilepsy to be largely aware
of their childrens emotional and
behavioral difculties, but are frus-
trated with inadequate services
5
and
stigma associated with accessing
mental health care, particularly among
minority families.
43
Reported unmet
needs, and lack of a medical home
approach, suggest that the existing
system of care is not fully responsive
to these issues.
Physical healthassociations of epilepsy/
seizure disorder have not been well
studied. Reported associations with
asthma, allergies, and ear infections
could reect common etiologic factors
(eg, immune-mediated response, envi-
ronmental triggers, genetic predis-
position), but must be interpreted with
caution, as parents may have preferen-
tial recall for these conditions, especially
if related to seizure onset or exacer-
bations, or frequent contact with phy-
sicians more likely to assign these
diagnoses. Our study conrmed repor-
ted associations with headaches.
4446
Researchers have suggested that mi-
graine and epileptic attacks could rep-
resent a clinical continuum resulting
from altered cortical hyperexcitability.
47
Children with a prior history of seizures
who have continuing headaches could
be an important population to study in
relation to this hypothesis.
Most prior studies of school perfor-
mance in childhood epilepsy have re-
lied on subjects recruited from medical
settings, with almost all showing in-
creased likelihood of academic dif-
culties.
9,38,48,49
High rates of school
problems and grade repetition in our
community-based sample support
calls for further study of possible neu-
ropsychological decits, including
declines in processing speed
50
and
vulnerabilities in working memory in
children with seizures.
51
One study
suggests there may be a window
early after onset of seizures to amelio-
rate impact on school performance.
52
We also need more information on
specic contributors to problems
with social competence, and ways to
compensate for or adapt to these
decits.
Almost 40% of children in our study
previously diagnosed with epilepsy/
seizure disorder were not reported
by parents to currently have the con-
dition. Althoughthese datacouldreect
a true remission of seizure activity, they
could result from an initial mis-
diagnosis of epilepsy/seizure disor-
der, inclusion of some children with
single febrile seizures, or variation in
interpretations of the terms current
versus ever having seizures. Other
studies have reported children with
a history of prior epilepsy to have
worse behavior problems, lower so-
cial competency, slower processing
speeds, and worse reading and spell-
ing abilities.
53,54
It is not possible within
the limitations of the NSCH dataset to
answer the important question of
whether it is only those children who
have additional neurologic conditions
(eg, cerebral palsy), who have in-
creased risks of comorbidities and
functional limitations, even if seizures
are reported to resolve. Our nding of
higher frequency of comorbidities
compared with children never repor-
ted to have seizures suggests that
children with a previous history of ep-
ilepsy remain a clinically important,
potentially vulnerable group that war-
rants further longitudinal study.
Adults with epilepsy have high re-
ported rates of mental health and de-
velopmental comorbidities, including
learning disability,
11
anxiety,
55,56
de-
pression, and suicidal ideation
57,58
; and
physical comorbidities including se-
vere headaches, asthma, heart dis-
ease,
59
and arthritis.
60
High rates of
unemployment
61
and lower edu-
cational achievement
62
are reported
frequently. Pathways to poorer adult
functioning have been attributed to the
effects of recurrent seizures, medi-
cations, and social stigma, but altered
neurodevelopment of the brain start-
ing very early in the life course may
play a role.
63
More research is needed
to determine whether early inter-
vention to address cumulative comor-
bidities could disrupt what appear
to be complex and continuing path-
ways to poorer health outcomes in
adulthood.
Study limitations include reliance on
parent report, susceptibletorecall bias
and inaccuracies, for assigning chil-
dren to diagnostic categories, and the
cross-sectional nature of the data that
preclude any inferences about di-
rection of observed associations. Par-
ent report has been widely used in the
literature to give valid estimates of
childhood neurodevelopmental con-
ditions,
6466
and our estimated preva-
lences were in the same general range
as those obtained from MADDSP using
different methods of case ascertain-
ment.
2
Our study lacked data on dif-
ferent subtypes of epilepsy/seizure
disorder (eg, absence, Lennox Gas-
taut), etiology, frequency or duration of
seizures, age at onset or remission, use
of medications or other treatment
modalities, or whether children had
seen a neurologist, or were diagnosed
with additional neurologic conditions.
We could not exclude children who had
received a misdiagnosis of epilepsy
or seizure disorder; however, the
strengths of this study, including the
large, nationally representative nature
of the study sample, coupled with rich
data on a wide range of potential
comorbid conditions and measures of
child and family function, balance if
not outweigh these potential short-
comings. The ndings likely reect
patterns of morbidity encountered
by community-based pediatricians in
daily practice.
262 RUSS et al
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
CONCLUSIONS
The estimated1%prevalence of lifetime
epilepsy/seizure disorder for the US
child population is slightly higher than
prior estimates. High levels of develop-
mental and mental health comorbidi-
ties reported for children with current
epilepsy/seizure disorder underscore
the need for a proactive approach to the
prevention of comorbidities, and a more
structured approach to early detection
and management.
67
Further study of the
pathophysiologic processes contribut-
ing to the development of comorbid
conditions may provide clues to the eti-
ology of individual epilepsy/seizure dis-
orders. Children with reported previous
but not current epilepsy appear to con-
tinue to manifest higher rates of neu-
rodevelopmental comorbidities and as
a clinical populations are in need of
more detailed characterization.
ACKNOWLEDGMENT
Dr Halfon was supported in part by
funding from the Maternal and Child
Health Bureau of the Health Resour-
ces and Services Administration for
the University of California Los Angeles
National Center for Education in Ma-
ternal and Child Health Alliance for
Information on Maternal and Child
Health Child and Adolescent Policy
Center.
REFERENCES
1. Jones JE, Austin JK, Caplan R, Dunn D,
Plioplys S, Salpekar JA. Psychiatric dis-
orders in children and adolescents who have
epilepsy. Pediatr Rev. 2008;29(2):e9e14
2. Murphy CC, Trevathan E, Yeargin-Allsopp M.
Prevalence of epilepsy and epileptic seizures
in 10-year-old children: results from the
Metropolitan Atlanta Developmental Dis-
abilities Study. Epilepsia. 1995;36(9):866872
3. Raspall-Chaure M, Neville BG, Scott RC. The
medical management of the epilepsies in
children: conceptual and practical consid-
erations. Lancet Neurol. 2008;7(1):5769
4. Baker GA, Hargis E, Hsih MM, et al; In-
ternational Bureau for Epilepsy. Perceived
impact of epilepsy in teenagers and young
adults: an international survey. Epilepsy
Behav. 2008;12(3):395401
5. Wu KN, Lieber E, Siddarth P, Smith K, Sankar
R, Caplan R. Dealing with epilepsy: parents
speak up. Epilepsy Behav. 2008;13(1):
131138
6. Dunn DW, Austin JK, Harezlak J, Ambrosius
WT. ADHD and epilepsy in childhood. Dev
Med Child Neurol. 2003;45(1):5054
7. Dunn DW, Austin JK, Perkins SM. Prevalence
of psychopathology in childhood epilepsy:
categorical and dimensional measures.
Dev Med Child Neurol. 2009;51(5):364372
8. Kaufmann R, Goldberg-Stern H, Shuper A.
Attention-decit disorders and epilepsy in
childhood: incidence, causative relations
and treatment possibilities. J Child Neurol.
2009;24(6):727733
9. Bailet LL, Turk WR. The impact of childhood
epilepsy on neurocognitive and behavioral
performance: a prospective longitudinal
study. Epilepsia. 2000;41(4):426431
10. Beghi M, Cornaggia CM, Frigeni B, Beghi E.
Learning disorders in epilepsy. Epilepsia.
2006;47(suppl 2):1418
11. Sillanp M. Learning disability: occur-
rence and long-term consequences in
childhood-onset epilepsy. Epilepsy Behav.
2004;5(6):937944
12. Caplan R, Siddarth P, Gurbani S, Hanson R,
Sankar R, Shields WD. Depression and
anxiety disorders in pediatric epilepsy.
Epilepsia. 2005;46(5):720730
13. Caplan R, Siddarth P, Stahl L, et al. Child-
hood absence epilepsy: behavioral, cogni-
tive, and linguistic comorbidities. Epilepsia.
2008;49(11):18381846
14. Franks RP. Psychiatric issues of childhood
seizure disorders. Child Adolesc Psychiatr
Clin N Am. 2003;12(3):551565
15. Pellock JM. Dening the problem: psychi-
atric and behavioral comorbidity in chil-
dren and adolescents with epilepsy.
Epilepsy Behav. 2004;5(suppl 3):S3S9
16. Plioplys S. Depression in children and
adolescents with epilepsy. Epilepsy Behav.
2003;4(suppl 3):S39S45
17. Cowan LD, Leviton A, Bodensteiner JB, Doherty
L. Problems in estimating the prevalence of
epilepsy in children: the yield from differ-
ent sources of information. Paediatr Peri-
nat Epidemiol. 1989;3(4):386401
18. Sillanp M, Helen Cross J. The psychoso-
cial impact of epilepsy in childhood. Epi-
lepsy Behav. 2009;15(suppl 1):S5S10
19. National Institute of Neurological Disorders
and Stroke. 2007 epilepsy research
benchmarks. National Institutes of Health;
2007. Updated August 26, 2010. Available at:
www.ninds.nih.gov/research/epilepsyweb/
2007_benchmarks.htm. Accessed January
11, 2011
20. Blumberg S, Foster E, Frasier A, et al Design
and operation of the National Survey of
Childrens Health, 2007. National Center for
Health Statistics. Hyattsville, MD: Department
of Health and Human Services, Centers for
Disease Control and Prevention, National
Center for Health Statistics; 2009. Available at:
ftp://ftp.cdc.gov/pub/health_statistics/
nchs/slaits/nsch07/2_Methodology_Report/.
Accessed October 22, 2009
21. Blumberg S, Carle C, OConnor K, Moore K,
Lippman L. Social competence: develop-
ment of an indicator for children and
adolescents. Child Ind Res. 2008;1:176197
22. Macomber JE, Moore KA. Benchmarking
measures of child and family well-being in
the 1997 NSAF. Washington, DC: Urban In-
stitute; 1999. Report No.: 6. Available at:
www.urban.org/publications/410137.html.
Accessed October 22, 2009
23. Child and Adolescent Health Measurement
Initiative (CAHMI). National survey of child-
rens health indicator dataset. 2007. Avail-
able at: www.childhealthdata.org. Accessed
May 22, 2011
24. Zou G. A modied poisson regression
approach to prospective studies with bi-
nary data. Am J Epidemiol. 2004;159(7):
702706
25. Beilmann A, Napa A, St A, Talvik I, Talvik T.
Prevalence of childhood epilepsy in Estonia.
Epilepsia. 1999;40(7):10111019
26. Eriksson KJ, Koivikko MJ. Prevalence, clas-
sication, and severity of epilepsy and ep-
ileptic syndromes in children. Epilepsia.
1997;38(12):12751282
27. Fong GC, Mak W, Cheng TS, Chan KH, Fong
JK, Ho SL. A prevalence study of epilepsy in
Hong Kong. Hong Kong Med J. 2003;9(4):
252257
28. Kurtz Z, Tookey P, Ross E. Epilepsy in young
people: 23 year follow up of the British
national child development study. BMJ.
1998;316(7128):339342
29. Larsson K, Eeg-Olofsson O. A population
based study of epilepsy in children from
a Swedish county. Eur J Paediatr Neurol.
2006;10(3):107113
30. Oka E, Ohtsuka Y, Yoshinaga H, Murakami N,
Kobayashi K, Ogino T. Prevalence of child-
hood epilepsy and distribution of epileptic
ARTICLE
PEDIATRICS Volume 129, Number 2, February 2012 263
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
syndromes: a population-based survey in
Okayama, Japan. Epilepsia. 2006;47(3):626630
31. Sidenvall R, Forsgren L, Heijbel J. Preva-
lence and characteristics of epilepsy in
children in northern Sweden. Seizure. 1996;
5(2):139146
32. Waaler PE, Blom BH, Skeidsvoll H, Mykletun
A. Prevalence, classication, and severity of
epilepsy in children in western Norway.
Epilepsia. 2000;41(7):802810
33. Tellez-Zenteno JF, Pondal-Sordo M, Matijevic
S, Wiebe S. National and regional preva-
lence of self-reported epilepsy in Canada.
Epilepsia. 2004;45(12):16231629
34. Schiariti V, Farrell K, Houb JS, Lisonkova S.
Period prevalence of epilepsy in children in
BC: a population-based study. Can J Neurol
Sci. 2009;36(1):3641
35. Chin RF, Neville BG, Peckham C, Wade A,
Bedford H, Scott RC; NLSTEPSS Collabo-
rative Group. Socioeconomic deprivation
independent of ethnicity increases status
epilepticus risk. Epilepsia. 2009;50(5):1022
1029
36. Hauser WA, Annegers JF, Kurland LT. In-
cidence of epilepsy and unprovoked seiz-
ures in Rochester, Minnesota: 19351984.
Epilepsia. 1993;34(3):453468
37. Cameld CS, Cameld PR, Gordon K, Wirrell
E, Dooley JM. Incidence of epilepsy in
childhood and adolescence: a population-
based study in Nova Scotia from 1977 to
1985. Epilepsia. 1996;37(1):1923
38. Fastenau PS, Jianzhao Shen , Dunn DW,
Austin JK. Academic underachievement
among children with epilepsy: proportion
exceeding psychometric criteria for learn-
ing disability and associated risk factors.
J Learn Disabil. 2008;41(3):195207
39. Tuchman R. Autism and epilepsy: what has
regression got to do with it? Epilepsy Curr.
2006;6(4):107111
40. Saemundsen E, Ludvigsson P, Rafnsson V.
Autism spectrum disorders in children
with a history of infantile spasms: a pop-
ulation-based study. J Child Neurol. 2007;22
(9):11021107
41. Hesdorffer DC, Ludvigsson P, Olafsson E,
Gudmundsson G, Kjartansson O, Hauser WA.
ADHD as a risk factor for incident un-
provoked seizures and epilepsy in children.
Arch Gen Psychiatry. 2004;61(7):731736
42. Pellock JM. Understanding co-morbidities
affecting children with epilepsy. Neurol-
ogy. 2004;62(5 suppl 2):S17S23
43. Vona P, Siddarth P, Sankar R, Caplan R.
Obstacles to mental health care in pediatric
epilepsy: insight from parents. Epilepsy
Behav. 2009;14(2):360366
44. Wirrell EC, Hamiwka LD. Do children with
benign rolandic epilepsy have a higher
prevalence of migraine than those with
other partial epilepsies or nonepilepsy
controls? Epilepsia. 2006;47(10):16741681
45. Cai S, Hamiwka LD, Wirrell EC. Peri-ictal
headache in children: prevalence and
character. Pediatr Neurol. 2008;39(2):9196
46. Clarke T, Baskurt Z, Strug LJ, Pal DK. Evi-
dence of shared genetic risk factors for
migraine and rolandic epilepsy. Epilepsia.
2009;50(11):24282433
47. Piccinelli P, Borgatti R, Nicoli F, et al. Re-
lationship between migraine and epilepsy in
pediatric age. Headache. 2006;46(3):413421
48. Canavese C, Rigardetto R, Viano V, et al. Are
dyslexia and dyscalculia associated with
Rolandic epilepsy? A short report on ten Italian
patients. Epileptic Disord. 2007;9(4):432436
49. Piccinelli P, Borgatti R, Aldini A, et al. Aca-
demic performance in children with rolan-
dic epilepsy. Dev Med Child Neurol. 2008;
50(5):353356
50. Austin JK, Perkins SM, Johnson CS, et al. Self-
esteem and symptoms of depression in chil-
dren with seizures: relationships with neuro-
psychological functioning and family variables
over time. Epilepsia. 2010;51(10):20742083
51. Schouten A, Oostrom KJ, Pestman WR,
Peters AC, Jennekens-Schinkel A; Dutch
Study Group of Epilepsy in Childhood.
Learning and memory of school children
with epilepsy: a prospective controlled
longitudinal study. Dev Med Child Neurol.
2002;44(12):803811
52. Fastenau PS, Johnson CS, Perkins SM, et al.
Neuropsychological status at seizure onset
in children: risk factors for early cognitive
decits. Neurology. 2009;73(7):526534
53. Berg AT, Langtt JT, Testa FM, et al. Global
cognitive function in children with epilepsy:
a community-based study. Epilepsia. 2008;
49(4):608614
54. Berg AT, Vickrey BG, Testa FM, Levy SR,
Shinnar S, DiMario F. Behavior and social
competency in idiopathic and cryptogenic
childhood epilepsy. Dev Med Child Neurol.
2007;49(7):487492
55. Gaitatzis A, Trimble MR, Sander JW. The
psychiatric comorbidity of epilepsy. Acta
Neurol Scand. 2004;110(4):207220
56. Gaitatzis A, Carroll K, Majeed A, W Sander J.
The epidemiology of the comorbidity of
epilepsy in the general population. Epi-
lepsia. 2004;45(12):16131622
57. Tellez-Zenteno JF, Patten SB, Jett N, Williams J,
Wiebe S. Psychiatric comorbidity in epilepsy:
a population-based analysis. Epilepsia. 2007;
48(12):23362344
58. Bell GS, Gaitatzis A, Bell CL, Johnson AL, Sander
JW. Suicide in people with epilepsy: how great
is the risk? Epilepsia. 2009;50(8):19331942
59. Strine TW, Kobau R, Chapman DP, Thurman
DJ, Price P, Balluz LS. Psychological dis-
tress, comorbidities, and health behaviors
among U.S. adults with seizures: results
from the 2002 National Health Interview
Survey. Epilepsia. 2005;46(7):11331139
60. Kobau R, Zahran H, Thurman DJ, et al;
Centers for Disease Control and Prevention
(CDC). Epilepsy surveillance among adults
19 States, Behavioral Risk Factor Sur-
veillance System, 2005. MMWR Surveill
Summ. 2008;57(6):120
61. Kobau R, Zahran H, Grant D, Thurman DJ,
Price PH, Zack MM. Prevalence of active
epilepsy and health-related quality of life
among adults with self-reported epilepsy in
California: California Health Interview Sur-
vey, 2003. Epilepsia. 2007;48(10):19041913
62. Shackleton DP, Kasteleijn-Nolst Trenit DG,
de Craen AJ, Vandenbroucke JP, West-
endorp RG. Living with epilepsy: long-term
prognosis and psychosocial outcomes.
Neurology. 2003;61(1):6470
63. Hermann B, Seidenberg M, Jones J. The
neurobehavioural comorbidities of epilepsy:
can a natural history be developed? Lancet
Neurol. 2008;7(2):151160
64. Blanchard LT, Gurka MJ, Blackman JA.
Emotional, developmental, and behavioral
health of American children and their
families: a report from the 2003 National
Survey of Childrens Health. Pediatrics.
2006;117(6). Available at: www.pediatrics.
org/cgi/content/full/117/6/e1202
65. Gurney JG, McPheeters ML, Davis MM. Pa-
rental report of health conditions and
health care use among children with and
without autism: National Survey of Child-
rens Health. Arch Pediatr Adolesc Med.
2006;160(8):825830
66. Kogan MD, Blumberg SJ, Schieve LA, et al.
Prevalence of parent-reported diagnosis of
autism spectrum disorder among children in
the US, 2007. Pediatrics. 2009;124(5):13951403
67. Barry JJ, Ettinger AB, Friel P, et al; Advisory
Group of the Epilepsy Foundation as part of
its Mood Disorder. Consensus statement:
the evaluation and treatment of people
with epilepsy and affective disorders. Epi-
lepsy Behav. 2008;13(suppl 1):S1S29
264 RUSS et al
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from
DOI: 10.1542/peds.2010-1371
; originally published online January 23, 2012; 2012;129;256 Pediatrics
Shirley A. Russ, Kandyce Larson and Neal Halfon
A National Profile of Childhood Epilepsy and Seizure Disorder

Services
Updated Information &
ml
http://pediatrics.aappublications.org/content/129/2/256.full.ht
including high resolution figures, can be found at:
References
ml#ref-list-1
http://pediatrics.aappublications.org/content/129/2/256.full.ht
at:
This article cites 63 articles, 11 of which can be accessed free
Citations
ml#related-urls
http://pediatrics.aappublications.org/content/129/2/256.full.ht
This article has been cited by 7 HighWire-hosted articles:
Subspecialty Collections
_sub
http://pediatrics.aappublications.org/cgi/collection/autism:asd
Autism/ASD
eficit:hyperactivity_disorder_adhd_sub
http://pediatrics.aappublications.org/cgi/collection/attention-d
Attention-Deficit/Hyperactivity Disorder (ADHD)
nt:behavioral_issues_sub
http://pediatrics.aappublications.org/cgi/collection/developme
Development/Behavioral Issues
the following collection(s):
This article, along with others on similar topics, appears in
Permissions & Licensing
tml
http://pediatrics.aappublications.org/site/misc/Permissions.xh
tables) or in its entirety can be found online at:
Information about reproducing this article in parts (figures,
Reprints
http://pediatrics.aappublications.org/site/misc/reprints.xhtml
Information about ordering reprints can be found online:
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Grove Village, Illinois, 60007. Copyright 2012 by the American Academy of Pediatrics. All
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at Indonesia:AAP Sponsored on August 18, 2014 pediatrics.aappublications.org Downloaded from