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Editor,—Seizures in infancy and early childhood responsive to pyridoxine are well recognised but rare. Baxter has recently observed that almost a third of neonatal cases of pyridoxine dependency present with apparent birth asphyxia and/or suspected hypoxic-ischaemic encephalopathy, and recommended that, because of the high proportion of atypical cases, all children with early onset (younger than 3 years old) intractable seizures or status should receive a trial of pyridoxine whatever the suspected cause.1 Following this recommendation can be of remarkable benefit.
We report a case of a caucasian boy, born at term, who presented at delivery in a state of unexpected collapse requiring intubation and resuscitation. He developed tonic seizures within hours of birth and was treated with phenobarbitone, phenytoin, and clonazepam. At 48 hours, an EEG showed a burst suppression pattern. There was biochemical evidence of multi-organ damage. He was extubated on day 5 and discharged on day 16 on phenobarbitone. He continued to have frequent myoclonic seizures. At 6 months, phenobarbitone was replaced by sodium valproate with some initial benefit. By 7 months, he was having focal motor seizures affecting his right arm up to 40 times a day and additional atypical absences and tonic seizures. He also showed signs of an emerging spastic quadraparesis. EEG showed right sided spike and wave discharge with a frontal emphasis. At 8 months a trial of oral pyridoxine (30 mg/kg/day) was given. No seizures have been observed since pyridoxine was started. He is now 16 months old. He is maintained on pyridoxine 15 mg/kg/day; valproate has been discontinued. The EEG no longer shows spike and wave activity. The signs of spastic quadraparesis remain.
We have reviewed the notes of children attending The David Lewis Centre, a residential school for children with severe epilepsy. Children at The David Lewis Centre are referred from all over the UK and their early epilepsy management has been undertaken at many different centres. 31 children with intractable cryptogenic epilepsies, which started before they were 3 years old, were identified (dates of birth 1979–1992). Only one of these children was recorded as having received a trial of pyridoxine early in the evolution of their epilepsies. The true prevalence of pyridoxine responsive epilepsy is difficult to assess if the recommendations of Baxter are seldom applied. Giving pyridoxine can be diagnostic and therapeutic—not giving a trial of pyridoxine is common and can leave a treatable cause of difficult epilepsy unrecognised and inadequately treated.
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