An 18-month-old girl presents to the ED with a temperature of 39°C and a background history of one previous simple febrile convulsion.
Which ONE of the following statements is TRUE?
Answer: C: This child’s clinical findings suggest a viral URTI with a high temperature, and her likelihood of recurrent febrile seizure is 30%. Febrile convulsions are the most common seizure disorder in childhood and usually have an excellent prognosis. They are rare before 9 months and after 6 years of age. Febrile seizures have a genetic origin; the febrile seizure gene has been mapped to chromosomes 19p and 8q13– 21. The most important task is to determine the cause of the fever and to rule out meningitis or encephalitis; these two serious conditions can usually be excluded on clinical grounds when children emerge from their short postictal state and return to a normal physiological well state. If any doubt exists about the possibility of meningitis, an LP with examination of the CSF is indicated, especially in children <12 months, if seizures are complex or sensorium remains clouded after a short postictal period. Viral infections are most frequently the cause of febrile convulsions.
A simple febrile convulsion is diagnosed in the presence of a:
About 30% of children have recurrent febrile seizures with a subsequent febrile illness. Factors associated with increased recurrence risk include: age <12 months; lower temperature before seizure onset; a positive family history of febrile seizures; and complex features. Most children with febrile seizures have a similar risk of epilepsy as the general population (1%). The risk of subsequent epilepsy increases if atypical features are present, or if independent risk factors for epilepsy exist.
The height of fever is no longer strongly statistically correlated with a bacterial illness, due to the current low prevalence of streptococcal bacteremia after the introduction of PCV7 immunization. Furthermore, antipyretics have not been shown to prevent seizure recurrences. Their role is restricted to improve comfort for the child. Seizures lasting >5 min should be terminated with a benzodiazepine as a first-line therapy. Anticonvulsant prophylaxis for preventing recurrent febrile convulsions is controversial and no longer recommended for most children. In selected cases where parental anxiety is very high and recurrent febrile seizures have occurred, some paediatricians and neurologists still advocate the use of oral diazepam as prophylaxis during a febrile illness. The side effects of this approach are usually minor, but this is certainly a controversial prophylactic measure and not a practice that is widespread.
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A 3-year-old boy presents to the ED with a simple febrile convulsion following a 1-day history of coryza. Examination reveals a well-looking child with an otitis media as potential source of fever.
Which ONE of the following is TRUE?
Answer: D: This boy presents with a simple febrile seizure in the setting of clinical findings suggestive of otitis media. The treatment for his viral otitis media is a nonsteroidal anti-inflammatory drug (NSAID) of which ibuprofen is well studied in this setting.
Children satisfying the criteria for simple febrile convulsions do not routinely require further investigations, aside from a blood sugar, and can usually be discharged home with appropriate follow-up. The yield from ‘baseline blood tests’ is extremely low, and electrolyte analysis is only indicated if a history of vomiting, diarrhoea or poor oral intake is present. Laboratory testing such as serum electrolytes should be individualized and are generally unwarranted. An underlying metabolic disorder would usually not present for the first time at age 3, and the patient would normally have some other features in the history to suggest such a disorder including failure to thrive, vomiting, abnormal development, features of malaise and previous seizures.
It is rare for bacterial meningitis to be diagnosed on a routine LP after a simple febrile seizure. If the only indication for performing an LP is the seizure, meningitis will be found in <1% of patients and less than one-half of these will have bacterial meningitis. A more appropriate option would be to arrange careful observation of the child within the ED or a short stay admission ward to detect other clinical features of invasive bacterial disease. The American Academy of Pediatrics recommends an LP in the setting of febrile seizures and:
It is the author’s opinion that an LP should be considered if the febrile seizure is atypical or febrile status epilepticus (seizure >30 minutes) is the presenting seizure type.
Similarly, an electroencephalogram (EEG) and neuroimaging is not warranted after a simple febrile seizure. Patients with symptoms falling outside of the definition of simple febrile seizure have an atypical or complex febrile seizure and should be admitted for further investigation.
Which ONE of the following statements is INCORRECT regarding the management of a 4-year old girl with a known seizure disorder on sodium valproate who presents to the ED with a prolonged seizure of >15 minutes?
Answer: B: Standard protocols suggest the following sequence of therapies is effective:
Consider anaesthetic agents (thiopentone, propofol, isoflurane) or other anticonvulsants. Once anaesthetic agents are considered for termination, definitive airway management with intubation and mechanical ventilation is mandated.
Phenytoin loading is reduced in the setting of patients who are known to be on phenytoin where there is some risk of toxicity. Normal doses should be used if phenytoin level is known to be low. Intravenous sodium valproate has been shown to be efficacious in the management of refractory status epilepticus (SE). Intravenous Keppra is a drug that also shows promise in the management of refractory SE. Other novel approaches to the management of SE include:
At this stage in management, patients should usually be cared for in an ICU setting, preferably with EEG monitoring available to detect non-convulsive status.
A 3-week-old boy is brought in by his father with a 2-day history of recurrent focal seizures associated with periods of unresponsiveness. On examination he is noted to be drowsy with a distended anterior fontanel and a heart rate of 75 bpm.
Which ONE of the following is the MOST appropriate answer?
Answer: D: Neonatal seizures often present in a subtle way and often carry a poor prognosis. Unlike seizures in older children, neonatal seizures are less likely to be idiopathic and need a more extensive evaluation. The differential diagnosis includes:
The clinical findings in this case are suggestive of raised intracranial pressure; a non-accidental injury should always be excluded. In this particular case, a work-up to cover the above differentials would include an urgent brain CT scan to exclude acute or acute on chronic subdural haemorrhage.
This neonate needs resuscitative care with oxygen and fluid. Neonatal status epilepticus is best terminated with phenobarbitone loading as first choice, followed by benzodiazepines as second-line therapy if this fails. BP assessment in neonates is notoriously inaccurate, as is the fundoscopic exam, therefore cushings triad (bradycardia, hypotension, papilloedema ) may be hard to define and the drowsiness and bradycardia may be enough evidence for mannitol administration to prevent or ameliorate raised intracranial pressure and possible uncal or tonsillar herniation.
A trial of pyridoxine is an excellent option once obvious traumatic, infective or metabolic causes have been excluded, and particularly if the seizures have been ongoing and have not responded to the standard status epilepticus regimes. It is commonly commenced in an ICU or paediatric ward scenario.
Regarding anti-convulsive therapy for epilepsy syndromes in children, which ONE of the following is TRUE?
Answer: D: In general, anticonvulsants are commenced after a patient has had two or more seizures. This decision is usually taken in conjunction with the child’s follow-up team such as neurologist, paediatrician or GP. Factors that are included in this decision are:
Table below summarizes the most common anticonvulsants used in paediatric epilepsy syndromes. Topiramate is an anticonvulsant that is specific as adjunctive therapy for partial seizures or Lennox-Gastaut syndrome. Levetiracetam (Keppra) is indicated for adjunctive therapy in partial seizures, GTC and juvenile myoclonic seizures.
COMMON ANTI-CONVULSANTS USED IN PAEDIATRIC EPILEPSY SYNDROMES:
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