Abstracts

Rationale: Phenobarbital is commonly used for the treatment of epilepsy in the developing world, but in most developed countries, it has fallen into disrepute. The efficacy of phenobarbital in adults is undisputed, but concerns remain about its side effects, especially among children. Recent cost-effectiveness analyses have supported the use of phenobarbital in developing countries, yet these studies did not incorporate the economic consequences of cognitive side effects among children or potential seizure exacerbation by phenobarbital. Methods: We conducted a systematic review of the literature regarding the use of phenobarbital in children, as well as the literature estimating the economic cost of cognitive delay in children in developing countries. Results: We examined 31 clinical studies and 7 reviews, including 9 studies conducted in developing countries. We incorporated information from 3 cost-effectiveness evaluations as well as the literature regarding quality of life measures among children with epilepsy. We conclude that despite its many advantages, phenobarbital is not appropriate for first-line use in children in the developing world. Conclusions: We propose specific measures to build the health care infrastructure necessary to deliver patient-oriented care for children with epilepsy. We draw on the lessons learned from recent international initiatives in HIV care and acute respiratory illness. These measures include 1) training of community health workers to recognize clinical features that indicate contraindications to the use of phenobarbital, 2) development of laboratory facilities, 3) bulk and advanced purchasing agreements to make newer anticonvulsants more affordable, and 4) closer collaboration between pharmaceutical companies, governments and NGOs to ensure effective supply and distribution of anticonvulsants.