In this episode, we cover the full spectrum from febrile seizures all the way to status epilepticus with Dr. John Gaitanis, a pediatric neurologist who specializes in care for children with epilepsy. Dr. Gaitanis teaches us what to look out for on neurologic exam, how to counsel families about safety precautions, and the differential diagnosis for seizure-like activity in infants and children. We also discuss the exciting future of epilepsy treatment.
Defined as seizures that occur in the setting of a fever (temperature >100.4ºF or 38ºC) in children aged 6 months to 5 years old without a known history of epilepsy. They are seen in 2-5% of all children (Subcommittee on Febrile Seizures, 2008). Thought to be a response to fever and cytokines in the setting of genetic predisposition towards seizure activity. Febrile seizures generally occur early in the course of illness and may be the presenting sign.
The distinction between simple and complex febrile seizures is based on focality, duration, and recurrence.
Simple febrile seizures are generalized, last less than 15 minutes, and only occur once within 24 hours.
Complex febrile seizures are focal, prolonged (>15 minutes), and recur multiple times within 24 hours.
Recommendations from: AAP Subcommittee on Febrile Seizures (2008 and 2011)
What can we tell parents and caregivers about the prognosis?
Generalized:
Focal:
A routine office EEG is 30-45 minutes long and has approximately 50% sensitivity (Baldwin et al, 2014). A normal EEG is not entirely reassuring but an abnormal EEG is concerning.
CT is generally avoided in children to limit total radiation exposure and because MRI provides better quality visualization. Administer gadolinium contrast only if the initial read suggests a structural abnormality to look for breakdown of the blood-brain barrier (Gaillard et al, 2009).
Expert Opinion: If the child has a reassuring exam, consider deferring to outpatient imaging. In the hospital it can be difficult to keep young patients NPO for sedation when there is no exact time scheduled.
Biking and swimming have their own inherent risks, and patients with seizures should take the same precautions as any other child (ex. never swim unsupervised, never bike without a helmet). It is important to recognize that while many children may outgrow their seizures, the effects of limiting their participation in sports and activities with friends can have long-term effects.
Most states have their own policies on driving, but most require that a patient be 6 months seizure-free to drive. Make sure to counsel patients that they should avoid driving if they miss a dose of seizure medication or are sleep deprived.
Important to consider the age of the patient. Ask if parents/caregivers have videos of the episodes and show them examples if not.
Initiation of AEDs is recommended after two unprovoked seizures (febrile seizures do not count), as the risk of having another seizure is close to 80%. AEDs should be continued until the patient has been seizure free for at least two years (Sidhu et al, 2013). Check an EEG and taper slowly. Options for AEDs include:
Defined as seizure activity lasting greater than 30 minutes or multiple seizures with no return to consciousness. Should be treated urgently to reduce risk of brain damage (Lowenstein et al, 1999).
The FEBSTAT study found that 10% of participants with febrile status epilepticus lasting >30 minutes had abnormalities of the hippocampus on follow-up imaging with MRI (Lewis et al, 2014). The concern is that hippocampal sclerosis caused by prolonged seizure activity could increase risk of developing temporal lobe epilepsy later in life.
1st line: IV lorazepam 0.1mg/kg, can give a second dose if seizure continues after 5-10 minutes
2nd line: IV fosphenytoin (20mg/kg) OR IV levetiracetam (40mg/kg)
3rd line: IV phenobarbital (20mg/kg)
4th line: Induction of medical coma with a phenobarbital, midazolam, or propofol drip.
Be sure to assess respiratory status and need for intubation throughout the process. May miss high CO2 in the setting of normal oxygen saturation maintained with supplemental oxygen.
Important to consider for patients with refractory seizures despite treatment with multiple AEDs.
Case Study: Dravet Syndrome & Cannabidiol
Dravet syndrome is a rare form of severe epilepsy caused by mutations in the sodium channel SCN1A gene. Patients develop frequent seizures of multiple types that are refractory to multiple lines of therapy. They also experience neurodevelopmental regression and are at greater risk for sudden unexpected death in epilepsy (SUDEP). This condition has been central to FDA approval of cannabidiol for treatment of certain seizure types (Devinsky et al, 2017).
Listeners will develop a framework for the diagnosis and management of pediatric seizures and epilepsy.
After listening to this episode listeners will…
Dr. Gaitanis reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Gaitanis J, Mao C, Chiu C, Berk J. “#18 Shaking Things Up: Pediatric Seizures & Epilepsy with Dr. John Gaitanis”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com. February 3, 2020.
Subcommittee on Febrile Seizures. Febrile Seizures: Clinical Practice Guideline for the Long-term Management of the Child With Simple Febrile Seizures. Pediatrics. 2008. [https://pubmed.ncbi.nlm.nih.gov/18519501/]
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